RESUMEN

BACKGROUND: Sarcopenia is a muscle disorder causing a progressive reduction of muscle mass and strength, but the mechanism of its manifestation is still partially unknown. The three main parameters to assess are: muscle strength, muscle volume or quality and low physical performance. There is not a definitive approach to assess the musculoskeletal condition of frail population and often the available tests to be performed in those clinical bedridden patients is reduced because of physical impairments. In this paper, we propose a novel instrumental multi-domain and non-invasive approach during a well-defined protocol of measurements for overcoming these limitations. A group of 28 bedridden elder people, subjected to surgery after hip fracture, was asked to perform voluntary isometric contractions at the 80% of their maximum voluntary contraction with the non-injured leg. The sensor employed before and/or during the exercise were: ultrasound to determine the muscle architecture (vastus lateralis); force acquisition with a load cell placed on the chair, giving an indication of the muscle strength; surface electromyography (EMG) for monitoring muscular electrical activity; time-domain (TD) near-infrared spectroscopy (NIRS) for evaluating muscle oxidative metabolism. RESULTS: A personalized "report card" for each subject was created. It includes: the force diagram (both instantaneous and cumulative, expected and measured); the EMG-force diagram for a comparison between EMG derived median frequency and measured force; two graphs related to the hemodynamic parameters for muscle oxidative metabolism evaluation, i.e., oxy-, deoxy-, total-hemoglobin and tissue oxygen saturation for the whole exercise period. A table with the absolute values of the previous hemodynamic parameters during the rest and the ultrasound related parameters are also included. CONCLUSIONS: In this work, we present the union of protocols, multi-domain sensors and parameters for the evaluation of the musculoskeletal condition. The novelties are the use of sensors of different nature, i.e., force, electrical and optical, together with a new way to visualize and combine the results, by means of a concise, exhaustive and personalized medical report card for each patient. This assessment, totally non-invasive, is focused on a bedridden population, but can be extended to the monitoring of rehabilitation progresses or of the training of athletes.

Asunto(s)

RESUMEN

Climbing is a physically demanding discipline, placing significant loads on the finger flexors. Notwithstanding the documented greater endurance capacity of experienced climbers, the mechanisms explaining these training-induced adaptations remain unknown. We therefore investigate whether two non-competing strategies - muscle adaptation and alternate muscle recruitment - may explain the disparity in endurance capacity in participants with different climbing experience. We analysed high-density surface electromyograms (EMGs) from 38 Advanced and Intermediate climbers, during suspension exercises over three different depths (15, 20, 30 mm) using a half-crimp grip position. From the spatial distribution of changes in MeDian Frequency and Root Mean Square values until failure, we assessed how much and how diffusely the myoelectric manifestations of fatigue took place. Advanced climbers exhibited greater endurance, as evidenced by significantly longer failure time (p < 0.009) and lower changes in MDF values (p < 0.013) for the three grip depths. These changes were confined to a small skin region (nearly 25% of the grid size), centred at variable locations across participants. Moreover, lower MDF changes were significantly associated with longer suspension times. Collectively, our results suggest that muscle adaptation rather than load sharing between and within muscles is more likely to explain the improved endurance in experienced climbers.

Asunto(s)

RESUMEN

It is unclear how hamstring stiffness influences lower limb muscle activation during jump-landing mechanics. The study aimed to investigate the role of the hamstring stiffness on lower limb muscle recruitment during jumping manoeuvres. Thirty male athletes were recruited and allocated into high- and low-stiffness groups. Hamstring stiffness was determined as the average stiffness of bilateral hamstrings using a MyotonPRO. Surface electromyography of the bilateral gluteus maximus, quadriceps, and hamstring muscles was assessed during the takeoff, at ground contact, and at landing, while ground reaction force (GRF) was measured during the squat jump, countermovement jump, and drop vertical jump. The results showed that athletes with greater hamstring stiffness exhibited a higher median frequency of the lateral hamstrings in both limbs and the vastus medialis in the dominant limb than the low-stiffness group during takeoff, adjustment, and landing phases for all vertical jumps. The high stiffness group landed with lower vertical GRF in the drop vertical jump. In conclusion, athletes with high hamstring stiffness showed greater motor unit recruitment during takeoff and landing phases. This recruitment did not influence takeoff performance but aid with absorbing landing force. Therefore, the contribution of the lower limb muscle stiffness should be considered in sports activities.

RESUMEN

Investigation of the contralateral repeated bout effect (CL-RBE) in women is scarce. Therefore, this study aimed at examining whether CL-RBE exists in women. Twelve healthy women (age: 20.9 ± 2.5 years) performed two bouts of maximal elbow flexor eccentric exercise (3 sets × 15 repetitions per bout) separated by 14 days, using the opposite arms. Surface Electromyography (EMG) was recorded during both exercise bouts. The isokinetic muscle strength (60°/s), muscle soreness, range of motion (ROM), limb girth, and blood creatine kinase activity were measured pre-exercise, and at 24 and 48 h post-exercise with the muscle strength being measured immediately post-exercise as well. Significant main effects of time were observed for muscle strength, muscle soreness and ROM (p < 0.05). There were no significant differences between bouts for all the measured variables including the EMG median frequency (p > 0.05). These results suggest that the CL-RBE of elbow flexors was not evident in young healthy women. This was because the mild muscle damage induced by the initial bout of exercise was either not enough to initiate the CL-RBE or the CL-RBE in women lasted shorter than two weeks. This study provides important information for future studies on CL-RBE in women.

RESUMEN

Mechanisms underlying exercise-induced muscle fatigue and recovery are dependent on peripheral changes at the muscle level and improper control of motoneurons by the central nervous system. In this study, we analyzed the effects of muscle fatigue and recovery on the neuromuscular network through the spectral analysis of electroencephalography (EEG) and electromyography (EMG) signals. A total of 20 healthy right-handed volunteers performed an intermittent handgrip fatigue task. In the prefatigue, postfatigue, and postrecovery states, the participants contracted a handgrip dynamometer with sustained 30% maximal voluntary contractions (MVCs); EEG and EMG data were recorded. A considerable decrease was noted in EMG median frequency in the postfatigue state compared with the findings in other states. Furthermore, the EEG power spectral density of the right primary cortex exhibited a prominent increase in the gamma band. Muscle fatigue led to increases in the beta and gamma bands of contralateral and ipsilateral corticomuscular coherence, respectively. Moreover, a decrease was noted in corticocortical coherence between the bilateral primary motor cortices after muscle fatigue. EMG median frequency may serve as an indicator of muscle fatigue and recovery. Coherence analysis revealed that fatigue reduced the functional synchronization among bilateral motor areas but increased that between the cortex and muscle.

Asunto(s)

RESUMEN

Employees who work long hours frequently complain of muscle fatigue caused by prolonged sitting. As a result, products that assist them when resting in a chair in a reclining position, in order to relieve fatigue and improve comfort are required. To ensure that the new product works as intended, a usability test based on prototyping must be developed. The research process was divided into three stages: firstly, the development of the perception assessment questionnaire; secondly, a validated factor analysis (CFA) was conducted on the perception assessment data of 26 subjects and the measurement model was fitted to verify the reliability and validity of the questionnaire; finally, the sEMG technique was used to verify the comfort level of 21 subjects. Based on usability experiments and an exploration of human factor relationships, this study develops a prototype testing model, which focuses on the comfort perception of body parts, as a means of promoting innovation in the design and manufacturing industry.

RESUMEN

Amyotrophic lateral sclerosis is a chronic degenerative disease that affects motor neurons, thereby promoting functional changes in the human body. The study evaluated the electromyographic fatigue threshold of the masseter and temporal muscles of subjects with amyotrophic lateral sclerosis. A total of eighteen subjects were divided into two groups: amyotrophic lateral sclerosis (n=9) and disease-free control (n=9). The groups were equally divided according to gender (7 males, 2 females). The fatigue threshold was analysed using median frequencies obtained during the 5-second window (initial [IP], mid [MP], and final [FP] periods) of electromyographic signalling of the masseter and temporal muscles bilaterally, with reduction in muscle force during maximal voluntary dental clenching. Significant difference (p<0.05) in the left temporal muscle: IP (p=0.05) and MP (p=0.05) periods was demonstrated. The amyotrophic lateral sclerosis group showed a decrease in median frequency of the electromyographic signal of the masseter and temporal muscles compared to the control group. Amyotrophic lateral sclerosis promotes functional impairment of the stomatognathic system, especially at the electromyographic fatigue threshold of the masticatory muscles.

Asunto(s)

RESUMEN

In hypertonic muscles of patients with upper motor neuron syndrome (UMNS), investigation with surface electromyography (EMG) with the muscle in a shortened position and during passive muscle stretch allows to identify two patterns underlying hypertonia: spasticity and spastic dystonia. We recently observed in Para swimmers that the effect of fatigue on hypertonia can be different from subject to subject. Our goal was, therefore, to understand whether this divergent behavior may depend on the specific EMG pattern underlying hypertonia. We investigated eight UMNS Para swimmers (five men, mean age 23.25 ± 3.28 years), affected by cerebral palsy, who presented muscle hypertonia of knee flexors and extensors. Muscle tone was rated using the Modified Ashworth Scale (MAS). EMG patterns were investigated in rectus femoris (RF) and biceps femoris (BF) before and after two fatiguing motor tasks of increasing intensity. Before the fatiguing tasks, two subjects (#2 and 7) had spasticity and one subject (#5) had spastic dystonia in both RF and BF. Two subjects (#3 and 4) showed spasticity in RF and spastic dystonia in BF, whereas one subject (#1) had spasticity in RF and no EMG activity in BF. The remaining two subjects (#6 and 8) had spastic dystonia in RF and no EMG activity in BF. In all the 16 examined muscles, these EMG patterns persisted after the fatiguing tasks. Spastic dystonia increased (p < 0.05), while spasticity did not change (p > 0.05). MAS scores increased only in the muscles affected by spastic dystonia. Among the phenomena possibly underlying hypertonia, only spastic dystonia is fatigue-dependent. Technical staff and medical classifiers should be aware of this specificity, because, in athletes with spastic dystonia, intense and prolonged motor activity could negatively affect competitive performance, creating a situation of unfairness among Para athletes belonging to the same sports class.

RESUMEN

Background: This study aimed to clarify the effect of music tempo on runners' perception of fatigue at different exercise intensities and while listening to music of different tempos through running experiments. Methods: This study used a within-subject two-factor experimental design with music tempo (fast music, slow music, no music) and exercise intensity (high intensity, low intensity) as independent variables and the time to fatigue perception (TFP), the difference in heart rate (HR) and the difference in the median frequency (MF) of surface electromyography (sEMG) signals as observation indexes. Eighteen participants completed a total of 108 sets of running experiments. Results: (1) The main effect of music tempo on the TFP was significant (p < 0.001). (2) The main effect of exercise intensity on the TFP was significant (p < 0.001), and the main effect on the difference in HR was significant (p < 0.001). (3) The interaction effect of music tempo and exercise intensity on the TFP was significant (p < 0.05). Conclusions: Exercisers' subjective perception of fatigue was affected by music tempo and the interaction between music tempo and exercise intensity, and exercisers' objective fatigue perception was influenced mostly by exercise intensity. The findings of this study provide guidance for runners' choice of music at different intensities of exercise. Whether it is low-intensity exercise or high-intensity exercise, listening to fast music while exercising can help runners perform better mentally and physically during their runs.

Asunto(s)

RESUMEN

Muscle fatigue is a risk factor for developing shoulder musculoskeletal disorders. The aim of this study was to identify shoulder electromyographic indicators that are most indicative of muscle fatigue during a laboratory simulated manual handling task. Thirty-two participants were equipped with electromyographic electrodes on 10 shoulder muscles and moved boxes for 45-minutes. The modified rate of perceived exertion (mRPE) was assessed every 5-minutes and multivariate linear regressions were performed between myoelectric manifestation of fatigue (MMF) and the mRPE scores. During a manual handling task representative of industry working conditions, spectral entropy, median frequency, and mobility were the electromyographic indicators that explained the largest percentage of the mRPE. Overall, the deltoids, biceps and upper trapezius were the muscles that most often showed significant changes over time in their electromyographic indicators. The combination of these three indicators may improve the accuracy for the assessment of MMF during manual handling. Practitioner Summary: To date, muscle fatigue has primarily been assessed during tasks done to exhaustion, which are not representative of typical working conditions. During a manual handling task representative of industry working conditions, EMG-derived spectral entropy, and median frequency, both extracted from time-frequency analysis, and mobility extracted from time domain, were the best indicators of the manifestation of muscle fatigue.

Asunto(s)

RESUMEN

BACKGROUND: Physical activity may benefit health and reduce risk for chronic complications in normal and people with diabetes and peripheral vascular diseases. However, it is unclear whether leg muscle fatigue after weight-bearing physical activities, such as brisk walking, may increase risk for plantar tissue injury. In the literature, there is no evidence on the effect of muscle fatigue on plantar pressure after various walking intensities. The objectives of this study were to investigate the effects of various walking intensities on leg muscle fatigue and plantar pressure patterns. METHODS: A 3 × 2 factorial design, including 3 walking speeds (1.8 (slow and normal walking), 3.6 (brisk walking), and 5.4 (slow running) mph) and 2 walking durations (10 and 20 min) for a total of 6 walking intensities, was tested in 12 healthy participants in 3 consecutive weeks. The median frequency and complexity of electromyographic (EMG) signals of tibialis anterior (TA) and gastrocnemius medialis (GM) were used to quantify muscle fatigue. Fourier transform was used to compute the median frequency and multiscale entropy was used to calculate complexity of EMG signals. Peak plantar pressure (PPP) values at the 4 plantar regions (big toe, first metatarsal head, second metatarsal head, and heel) were calculated. RESULTS: Two-way ANOVA showed that the walking speed (at 1.8, 3.6, 5.4 mph) significantly affected leg muscle fatigue, and the duration factor (at 10 and 20 min) did not. The one-way ANOVA showed that there were four significant pairwise differences of the median frequency of TA, including walking speed of 1.8 and 3.6 mph (185.7 ± 6.1 vs. 164.9 ± 3.0 Hz, P = 0.006) and 1.8 and 5.4 mph (185.7 ± 6.1 vs. 164.5 ± 5.5 Hz, P = 0.006) for the 10-min duration; and walking speed of 1.8 and 3.6 mph (180.0 ± 5.9 vs. 163.1 ± 4.4 Hz, P = 0.024) and 1.8 and 5.4 mph (180.0 ± 5.9 vs. 162.8 ± 4.9 Hz, P = 0.023) for the 20-min duration. The complexity of TA showed a similar trend with the median frequency of TA. The median frequency of TA has a significant negative correlation with PPP on the big toe ( r = -0.954, P = 0.003) and the first metatarsal head ( r = -0.896, P = 0.016). CONCLUSIONS: This study demonstrated that brisk walking and slow running speeds (3.6 and 5.4 mph) cause an increase in muscle fatigue of TA compared to slow walking speed (1.8 mph); and the increased muscle fatigue is significantly related to a higher PPP.

Asunto(s)

RESUMEN

A greater proportion of glycolytic muscle fibers is a manifestation of skeletal muscle dysfunction in Chronic Obstructive Pulmonary Disease (COPD). Here, we propose to use the spectral analysis of the electromyographic signal as a non-invasive approach to investigate the fiber muscle composition in COPD. We recorded the electromyographic activity of Rectus Femoris (RF), Vastus Lateralis (VL), Vastus Medialis (VM) and Biceps Femoris (BF) muscles, in ten patients and ten healthy individuals, during non-fatiguing, flexion-extension leg movements. The mean (MNF) and median frequencies (MDF) were calculated, and the most common profiles of electromyographic power spectrum were characterized by using the principal component analysis. Frequency parameters showed higher values in patients with COPD than in the control group for the RF (+25% for MNF; +21% for MNF), VL (+16% for MNF; 16% for MNF) and VM (+22% for MNF; 22% for MNF) muscles during the extension movements and for the BF (+26% for MNF; 34% for MNF) muscle during flexion movements. Spectrum profiles of the COPD patients shifted towards the higher frequencies, and the changes in frequency parameters were correlated with the level of disease severity. This shift of frequencies may indicate an increase in glycolytic muscle fibers in patients with COPD. These results, along with the non-fatigable nature of the motor task and the adoption of a non-invasive method, encourage to use electromyographic spectral analysis for estimating muscle fiber composition in patients with COPD.

RESUMEN

Developing a computational method for recognizing preterm delivery is important for timely diagnosis and treatment of preterm delivery. The main aim of this study was to evaluate electrohysterogram (EHG) signals recorded at different gestational weeks for recognizing the preterm delivery using random forest (RF). EHG signals from 300 pregnant women were divided into two groups depending on when the signals were recorded: i) preterm and term delivery with EHG recorded before the 26th week of gestation (denoted by PE and TE group), and ii) preterm and term delivery with EHG recorded during or after the 26th week of gestation (denoted by PL and TL group). 31 linear features and nonlinear features were derived from each EHG signal, and then compared comprehensively within PE and TE group, and PL and TL group. After employing the adaptive synthetic sampling approach and six-fold cross-validation, the accuracy (ACC), sensitivity, specificity and area under the curve (AUC) were applied to evaluate RF classification. For PL and TL group, RF achieved the ACC of 0.93, sensitivity of 0.89, specificity of 0.97, and AUC of 0.80. Similarly, their corresponding values were 0.92, 0.88, 0.96 and 0.88 for PE and TE group, indicating that RF could be used to recognize preterm delivery effectively with EHG signals recorded before the 26th week of gestation.

RESUMEN

BACKGROUND: Lumbar disc herniation (LDH) can affect lower limb muscle function resulting in an abnormal gait. This study aims to use surface electromyography (SEMG) to evaluate patients with L4/L5 and L5/S1 LDH throughout muscle movement. METHODS: Twenty L4/L5 LDH patients (L5 Group), twenty L5/S1 LDH patients (S1 Group), and twenty healthy controls (Healthy) were recruited for the study. SEMG of bilateral tibialis anterior (TA) and lateral gastrocnemius (LG) muscles of patients were recorded using the DELSYS Wireless EMG System (TrignoTM Wireless Systems, Delsys Inc., USA). Root-mean-square (RMS), mean power frequency (MPF), and median frequency (MF) were compared between bilateral limbs in each participant. RESULTS: Reduced MPF and MF was found in TA measurements of the L5 Group and LG measurements of the S1 Group. The MPF and MF of the TA of symptomatic limbs of the L5 Group were reduced when compared to asymptomatic limbs (p= 0.006, p= 0.012, p< 0.05), and there were no significant differences in LG measurements (p> 0.05). The LG MPF and MF of the S1 Group in symptomatic limbs were reduced when compared to asymptomatic limbs (p= 0.006, p= 0.017, p< 0.05), and there were no significant differences in TA measurements (p> 0.05). Although there were no significant differences in RMS between bilateral limbs of the L5 and S1 Groups, we found some changes in RMS curves. First, compared to asymptomatic limbs of L4/L5LDH patients, ß-peaks in the TA of symptomatic limbs appeared earlier. Second, two peaks in the LG of symptomatic limbs were found in L5/S1 LDH patients. CONCLUSION: TA is affected in patients with LDH of L4/L5, and LG is affected in patients with LDH of L5/S1. As demonstrated, SEMG can identify LDH-related muscle dysfunction.

Asunto(s)

Asunto(s)

RESUMEN

(1) Background: The importance of a strong and stable trunk musculature is well known, but there is a lack of reliable, valid and objective test batteries with the necessary test economy, practicability and cost-benefit ratio. The aim of the present study was to evaluate the Bourban test for the validity of its exercise selection representing the ventral, right/left lateral and dorsal muscle chain. (2) Methods: 33 male sports students (24.1 ± 2.4 years, 181.6 ± 5.5 cm, 80.8 ± 7.3 kg) participated in the study. Median Frequency (MDF) and Mean Frequency (MNF) were calculated from the electromyographic signals and used to check whether fatigue of the suggested target musculature actually occurs during the different exercises and thus the exercise is representative for this part of the trunk. (3) Results: In all exercises significant fatigue was measured for MDF and MNF in the muscles working as agonists. (4) Conclusion: It can be stated that the Bourban trunk muscle strength test is a valid and economic test instrument for the evaluation of trunk strength (endurance). Compared to technically supported measuring systems, the Bourban test seems to be a flexible and cost-effective alternative for the broad mass.

RESUMEN

OBJECTIVES: The objective of this study was to evaluate the electromyographic fatigue of the masseter and temporalis muscles in individuals with and without osteoporosis. METHODS: Median frequency of the initial, mid, and final periods of the electromyographic signal in the 33 subjects with osteoporosis (OG) and 33 subjects without osteoporosis [control (CG)] was analyzed. RESULTS: OG showed a decrease in median frequency along the electromyographic signal, with a significant difference for the right masseter: initial vs. mid periods, initial vs. final periods; left masseter: initial vs. final periods; temporal (right and left): initial vs. mid periods, initial vs. final periods, and mid vs. final periods. Percentage comparison of median frequency between the initial and mid periods and between initial and final periods in the OG showed a significant difference in the masticatory muscles. DISCUSSION: The findings suggest that osteoporosis is associated with changes in the function of masticatory muscles, especially when measured by electromyographic fatigue.

Asunto(s)

RESUMEN

There is currently little information on the positioning of reference electrode (RE). It is generally accepted that it must be positioned on electrically neutral tissues, such as tendons or bony prominences. The objective of this study is to analyze the characteristics of the electromyographic signal (EMG) for different positions of RE as well as at different levels of muscle contraction. Signals from the brachial biceps and triceps were recorded from 18 healthy women (BMI: 21.20 kg/m2 ± 1.72; mean age: 21.94 ± 1.98 years old) during 100 and 50% maximum flexion voluntary isometric contractions, as well as at rest. For each situation, the RE was randomly positioned in 4 different locations: a) homolateral acromion; b) homolateral brachial biceps; c) styloid process of the contralateral ulna; and d) lateral malleolus of the contralateral ankle. For statistical analysis, Shapiro-Wilk and Kruskal-Wallis tests were used, followed by Dunn's post-hoc test, at a significance level of 5% (p < 0.05). RMS, normalized RMS, PSD, median frequency and levels of energy at 60 Hz, 120 Hz and 180 Hz were assessed for the different sites of RE. The results show that the positioning of the RE on the four experimental locations did not change important features of the electromyographic signals in the time and frequency domains, for the three levels of isometric contractions studied. Such findings compel us to re-think the current trend regarding the RE position followed by the great majority of the researches in areas such as physical therapy.

Asunto(s)

RESUMEN

The primary purpose was to determine if there is a difference between the median frequency slopes of 5 posterior shoulder muscles during the initial portion of the Posterior Shoulder Endurance Test (PSET) at the 90° and 135° shoulder abduction positions. Fifty-five healthy volunteers (31 females) participated. The median frequency of the posterior deltoid (PD), upper trapezius (UT), middle trapezius (MT), lower trapezius (LT), and infraspinatus (INF) was measured during the PSET at 90° and 135° of shoulder abduction. External torque of 13 ±â€¯1 Nm was used for females and 21 ±â€¯1 Nm for males. A fixed effect multi-variable regression model was used to investigate the median frequency slopes. Males and females were analyzed separately. Median frequency slopes demonstrated fatigue in all 5 of the muscles. The PD fatigued greater than the UT in males (p = 0.0215) and greater than the LT in females (p = 0.008). The time to task failure (TTF) was greater at 90° than 135° for females and males (p = 0.016; p = 0.0193) respectively. The PSET causes fatigue in all of the muscles that were tested, with the PD fatiguing at a greater rate compared to one muscle for each sex. This investigation supports using TTF as a clinical measure of shoulder girdle endurance at 90° shoulder abduction.

Asunto(s)

RESUMEN

Spectral entropy (SE) is a measurement from information theory field that provides an estimation of EEG regularity and may be useful as a summary of its spectral properties. Previous studies using small samples reported a deficit of EEG entropy modulation in schizophrenia during cognitive activity. The present study is aimed at replicating this finding in a larger sample, to explore its cognitive and clinical correlates and to discard antipsychotic treatment as the main source of that deficit. We included 64 schizophrenia patients (21 first episodes, FE) and 65 healthy controls. We computed SE during performance of an odd-ball paradigm, at the windows prior (-300 to 0ms) and following (150 to 450ms) stimulus presentation. Modulation of SE was defined as the difference between post- and pre-stimulus windows. In comparison to controls, patients showed a deficit of SE modulation over frontal and central regions, also shown by FE patients. Baseline SE did not differ between patients and controls. Modulation deficit was directly associated with cognitive deficits and negative symptoms, and inversely with positive symptoms. SE modulation was not related to antipsychotic doses. Patients also showed a smaller change of median frequency (i.e., smaller slowing of oscillatory activity) of the EEG from pre- to post-stimulus windows. These results support that a deficit of fast modulation contributes to cognitive deficits and symptoms in schizophrenia patients.

Asunto(s)