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The effects of coronavirus on human nasal ciliated respiratory epithelium.

Human coronavirus (HCoV) accounts for 15-30% of common colds, but only one case report has described the effect of a coronavirus infection, that was asymptomatic, on human respiratory epithelium. The authors examined the effects of infection with HCoV on ciliary structure and function in healthy volunteers infected by intranasal inoculation with HCoV 229E. A further four volunteers were sham infected with ultraviolet-inactivated virus. Immediately before inoculation (day 0) and 3 days later (day 3), ciliated epithelium was obtained by brushing the inferior nasal turbinate. Ciliary beat frequency was determined and beat pattern analysed for evidence of dyskinesia (0=normal, 3=severely dyskinetic) using digital high-speed video photography. Ciliary ultrastructure was examined by transmission electron microscopy. Symptom diaries were kept for the duration of the study. All subjects inoculated with HCoV, including the three who did not develop symptoms of an upper respiratory tract infection, had disruption of their respiratory epithelium on day 3. Although there was no difference in the mean ciliary beat frequency between day 0 (11.3 Hz (95% confidence interval (CI): 8.6-14.0) and day 3 (9.4 Hz (95% CI 7.2-11.6)), there was a significant increase (p<0.05) in the ciliary dyskinesia score between day 0 (0.2 (95% CI 0-0.5)) and day 3 (1.1 (95% CI 0.5-1.7). In sham-infected subjects, no differences in epithelial integrity, or ciliary structure and function were found between day 0 and day 3. Inoculation of healthy volunteers with human coronavirus caused disruption of the ciliated epithelium and ciliary dyskinesia. This is likely to impair mucociliary clearance. Damage to the respiratory epithelium, due to human coronavirus infection, may occur without overt clinical symptoms.

Adult↗

Home dampness, moulds and their influence on respiratory infections and symptoms in adults in Finland.

The aim of this study was to analyse the prevalence of mouldy homes and their association with respiratory symptoms and diseases in a subarctic climate. A questionnaire was mailed to a random sample of 2,000 males and females, aged 25-64 yrs, living in the county of Kuopio, Finland. A total of 1,521 (76%) responded and 1,460 were selected for the final analysis. The prevalence of homes with visible mould was 4%; with the odour of mould 5%; with damp spots, visible mould or the odour of mould 15%; and with moisture/ water damage, damp spots, visible mould or the odour of mould 23%. The number of reports of bronchitis, common cold, atopy, allergic rhinitis, rhinitis, fever and chills, hoarseness, fatigue, difficulties in concentration, lumbar backache and stomach ache were strongly associated with living in a damp home. Bronchitis, hoarseness and difficulties in concentration had the strongest associations, with adjusted odds ratios (95% confidence limits) of: 2.04 (1.49-2.78), 2.23 (1.37-3.63) and 2.17 (1.35-3.50), respectively. After controlling for a possible reporting bias by excluding those subjects reporting lumbar backache and recurrent stomach pain, eye irritation and tiredness remained significant. In conclusion, living in a home with mould problems may increase the risk of respiratory infections and symptoms in adults.

Adult↗

Human coronavirus 229E encodes a single ORF4 protein between the spike and the envelope genes.

BACKGROUND: The genome of coronaviruses contains structural and non-structural genes, including several so-called accessory genes. All group 1b coronaviruses encode a single accessory protein between the spike and envelope genes, except for human coronavirus (HCoV) 229E. The prototype virus has a split gene, encoding the putative ORF4a and ORF4b proteins. To determine whether primary HCoV-229E isolates exhibit this unusual genome organization, we analyzed the ORF4a/b region of five current clinical isolates from The Netherlands and three early isolates collected at the Common Cold Unit (CCU) in Salisbury, UK. RESULTS: All Dutch isolates were identical in the ORF4a/b region at amino acid level. All CCU isolates are only 98% identical to the Dutch isolates at the nucleotide level, but more closely related to the prototype HCoV-229E (>98%). Remarkably, our analyses revealed that the laboratory adapted, prototype HCoV-229E has a 2-nucleotide deletion in the ORF4a/b region, whereas all clinical isolates carry a single ORF, 660 nt in size, encoding a single protein of 219 amino acids, which is a homologue of the ORF3 proteins encoded by HCoV-NL63 and PEDV. CONCLUSION: Thus, the genome organization of the group 1b coronaviruses HCoV-NL63, PEDV and HCoV-229E is identical. It is possible that extensive culturing of the HCoV-229E laboratory strain resulted in truncation of ORF4. This may indicate that the protein is not essential in cell culture, but the highly conserved amino acid sequence of the ORF4 protein among clinical isolates suggests that the protein plays an important role in vivo.

Aged↗

Medicinal plants popularly used in the Xingó region - a semi-arid location in Northeastern Brazil.

The aim of this study was to identify plant species among the diverse flora of the caatinga ecosystem that are used therapeutically. Research was undertaken in the municipalities of Piranhas and Delmiro Gouveia, in the Xingó region (state of Alagoas, NE Brazil). In order to identify the medicinal plants used in this region, semi-structured questionnaires were applied. The species cited were collected and sent to the Xingó Herbarium for taxonomic analysis. The relative importance (RI) of each species cited was calculated to verify their cultural importance. The therapeutic indications attributed to the species were classified under 16 body systems. A total of 187 medicinal species were cited, from 64 families and 128 genera. The main indications for medicinal plant use were against common colds, bronchitis, cardiovascular problems, kidney problems, inflammations in general, and as tranquilizers. Approximately 16% (30 plant species) were versatile in relation to their use, with an Relative Importance value over 1, having been indicated for up to nine body systems. The body systems that stood out the most were: the respiratory system, the gastrointestinal system, and infectious diseases. Most cited plant parts used for medicinal purposes were flowers, leaves, and inner stem bark.

Adult↗

Investigation of biochemical and histopathological effects of Mentha piperita L. and Mentha spicata L. on kidney tissue in rats.

Peppermint plants have been used as a herbal medicine for many conditions, including loss of appetite, common cold, bronchitis, sinusitis, fever, nausea, vomiting and indigestion. This study is aimed at investigating the biochemical and histological effects of Mentha piperita L., growing in the Yenisar Bademli town of Isparta City, and Mentha spicata L., growing on the Anamas high plateau of Isparta City, on rat kidney tissue. Forty-eight male Wistar albino rats weighing 200-250 g were used for this study. Animals were divided into four experimental groups, each with 12 rats, as follows: control group (group I); 20 g/L M. piperita tea (group II); 20 g/L M. spicata tea (group III); 40 g/L M. spicata tea (group IV). The control group rats were given commercial drinking water (Hayat DANONESA water). The tea for the other groups was prepared daily and provided at all times to the rats during 30 days as drinking water. Plasma urea and creatinine levels were determined, and the levels of thiobarbituric acid reactive substance (TBARS) and the activities of glutathione peroxidase (GSH-Px), catalase (CAT) and superoxide dismutase (SOD) were studied in the homogenates of kidney tissue. The levels of plasma urea and creatinine were increased significantly (P < 0.0033) in groups III and IV when compared with group I. The activities of SOD and GSH-Px were decreased significantly (P < 0.0033) in group IV when compared with group I. The activities of CAT were decreased significantly in groups III and IV (P < 0.033, P < 0.0033, respectively) when compared with group I. TBARS levels were increased significantly (P < 0.0033) in groups III and IV when compared with group I. In groups II, III and IV, hydropic degeneration of tubular epithelial cells, the epithelial cells with picnotic nuclei and eosinophilic cytoplasm, tubular dilatation and enlargements in Bowman capsules were observed histologically. However, in group II histopathological changes were more slight than in groups III and IV. In group IV, in addition to these changes, extremely hydropic degeneration of tubular epithelial cells, some atrophic tubules and glomerules, and focal mononuclear cell infiltrations in the kidney tissues of the rats were observed. In conclusion, the results indicate that M. piperita does not show nephrotoxicity but M. spicata presents markedly nephrotoxic changes in rats.

Animals↗

Investigation of biochemical and histopathological effects of Mentha piperita Labiatae and Mentha spicata Labiatae on liver tissue in rats.

The plant Mentha piperita, or peppermint, is commonly used in the treatment of loss of appetite, common cold, bronchitis, sinusitis, fever, nausea and vomiting, and indigestion as a herbal agent. In this study, we aimed to investigate biochemical and histological effects of M. piperita Labiatae, growing in the Yenisar Bademli town of Isparta city, and Mentha spicata Labiatae, growing in the Anamas high plateau of the Yenisar Bademli town, on the rat liver tissue. Forty-eight male Wistar albino rats weighing 200-250 g were used for this study. Rats were divided into four groups of 12 animals: Group I received no herbal tea (control group); Group II received 20 g/L M. piperita tea; Group III received 20 g/L M. spicata tea; and Group IV received 40 g/L M. spicata tea. Herbal teas were prepared daily and provided at all times to the rats during 30 days as drinking water. Liver function tests, including aspartate aminotransferase (AST/GOT) and alanine aminotransferase (ALT/GPT) activities were measured. To evaluate liver antioxidant defences, superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), catalase (CAT) and thiobarbituric acid reactive substance (TBARS) activities were determined in the homogenates of liver tissue. In addition, liver tissues were submitted for histopathologic examination. AST and ALT activities were increased in Group II, Group III and Group IV gradually when compared with the control group. The difference between Group II and the control group was not statistically significant (P > 0.016). Increases in AST and ALT activities of Group III and Group IV were statistically significant when compared with the control group. SOD, GSH-Px and CAT activities were increased in Group II when compared with the control group but the difference was not statistically significant (P > 0.016). However, SOD, GSH-Px activities and the TBARS level were significantly increased, and CAT activity was significantly decreased in Group III when compared with the control group. In Group IV, while SOD, GSH-Px and CAT activities were decreased, the TBARS level was increased as compared with the control group (P < 0.0016). Histopathological evaluation of experimental groups revealed a mild to severe degree of hepatic damage when compared to the control group. In Group II, there was only minimal hepatocytes degeneration. In Groups III and IV, there were granular or ballooning hepatocyte degeneration and necrosis, sinusoidal and central vein dilatation. It was concluded that lipid peroxidation and hepatic damage occurs after M. piperita and M. spicata administration in rat liver and the damage seems to be dose dependent.

Alanine Transaminase↗

2-methoxycinnamaldehyde reduces IL-1beta-induced prostaglandin production in rat cerebral endothelial cells.

Prostaglandin E2 (PGE2) works as a common final mediator of the febrile. Guizhi-Tang, one of the most famous traditional Chinese medical formula used to treat influenza, common cold and other pyretic conditions, was previously reported to reduce the production of PGE 2 in rats. 2-Methoxycinnamaldehyde is a principle compound isolated from Guizhi-Tang. The aim of the present study was to investigate the effects of 2-methoxycinnamaldehyde on PGE2 production of rat cerebral endothelial cells (CECs). 2-Methoxycinnamaldehyde dose-dependently inhibited interleukin (IL)-1beta-induced PGE2 production in CECs with IC50 values of 174 microM. IL-1beta stimulation increased the protein, activity and mRNA expression of cyclooxygenase (COX)-2 but not COX-1. 2-Methoxycinnamaldehyde reduced IL-1beta-induced protein and activity of COX-2, but did not influence the COX-2 mRNA expression. Our results show that prostaglandin production in CECs during stimulated conditions is sensitive to inhibition by 2-methoxycinnamaldehyde and suggest that 2-methoxycinnamaldehyde may reduce COX-2 protein level and activity but not COX-2 mRNA.

Acrolein↗

Antipyretic activity of gingyo-san, a traditional medicine, in influenza virus-infected mice.

Gingyo-san is composed of 10 crude drugs and used as a traditional antipyretic medicine for the treatment of the common cold and influenza virus infection. In a murine intranasal influenza infection model, fever produced by the infection has been demonstrated to be reduced by suppressing interferon-induced interleukin (IL)-1 alpha production. Thus, we focused on the serum level of IL-1 alpha which produces such novel antipyretic activity, and evaluated the relationship between defervescence and the suppression of IL-1 alpha production by Gingyo-san in influenza virus-infected mice. Fever was produced in the infected mice 33-44 h after infection. Oral administration of a hot water-extract of Gingyo-san (8.9-12.5 mg/0.25 ml/mouse x 3 per day) significantly reduced fever production and suppressed the rise in IL-1 alpha production to the level in uninfected mice. No apparent toxicity by Gingyo-san was observed in infected mice. When the hot water-extract of each 10 of the crude components of Gingyo-san (an unknown amount extracted from 6.25 mg/0.25 ml/mouse x 3 per day for Saigae Tataricae Cornu and 3.5 mg/0.25 ml/mouse x 3 per day for the other 9) was orally administered to infected mice, 6 showed significant antipyretic activity. Of these 6, Saigae Tatricae Cornu significantly suppressed the rise in IL-1 alpha production to the basal level while the other 5 did not affect serum IL-1 alpha. Thus, of the 10 crude components of Gingyo-san, Saigae Tataricae Cornu simultaneously exhibited antipyretic and IL-1 alpha-regulatory activities. The novel antipyretic action of Gingyo-san may be mainly mediated by Saigae Tataricae Cornu which regulates the elevated serum IL-1 alpha level produced by influenza infection.

Analgesics, Non-Narcotic↗

Preparation of bupleurum nasal spray and evaluation on its safety and efficacy.

Radix Bupleuri is widely used in traditional medicine for the treatment of fever, pain, and inflammation associated with influenza or the common cold. The essential oil extracted from the herb is generally claimed to play the major role in the efficacious treatment of fever. The purpose of the present study was to formulate an intranasal delivery system for the essential oil in an aqueous solution used in the form of nasal spray. From 450 g Radix Bupleuri was extracted the essential oil in the amount of about 0.2 ml, which was slightly water-soluble and viscous with low-fluidity. In order to dissolve the essential oil evenly in the aqueous solution, tween-80 (TW-80, used in 10% (w/v) solution), propylene glycol (PG) and diethylene glycol monoethyl ether (TC) were selected as the favorable solubilizing agents, whose amount was respectively determined by L16(4(5)) orthogonal design. An aqueous solution with clarity and no ciliotoxicity was prepared when TW-80 8% (v/v), PG 14.4% (v/v) and TC 14.4% (v/v) were added. Employed to evaluate the acute toxicity, the rats grew well and were kept active and healthy within 14 d after an intranasal administration of this preparation at the dose of oil from 10 g Bupleuri/kg (50-fold higher than the clinical dose), indicating that there would be no serious toxicity at the normal dose. Intranasal administration of this preparation to 2 kg rabbits with fever induced by subcutaneous injection of turpentine decreased body temperature markedly (0.5, 0.8 and 1.0 degrees C respectively at the dose of oil from 1, 2 and 4 g Bupleuri/body). In addition, the administration significantly reduced fever in 200 g rats induced by intramuscular injection of colicine suspension (0.6 degrees C at the dose of oil from 0.8 g Bupleuri/body). The results suggest that the formulation of nasal spray for the essential oil from Radix Bupleuri can be potentially effective in the treatment of fever.

Administration, Intranasal↗

[The effect of ginger on serotonin induced hypothermia and diarrhea].

One of the important medicinal properties of ginger is known to remove chills caused by common cold and to warm body. In the present study, acetone extract of ginger at 100 mg/kg p.o. significantly inhibited serotonin (5-HT) induced hypothermia. Therefore, the active constituents of ginger were further examined. The acetone extract was functioned into 4 fractions by column chromatography. Fractions 1 and 2 showed significant activity. Fraction 2 was further purified and [6]-shogaol which was obtained from fraction 2-2, at 10 mg/kg p.o. was shown to inhibit 5-HT induced hypothermia. Anticathartic activity is known to be one of the medicinal effects of ginger. In the present study, acetone extract of ginger at 75 mg/kg p.o., significantly inhibited 5-HT induced diarrhea. In order to clarify the active constituents, the acetone extract was fractionated into 4 fractions by silica gel chromatography. Fractions 2 and 3, which was especially effective, were further purified and [6]-shogoal, [6]-dehydrogingerdione, [8]- and [10]-gingerol were found to have an anticathartic action. [6]-Shogaol was more potent than [6]-dehydrogingerdione, [8]- and [10]-gingerol.

Acetone↗

[Pharmacognostical studies on the folk medicine in Sichuan Prov. in China. II. On tu-er-feng derived from Gerbera plants].

Tu-er-feng is one of famous Chinese folk medicines in Sichuan prov. for common cold with cough, rheumatism, etc. Its sources are said to be either whole plants of some Gerbera or Ainsliaea species of family Compositae. In the recent markets, two types of Tu-er-feng are surely available. In this paper, Tu-er-feng derived from Gerbera species are studied to clarify the botanical origin; comparing mainly with the internal morphologies of the leaves and roots of G. piloselloides, G. delavayi, G. nivea, G. anandria (= Leibnitzia anandria) and G. jamesonii. As the result, G. piloselloides is determined as the botanical origin of Tu-er-feng obtained from the recent 16 markets.

Drugs, Chinese Herbal↗

Current perspective on exercise immunology.

By far, the most important finding that has emerged from exercise immunology studies is that positive immune changes take place during each bout of moderate physical activity. Over time, this translates to fewer days of sickness with the common cold and other upper respiratory tract infections. This is consistent with public health guidelines urging individuals to engage in near-daily physical activity of 30 minutes or more. Risk of upper respiratory tract infections can increase when athletes push beyond normal limits. The infection risk is amplified when other factors related to immune function are present, including exposure to novel pathogens during travel, lack of sleep, severe mental stress, malnutrition, or weight loss. Many components of the immune system exhibit adverse change after prolonged, heavy exertion lasting longer than 90 minutes. These immune changes occur in several compartments of the immune system and body (eg, the skin, upper respiratory tract mucosal tissue, lung, blood, and muscle). During this "open window" of impaired immunity (between 3 and 72 hours, depending on the immune measure), viruses and bacteria may gain a foothold, increasing the risk of subclinical and clinical infection. In general, if symptoms are from the neck up, moderate exercise is probably acceptable (and some researchers would argue even beneficial) when an athlete is sick, whereas bed rest and a gradual progression to normal training are recommended when the illness is systemic.

Attitude of Health Personnel↗

Arrhythmogenic right ventricular cardiomyopathy with an initial manifestation of severe left ventricular impairment and normal contraction of the right ventricle.

A case of arrhythmogenic right ventricular cardiomyopathy (ARVC) with an initial manifestation of severe impairment of the left ventricle (LV) and normal contraction of the right ventricle (RV) is presented. A 43-year-old man was admitted to hospital because of congestive heart failure following a common cold. The LV function was diffusely and severely hypokinetic. Coronary arteriogram revealed normal vessels. An endomyocardial biopsy specimen obtained from the RV septum revealed mild infiltration of lymphocytes with focal myocytes necrosis and so healing myocarditis was suspected. The specimen did not include any fatty replacement of myocytes. Since then, the patient suffered from recurrent congestive heart failure as well as nonsustained ventricular tachycardia and required frequent hospitalization. Progressive impairment, dilation, and thinning of both ventricles were observed on serial echocardiographic examinations. Although the RV gradually enlarged and became impaired, severe dilatation and impairment of the LV has always been predominant in the patient's clinical course. After medical follow-up for 10 years, he died suddenly of ventricular fibrillation and pump failure. The autopsy revealed extensive fibrofatty replacement of myocytes in both the ventricles, extending from the outer layer to the inner layer of myocardium in the RV and to the middle layer in the LV. These features were compatible with arrhythmogenic right ventricular cardiomyopathy or perimyocarditis, although only the rightsided bundle of the interventricular septum was completely replaced by fatty tissue, which can not be explained as a sequel of perimyocarditis. Moreover, apoptosis was present in the myocyte nuclei of the myocardial layers bordering the area of fatty replacement. Therefore, myocarditis may have triggered or accelerated the process of apoptosis leading to ARVC.

Adult↗

Effect of d-pseudoephedrine on cough reflex and its mode of action in guinea pigs.

d-Pseudoephedrine (PSE) is one of the main ingredients of Ephedrae herba. Although PSE is widely applied for patients with a common cold and upper respiratory inflammation as a decongestant, the effects of PSE on cough have never been reported. In this study, we investigated the antitussive effects of intraperitoneal injection of PSE on the cough reflex induced by microinjection of citric acid into the larynx of guinea pigs. PSE decreased the number of cough reflexes dose-dependently (-18.3 +/- 5.0% at 20 mg/kg, P<0.05; -41.1 +/- 7.2% at 60 mg/kg, P<0.01). Furthermore, PSE (60 mg/kg) increased the threshold intensity for inducing fictive cough by electrical micro-stimulation of the nucleus tractus solitarius (+72.7 +/- 8.4%, P<0.01). On the afferent discharge of the superior laryngeal nerve, PSE suppressed the increases of amplitude and frequency when stimulated by citric acid at laryngeal mucosa. These results demonstrate that PSE possesses an antitussive effect that might be derived from both central and peripheral actions.

Animals↗

[Angle-closure glaucoma: important points in the diagnosis and follow-up].

A 74-year-old woman visited her local physician complaining of fever, cough, headache, hyperemic left conjunctiva, and blurred vision. She was diagnosed as having common cold and medicated for it, and later, she visited our department. She had a shallow left anterior chamber with moderately dilated pupil. Gonioscopic examination of the left eye revealed a narrow angle corresponding to grade 1 by Shaffer grading system. Left intraocular pressure was 16 mmHg. She was diagnosed to have had a spontaneous recovery from a subacute attack of angle-closure glaucoma. Laser iridectomy was performed and she was put on a regular ophthalmological follow-up. Three years later, she experienced an attack of left angle-closure glaucoma secondary to lens intumescence. She was treated by phacoemulsification and aspitaion which resulted in the eventual cure.

Aged↗

Panel discussion: pathogenesis of otitis media. Bacteriology and immunology.

Three features of otitis media with effusion (OME) are important in understanding its pathogenesis: 1. it is most common among children, when the eustachian tube is poorly developed; 2. it is most common during the winter months, when the common cold is prevalent; and 3. bacteria are found in a large number of middle ear effusions from OME patients. Although middle ear effusions are conventionally thought to be sterile, numerous recent investigations favor a bacterial pathogenesis of OME. Four possibilities can be considered: 1. bacteria are modified by antibiotics or antibodies, causing a lingering inflammation; 2. early antibiotic treatment may interfere with the development of local immunity; 3. bacterial antigen trapped in the middle ear causes immune injury leading to OME; and 4. bacterial endotoxin and inflammatory mediators cause middle ear effusions.

Animals↗

Infectious adult croup.

From January 1980 to December 1987, seven patients with acute inflammatory swelling of the subglottic space were treated. Their ages ranged from 25 to 73 years. Medical history and symptomatology are similar to those characteristic of laryngotracheobronchitis (croup) in the pediatric age groups (i.e., an antecedent common cold followed by a barking cough and varying symptoms of upper airway obstruction). Physical findings before and after treatment were confirmed and documented by anteroposterior radiographs of the neck. Three patients required airway intervention but there were no deaths. To our knowledge there are no previous reports in the English literature describing this entity in adults. The purpose of this presentation was to introduce physicians, in general, and otolaryngologists, in particular, to this potentially serious infection. Our limited experience suggests that the pathogenesis and management of croup in adults are very similar to those in children.

Adult↗

Decline of ambient air pollution levels and improved respiratory health in Swiss children.

The causality of observed associations between air pollution and respiratory health in children is still subject to debate. If reduced air pollution exposure resulted in improved respiratory health of children, this would argue in favor of a causal relation. We investigated whether a rather moderate decline of air pollution levels in the 1990s in Switzerland was associated with a reduction in respiratory symptoms and diseases in school children. In nine Swiss communities, 9,591 children participated in cross-sectional health assessments between 1992 and 2001. Their parents completed identical questionnaires on health status and covariates. We assigned to each child an estimate of regional particles with an aerodynamic diameter < 10 microg/m3 (PM10) and determined change in PM10 since the first survey. Adjusted for socioeconomic, health-related, and indoor factors, declining PM10 was associated in logistic regression models with declining prevalence of chronic cough [odds ratio (OR) per 10-microg/m3 decline = 0.65, 95% confidence interval (CI), 0.54-0.79], bronchitis (OR = 0.66; 95% CI, 0.55-0.80), common cold (OR = 0.78; 95% CI, 0.68-0.89), nocturnal dry cough (OR = 0.70; 95% CI, 0.60-0.83), and conjunctivitis symptoms (OR = 0.81; 95% CI, 0.70-0.95). Changes in prevalence of sneezing during pollen season, asthma, and hay fever were not associated with the PM10 reduction. Our findings show that the reduction of air pollution exposures contributes to improved respiratory health in children. No threshold of adverse effects of PM10 was apparent because we observed the beneficial effects for relatively small changes of rather moderate air pollution levels. Current air pollution levels in Switzerland still exceed limit values of the Swiss Clean Air Act; thus, children's health can be improved further.

Adolescent↗