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Events and Competitions - Student Poster Sessions
1998 Poster Session

Abstract 1 Compliance and Side Effects in an Antenatal Iron Supplementation Trial in Ekwendeni , Malawi
The Relation Between Newborn Hemoglobin F and Risk Factors for Sudden Infant Death Syndrome (SIDS)
Validation of Syndromic Case Management of Reproductive Tract Infections (RTIs) Among Pregnant Women in Jamaica
Understanding News Media Coverage of Managed Care Ethics
The Feeding, Binding, And Rapid Screeing of Recombinant Human Antibodies Which Bind and Disrupt the Midguts of Disease Vectors and Pesters, Using the Malaria Vector Mosquito Anopheles Gambiae as a Mode
Parent and Adolescent Perspectives on Psychological Impact of Diabetes Mellitus Type I on Daily Life
The Sociocultural Aspects of AIDS: A Study of Women in Siaya, Kenya
Towards a Model of Organizational Effectiveness: A Multiple Case Study of Anti-Hunger Advocacy Organizations
The Effect of Active and Passive Cigarette Smoking on the Occurance of Breast Cancer
Antmycobacterial Activity of Cerulenin and its effects of Lipid Biosynthesis
The Protection of Public Health, Safety, and Welfare by Identification and Regulation of Dangerous Procedures
Cervicography Screening for Cervical Cancer Among 8,460 Women in a High-Risk Population
Detection of Polio Virus in Environmental Samples Utilizing One-Step Reverse Transcriptase-PCR
The Descriptive Epidemiology of a Nationwide Outbreak of Dermatologic Adverse Effects
Coordination of Lower-Extremity Segments: Implications for the Control of Artificial Limbs

Abstract 1

Compliance and Side Effects in an Antenatal Iron Supplementation Trial in Ekwendeni , Malawi

Emily A. Bobrow , MPH. Emory University
Other Authors: MW Young, F van der Haar

A prospective, randomized trial to compare weekly with daily iron supplementation in pregnant women was conducted in rural Malawi , April-Sept., 1997. A total of 413 women were stratified into non-anemic (Hb 110g/L), mildly anemic (100-109g/L), moderately anemic (70-99g/L) groups. The women were randomly assigned to self-administer either a weekly dose (n=202) of 120mg iron sulfate+0.50 mg folate, or a daily dose (n=211) of 60mg iron sulfate+0.25mg folate. Towards the end of the study, a subsample of women (weekly n=97,daily n=99) were interviewed concerning compliance and side effects. Compliance as measured by pill count was significantly (p<0.001) higher in the weekly group with 2.6% pills left, as compared to 5.2% in the daily group. The incidence of taking all the pills also was higher (p=0.02) in the weekly than in the daily group; 97% vs. 88%. Although no difference in compliance was'found by fecal iron testing in a subsample of women (n=102), more anemic women in the weekly regimen, 76% vs. 45% in the daily group, were compliant (p=0.015). The percentage of women reporting side effects did not differ between the groups, 30% and 28% in the weekly and daily groups, respectively. The hemoglobin responses, (weekly 1.0ñ13.5g/L, daily 1.8ñ14.0g/L), did not differ significantly between groups, irrespective of anemia classification. In pregnant women in rural Malawi , a weekly iron supplement regimen, as compared to a daily supplement, induced better compliance with a similar hematological response and an equal frequency and variety of side effects.

Abstract 2

The Relation Between Newborn Hemoglobin F and Risk Factors for Sudden Infant Death Syndrome (SIDS)

Diana L. Cochran, BSMT, MHS, DrPH, Oklahoma University

Studies have reported higher hemoglobin F (HbF) fractions in infants dying of sudden infant death syndrome(SIDS)compared to age-matched, deceased and living non-SIDS infants. Persistent elevations of HbF may increase the risk of SIDS by reducing the amount of oxygen available to the infant during periods of relative hypoxia. This cross-sectional study examined the associations between newborn HbF fractions and risk factors for SIDS in 633 infants born at Via-Christi Regional Medical Center , Wichita , KS from February 28 - August 5, 1997. HbF was measured from cord blood samples using high performance liquid chromatography methodology. Data on prenatal SIDS risk factors were collected from medical records. Mean HbF fractions were statistically significantly higher in infants with the following SIDS risk factors: maternal smoking, (p=.0313) , intrauterine growth -retardation (IUGR) , (p=.0001) pregnancy weight gain greater than 20 lbs., (p= .0018),and pregnancy complications defined as pre-eclampsia, eclampsia, placental abruption or previa, (p=.0276) . An elevated HbF fraction, defined as > 77% was significantly associated with maternal smoking, (OR=1.77, 95% CI=l.09, 2.87) maternal anemia, (OR=1.78, 35% CI=1.08, 2.91), IUGR, (OR=3.56, 95% CI=1.62, 7.82), and pregnancy complications (OR= 3.15, 952. CI=1.48, 9.48). This study gives insight into the possible role of HbF in the etiology of SIDS by demonstrating higher fractions in newborns exposed to SIDS risk factors that are markers for maternal or fetal hypoxia during pregnancy.

Abstract 3

Validation of Syndromie Case Management of Reproductive Tract Infections (RTIs) Among Pregnant Women in Jamaica

Gelen R. Del Rosario, DrPH, University of Alabama
Other Authors: P. Kamara, S. Kristensen, T. Hylton-Kong, H. Weiss, P. Jolly and S.H. Vermund.

RTIs are a major cause of prenatal morbidity and mortality. Syndromic case management is a low technology approach for managing RTIs in developing countries, but its utility, is unknown. In four prenatal clinics in Kingston , 269 pregnant women were assessed for RTI by trained nurses and physicians using VIHO revised syndromic algorithms. Laboratory samples were collected simultaneously as the "gold standard." Bacterial vagninosis (BV) was seen 6.9% (n=18) of pregnant women. The revised WHO algorithm detected only 1l %(2) of BV and falsely identified 100%(27) with BV. Among 48 (18%) women with laboratory documented trichomonas, only 35%(17) were suggested by the algorithm and 26% (67) of the pregnant women were falsely identified to have trichomonas by the WHO method. Candidiasis was noted in 31% (79). The algorithm identified only 240% (19) and 130% (34) were falsely identified to have candidiasis. Gonorrhea or chlamydia were noted in 21% (54) of the women. The algorithm identified 67% (36) and 30% (77) were erroneously classified with gonorrhea or chiamydia. Syndromic RTI approaches were inefficient among pregnant women in Jamaica ; both sensitivity and specificity were too low to justify its use in pregnancy screening.

Abstract 4

Understanding News Media Coverage of Managed Care Ethics

Michael Fagen, MPH, University of Illinois at Chicago

As the managed care model for health care delivery has become more prominent, questions regarding the ethics of managed care have arisen. The scholarly literature identifies five major ethical issues in the managed care model: rationing of health care, effects on the doctor-patient relationship, the role of managed care in health care reform, profit-making, by managed care companies, and the bureaucratic nature of managed health care delivery. For the majority of Americans, however, it is probable that their introduction to managed care ethics has come through the mass media. In an effort to understand the media perspective on managed care ethics, forty recent Los Angeles Times newspaper articles were analyzed. The Times was chosen since California has the largest population of managed health care consumers in the U.S. , and should be a predictor of the evolving national experience. The analysis revealed that each article dealt with one or more of the five broad themes related to managed care ethics identified in the scholarly literature, while emphasizing conflict between health care consumers and their managed care insurers. Furthermore, the articles spoke primarily from the consumer's viewpoint, and exhibited both a public-centered and operative-centered approach to news framing. These frames were predicted by the literature on news media behavior, highlighting the opportunity for media advocates to influence coverage of managed care ethics. The analysis concludes by urging health care consumers to critically assess media coverage of managed care ethics while adding their voice to the debate regarding the proper organization of the health care system.

Abstract 5

The Feeding, Binding, and Rapid Screening of Recombinant Human Antibodies Which Bind and Disrupt the Midguts of Disease Vectors and Pests, Using the Malaria Vector Mosquito Anopheles Gambiae as a Model

Brian D. Foy, BS, Tulane University
Other Authors: Gerry F. Killeen and John C. Beier, Department of Molecular and Cellular Biology and the Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine

The worldwide impact that insects and other arthropods have directly on human health, as well as food supplies and livestock is enormous; for malaria alone, an estimated 300-500 million people are infected each year. The midgut of disease vectors and pests is the organ for bloodmeal and food digestion, and it also serves as the primary site of pathogen infection into the vector. We demonstrate a system for the rapid screening of expression libraries to isolate specific proteins which either kill the vector/pest or prevent pathogen transmission to the vector. In our model, we have panned a library of phage-displayed, recombinant human antibodies (scFv) on An.gambiae midguts and demonstrate both the ability to feed scFv to mosquitoes in their bloodmeal, as well as scFv binding to their target antigens within the vector. To rapidly screen these scFv for anti-vector activity, we employ a novel strategy in which a particular scFv clone is fed in the same mixture with its own parent bacteria. This strategy enables rapid determination and isolation of the particular bioactive clone on which a dead mosquito fed, by isolating the specific scFv-gene-harboring bacteria from their midguts. The molecular targets of scFv or other expression library molecules used in this system could be important immunogens for development into both human and veterinary anti-vector or transmission-blocking vaccines. Additionally, these bioactive molecules themselves could be used to create transgenic pest-resistant crops.

Abstract 6

Parent and Adolescent Perspectivies on Psychological Impacts of Diabetes Mellitus Type I on Daily Life 

Johanne Harvey, MD, University of Minnesota
Other Authors: Darryl Ross Goetz, LP, PhD, University of Minnesota

A survey of parents and adolescents at the Multidisciplinary Pediatric Diabetes Clinic, University of Minnesota , was conducted to assess the perceived psychological impact of diabetes on adolescent daily life, both from the parent and the adolescent perspective. Parents of adolescent with diabetes and adolescents pabents were invited to complete the survey. Twenty-six parents of adolescents and 21 adolescents participated. A Likert- type scale 1 (strongly agree) to 5 (strongly disagree) was used for questions pertaining to how diabetes affects: mood, family, friends, school work and youth activities. Another set of questions examined the most frequently endorsed concems and needs for education related to diabetes that adolescents and their parents ranked a multiple choices. Frequencies, Student's t-test and Fisher's Exact Test were utilized.

A significantly greater proportion of adolescents than parents indicated diabetes had an impact on friendship, family relationship and school work. The top three concerns for parents were future diabetes complications (50%), now their child felt about themselves (50%) and if child remember to take insulin (43.8%). For adolescents, the three top concerns were remembering to take insulin (66.7%), academic and school work (58.3%) and how they felt about themselves (41.7%). Fisher's exact test revealed a significantly greater proportion of youth concerned about school work than parents among their three top concerns (p=0.0015). The top three needs for education for parents were related to management of diabetes during illness (46.7%, p=0.010 Fisher's exact), complications of diabetes (46.7%) and how to live well with diabetes (40.0%). For adolescents, hypoglycemia education (p=0.032, Fisher's Exact) and how to live well with diabetes were equally nominated (45.5%). Diabetes ketoacidosis and complications of diabetes were both identified 36.6% of the time. Those findings highlight important elements for multidisciplinary assessment and understanding regarding the psychological impact of diabetes on the lives of adolescents. More effective anticipatory guidance to adolescents and adults can be done to healthly transition to self-management and independence.

Abstract 7

The Sociocultural Aspects of AIDS: A Study of Women in Siaya, Kenya

M. Helaine Hatter, MPH, University of California at Los Angeles School of Public Health, African Areas Studies

Transmission of HIV/AIDS is rampant in the Siaya district in Western Kenya . The 1996 reported prevalence of AIDS in Siaya was 29%. Since women have the highest reported prevalence rate of AIDS in Siaya, two focus groups were conducted with women ages 15-25 and 26 and over. Three trained, Luo speaking, moderators administered a questionnare and conducted the focus group discussions (in September 1997) that addressed knowledge, attitudes and practices about IHV/AIDS and cultural practices. In general, participants were fanuliar with HIV infection and AIDS and considered these conditions leading health problems in Siaya. Although participants were fairly knowledgeable in the causes of AIDS, modes of transmission and preventive measures, very few practiced preventive behaviors. In addition. many of the respondents believed in a cultural disease called "CHIRA", which is acquired by breaking cultural traditions. Many of the respondents believed that the results and physical symptoms of CHIRA are very similar to AIDS and it is hard to distinguish the difference between the two. Many participants believed that CHIRA can be treated by a traditional healer and people actually get better however AIDS cannot. In addition. many of the participants believed that many people suspected of having AIDS may deny that they have the disease, and believe that they have CHIRA--which is treatable by traditional healers. Participants also mentioned practicing many cultural traditions, such as polygamy, wife- inheritance, having little control over abstinence or condom use as well as being victims of male dominance. All of these factors make Siayans, especially women more vulnerable to AIDS. Many of the women suggested that some of the Luo cultural practices and traditions should be changed in order tn decrease the disease AIDS. Marriage is a major risk factor for AIDS.

Abstract 8

Towards a Model of Organizational Effectiveness: A Multiple Case Study of Anti-Hunger Advocacy Organizations  

Barbara A. Laraia, RD, MPH, Department of Nutrition, University of North Carolina at Chapel Hill

Domestic hunger has been an increasing concern since social welfare program decreases in the early 1980s. The USDA's first national estimates of hunger, based on previously validated survey items, revealed in 1997 that almost 12 million households in the United States are food insecure. Over 100 state and local anti-hunger advocacy organizations and their partners work at the local level to combat food insecurity and hunger. Their efforts include direct services, public education and policy change. In the climate of devolution and decentralization states are receiving greater responsibility to solve social welfare issues but with limited resources. As governmental and other resources diminish, it is important that advocacy groups work effectively and efficiently. In order to focus on the strategic efforts at the local level that influence state and local food policy a multiple case study was performed. Working with the Food Research and Action Center (FRAC), a national anti-hunger advocacy organization, four diverse, successful state anti-hunger advocacy organizations were selected based on Patton's maximum variation purposeful sample selection criteria. Date collection precedures include document review, key informant interviews and participant observation. Data analysis using Non-numerical Unstructured Data Indexing Searching (NUD*IST) software was conducted using grounded theory methods.

Organizational structures, decision-making and selection of strategies and tactics, and outcomes of four widely diverse state anti-hunger advocacy organizations are reviewed. Coalition building with emergency food programs, mechanisms to engage people with low incomes, public education campaigns, policy analysis and lobbying were strategies common to the organizations. A merging of the anti-hunger advocacy and community food security coalition movement is described and implications are discussed. A model organizational effectiveness based on this case study will be presented.

Abstract 9

The Effect of Active and Passive Cigarette Smoking on the Occurrence of Breast Cancer

Timothy L. Lash, MPH, Boston University

Exposure to tobacco smoke has not been thought to cause breast cancer. Novel perspectives on measuring the effect of tobacco smoke on the occurrence of breast cancer and studies of genetically susceptible populations argue for further investigation. The author studies female residents of five Massachusetts towns between 1983 and 1986 with case-control design. Exposure conditions were defined to correspond with a model of breast tissue susceptibility at stages of breast tissue development. Ever-active smokers had a relative risk of 2.0 (95 percent CI 1.1-3.6) compared to never-active, never-passive smokers. Women who smoked only before their first pregnancy (RR of 4.4; 95 percent CI 1.2-16) and women who quit smoking 5 to 15 years before their index year (RR of 3.9; 95 percent CI 1.4-10) were at the highest risk. Passive-only had a relative risk of 2.0 (95 percent CI 1.1-3.7) compared to never-active, never-passive smokers. Women exposed to passive smoke before age 12 years had a relative risk of 4.5 (95 percent CI 1.2-16) among passive-only smokers and 7.5 (95 percent CI 1.6-3.6) among ever-active smokers. Women first exposed to passive smoke after age 12 had lower, though still elevated, relative risks. The pattern of associations between exposure to cigarette smoke and breast cancer occurrence comports with a model of breast carcinogenesis.

Abstract 10

Antmycobacterial Activity of Cerulenin and its Effects of Lipid Biosynthesis

Nikki M. Parrish, BA, MHS (parrish.gif; 200x147)
Johns Hopkins University School of Hygiene and Public Health
Other Authors: Francis P. Kuhajda, Henry S. Heine, William R. Bishai, James D. Dick, Johns Hopkins School of Hygiene and Public Health

Cerulenin is a potent inhibitor of fatty acid synthase (FAS) in a variety of prokaryotic and eukaryotic cells. Using a standardized mycobacterial susceptibility test, we have observed that cerulenin inhibits the growth of several species of mycobacteria including tuberculous species such as Mycobacterium tuberculosis (H37Rv and clinical isolates) and M. bovis BCG (BCG), as well as several non-tuberculous species: M. smegmatis, the M. avium-intracellulare complex (MAC), M. kansasii, and others. All species and strains tested, including multi-drug resistant isolates of M. tuberculosis, were susceptible to ceruienin with minimal inhibitory concentrations ranging from 1.5 to 12.5 gg/ml. Two-dimensional thin-layer chromatography revealed different inhibition patterns of lipid synthesis between tuberculous and non- tuberculous mycobacteria. Cerulenin treatment resulted in a relative increase in phospholipids and mycolic acids in MAC and M. smegmatis, whereas, in cerulenin-treated BCG, phospholipids and mycolic acids diminished relative to controls. In addition, long chain extractable lipids (intermediate in polarity) triglycerides, and glycopeptidolipids decreased with cerulenin treatment in all three species of mycobacteria tested. Qualitative changes in several of these lipid classes indicate inhibition in the synthesis of intermediate and long chain fatty acids. Our results suggest that cerulenin's primary effect may be inhibition of intermediate and long chain lipid synthesis, with little effect on the synthesis of other lipid classes. In addition, the BCG-specific reduction in phospholipids and mycolic acids suggests the presence of a unique cerulenin-sensitive FAS system in tuberculous mycobacteria. Since pathogenic mycobacteria produce novel long chain fatty acids, inhibition of fatty acid synthesis offers a potential target for the development of antimycobacterial drugs.

Abstract 11

The Protection of Public Health, Safety, and Welfare by Identification and Regulation of Dangerous Procedures

Richard W. Rubin, DDS, University of Pittsburgh

This study was designed to help identify procedures within health professions which present a clear potential for harm and present a high relative risk to the public. It was performed in 2 stages over a 6 month period involving over 150 professionals. The first stage was a survey to both lay persons and professionals asking them to list medical procedures which they considered to be dangerous and would therefore require licensing. This information was content analyzed to compile a consensus summary of procedures which was then used in a second survey of health professionals in which they were asked to rate the relative risk of each of the procedures (independent of whether they actually performed the procedure), and the degree to which it was a function of their own daily occupation. Prelimnary indications from the second survey indicate: validation of the initial listing of procedures as being dangerous and in need of licensure; the emerging list of procedures shows a resemblance to the Ontario list of controlled acts (1993); the procedures rated as highest risk include surgery, prescription writing, infant care, and anesthesiology. The session will include final results of the survey, a discussion of methodologies for defining and understanding procedures dangerous to the health, welfare and safety of the public, and the relationship of this information to the regulation and licensure process.

Abstract 12

Cervicography Screening for Cervical Cancer Among 8,460 Women in a High-Risk Population

Diana L. Schneider, BA, MA, Uniformed Services
Other Authors: Rolando Herroro, Concepcion Bratti, Mitchell D. Greenberg, Allan Hildesheim, Iliana Balmaceda, Mar E. Sherman, Michael J. Campion, Jorge Morales, Martha L. Hutchinson, Thomas V. Sedlacek, Attila Lorincz, Laurie Mango, Sholom Wacholder, Mario Alfaro and Mark Schiffman

Cervicography was evaluated as a primary screening method for cervical cancer. Cervicography, a visual screening system, may have important implications in underserved areas where specialized medical and/or laboratory expertise is not available. Cervigrams of 8,460 women were taken upon enrollment into a population-based study of cervical neoplasia. Cervicography results were compared with a referent diagnosis determined by histology and three cytologic tests, conventional cytology, and presence of cancer-associated human papillomavirus types.

Cervicography identified all 11 cancers, whereas cytology missed one. Cervicography yielded sensitivities of 49.3% overall (specificity = 95.0%), 54.6% in women less than age 50, and 26.9% in women 50 or over for detecting either high-grade squamous intraepithelial lesions (HSIL) or cancer. Cytology yielded an overall sensitivity for detecting HSIL or cancer or 77.2% (specificity = 94.2%). Cervicography performed marginally better than cytology for the detection of invasive cervical cancer. Cytology performed better the Cervicography for the detection of HSIL. Cervicography might best be performed in premenopausal women.

Abstract 13

Detection of Polio Virus in Environmental Samples Utilizing One-Step Reverse Transcriptase-PCR

Debra Sellers, BS, MPH, Department of Environmental and Occupational Health, University of South Florida
Other Authors: D. Kazanis and L. Stark, Flordida Department of Health

The Tampa Branch Laboratory of the Department of Health is studying the movement of polio virus in septic tank effluent through unsaturated soil. Traditional methods of detecting poliovirus involve cell-culture, which is expensive and time-consuming. Our one-step, one-tube reverse transcriptase-PCR or RT-PCR method which is a modified technique (C. Chezzi) is more rapid and less-expensive. Poliomyelitis, an RNA virus, requires a reverse transcriptase step to produce cDNA before PCR can amplify and detect the virus. We have modified Chezzi's technique through the use of a Boehringer Mannheim's High Pure Viral RNA extraction kit which is faster and more efficient. Utilizing this method, we have been able to detect the virus from infected tissue culture fluid in traditional media as well as in lysate water. The lysate water samples resemble the environmental samples that the laboratory will be testing in future studies.

Abstract 14

The Descriptive Epidemiology of a Nationwide Outbreak of Dermatologic Adverse Effects

Warren Swee, MPH, George Washington University
Other Author: Kari Klontz, MD, MPH

The use of a commercially marketed hair straightener, over the period of June 1994 to January 1995, resulted in a nationwide outbreak of dermatologic adverse effects and led to 3,146 individual consumer complaints to the US Food and Drug Administration. We performed a survey-based retrospective studv of 454 randomly selected individuals, 23 months after FDA's acquisition of original complaints, in order to assess the quality, severity, frequency, and long-term sequence of adverse effects.

Of 454 respondents, primarily Black females (96%), 95% reported hair breakage, 73% reported hair loss at the scalp, 28% reported burns or blisters on the scalp, and 41% reported hair discoloration (mainly to a greenish tinge). Among those who reported alopecia, hair loss was predominantly patchy (63%) and occurred more frequently in the coronal (63%) and temporal (63%) regions of the scalp. The responses to adverse effects were examined and revealed that 19% of complainants sought medical attention, 6% reported using Rogaine, 47% reported wearing wigs and 41% reported using hair weaves. The two year follow up revealed that only 10% of complainants indicated that their hair had returned to its original quality, 67% reported slower hair growth, 57% reported thinner hair than normal, and 46% reported increasingly brittle hair than normal. Individuals who experienced scalp burns or blisters or hair loss from the scalp were more likely (O.R.=2.7, 95% CI 1.3, 5.5) to experience long-term sequelae than those who did not and persons over 65 years of age had a greater probability of remaining bald than did persons aged 15 to 55 (p < 0.05). The dermatologic outbreak following the use of a hair relaxing agent resulted in significant and severe damage to both the scalp and hair of product users. Furthermore, long-term sequelae suggest potentially life-long damage to hair follicles of the scalp.

At the conclusion of the presentation, the participant should be aware of the catastrophic consequences which have occurred due to a lack of governmental regulation on the production and sales of cosmetics. Cosmetics such as hair relaxers are not benign products; they are potentially caustic agents and require well defined safety regulations.

Abstract 15

Coordination of Lower-Extremity Segments: Implications for the Control of Artificial Limbs

Saunders N. Whittlesey, MS, University of Massachusetts at Amherst
Other Authors: T. Ward, R.E.A. van Emmerick and J. Hamill, Department of Exercise Science, University of Massachusetts at Amherst

This study developed a theoretical basis for the control of prosthetic legs, which due to the severing of leg musculature are primarily controlled by movements of the hips and thighs. Modern prostheses, despite improvements in weight and shock absorption, still afford gait patterns that are conspicuously abnormal and incur a 50% greater energy cost while walking. A number of studies have demonstrated that changes in leg mass can improve amputee walking patterns, but there appears to be no theoretical basis to completely "plain the effects of segment inertial characteristics - mass (m), mass center (d), and moment of inertia (I). Thus, a set of equations were developed to specify the interactions between the hips, diigh, and lower leg. These equations determined that the sensitivity of the lower leg to movements of the hips and thighs was proportional to the ratio md/I. To test this theory, four normal subjects walked with legs weighted in manners that manipulated this parameter. Increases in leg mass decreased walking velocities, consistent with existing literature, but only the condition that increased md altered the subjects' overall gait pattern.





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