In pursuit of the unicorn.

This short review was prompted by The Physiological Society's recent online symposium on variability. It does not deal with a specific methodology, but rather with the myth that certain environmentally-induced clinical conditions can be identified, quantified, simplified and monitored with a single methodology. Although this might be possible with some clinical conditions, others resist the prevailing reductionist approach of minimizing rather than exploring variation in pathogenesis and pathology, and will not be understood fully until the variation in cause and effect are embraced. This is likely to require comprehensive methodologies and collaboration.

Hand temperature responses to local cooling after a 10-day confinement to normobaric hypoxia with and without exercise.

The study examined the effects of a 10-day normobaric hypoxic confinement (FiO2: 0.14), with [hypoxic exercise training (HT); n = 8)] or without [hypoxic ambulatory (HA; n = 6)] exercise, on the hand temperature responses during and after local cold stress. Before and after the confinement, subjects immersed their right hand for 30 min in 8 °C water [cold water immersion (CWI)], followed by a 15-min spontaneous rewarming (RW), while breathing either room air (AIR), or a hypoxic gas mixture (HYPO). The hand temperature responses were monitored with thermocouples and infrared thermography. The confinement did not influence the hand temperature responses of the HA group during the AIR and HYPO CWI and the HYPO RW phases; but it impaired the AIR RW response (-1.3 °C; P = 0.05). After the confinement, the hand temperature responses were unaltered in the HT group throughout the AIR trial. However, the average hand temperature was increased during the HYPO CWI (+0.5 °C; P ≤ 0.05) and RW (+2.4 °C; P ≤ 0.001) phases. Accordingly, present findings suggest that prolonged exposure to normobaric hypoxia per se does not alter the hand temperature responses to local cooling; yet, it impairs the normoxic RW response. Conversely, the combined stimuli of continuous hypoxia and exercise enhance the finger cold-induced vasodilatation and hand RW responses, specifically, under hypoxic conditions.

Peak oxygen uptake and regional oxygenation in response to a 10-day confinement to normobaric hypoxia.

We investigated the effect of hypoxic acclimatization per se, without any concomitant influence of strenuous physical activity on muscle and cerebral oxygenation. Eight healthy male subjects participated in a crossover-designed study. In random order, they conducted a 10-day normoxic (CON) and a 10-day hypoxic (EXP) confinement. Pre and post both CON and EXP confinements, subjects conducted two incremental-load cycling exercises to exhaustion; one under normoxic, and the other under hypoxic (F(I)O(2) = 0.154) conditions. Oxygen uptake (V˙O(2)), ventilation (V˙(E)), and relative changes in regional hemoglobin oxygenation (Δ([HbO(2)]) in the cerebral cortex and in the serratus anterior (SA) and vastus lateralis (VL) muscles were measured. No changes were observed in the CON confinement. Peak work rate and V˙O(2peak) were similar pre and post in the EXP confinement, whereas V˙(E) increased in the EXP post normoxic and hypoxic trials (P < 0.05). The exercise-induced drop in VL Δ[HbO(2)] was less in the post- than pre-EXP trial by 4.0 ± 0.4 and 4.2 ± 0.6 µM during normoxic and hypoxic exercise, respectively. No major changes were observed in cerebral or SA oxygenation. These results demonstrate that a 10-day hypoxic exposure without any concomitant physical activity had no effect on normoxic or hypoxic V˙O(2peak), despite the enhanced VL oxygenation.

PlanHab Study: Consequences of combined normobaric hypoxia and bed rest on adenosine kinetics.

Adenosine plays a role in the energy supply of cells and provokes differential, hormone-like functions in circulating cells and various tissues. Its release is importantly regulated by oxygen tension. This renders adenosine and its kinetics interesting to investigate in humans subjected to low oxygen conditions. Especially for space exploration scenarios, hypoxic conditions - together with reduced gravity - represent two foreseen living conditions when planning manned long-duration space missions or planetary habitats. The PlanHab study investigated microgravity through inactivity in bed rest and normobaric hypoxia to examine their independent or combined effect on adenosine and its kinetics. Healthy male subjects (n = 14) completed three 21-day interventions: hypoxic bed rest (HBR); hypoxic ambulatory confinement (HAMB); normoxic bed rest (NBR). The interventions were separated by 4 months. Our hypothesis of a hypoxia-triggered increase in adenosine was confirmed in HAMB but unexpectedly also in NBR. However, the highest adenosine levels were noted following HBR. Furthermore, the percentage of hemolysis was elevated in HBR whereas endothelial integrity markers stayed low in all three interventions. In summary, these data suggest that neocytolysis accounts for these effects while we could reduce evidence for microcirculatory changes.

Human temperature regulation during subanesthetic levels of nitrous oxide-induced narcosis.

The present study investigated whether nitrous oxide (N2O) attenuates shivering thermogenesis during cold water immersion in a dose-dependent manner. Seven male subjects were immersed to the neck for 60 min in 20 degrees C water on five separate occasions while breathing either air (AIR) or a normoxic mixture of 10, 15, 20, or 25% N2O balanced with N2. All N2O concentrations investigated caused a significant (P < 0.02) reduction in shivering thermogenesis compared with AIR. Despite similar heat flux from the skin, the relative changes in esophageal temperature from resting preimmersion levels were significantly greater (P < 0.05) during the N2O trials compared with AIR, with no significant difference among the N2O conditions. A dose-dependent trend in the perception of thermal comfort was observed for the N2O conditions. It is concluded that shivering thermogenesis, and thus thermal balance, is affected to the same degree for the range of inspired N2O concentrations investigated, with no discernable dose-dependent effect.

Determination of esophageal probe insertion length based on standing and sitting height.

The present study derives simple formulas for the prediction of optimal insertion length of an esophageal temperature-sensitive probe from the measurements of either standing or sitting height. The formulas assume that the optimal site for an esophageal temperature probe is in the region of the esophagus bounded by the left ventricle and aorta, corresponding to the level of the eighth and ninth thoracic vertebrae (T8 and T9, respectively). An esophageal probe was constructed of polyethylene tubing containing 1-cm segments of alternating radiopaque and nonradiopaque tubing in the distal 20 cm of the probe. The probe was inserted through a nostril into the esophagus of 20 subjects (12 males and 8 females) of various heights (range 163-194.6 cm) and weights (range 52.2-100.8 kg), and lateral chest radiograms were obtained for determination of the insertion length of the probe (L) required to situate the probe in the retrocardiac esophagus. Analysis of the radiograms demonstrated that, at the level of the intervertebral disc between T8 and T9, the probe was below the tracheal bifurcation and close to the left ventricle. The distance from the nasal flare to this level showed a good correlation with the subject's stretched stature (r2 = 0.71) and sitting height (r2 = 0.86). The following equations were derived to predict the placement of the esophageal probe at the T8/T9 level based on standing height: L (CM) = 0.228 x (standing height) - 0.194, and sitting height: L (cm) = 0.479 x (sitting height) - 4.44.

Estimation of regional cutaneous cold sensitivity by analysis of the gasping response.

Regional cutaneous sensitivity to cooling was assessed in males by separately immersing four discrete skin regions in cold water (15 degrees C) during head-out immersion. The response measured was gasping at the onset of immersion; the gasping response appears to be the result of a nonthermoregulatory neurogenic drive from cutaneous cold receptors. Subjects of similar body proportions wore a neoprene "dry" suit modified to allow exposure to the water of either the arms, upper torso, lower torso, or legs, while keeping the unexposed skin regions thermoneutral. Each subject was immersed to the sternal notch in all four conditions of partial exposure plus one condition of whole body exposure. The five cold water conditions were matched by control immersions in lukewarm (34 degrees C) water, and trials were randomized. The magnitude of the gasping response was determined by mouth occlusion pressure (P0.1). For each subject, P0.1 values for the 1st min of immersion were integrated, and control trial values, although minimal, were subtracted from their cold water counterpart to account for any gasping due to the experimental design. Results were averaged and showed that the highest P0.1 values were elicited from whole body exposure, followed in descending order by exposures of the upper torso, legs, lower torso, and arms. Correction of the P0.1 response for differences in exposed surface area (A) and cooling stimulus (delta T) between regions gave a cold sensitivity index [CSI, P0.1/(A.delta T)] for each region and showed that the index for the upper torso was significantly higher than that for the arms or legs; no significant difference was observed between the indexes for the upper and lower torso.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of occluded venous return on core temperature during cold water immersion.

Recent studies using inanimate and animal models suggest that the afterdrop observed upon rewarming from hypothermia is based entirely on physical laws of heat flow without involvement of the returning cooled blood from the limbs. During the investigation of thermoregulatory responses to cold water immersion (15 degrees C), blood flow to the limbs (minimized by the effects of hydrostatic pressure and vasoconstriction) was occluded in 17 male subjects (age, 29.0 +/- 3.3 yr). Comparisons of rectal (Tre) and esophageal temperature (Tes) responses were made during the 5 min before occlusion, during the 10-min occlusion period, and for 5 min immediately after the release of the cuffs (postocclusion). In the preocclusion phase, Tre and Tes showed similar cooling rates. The occlusion of blood flow to the extremities significantly arrested the cooling of Tes (P less than 0.05) with little effect on Tre. Upon release of the pressure cuffs, the returning extremity blood flow resulted in an increased rate of cooling, that was three times greater at the esophageal site (-0:149 +/- 0.052 vs. -0.050 +/- 0.026 degrees C.min-1). These results suggest that the cooled peripheral circulation, minimized during cold water immersion, may dramatically affect esophageal temperature and the complete neglect of the circulatory component to the afterdrop phenomenon is not warranted.

Human temperature regulation during narcosis induced by inhalation of 30% nitrous oxide.

The study investigated the effect of inhalation of 30% nitrous oxide (N2O) on temperature regulation in humans. Seven male subjects were immersed to the neck in 28 degrees C water on two separate occasions. They exercised at a rate equivalent to 50% of their maximum work rate on an underwater cycle ergometer for 20 min and remained immersed for an additional 100 min after the exercise. In one trial (AIR) the subjects inspired compressed air, and in the other trial (N2O) they inspired a gas mixture containing N2O (20.93% O2-30% N2O-49.07% N2). Sweating, measured at the forehead, and shivering thermogenesis, as reflected by O2 uptake, were monitored throughout the 100-min recovery period. The threshold core temperatures at which sweating was extinguished and shivering was initiated were established relative to resting preexercise levels. Neither the magnitude of the sweating response nor the core threshold at which it was extinguished was significantly affected by the inhalation of N2O. In contrast, shivering thermogenesis was both significantly reduced during the N2O condition and initiated at significantly lower core temperatures [change in esophageal temperature (delta T(es)) = -0.98 +/- 0.33 degrees C and change in rectal temperature (delta T(re)) = -1.26 degrees C] during the N2O than during the AIR condition (delta T(es) = -0.36 +/- 0.31 degrees C and delta T(re) = -0.44 +/- 0.22 degrees C).(ABSTRACT TRUNCATED AT 250 WORDS)

Nitrogen narcosis attenuates shivering thermogenesis.

Thermoregulatory responses of eight healthy subjects (six men and two women) were compared when they were head-out immersed in 15 degrees C water at both 1 and 6 ATA. Both trials were conducted in a hyperbaric chamber. During the immersions, esophageal temperature (T(es)) and skin temperature at two sites (chest and calf) were recorded at minute intervals. Oxygen uptake was determined at 5-min intervals with the Douglas bag method. The order of the two trials was alternated. The rate of T(es) cooling was greater during the 6-ATA trial [2.1 +/- 0.5 degrees C/h (SE)] than during the 1-ATA trial (1.3 +/- 0.5 degrees C/h; P < 0.01). Despite the greater rate of core cooling, and presumably a greater thermal drive for shivering, the oxygen uptake response for a similar decrement in T(es) was lower during exposure to 6 than to 1 ATA (P < 0.05). Also, for similar displacement in T(es), the subjects perceived the immersions at 6 ATA to be less cold than those at 1 ATA (P < 0.05). It is concluded that the development of hypothermia in compressed-air divers may be due, in large part, to the attenuation of heat production and cold perception. Most likely, the observed effects on the autonomic responses and thermal perception are due to an inhibitory action of hyperbaric nitrogen on central neural structures involved in temperature regulation.

Core temperature "null zone".

An experimental protocol was designed to investigate whether human core temperature is regulated at a "set point" or whether there is a neutral zone between the core thresholds for shivering thermogenesis and sweating. Nine male subjects exercised on an underwater cycle ergometer at a work rate equivalent to 50% of their maximum work rate. Throughout an initial 2-min rest period, the 20-min exercise protocol, and the 100-min recovery period, subjects remained immersed to the chin in water maintained at 28 degrees C. On completion of the exercise, the rate of forehead sweating (Esw) decayed from a mean peak value of 7.7 +/- 4.2 (SD) to 0.6 +/- 0.3 g.m-2.min-1, which corresponds to the rate of passive transpiration, at core temperatures of 37.42 +/- 0.29 and 37.39 +/- 0.48 degrees C, as measured in the esophagus (Tes) and rectum (Tre), respectively. Oxygen uptake (VO2) decreased rapidly from an exercising level of 2.11 +/- 0.25 to 0.46 +/- 0.09 l/min within 4 min of the recovery period. Thereafter, VO2 remained stable for approximately 20 min, eventually increased with progressive cooling of the core region, and was elevated above the median resting values determined between 15 and 20 min at Tes = 36.84 +/- 0.38 degrees C and Tre = 36.80 +/- 0.39 degrees C. These results indicate that the core temperatures at which sweating ceases and shivering commences are significantly different (P less than 0.001) regardless of whether core temperature is measured within the esophagus or rectum.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of hypoglycemia on thermoregulatory responses.

The effects of hypoglycemia on sweating, skin blood perfusion, and shivering responses were investigated in 10 healthy male volunteers. They exercised on an underwater cycle ergometer while immersed to the neck in 28 degrees C water for 20 min at 50% of their maximal work rate. The exercise-induced elevation in esophageal temperature (T(es)) initiated the sweating response (Esw) and increased skin blood perfusion (SkBP) as measured at the forehead. In the 99-min postexercise immersion period, the values of T es relative to resting level (delta T(es)) at which Esw abated, SkBP reached preexercise values, and shivering commenced were defined as the delta T(es) thresholds for cessation of sweating, passive vasodilation, and onset of shivering, respectively. Two trials were conducted 1 wk apart. The subject was hypoglycemic in one trial and euglycemic in the other (plasma glucose was maintained at 2.8 and 5 mM, respectively) with the use of the hyperinsulinemic (insulin infusion rate = 60 mU.m-2.min-1) glucose-clamp technique. Oxygen uptake, Esw, T(es), mean skin temperature, heat flux from the skin, and SkBP were recorded at minute intervals. Although heat flux and SkBP attained significantly higher end-exercise levels during euglycemia, the responses were similar during the postexercise cooling period. Hypoglycemia did not affect the Esw response during the exercise and cooling periods. Whereas the exercise delta T(es) response was unaffected by hypoglycemia, the decrease in T(es) was greater (P < or = 0.005) during the hypoglycemic than during the euglycemic condition. Hypoglycemia did not alter the delta T(es) threshold for cessation of sweating and passive vasodilation but reduced (P < or = 0.001) the delta T(es) threshold for onset of shivering (from -0.09 +/- 0.07 degrees C in the euglycemic condition to -0.65 +/- 0.12 degrees C in the hypoglycemic condition). The present results indicate that hypoglycemia (2.8 mM) does not affect the delta T(es) threshold for cessation of thermoregulatory sweating or the threshold for passive vasodilation during recovery from exercise-induced moderate heat stress but that it decreases the core temperature threshold for shivering during cold exposure.

Treatment of mild immersion hypothermia by direct body-to-body contact.

Body-to-body contact is often recommended for rewarming mildly hypothermic victims in the field. This procedure involves a euthermic individual donating heat to the recipient by direct contact in an insulated bag. However, this technique has not been critically evaluated and may not be beneficial because there is limited direct contact between recipient and donor, peripheral vasoconstriction may impair heat transfer to the core, skin warming may blunt the recipient's shivering response, and cold stress to the donor may be excessive. The present study was designed to evaluate whether donation of heat by a donor would be sufficient to enhance rewarming of a hypothermic subject (recipient). Six pairs of recipients (5 men, 1 woman) and donors (2 men, 4 women) participated in the study. Esophageal and skin temperatures, cutaneous heat flux, and oxygen consumption were measured. Recipients were immersed in 8 degrees C water until esophageal temperature decreased to a mean of 34.6 +/- 0.7 degrees C (SD). They then were rewarmed by one of three methods: rewarming by the endogenous heat generated by shivering only (SH), body-to-body rewarming (BB), or rewarming with a constant-heat source manikin (MAN). Mean afterdrop for the three conditions was 0.54 +/- 0.2, 0.54 +/- 0.2, and 0.57 +/- 0.2 degrees C for SH, BB, and MAN, respectively (NS), and the rate of rewarming was 2.40 +/- 0.8, 2.46 +/- 1.1 and 2.55 +/- 0.9 degrees C/h for SH, BB, and MAN, respectively (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of core cooling on short and long latency reflex responses.

Subjects were immersed in 10 degrees C water until the rectal temperature dropped to 35 degrees C. Reflexes of wrist flexors were tested before and after cooling with tendon taps and torque motor produced perturbations. Comparison of pre- and post-cooling reflex responses showed that the longer latency reflex (LLR) was delayed in onset more than the short latency monosynaptic reflex (SLR) response. This implies that a portion of the LLR pathway is separate and distinct from the SLR pathway.

Hyperbaric oxygen therapy does not affect recovery from delayed onset muscle soreness.

PURPOSE: This study investigated whether hyperbaric oxygen therapy (HBOT) improves recovery after exercise-induced muscle injury. METHODS: Healthy male subjects (N = 24) were randomly assigned to either a placebo group or a HBOT group. Subjects were tested for maximal isometric strength (preexercise) of their right elbow flexors. Each subject then completed a high-force eccentric workout of the elbow flexor muscle group to induce delayed onset muscle soreness (DOMS). On the seven successive days after this workout, the subjects were exposed to a hyperbaric environment of 2.5 ATA for 60 min, inspiring either a normoxic mixture (P(I)O2 = 0.2 ATA; placebo group) or a hyperoxic gas mixture (P(I)O2 = 2.5 ATA; HBOT group). Before the eccentric workout and daily for the next 10 d, measurements were obtained regarding: maximal isometric muscle strength of the elbow flexor muscles, right upper arm circumferences, and rating of the perceived muscle soreness. RESULTS: Isometric strength decreased significantly from preexercise levels of 25.1 +/- 3.8 kp to postexercise levels of 12.0 +/- 4.6 kp, for the HBOT group, and from 24.6 +/- 3.4 kp to 12.5 +/- 3.7 kp, respectively, for the placebo group. Over the 10-d recovery period, there was no difference in the rate of recovery of muscle strength between the two groups. Perceived soreness peaked at about 48 h after exercise with no difference between groups. Also, the exercise-induced increases in arm circumference were similar in the two groups. CONCLUSIONS: These results indicate that HBOT is not an effective therapy for the treatment of DOMS.

Contribution of core cooling rate to shivering thermogenesis during cold water immersion.

The contribution of core cooling rate to the thermogenic response in humans, for a similar combination of core and peripheral thermal inputs, was studied. Seven male subjects were immersed in 15 degrees C water on two occasions. Trial A was conducted without any intervention. During Trial B extremity blood flow was occluded for 10 min to allow limb blood to cool toward the temperature of the surrounding tissues. Upon release of cuff pressure the cooled, trapped blood returned to the core region instigating a decrease in esophageal temperature (Tes), with a concomitant increase in heat production (H). The slope of the Tes-H relationship during the dynamic post-occlusion phase was defined as central thermosensitivity (beta B). The slope of the Tes-H relationship during Trial A (beta A), evaluated over a similar range of core temperatures but over a longer time period, was compared with beta B to determine the influence of core cooling rate on the thermogenic response. The rate of core cooling (Tes) increased from -0.05 +/- 0.01 degrees C.min-1 in Trial A to -0.23 +/- 0.02 degrees C.min-1 with cuff occlusion-release in Trial B, resulting in a significant increase in beta B when compared to beta A (-2.99 +/- 0.36 vs. -1.90 +/- 0.24 W.kg-1.degrees C-1). Results of this study indicate that during cold water immersion: 1) dynamic core temperature significantly contributes to the magnitude of metabolic heat production; and 2) individual differences exist in central thermosensitivity.

Inhalation rewarming from hypothermia: an evaluation in -20 degrees C simulated field conditions.

The present study evaluates the efficacy of inhaling warm moist air as a method of rewarming from hypothermia in -20 degrees C field conditions. The method of inhalation rewarming is compared to two other methods of rewarming: a) passive rewarming; and b) passive rewarming, with a respiratory heat exchanger designed to minimize respiratory heat loss. Eight male subjects were rendered hypothermic by immersion in 15 degrees C water for 1 h. They were withdrawn from the tank earlier, in the event that their rectal temperature (Tre) decreased to 35 degrees C, or by 1.5 degrees C from the pre-immersion value. Upon completion of the immersion, they were placed in a well-insulated sleeping bag assembly and transferred to a cold room maintained at -20 degrees C for a 2 h rewarming period. They participated in 3 trials: Control-passive rewarming; Heat Treat-inhalation rewarming with the Heat Treat; HME-passive rewarming in conjunction with a respiratory heat and moisture exchanger (HME). During the rewarming period, inspired air temperature was -19.4 +/- 1.1 degrees C in the control trial. In the HME and Heat Treat trials subjects breathed via an oro-nasal mask. The inspired air temperature was +20.5 +/- 1.2 degrees C in the HME and +36.2 +/- 2.9 degrees C in the Heat Treat trial. The post-immersion drop in Tre was significant in all conditions. The reduction in the post-exposure drop in Tre observed with the Heat Treat may be attributed to the minimization of respiratory heat loss, since the magnitude of the reduction was similar to that observed with the HME.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of predictive formulae for determining metabolic rate during cold water immersion.

Five models predicting shivering thermogenesis on the basis of steady state skin and core temperature were evaluated: Hayward et al., Stolwijk and Hardy,; Nadel et al.,; Timbal et al., and Brown and Brengelmann, using the empirical data derived from a cold water immersion study by Morrison et al. A residual analysis indicated that all models generated substantial errors of prediction. The best overall predictors were expressions suggested by Hayward et al., while the predictive equation of Nadel et al. ranked second. Derivation of personal coefficients significantly improved the prediction of all models and a subsequent modification of the standard models, adding temperature derivative terms, further reduced the magnitude of the error. An analysis of the residuals indicated that peripheral and core temperatures should be weighted according to the characteristics of thermosensitive neural structures in these regions.

Determining the rate of body heat storage by incorporating body composition.

The rate of body heat storage (S) is often used as an index of thermal stress. The traditional approach for determining S assumes that the specific heat (Cp) of all body tissues may be averaged to 0.83 kcal X kg-1 X degrees C-1, irrespective of the actual proportion of different tissues in the body. The present theoretical analysis primarily partitions the body into N compartments. However, this analytical approach involves the difficulty of making an exact evaluation of the mass and temperature of multiple compartments. Therefore, by adopting a two-compartment (core and shell) model, the specific heat capacities, mass fractions, and changes in the temperatures of the two compartments are combined, and S is defined as a function of adiposity (= mass fraction of peripheral tissues). Evaluation of a newly developed equation showed close agreement with observations during a series of cold-water immersion trials, and indicated that the new approach seems to adequately predict S as related to body composition.

Temperature and humidity within the clothing microenvironment.

The present study investigates clothing microenvironment conditions that may develop during prolonged exposure of workers to a hot environment. Five subjects were exposed to a linear increase in ambient temperature from 20-40 degrees C over a 90-min period, and then remained at 40 degrees C for an additional 90 min. During the exposures, subjects were clad in four types of helicopter personnel suits (Gore-Tex, Cotton Ventile, Nomex/Insulite, and Nomex/Neoprene), incorporating both dry-suit and wet-suit designs. Continuous assessment was made of skin temperature, rectal temperature, and of microenvironment temperature, relative humidity, and vapor pressure (T mu, RH mu, and VP mu) 8 mm from the surface of the skin. Results indicate that although microenvironment temperatures were similar among suits and slightly lower than that of the environment, the RH mu and VP mu were much greater than those of the ambient air. The Nomex/Insulite and Nomex/Neoprene suits showed the highest VP mu, of which only the Nomex/Insulite resulted in significantly greater increases in rectal temperature, likely due to complete covering of the body with the impermeable insulite component. The present study demonstrates the need to discern between the ambient conditions and the conditions encountered next to the skin when protective clothing is worn.