Biomedical subjects

C Milan

Publications and source records attributed to C Milan.

At least 37 records · Page 2Linked to original sources

PubMed1997

Non-Hodgkin's lymphoma: time trends for incidence and survival in Côte-d'Or, France.

BACKGROUND: A generally reported increased incidence of non-Hodgkin's lymphomas (NHL) and a recent evolution in treatment strategies, as well as several clinical trials suggesting improved survival, have prompted this study to evaluate time trends in incidence and prognosis of NHL. METHOD: NHL recorded by the population-based Registry of Hematopoietic Malignancies in Côte-d'Or (France) were considered over three 4-year periods from 1980 to 1992. A multivariate survival analysis was carried out in terms of both crude and relative survivals. RESULTS: Overall incidence, increased over the 12 years considered, by an average of 6.8% per annum (P < 0.05). Only two cases of AIDS-related NHL were registered during this period. NHL incidence has increased slightly more for males than for females, further widening the gap in incidence between the sexes. In terms of histological grade the increase in incidence was more pronounced for low-grade and high-grade NHL than for intermediate-grade NHL. The overall 5-year relative survival rate was 69.3%. In multivariate relative survival analysis, neither sex, age, period of diagnosis nor place of hospitalization were significant prognostic factors. Only place of residence, with RR 2.2 (1.41-3.42) for people living in rural areas compared to urban areas and histological type, according to the working formulation with RR 3.8 (2.22-6.61) for high-grade tumours compared to low-grade tumours, remained informative for prognosis. CONCLUSIONS: Although incidence of NHL has increased in Côte-d'Or, this trend has remained independent of the AIDS epidemic. Contrary to the findings of clinical trials, the patients' survival in this population-based series has not been shown to have improved over the study period.

Adult↗

PubMed1997

A hospital-based and a population-based stroke registry yield different results: the experience in Dijon, France.

BACKGROUND AND PURPOSE: The aim of this study was to demonstrate the different results obtained from a population-based and a hospital-based stroke study in the same city. METHODS: Between January 1 and December 31, 1993, we collected information on all of the first strokes in the population of the city of Dijon, in conjunction with the Dijon Stroke Registry, collecting the first-ever strokes from patients living in Dijon as well as on all the first strokes in residents and nonresidents of Dijon who were treated at Dijon University Hospital. Demographic details, medical history, vascular risk factors, stroke subtype, as diagnosed by CT scan, and mortality rates were compared between the strokes observed in the population of the city of Dijon among residents as well as nonresidents in Dijon who were treated at Dijon University Hospital. RESULTS: We collected information on 210 strokes observed in the population of Dijon city, 171 Dijon residents and 395 non-Dijon city residents hospitalized at the University Hospital of Dijon. These three groups were quite different. The residents of Dijon treated for stroke at the University Hospital were younger and their incidence of cerebral hemorrhage, cardiac arrhythmia, ischemic heart disease and case fatality rate were higher than those from the Dijon Stroke Registry. CONCLUSIONS: Type of stroke data bank is very important in order to describe cerebrovascular disease. Hospital-based studies tend to include more severe strokes, those occurring in a younger population, and those having a higher mortality. Population-based studies, on the other hand, give a somewhat different picture of stroke.

Age Distribution↗

PubMed1997

Participation in faecal occult blood screening for colorectal cancer in a well defined French population: results of five screening rounds from 1988 to 1996.

OBJECTIVE: To evaluate the influence on compliance of demographic variables and of the way of proposing a faecal occult blood test in a colorectal cancer mass screening programme. SETTING: Well defined population in Burgundy (France). METHODS: From 1988 to 1996 five screening rounds were conducted in people aged 45 to 74 on entering the study. The screening test was provided free of charge by primary care physicians over a four month period, then mailed to non-consultants, followed by a potential reminder letter. The whole population was invited to participate in each screening campaign. RESULTS: During the five successive rounds, compliance was 52.8%, 54.0%, 57.3%, 58.3%, and 56.2%. It was higher in women than in men, in those initially aged 50 to 69 than in the extreme age groups, and in urban than in rural areas. Overall, 68.7% of the invited population completed at least one screening test and 37.2% completed the five rounds. Among those who participated once in a screening campaign, between 79.6% and 87.6% participated in the succeeding ones. Compliance was higher when the test was proposed by GPs (varying between 85.2% and 94.0% according to the screening campaign) than when it was sent by post (varying between 26.0% and 33.7%). CONCLUSION: In France, a participation rate of over 50% can be achieved in colorectal cancer screening by means of a faecal occult blood test. To achieve this, primary care physicians have to play an active part in the programme and the test must be mailed to non-consultants.

Aged↗

PubMed1997

Randomized trial comparing monthly low-dose leucovorin and fluorouracil bolus with bimonthly high-dose leucovorin and fluorouracil bolus plus continuous infusion for advanced colorectal cancer: a French intergroup study.

PURPOSE: This multicenter study compared the therapeutic ratio of a monthly schedule of low-dose leucovorin (LV) and fluorouracil (5-FU) bolus with a bimonthly schedule of high-dose LV and 5-FU bolus plus continuous infusion in patients with advanced colorectal cancer. PATIENTS AND METHODS: Of the 448 patients randomly assigned to treatment, 433 were assessable. Treatment A was a monthly regimen of intravenous (IV) LV 20 mg/m2 plus bolus 5-FU 425 mg/m2 for 5 days every 4 weeks. Treatment B was a bimonthly regimen of IV LV 200 mg/m2 as a 2-hour infusion followed by bolus 5-FU 400 mg/m2 and 22-hour infusion 5-FU 600 mg/m2 for 2 consecutive days every 2 weeks. Therapy was continued until disease progression. Second-line chemotherapy, which included 5-FU continuous infusion, was allowed in both arms. RESULTS: The response rates in 348 patients with measurable lesions were 14.4% (monthly regimen) and 32.6% (bimonthly regimen) (P = .0004). The median progression-free survival times were 22 weeks (monthly regimen) and 27.6 weeks (bimonthly regimen) (P = .0012). The median survival times were 56.8 weeks (monthly regimen) and 62 weeks (bimonthly regimen) (P = .067). Grade 3-4 toxicities occurred in 23.9% of patients in the monthly arm compared with 11.1% of those in the bimonthly arm (P = .0004). Patients in arm A more frequently experienced severe granulocytopenia (7.3% v 1.9%), diarrhea (7.3% v 2.9%), and mucositis (7.3% v 1.9%) than patients in arm B. CONCLUSION: The bimonthly regimen was more effective and less toxic than the monthly regimen and definitely increased the therapeutic ratio. However, there was no evidence of increased survival.

Adult↗

PubMed1996

[Determining factors for adjuvant treatment of breast cancer in the Côte d'Or region 1982-1990. Registry of gynecologic cancers at the Côte d'Or].

In the search for changing medical practices, this population-based study dealt with the breakdown of adjuvant systemic breast cancer treatments from 1982 to 1990. The 1,760 women recorded by the cancer registry of the French Côte d'Or region (241,020 women in 1990) during 1982-1990, who were found to have both a non metastatic breast invasive carcinoma and a no perceptible residual disease after locoregional treatment completion were the subjects of this analysis. Forty percent of the patients received adjuvant treatment: 17% only had chemotherapy, 7% had chemotherapy associated with hormonal therapy and 16% only had hormonal therapy. Chemotherapy was the only adjuvant treatment for the patients under 35 years of age. Hormonal therapy was the main treatment for the patients over 74. For patients from 35 to 74 with a non-inflammatory tumour, the determination of adjuvant treatment was multifactorial. For each modality of adjuvant treatment, the logistic regression model provided an assessment of the contribution of each independant variable to the risk of being treated. This method has focused on period effect after adjustment on the tumor and patient characteristics. Adjuvant treatments were more widely used in the late 1980s than in the early 1980s (OR = 1.9; p = 0.006). On the one hand, the use of chemotherapy-hormonal therapy association remained stable and the use of chemotherapy decreased with a boundary significance (OR = 0.6; p = 0.056); on the other hand, the use of hormonal therapy dramatically increased and was 3.5 times as high for the period 1988-1990 as for the period 1982-1984 (OR = 3.5, p < 0.0001). Comprehensive study of survival trends after breast cancer should take into account the adjuvant systemic treatments and the conditions of their indications to separate their potential beneficial effects from the effects of lead time bias. Necessity of treatment indicator quality control was emphasised.

Adult↗

PubMed1995

Prospective study of prognostic factors in patients with unresected hepatic metastases from colorectal cancer. Fondation Française de Cancérologie Digestive.

Prognostic factors of unresected liver metastases in patients with colorectal cancer are not well established. A total of 544 patients with unresected liver metastases from colorectal cancer were registered in a national survey over a 1-year period and followed until death. Twenty factors were studied in a univariate analysis (log rank test) and 16 influenced survival (P < 0.01). These 16 factors were entered in a multivariate analysis (Cox model) and eight, ranging from the most significant (relative risk of death 1.9) to the less significant (relative risk of death 1.2), independently influenced survival: performance status, alkaline phosphatase level, number of involved liver segments, administration of chemotherapy, presence of extrahepatic metastases, site of the primary tumour, prothrombin time and resection of the primary lesion. Two simple classifications are proposed, taking into account the performance status and the alkaline phosphatase level, or the performance status and the number of involved liver segments.

Aged↗

PubMed1995

Cerebrovascular disease in children under 16 years of age in the city of Dijon, France: a study of incidence and clinical features from 1985 to 1993.

Our motivation for undertaking the present survey was to determine the incidence, the distribution, and the clinical features of ischemic and hemorrhagic strokes in children under 16 years old, in a well-defined population-based study. The survey was carried out on the population of the City of Dijon (150,000 inhibitants) from January 1, 1985 to December 31, 1993, collecting prospectively both in adulthood and in childhood (23,877 resident children). Diagnosis of stroke was established on the basis of clinical features and the mechanism was identified by CT scan from 1985 to 1987, and by CT scan and magnetic resonance imaging from 1987 to 1993. When a hemorrhagic stroke was identified, a cerebral arteriogram and an investigation of the coagulation factors were performed. When an ischemic stroke was identified, the following were performed: an ultrasound examination of the cervical arteries, a cerebral arteriogram, a lumbar puncture, an investigation of the coagulation factors and lipid status, a measurement of homocysteine in the plasma and the urine, an electrocardiogram (EKG), a Holter procedure, and a cardiac echography. During the 9 full calendar years of this study we observed 28 stroke patients from a population of 23,877 resident children. There were 17 cases of ischemic stroke, representing some 61% percent of the total, as well as 11 cases of hemorrhagic stroke, 39% percent of the total. The average annual incidence rate was 13.02/100,000 for all strokes, 7.91/100,000 for ischemic strokes, and 5.11/100,000 for hemorrhagic strokes.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1995

A proposal for a new approach to intergroup cancer trials.

Currently, North American intergroup trials are conducted according to the Intergroup Guidelines, which require that a lead group take responsibility for data management. Intergroup studies conducted in this manner have been very successful in rapidly accruing large numbers of patients to trials addressing significant questions, but it has been difficult for group statistical centres to cope with the resultant peaks in data flow. Our groups recently succeeded in combining the data from three independently designed and conducted trials to carry out a planned pooled analysis. This experience has led us to employ the same approach to data management in designing a forthcoming intergroup trial. We will use a common protocol and capture the same data elements on our forms, but each group will be responsible for the collection and quality control of its own data. A common data set will be created and updated periodically during the study, and will be used for the final analysis. We suggest that this model has advantages over the current approach to data management on intergroup trials, but still retains the features which distinguish an intergroup study from meta-analysis.

Clinical Trials as Topic↗

PubMed1994

Use of the multiple-day weighed record for Senegalese children during the weaning period: a case of the "instrument effect".

In West Africa, the multiple-day weighed record is the most widely used technique for measuring children's food intakes. The children's eating behavior might be disrupted by the frequent weighings and the presence of a field-worker in the home. We explored the possibility of such an "instrument effect" in a 7-d food survey of 70 Senegalese children aged 10-13 mo. Energy intakes decreased significantly during the food survey (P < 0.0001). The decrease affected both daytime breast milk intake (8%) and solid food intakes (15%). The children's weight gain also decreased from a presurvey value of 6.9 to 2.1 g.kg-1.wk-1, indicating that their intakes during the food survey were lower than their usual intakes. The food-survey methodology was responsible for this "instrument effect." Policy decision-makers should be aware that data collected with the multiple-day weighed record technique might not reflect African children's usual food intakes.

Africa↗

PubMed1994

Changing pattern of oesophageal cancer incidence in France.

BACKGROUND: Data from several Western countries suggest a rapid increase in the incidence of adenocarcinoma of the oesophagus, as well as variations in the sex ratio and the subsite distribution of oesophageal cancer. Although France has a high incidence rate of oesophageal cancer in males, no information was available on trends in its occurrence. The purpose of this study was to report changes in the pattern of oesophageal cancer incidence in three regions of France. METHODS: Data from the three population-based cancer registries of Calvados, Côte d'Or and Haute-Garonne were used to study time trends of oesophageal cancer by sex, age, subsite and histological type between 1978 and 1987. Annual incidence rates have been standardized by the direct method using the world standard population. To test the trend in cancer incidence, either an exponential curve of the form y = aekt was fitted to the annual incidence rates by means of a regression technique, or incidence rates were compared between two 5-year periods after age standardization by Mantel-Haenszel test. RESULTS: The mean annual variation of oesophageal cancer in males was -2.9% in Calvados (P < 0.05), + 0.5% in Côte d'Or (NS) and + 12.4% in Haute-Garonne (P < 0.05). The corresponding figures in females were + 7.9% (NS), + 19.6% (P < 0.05) and + 50.7% (NS). The significant variations in males (decrease in Calvados and increase in Haute-Garonne) were confined to the oldest age group (> or = 65 years). With regard to subsite, incidence in males increased in Haute-Garonne for the upper and the middle third, while there was a significant decrease in Calvados only for the middle third. For histological type, no increase in adenocarcinoma was noticed in males while there was a slight increase in incidence in females (statistically significant in Calvados). CONCLUSIONS: In France, the incidence of oesophageal cancer has decreased in the high-risk region (Calvados) in males, while there was a slight increase in the three studied regions in females. The important rise in incidence of oesophageal adenocarcinomas observed in some Western countries has yet to be seen in France.

Adenocarcinoma↗

PubMed1994

[Prevalence and prognostic value of transient ischemic complication preceding cerebral infarction].

To evaluate the prevalence, the aetiological profile and the neurological consequences at day 15 of a transient ischaemic attack (TIA) before a cerebral infarction, we undertook survey from 1985 to 1991, on 1,149 cases with cerebral infarction observed on the population of Dijon. On 1,149 cases, 275 (24%) were preceded by a TIA. Fifty seven cases were lacunar infarcts (20.7%) and 218 were cortical infarcts (79.3%). On the aetiological point of view, the group with 275 infarctions preceded by a TIA was statistically different from the group of 874 infarctions without any TIA, with higher blood pressure, cardiac arrhythmia, tobacco abuse and ischaemic cardiac disease history. Only 65 out of 275 infarctions preceded by one TIA (23.6%) had a perfect territorial relationship between the 2 attacks, and 210 out of 275 (76.4%) had no territorial relationship. While the Barthel score at day 15 was similar within the 2 groups, inversely, pseudo-bulbar syndrome was significantly more frequent in the first group. Former TIA does not increase the general handicap resulting from a cerebral infarct, nevertheless it gives rise to a pseudo-bulbar syndrome.

Aged↗

PubMed1994

[Factors determining the choice between mastectomy and conservative treatment in the Côte-d'Or department (France). The Côte-d'Op6 register of gynecological cancers].

The aim of this study is to check, for a defined period and within a geographic area, whether the increased use of breast conserving treatment was related to changes in tumor characteristics, or whether changes in therapeutical practice persisted after adjustment on patients and tumor characteristics. From 1982 to 1990, 1,952 women with invasive carcinomas were registered in the French "departement" of Côte-d'Or. Seventeen hundred and seven non metastatic patients were treated by loco-regional surgery. A breast conserving surgery was performed in 60% of cases. The incidence of this treatment raised from 32% in 1982 to 73% in 1987. In univariate analysis, factors determining the type of tumor excision were: age, hormonal status, tumor size, tumor location, "clinical seriousness", nodal status, multiple tumors, inflammatory tumors, neoadjuvant treatments and year of diagnosis. Age and tumoral factors remained significant in a logistic regression analysis. Other factors being constant, the odds ratios of mastectomy was 12.9 times lower in 1987-1990 than in 1982, and 2.1 times lower than in 1985-1986, showing a "period effect". Ninety four percent of patients treated by breast conserving surgery were irradiated post operatively, showing that the clinical research recommendations were well transferred to the clinical practice in this department.

Adult↗

PubMed1994

[Cancers of the corpus uteri on the Côte-d'Or 1982-1990. Incidence, clinical stage and survival].

In the French administrative "departement" of Côte-d'Or, between 1982 and 1990, the crude incidence rate and the age-adjusted world standardised incidence rate (ASR) for corpus uteri cancer were respectively 16.0 +/- 0.8 and 10.7 +/- 0.6 per 100,000 women per year. The incidence increased after 50 years of age, reaching a maximum of 66.7 per 100,000 women per year at the age of 70-74 and thereafter declined. Ninety-six percent of the patients were older than 50. The 5- and 10-year crude survival rates (all histologic types) were 66 +/- 3% and 61 +/- 4%. The 5- and 10-year relative survival rates were 76%. Histologic types were specified in 99.7% of cases, categorized as follows: 92.7% carcinomas (333 cases), 6.7% sarcomas (24 cases) and 0.3% lymphoma (one case). Carcinomas were clinically evaluated according to FIGO staging: stage I: 61.4% (205 cases); stage II: 7.7% (59 cases); stage III: 7.8% (26 cases); stage IV: 6.6% (22 cases) and unspecified stage: 6.6% (22 cases). The ASR by stage, were 6.4 +/- 0.5 (stage I); 0.8 +/- 0.2 (stage II); 1.3 +/- 0.2 (stages III and IV); 0.6 +/- 0.2 (unspecified stage). The 5-year relative survival rates related to FIGO stage were 90% (stage I); 85% (stage II); 25% (stage III) and 0% (stage IV). Elderly patients (> 75) had significantly lower survival rates. With respect to localized disease (stages I and II) the relative risk of death associated with age older than 75 was 4.9. The 5-year relative survival rate of patients with sarcoma was 37%.

Adult↗

PubMed1994

[Risk of locoregional recurrence after resection of cancer of the rectum].

Using the Registre des Tumeurs Digestives of the Côte-d'Or, a survey was conducted to study the risk of local recurrence of patients after curative surgery for rectum cancer diagnosed between 1976 and 1984 in the above mentioned department. Data was available in May 1987 for 448 patients, or 95% of the recorded cases. The cumulative local recurrence rate was 5.9% at 1 year, 19.1% at 3 years and 24.4% at 5 years. It was independent of sex, age, site of the cancer, time of diagnosis and length of distal margin (for cancers treated by anterior resection). On the other hand, the risk of local recurrence varied with macroscopic appearance (distinguishing fungating cancers from other macroscopic types), size (less than 6 cm on more than 6 cm), extension into the bowel wall (cancer limited or not to the wall) and degree of node invasion (no node involvement, 1 or 2 invaded nodes, more than 2 invaded nodes). The results of Cox model indicate that these 4 variables independently influence the risk of local recurrence. These data, which are interesting because of having been collected from a general population, are useful in planning therapeutic trials and in specifying postoperative surveillance methods. They suggest that, independently of extension into the bowel wall and node involvement, the macroscopic appearance and size of the cancer influence the risk of local recurrence.

Aged↗

PubMed1994

The 24-hour recall for Senegalese weanlings: a validation exercise.

OBJECTIVE: In Africa, where growth retardation is highly prevalent, the use of expensive and time-consuming diet assessment techniques is a major obstacle to the collection of dietary data on large samples of children. The 24-h recall could be a valuable alternative. Its validity and reproducibility were assessed by comparison with the precise weighing technique. DESIGN & SUBJECTS: Intakes of complementary foods of 45 Senegalese weanlings, aged 11-18 months, were estimated with both techniques on the same days. RESULTS: There was neither a level-dependent nor a systematic bias with the 24-h recall for energy and macronutrient intakes. Mean differences between techniques were < 11% of mean intakes. Rank order correlations (r) ranged from 0.60 to 0.81 for energy and macronutrients. However, the analysis by food group showed that the 24-h recall was less precise than the reference, especially for foods from the household common pot (r ranged from 0.31 to 0.61 for rice, oil and fish). In particular, measuring rice intake as a number of 'handfuls' was not satisfactory. The technique needs further improvement for these foods. CONCLUSION: Since it provides unbiased estimates of weanlings' intakes, the 24-h recall can be used for diet surveys of groups of children. Its lack of precision, which could cause attenuation in epidemiological studies, can be compensated by increasing the number of days of survey. This study suggests that a precision equivalent to that of a 1-day weighed survey could be obtained with two 24-h recalls, at a considerably lower cost.

Bias↗

PubMed1993

Influence of socioeconomic status on prognosis of colorectal cancer. A population-based study in Côte D'Or, France.

BACKGROUND: The prognostic significance of the socioeconomic status of patients treated for colorectal cancer, although stated in some studies, remains controversial. METHODS: The authors studied a population-based series of 771 patients with colorectal cancer diagnosed in Cote D'Or, France, between January 1976 and December 1980. Survival was studied for the first 5 years after diagnosis. The relationship between socioeconomic status, assessed by comfort of housing, and the main clinical prognostic factors was examined. The influence of comfort of housing on prognosis was studied with the Cox model, while controlling for these factors. Interactions between type of housing and other prognostic factors also were tested. RESULTS: Compared with patients living in a comfortable house, patients in the medium or no-comfort categories were more likely to receive diagnosis at an advanced stage (P = 0.03) and be treated by palliative therapy (P = 0.0005). After adjustment for these factors and age, sex, place of residence, and tumor site, patients living in no comfort had a twofold higher risk of dying during the follow-up period compared with patients living in comfortable housing, with the relative risk being 1.5 for the medium comfort category (95% confidence intervals, 1.3-3.2 and 1.2-1.7, respectively). This effect was more remarkable in patients with early-stage tumors than in patients with advanced tumors. CONCLUSIONS: Such findings should prompt public health measures for earlier access to care structures for people in a lower social class and research for a better understanding of the host-tumor relationship.

Age Factors↗

PubMed1993

Plasma lipoproteins in cortical infarction versus transient ischaemic attacks: a case control study.

The authors investigated the relationship between plasma lipids and the risk for cortical infarction (61 cases) and transient ischaemic attacks (TIA) (35 cases) compared with matched controls. They observed a maximal increase of total cholesterol, of very low-density lipoprotein and low-density lipoprotein (LDL), triglycerides, total apolipoprotein (Apo), B,LDL-Apo B and Apo-A1, and small size high-density lipoprotein (HDL) and large size HDL whose separation was not possible. In contrast they observed a decrease of HDL-ApoE, a distribution of LDL in a single fraction and the presence of LDL of low weight in the group with cortical infarction with or without cardiac arrhythmias. For the first time, we describe a decrease of the HDL-ApoE/total ApoE ratio. TIA differed from the former group by a low level of HDL and the lack of abnormalities of Apo-A1, distribution of small and large size HDL, and in the distribution and the weight of LDL. These data suggest that previously demonstrated differences in LDL-cholesterol and HDL-cholesterol levels between patients with ischaemic stroke and control subjects may apply to patients with cortical infarction, and that in TIA there are changes in the distribution and the weight of LDL.

Aged↗

PubMed1993

The energetic cost of some daily activities: a comparison in a young and old population.

We compared the energetic costs of some daily activities in two groups, 10 young people (24.3 +/- 2.8 years) and 10 old people (74.4 +/- 2.2 years): rising and sitting back down on a seat, getting up from and lying down on a bed and getting up from the floor. We measured the oxygen consumption and the time necessary for the activities. The results showed a noteworthy economical energetic procedure when rising and sitting back down on a seat among the older group. The values of the energy expenditure were respectively 3.9 +/- 1.3 cal/kg in the older group and 5.8 +/- 1.6 in the younger one with a standard seat (45 cm) and 2.7 +/- 1.2 vs 5.2 +/- 1.5 with a raised seat (60 cm). The activities did not vary significantly in time in the two age groups. This procedure could be understood as an adaptation of the energy expenditure to the reduced aerobic capacity with ageing. Conversely, getting up from and lying down on the floor or a standard hospital bed involved the same energy expenditure in the older and younger group, but performing these activities took significantly longer for the older people (+60% for getting up from the floor, +33% from the bed). As these activities revealed no economical energetic procedure in the older group, they appeared responsible for a strong factor of dependence. The importance of a learning process particularly for the most usual movements in everyday life is discussed.

Activities of Daily Living↗