Biomedical subjects

Max Bulsara

Publications and source records attributed to Max Bulsara.

At least 19 recordsLinked to original sources

PubMed2006

Constructing indices representing supportiveness of the physical environment for walking using the Rasch measurement model.

BACKGROUND: The objectives of this study were to use the Rasch model to 1) assess the psychometric properties of a physical environmental audit instrument and 2) to develop indices of interrelated environmental attributes that summarize environmental supportiveness for walking. METHODS: A set of items were derived representing two conceptual physical environmental constructs: 1) functional/safety, and; 2) aesthetics. Ad hoc criteria based on point-biserial and Rasch-based fit statistics were used to examine the construct validity and internal reliability of the two constructs. RESULTS: The Rasch-based fit statistics assisted in identifying 12 items that belonged to the functional/safety construct and 4 items that belonged to the aesthetic construct. The reliability of the two constructs were low to moderate (functional/safety r(beta) = 0.19 and aesthetics r(beta) = 0.35). CONCLUSION: Given the vast number of built environmental attributes, a means of developing summary indices is essential. Future studies should assess the reliability and validity of indices that summarize physical environmental characteristics conducive to walking before testing them in predictive models of physical activity. More research examining procedures for measuring the built environment and techniques for analyzing environmental data are needed to guide future research in this area.

Journal Article↗

PubMed2006

Pregnancy after breast cancer: population based study.

OBJECTIVES: To identify women who survived breast cancer and subsequently conceived and to determine the rate of pregnancy (proportion), management, outcome of the cancer, and outcome of the first subsequent pregnancy. DESIGN: Population based descriptive study with cases identified from the Western Australian data linkage system and validated by review of medical charts. Supplementary data obtained from hospital and clinician records. SETTING: Western Australia, 1982-2003. PARTICIPANTS: Women aged <45 with a diagnosis of breast cancer who subsequently conceived. MAIN OUTCOME MEASURES: Pregnancy outcome and rate, survival, time from diagnosis to pregnancy. RESULTS: Sixty two (54%) women with a diagnosis of breast cancer who subsequently conceived did so less than two years after their diagnosis: 29 of them had an abortion, 27 had a live birth, and six miscarried. Within a proportional hazards regression model subsequent pregnancy was associated with improved overall survival (hazard ratio 0.59, 95% confidence interval 0.37 to 0.95). When the model was stratified by time from diagnosis subsequent pregnancy was associated with improved overall survival in women who waited at least 24 months to conceive (0.48, 0.27 to 0.83) and a non-significant protective effect was seen for women who waited at least six months to become pregnant. CONCLUSIONS: Our study does not support the current medical advice given to premenopausal women with a diagnosis of with breast cancer to wait two years before attempting to conceive. This recommendation may be valid for women who are receiving treatment or have systemic disease at diagnosis, but for women with localised disease early conception, six months after completing their treatment, is unlikely to reduce survival.

Adolescent↗

PubMed2006

Increasing body mass index z-score is continuously associated with complications of overweight in children, even in the healthy weight range.

CONTEXT: Overweight/obesity in children is increasing. Incidence data for medical complications use arbitrary cutoff values for categories of overweight and obesity. Continuous relationships are seldom reported. OBJECTIVES: The objective of this study is to report relationships of child body mass index (BMI) z-score as a continuous variable with the medical complications of overweight. DESIGN: This study is a part of the larger, prospective cohort Growth and Development Study. SETTING: Children were recruited from the community through randomly selected primary schools. Overweight children seeking treatment were recruited through tertiary centers. PARTICIPANTS: Children aged 6-13 yr were community-recruited normal weight (n = 73), community-recruited overweight (n = 53), and overweight treatment-seeking (n = 51). Medical history, family history, and symptoms of complications of overweight were collected by interview, and physical examination was performed. Investigations included oral glucose tolerance tests, fasting lipids, and liver function tests. MAIN OUTCOME MEASURE: Adjusted regression was used to model each complication of obesity with age- and sex-specific child BMI z-scores entered as a continuous dependent variable. RESULTS: Adjusted logistic regression showed the proportion of children with musculoskeletal pain, obstructive sleep apnea symptoms, headaches, depression, anxiety, bullying, and acanthosis nigricans increased with child BMI z-score. Adjusted linear regression showed BMI z-score was significantly related to systolic and diastolic blood pressure, insulin during oral glucose tolerance test, total cholesterol, high-density lipoprotein, triglycerides, and alanine aminotransferase. CONCLUSION: Child's BMI z-score is independently related to complications of overweight and obesity in a linear or curvilinear fashion. Children's risks of most complications increase across the entire range of BMI values and are not defined by thresholds.

Adolescent↗

PubMed2006

Correlates of distances traveled to use recreational facilities for physical activity behaviors.

BACKGROUND: Information regarding how far people are willing to travel to use destinations for different types of recreational physical activity behaviors is limited. This study examines the demographic characteristics, neighborhood opportunity and specific-physical activity behaviors associated with distances traveled to destinations used for recreational physical activity. METHODS: A secondary analysis was undertaken of data (n = 1006) from a survey of Western Australian adults. Road network distances between respondents' homes and 1) formal recreational facilities; 2) beaches and rivers; and 3) parks and ovals used for physical activity were determined. Associations between distances to destinations and demographic characteristics, neighborhood opportunity (number of destinations within 1600 meters of household), and physical activity behaviors were examined. RESULTS: Overall, 56.3% of respondents had used a formal recreational facility, 39.9% a beach or river, and 38.7% a park or oval. The mean distance traveled to all destinations used for physical activity was 5463 +/- 5232 meters (m). Distances traveled to formal recreational facilities, beaches and rivers, and parks and ovals differed depending on the physical activity undertaken. Younger adults traveled further than older adults (7311.8 vs. 6012.6 m, p = 0.03) to use beaches and rivers as did residents of socio-economically disadvantaged areas compared with those in advantaged areas (8118.0 vs. 7311.8 m, p = 0.02). Club members traveled further than non-members to use parks and ovals (4156.3 vs. 3351.6 meters, p = 0.02). The type of physical activity undertaken at a destination and number of neighborhood opportunities were also associated with distance traveled for all destination types. CONCLUSION: The distances adults travel to a recreational facility depends on the demographic characteristics, destination type, physical activity behavior undertaken at that destination, and number of neighborhood opportunities. Knowing how far adults travel to undertake physical activity will assist in designing supportive neighborhoods and designing future ecological research.

Journal Article↗

PubMed2006

Risk factors for increased BTEX exposure in four Australian cities.

Benzene, toluene, ethylbenzene and xylenes (BTEX) are common volatile organic compounds (VOCs) found in urban airsheds. Elevated levels of VOCs have been reported in many airsheds at many locations, particularly those associated with industrial activity, wood heater use and heavy traffic. Exposure to some VOCs has been associated with health risks. There have been limited investigations into community exposures to BTEX using personal monitoring to elucidate the concentrations to which members of the community may be exposed and the main contributors to that exposure. In this cross sectional study we investigated BTEX exposure of 204 non-smoking, non-occupationally exposed people from four Australian cities. Each participant wore a passive BTEX sampler over 24h on five consecutive days in both winter and summer and completed an exposure source questionnaire for each season and a diary for each day of monitoring. The geometric mean (GM) and range of daily BTEX concentrations recorded for the study population were benzene 0.80 (0.04-23.8 ppb); toluene 2.83 (0.03-2120 ppb); ethylbenzene 0.49 (0.03-119 ppb); and xylenes 2.36 (0.04-697 ppb). A generalised linear model was used to investigate significant risk factors for increased BTEX exposure. Activities and locations found to increase personal exposure included vehicle repair and machinery use, refuelling of motor vehicles, being in an enclosed car park and time spent undertaking arts and crafts. A highly significant difference was found between the mean exposures in each of the four cities, which may be explained by differences in fuel composition, differences in the mix and density of industry, density of motor vehicles and air pollution meteorology.

Adult↗

PubMed2006

A study of potential interactive genetic factors in Huntington's disease.

AIM: To assess the role of genetic factors, other than the CAG repeat length, on the development of Huntington's disease (HD) in an isolated Caucasian population in the south-west of Western Australia. METHODS: 114 patients with symptomatic HD according to the Unified HD Rating Scale research criteria were examined along with 51 control patients. The length of the CAG repeat sequence in the IT15 gene and the adjacent CCG and Delta2642 polymorphisms were determined by polymerase chain reaction along with common genotypes of the angiotensin-converting enzyme (ACE) and apolipoprotein E (APOE) genes. RESULTS: The CAG expansion was associated with age of onset and the development of neurological dysfunction. We found no effect of the expanded CCG allele on age of onset, neurological dysfunction or the size of the CAG expansion. We observed a twofold increase in the Delta2642 polymorphism and the risk of developing symptomatic HD which was not significant (OR 2.06; 95% CI 0.60-7.07). The presence of an APOE epsilon4 allele was associated with an increased risk of HD which was not significant either (OR 1.04-1.73; 95% CI 0.10-10.68). ACE genotypes showed no association with risk factors for the disease. CONCLUSION: In our study of a geographically isolated Caucasian HD population in the south-west of Western Australia we have not observed that the expanded CCG allele, the Delta2642 polymorphism, the APOE epsilon4 allele and ACE genotypes are associated with an increased risk for the development of symptomatic HD.

Apolipoprotein E4↗

PubMed2006

Development of a reliable measure of walking within and outside the local neighborhood: RESIDE's Neighborhood Physical Activity Questionnaire.

BACKGROUND: The RESIDential Environment project (RESIDE) is a longitudinal study evaluating the impact of a new residential design code on walking. OBJECTIVE: To develop a reliable measure of walking--undertaken within and outside the neighborhood--and overall physical activity. METHODS: A test-retest reliability study was undertaken (n = 82, mean age 39 years). The instrument was based on the International Physical Activity Questionnaire (IPAQ-short version) and Active Australia Survey. It measured usual frequency and duration of (1) recreational- and transport-related walking within and outside the neighborhood and (2) other vigorous and moderate physical activities. RESULTS: Reliability of recall of whether participants had walked within (k = 0.84) and outside (0.73) the neighborhood was acceptable. Similarly, recall of frequency and duration of transport and recreational-related walking within the neighborhood was excellent (ICC > or = 0.82), as was recall of transport-related walking trips outside the neighborhood (ICC > or = 0.84). Reliability for duration of recreational walking outside the neighborhood was fair to good (ICC = 0.55). The reliability of indices of total physical activity based on MET min/week (ICC = 0.82) and MET min/week dichotomized to 'sufficient' physical activity for health (kappa = 0.67) were both acceptable. CONCLUSIONS: The Neighborhood Physical Activity Questionnaire (NPAQ) is sufficiently reliable for studies examining environmental correlates of walking within the neighborhood.

Adult↗

PubMed2006

Trends in registered blindness and its causes over 19 years in Western Australia.

PURPOSE: To estimate the population-based incidence rates of blindness registration and their trends over time in Western Australia. METHODS: A retrospective review was performed on all cases of bilateral blindness registered with the Association for the Blind of Western Australia between 1984 and 2002. The causes and mean age at blindness registration were ascertained and incidence rates of blindness due to various causes were calculated. RESULTS: A total of 3852 blind certificates were examined. From 1984 to 1994, the annual incidence of registered bilateral blindness decreased significantly at an average rate of 9.4% per year (p < 0.0001), but then rose at a mean rate of 4.1% per year (p < 0.0001). ARMD blindness similarly fell by 8.9% per year (p < 0.0001), but then rose after 1994 by 4.5% per year (p < 0.0001). The incidence due to glaucoma decreased at an average rate of 10.3% per year (p < 0.0001) until 1994 and then rose at 7.4% per year at borderline significance (p = 0.025). CONCLUSIONS: There has been a nonlinear decrease in the incidence of registered blindness, in particular glaucoma-related blindness, in Western Australia. Rates of total registered blindness and that due to ARMD fell from 1984 to 1994, but have risen since.

Blindness↗

PubMed2006

AlphaCor: Clinical outcomes.

PURPOSE: To study the outcomes of AlphaCor implantation. METHODS: : The AlphaCor artificial cornea is indicated for corneal blindness not treatable by donor grafting. Prospective preoperative and follow-up data were collected. Data were evaluated using SPSS for statistical analysis of outcomes, trends, and associations. RESULTS: This report includes data returned through February 28, 2006, for all 322 devices implanted, with mean follow-up in situ of 15.5 months and a maximum of 7.4 years. The probability of AlphaCor retention at 6 months and 1 and 2 years for protocol cases was 92%, 80%, and 62%, respectively, and off-label cases were at higher risk (P = 0.010), as were cases not prescribed medroxyprogesterone (MPG; P = 0.001). Currently, the most common complications were stromal melting, fibrous reclosure of the posterior lamellar opening, and white intraoptic deposits, with incidences in 2005 of 11.4%, 5.1%, and 2.6%, respectively. MPG seems to protect against melts, and eyes with a history of herpetic keratitis were not at increased risk. A history of glaucoma or the presence of tubes did not affect device retention. Complications culminated in loss of an eye in 1.3%. Mean preoperative visual acuity (VA) was hand movements. The VA achieved postoperatively (light perception to 20/20) was affected by previous pathology and postoperative course, with a mean improvement of 2 lines. CONCLUSION: AlphaCor provides a treatment option where a donor tissue graft would not succeed in severe corneal conditions, while being reversible to a donor graft in the event of complications for anatomic integrity. Surgical technique and adjunctive therapies are evolving with experience. Continued data collection is important for a fuller understanding of AlphaCor's role.

Adult↗

PubMed2006

In-patient hospital use in the last years of life: a Western Australian population-based study.

OBJECTIVES: To estimate the likelihood and costs of in-patient care in the last three years of life. METHODS: A population-based retrospective cohort study using linked hospital and death records to evaluate in-patient use by Western Australians who died in 2002. RESULTS: Age was unrelated to the likelihood of in-patient admission and inversely related to in-patient costs, after adjustment for sex, cause of death and proximity to death. In-patient costs increased in the final three quarters before death. In the last quarter before death, the predicted average quarterly in-patient cost increased 2.8 fold from quarter two and 3.8 fold from quarter three. CONCLUSIONS: Older decedents were not more likely to be hospitalised than younger decedents in the final three years of life. Moreover, once hospitalised, their in-patient costs were lower. In-patient costs were heavily concentrated in the three last quarters of life. IMPLICATIONS: Remaining lifetime is a significant predictor of in-patient costs. Failure to account for proximity to death will overemphasise the impact of population ageing on health care expenditure, because older people have a higher probability of dying.

Age Distribution↗

PubMed2006

The psychometrics of developing the patient empowerment scale.

Although patient empowerment is widely acknowledged as important by health professionals it remains a somewhat nebulous concept. An initial empowerment measure has been developed through an extensive review of literature combined with a series of in-depth interviews of cancer patients concerning their use of coping strategies. The results were analysed for major themes in relation to sense of control over the illness. A set of twenty-eight statements were formulated from themes into a Likert-type scale for self-completion by 100 cancer patients. The scale could be used in assessing level of empowerment amongst cancer patients thereby establishing through this information, the patient's ability to make decisions about coping with their illness.

Adaptation, Psychological↗

PubMed2005

Hepascore: an accurate validated predictor of liver fibrosis in chronic hepatitis C infection.

BACKGROUND: Staging hepatic fibrosis by liver biopsy guides prognosis and treatment of hepatitis C, but is invasive and expensive. We sought to create an algorithm of serum markers that accurately and reliably predict liver fibrosis stage among hepatitis C patients. METHODS: Ten biochemical markers were measured at time of liver biopsy in 117 untreated hepatitis C patients (training set). Multivariate logistic regression and ROC curve analyses were used to create a predictive model for significant fibrosis (METAVIR F2, F3, and F4), advanced fibrosis (F3 and F4), and cirrhosis (F4). The model was validated in 104 patients from other institutions. RESULTS: A model (Hepascore) of bilirubin, gamma-glutamyltransferase, hyaluronic acid, alpha(2)-macroglobulin, age, and sex produced areas under the ROC curves (AUCs) of 0.85, 0.96, and 0.94 for significant fibrosis, advanced fibrosis, and cirrhosis, respectively. In the training set, a score > or = 0.5 (range, 0.0-1.0) was 92% specific and 67% sensitive for significant fibrosis, a score <0.5 was 81% specific and 95% sensitive for advanced fibrosis, and a score <0.84 was 84% specific and 71% sensitive for cirrhosis. Among the validation set, the AUC for significant fibrosis, advanced fibrosis, and cirrhosis were 0.82, 0.90, and 0.89, respectively. A score > or = 0.5 provided a specificity and sensitivity of 89% and 63% for significant fibrosis, whereas scores <0.5 had 74% specificity and 88% sensitivity for advanced fibrosis. CONCLUSIONS: A model of 4 serum markers plus age and sex provides clinically useful information regarding different fibrosis stages among hepatitis C patients.

Adult↗

PubMed2005

The pet connection: pets as a conduit for social capital?

There is growing interest across a range of disciplines in the relationship between pets and health, with a range of therapeutic, physiological, psychological and psychosocial benefits now documented. While much of the literature has focused on the individual benefits of pet ownership, this study considered the potential health benefits that might accrue to the broader community, as encapsulated in the construct of social capital. A random survey of 339 adult residents from Perth, Western Australia were selected from three suburbs and interviewed by telephone. Pet ownership was found to be positively associated with some forms of social contact and interaction, and with perceptions of neighbourhood friendliness. After adjustment for demographic variables, pet owners scored higher on social capital and civic engagement scales. The results suggest that pet ownership provides potential opportunities for interactions between neighbours and that further research in this area is warranted. Social capital is another potential mechanism by which pets exert an influence on human health.

Adult↗

PubMed2004

Mortality in an Australian cohort of textile workers.

BACKGROUND: Workers in the textile industry may be exposed to textile dusts, a wide range of chemicals and electromagnetic radiation. AIM: To investigate the risk of mortality in a cohort of textile workers and examine whether specific occupational exposures were associated with mortality. METHOD: Data on members and former members of a textile industry union were extracted from membership cards and matched with the National Death Index to obtain date and cause of death. Exposure to 31 different substances was assessed using a specifically designed job exposure matrix that consisted of profiles of exposures in 11 occupational titles. These profiles were modified according to individual circumstances. Standardized mortality ratios (SMRs) were computed comparing the cohort to the Australian population and Mantel-Haenszel estimates of the rate ratios were computed comparing exposed with unexposed for each of the substances. RESULTS: There were 113 deaths in the cohort of 7684 workers. Male and female textile workers had similar risks of death from any cause, cancer or cardiovascular disease to the general Australian population. Male workers had an increased risk of death from injury (SMR = 157, 95% confidence interval 113-213). There were no statistically significant increases in risk with particular occupational exposures. CONCLUSION: Male textile workers are at higher risk of death from injury.

Adult↗

PubMed2004

A new asthma spacer device to improve compliance in children: a pilot study.

OBJECTIVE: This pilot study was designed to compare the acceptance, ease of use, and effects on compliance between currently used spacer devices and the Funhaler--a new small volume spacer device designed to improve adherence to asthma medication in children. METHODOLOGY: A matched questionnaire-based survey was conducted by two interviews of each caregiver by the same person. A total of 32 children were randomly recruited from seven clinics spanning widely differing socioeconomic and geographical areas of Perth, Western Australia. Preschool children taking regular inhaled asthma medication using an existing low volume spacer device and aged between 1.5 and 6 years, took part in the pilot study. Parents completed two matched questionnaires. The first questionnaire was completed at the beginning of the study and the second after 2 weeks' use of the Funhaler spacer. Data collected related primarily to ease of use of the devices, child and parental compliance, and treatment attitudes. During the study, parents were also called at random on one occasion to ascertain whether they had attempted to medicate their child the previous day. RESULTS: Using the Funhaler incentive spacer device, parents reported significantly more success at medicating their children (22/30 always successful) in comparison to using their existing spacer device (3/30). Parental adherence to prescribed frequency and the delivery technique of children were also improved. The children also showed improved satisfaction and willingness to use the device and parents' attitude towards medicating their children was improved with the Funhaler spacer device. CONCLUSIONS: Use of a novel, incentive spacer device (Funhaler) appeared to be associated with increased success and fewer problems in medicating children, improved child and parental adherence, and a more positive attitude towards treatment, suggesting that more extensive long-term efficacy trials with the device are warranted.

Anti-Asthmatic Agents↗

PubMed2004

Evaluating the impact of repeated community-wide health surveys on cardiovascular morbidity and mortality in the busselton population.

OBJECTIVE: To evaluate the impact of repeated community-wide mass health examinations on cardiovascular mortality and hospital morbidity trends in Busselton. METHOD: Population census, hospital admission and death data were used to calculate and compare cardiovascular mortality rates from 1965 to 1998 and hospital morbidity rates from 1971 to 1998 in Busselton residents aged 40 to 84 years with the remainder of the south-west region of Western Australia. RESULTS: Among men aged 40-69 years, the calendar year trends in standardised cardiovascular mortality and morbidity ratios were relatively flat and non-significant. Among women aged 40-69 years, the mortality ratio declined significantly up to 1989 (p = 0.03) but not over the whole period (p = 0.12), and the downward trend in the morbidity ratio did not reach statistical significance (p = 0.21). Among men aged 70-84 years, both the mortality and morbidity ratios rose significantly over time, whereas among women aged 70-84 years the mortality ratios showed a flat trend and the morbidity ratios a rising trend. These increasing trends were opposite to what was expected if the surveys had a beneficial impact. CONCLUSION: This analysis of trends, while failing to demonstrate a clear benefit of repeated mass health screenings on cardiovascular event rates, also highlights the difficulties in evaluating the longer-term impact on event rates of such programs and suggests that negative conclusions should be made with caution.

Adult↗

PubMed2004

Cold air analgesia in photodynamic therapy of basal cell carcinomas and Bowen's disease: an effective addition to treatment: a pilot study.

BACKGROUND: There is considerable interpatient variability in pain tolerance during and after treatment of skin cancer with photodynamic therapy (PDT). Additionally, erythema and edema are common, with mild crusting and healing over 1 to 2 weeks. OBJECTIVE: To determine whether concurrent cold air analgesia improves the tolerability of PDT. METHOD: Twenty-six patients with two similar superficial skin cancers were treated with PDT. One lesion was treated with cold air analgesia and the other without. Patients rated their pain during treatment using the Wong Baker Faces Pain Scale and detailed duration of posttreatment pain. At week 2, the inflammatory response was assessed. RESULT: A statistically significant difference in the analgesia group was shown with respect to the mean duration of pain and the level of erythema after the first treatment as well as pain scores during the second treatment. CONCLUSION: Patient acceptance of PDT for treatment of nonmelanoma skin cancer is improved with lessened morbidity assessed with concurrent use of cold air analgesia to the treatment field.

Analgesia↗

PubMed2003

The Australian Intervention Randomized Control of Rate in Atrial Fibrillation Trial (AIRCRAFT).

OBJECTIVES: The Australian Intervention Randomized Control of Rate in Atrial Fibrillation Trial was a multicenter trial of atrioventricular junction ablation and pacing (AVJAP) compared with pharmacologic ventricular rate control (medication [MED]) in patients with mild to moderately symptomatic permanent atrial fibrillation (AF). BACKGROUND: There have been very few prospective randomized trials, undertaken in highly symptomatic patients, comparing AVJAP with pharmacologic methods of ventricular rate control for patients with permanent AF. METHODS: There were 99 patients (70 men, mean age 68 +/- 8.6 years) at five centers. Forty-nine patients were randomized to AVJAP while 50 patients were randomized to pharmacologic control. The primary end point was cardiac function measured by echocardiography and exercise tolerance. The secondary end points were ventricular rate control, evaluated by 24-h ambulatory electrocardiographic monitoring, and quality of life. Data were collected at randomization and then at one month, six months, and 12 months post-randomization. RESULTS: At 12 months follow-up there was no significant difference in left ventricular ejection fraction (AVJAP: 54 +/- 17%; MED: 61 +/- 13% [p = ns]) or exercise duration on treadmill testing (AVJAP: 4.1 +/- 2 min; MED: 4.6 +/- 2 min [p = ns]); however, the peak ventricular rate was lower in the AVJAP group during exercise (112 +/- 17 beats/min vs. 153 +/- 36 beats/min, p < 0.05) and activities of daily life (117 +/- 16 beats/min vs. 152 +/- 37 beats/min, p < 0.05). The CAST quality-of-life questionnaire revealed that patients in the AVJAP group had fewer symptoms at six months (p = 0.003) and at 12 months (p = 0.004). The observed relative risk reduction in symptoms at 12 months was 18%. Global subjective semiquantitative measurement of quality of life using the "ladder of life" revealed that the AVJAP group reported a 6% better quality of life at six months (p = 0.011). CONCLUSIONS: In this trial, AVJAP for patients with mild to moderately symptomatic permanent AF did not worsen cardiac function during long-term follow-up, and quality of life was improved.

Activities of Daily Living↗