Introduction: Dental caries is an infectious disease with predominantly of cariogenic bacteria such as Streptococcus mutans (S. mutans). Xylitol is considered as one of the effective agents that can limit this dental infection. In this randomized, placebo-controlled trial, we aimed to evaluate the potential reflection of short-term xylitol consumption on pro-inflammatory cytokines (TNF-, IL-6 and IL-8) and S. mutans counts by ELISA and qPCR (Quantitative real-time PCR), respectively. Methods: In this study, 154 participants were assigned to two groups, control and xylitol. Dental examination, saliva and swab samples were done at baseline and at 3-week for clinical and microbiological assessment. Results: In xylitol group at the end of 3-week, gingival and plaque index scores were significantly decreased with respect to baseline values (p<0.001 and p<0.05, respectively). The salivary concentration of TNF-, IL-6 and IL-8 were statistically declined at 3-week, more so than those at baseline in xylitol group (p<0.001). S. mutans expression was reduced about 5-fold at 3-week use of xylitol and it was a statistically significant difference compared to baseline (p<0.001). Conclusion: Intriguingly, even short-term consumption of xylitol might play a favorable role in maintaining the oral health status, possibly as a result of decreasing the release of pro-inflammatory cytokines and the counts of S. mutans. Nonetheless, this investigation warrants further endorsement.
Background: Pharmacogenomics (PG) is a modern tool of personalizing treatment protocols to improve the efficacy and safety of drug prescriptions. These benefits are offset by a slow uptake in clinical application due to a host of physician factors, patient factors, and/or health system factors. Our study, thus, aimed to determine the knowledge, attitude, future expectations, and perceived barriers of medical students and physicians in Jordan regarding PG testing. Methods: A descriptive, cross-sectional study was conducted between February-August 2019. Physicians and senior medical students from academic and non-academic institutions in North Jordan (n=424) were surveyed. A structured, self-administered questionnaire was designed and piloted for the purpose of the study. A scoring system for each dimension assessed was calculated and presented using means. Mean scores were compared by sociodemographic and professional variables. Results: The response rate was 70.7%. The mean total PG knowledge score (±SD) was 5.42 (±1.51) out of 10, with a significantly higher mean among respondents aged ≥30 years (5.21 ± 1.62) compared to those <30 years-old (5.54 ± 1.43; p= 0.03). The mean total PG attitude score was 21.18 (±2.58) out of 24, with significant differences by seniority levels evident (p= 0.03). The future expectations of PG among our sample were high, with a mean score of 10.44 (±1.64) out of 12. The top three perceived barriers in applying PG were the high cost, lack of clinical guidelines, and limited knowledge and awareness. Conclusion: Physicians and medical students in Jordan have low overall knowledge, albeit strongly positive attitude and future expectations toward PG, despite the perceived high cost and lack of clinical guidelines. Thus, we strongly recommend adopting a comprehensive educational strategy that aims to integrate PG concepts into medical curricula, and promote the culture of continuous medical education about PG among practitioners.
Introduction and Objectives There are no cardiovascular risk prediction models developed in South Asian cohorts. Therefore, different risk models not validated in South Asians are being used. We aimed to compare cardiovascular risk predictions of Framingham risk score (FRS) and World health organization/International society of hypertension (WHO/ISH) charts for agreement in a sample of South Asians. Methods 10-year cardiovascular risk predictions of patients without previous cardiovascular diseases attending a non-communicable disease clinic were calculated using FRS (with BMI and with cholesterol) and WHO/ISH charts (with and without cholesterol). Patients were categorized into low(<20% ) and high(≥20%) cardiovascular risk groups on risk predictions. Agreement in risk categorisation with different prediction models was compared using Cohen’s kappa coefficient(κ). Results 169 patients (females 130(81.1%)) mean age 65 ±6.9 years were studied. 80(47.3%), 62(36.7%), 18(10.7%), and 16(9.5%) were predicted high-risk by FRS BMI-based, FRS cholesterol-based, WHO/ISH without-cholesterol and WHO/ISH with-cholesterol models, respectively. Agreement between the two FRS models (κ = 0.736, p<0.0001) and the two WHO/ISH models (κ = 0.804, p<0.0001) in stratifying patients into high and low-risk groups, were “good”. However, the agreements between, FRS BMI-based and WHO/ISH without-cholesterol models (κ = 0.234, p<0.0001) and FRS cholesterol-based and WHO/ISH with-cholesterol models (κ = 0.306, p<0.0001) were only “fair”. Conclusion Cardiovascular risk predictions of FRS were higher than WHO/ISH charts and the agreement in risk stratification was not satisfactory in Sri Lankans. Therefore, different cardiovascular risk prediction models should not be used interchangeably in the follow-up of South Asians.
The goal of this study was to assess the clinical effectiveness and safety profile of the COVID-19 treatment protocol (containing both hydroxychloroquine (HCQ) and azithromycin) in an Iraqi specialized hospital. Methods: This prospective study used a pre- and post-intervention design without a comparison group. The intervention was routine Ministry of Health (MOH) approved management of COVID-19 for all patients. The study was conducted in a public healthcare setting in Baghdad, Iraq from March 1st to May 25, 2020. The study outcome measures included the changes in clinical and biochemical parameters during the hospitalization period. Paired t-test and Chi-square test were used to compare the measures of vital signs, lab tests and symptoms before and after treatment. Results: The study included 161 patients who were admitted with positive RT-PCR and clinical symptoms of COVID-19. In terms of severity, 53 (32.9%) patients had mild condition, 47 (29.2%) had moderate condition, 35 (21.7%) had severe condition, and 26 (16.1%) had critical condition. Most patients (84.5%) recovered and were discharged without symptoms after testing negative with RT-PCR, while 11 (6.8%) patients died during the study period. The signs and symptoms of COVID-19 were reduced significantly in response to therapy regimen containing HCQ and azithromycin. The most common reported side effects were stomach pain, hypoglycemia, dizziness, itching, skin rash, QT prolongation, arrhythmia, and conjunctivitis. Conclusions: This natural trial showed that COVID-19 regimen containing both HCQ and azithromycin can be helpful to promote recovery of most patients and reduced their signs and symptoms significantly. It also shows some manageable side effects mostly those related to heart rhythm. In the absence of FDA-approved medications to treat COVID-19, the repurposing of HCQ and azithromycin to control the disease signs and symptoms can be useful.
Background Atopic dermatitis (AD) is the chronic inflammatory disorder that affects both in childhood and adulthood. Mounting evidence indicates that gut dysbiosis contributes to AD via the gut-skin axis. Constipation can result in alteration of the gut microflora. The clinical impact of constipation on AD has not been researched. Therefore, we aim to assess the risk of AD in constipated patients by the population-based cohort study. Methods We collected 87015 constipated people and 87015 people without constipation between 1999 and 2013 from the Taiwanese National Health Insurance Research Database. Propensity score analysis was administrated to match age, gender, comorbidities, and medications at a ratio of 1:1. Multiple Cox regression analysis was utilized to evaluate the adjusted hazard ratio of AD. In addition, sensitivity tests and a stratified analysis were conducted. Results The incidence of AD was 4.7 per 1,000 person-years in the constipation group, which was higher than the rate of 2.2 per 1,000 person-years observed in the non-constipation group. After adjustment for age, gender, comorbidities, corticosteroids, and antihistamine, constipated people had a 2.11-fold greater risk of AD compared to those without constipation (adjusted hazard ratio [aHR]: 2.11 (95% C.I. 1.98-2.24). Moreover, constipated people had a higher likelihood of AD, regardless of gender, comorbidities, as well as the usage of corticosteroids, and antihistamines. Conclusion Constipation is associated with a significantly risk factor of AD. Clinicians should be careful of the possibility of AD in constipated people. Further study is warranted to investigate the possible pathological mechanisms of this relationship.
Purpose: Some patients who undergo robot-assisted laparoscopic radical prostatectomy (RARP) continue to experience long-term urinary incontinence (UI). This study aimed to evaluate easily obtainable factors that can predict long-term UI following RARP. Materials and Methods: A total of 315 patients who underwent RARP for localized prostatic cancer were analyzed. We separated the patients into two groups, namely, the Continence group and the Incontinence group, according to the presence or absence of UI at 12 months after surgery, and we compared the patients’ characteristics and operative data to identify clinical signs associated with long-term UI. Additionally, correlations between these factors and postoperative urethral function were evaluated. Urinary continence was defined as both the use of 0 pads/per day and <2 g of urine lost using the 24-h pad weight test. Results: Of 315 patients, 250 (79.4%) achieved urinary continence and 65 (20.6%) had UI. Age, storage-related lower urinary tract symptoms before surgery, nerve-sparing surgery, and the 24-h urine loss immediately after urethral catheter removal significantly affected long-term UI after RARP. Multivariate logistic regression analyses revealed that the 24-h urine loss after catheter removal was a significant predictor of long-term UI. Receiver operating characteristic curve analysis identified a urine loss of 330 g/day as the optimal cutoff value, which yielded 92% sensitivity and 84% specificity, and it showed significant correlations with postoperative urethral function and the time to recover urinary continence. Conclusion: The 24-h urine loss immediately after urethral catheter removal may be the most reliable and useful predictor of long-term UI following RARP.
Purpose: To evaluate the effect of partial nephrectomy on renal function and to identify predictors of estimated glomerular filtration rate (eGFR) at six months after partial nephrectomy. Methods: Medical data of 154 consecutive patients who underwent partial nephrectomy for a renal mass between January 2015 and March 2020 were retrospectively analyzed. The primary outcome measure was eGFR at six months postoperatively. A non-linear regression analysis was performed to examine the association between primary outcome measure and candidate predictors. Results: Of the patients, 66 (42.9%) were females and 88 (57.1%) were males with a median age of 60 (range, 50 to 67) years. The median baseline eGFR was 90.40 (range, 74.96 to 102.97) mL/min/1.73 m2, while the median eGFR at six months was 77.12 (range, 61.06 to 91.93) mL/min/1.73 m2 (p<0.001). Baseline eGFR (=22.691, 95%CI: 18.821 to 26.460, when baseline eGFR levels change from 74.97 ml/min/1.73 m2 to 102.68 ml/min/1.73 m2, p<0.001) was found to be directly associated with the postoperative eGFR levels at six months. In contrary, advanced tumor size (=-3.168, 95%CI: -5.332 to -1.005, when tumor size levels change from 3 to 6 cm, p<0.001) and presence of hypertension ( = -3.479, 95%CI: -6.956 to -0.0031, p=0.049) were also found to be inversely associated with the postoperative eGFR levels at six months. Conclusion: Baseline eGFR values, tumor size, and presence of hypertension are significant predictors of eGFR values in the mid-term in patients undergoing partial nephrectomy.
Background: The relationship between socioeconomic status (SES) and the prognosis of HF with reduced (HFrEF) vs. preserved (HFpEF) ejection fraction remains unsettled. Objective: To analyze the relationship between SES and the prognosis of patients with incident HFrEF and HFpEF. Methods: Prospective study over 15 years (2003-2017) on 9658 patients diagnosed with HF. Main outcomes were mortality and hospitalizations for HF. The independent relationship between SES and the prognosis, stratifying patients for cardiovascular co-morbidity after propensity score-matching was analyzed. Results: After matching 7116 patients, during a median follow-up of 8.11 years, 5616 patients died (78.9%) and 5549 patients were hospitalized (78.0%). High income level was associated with a lower all-cause mortality (RR for HF patients [95% CI]: 0.86 [0.80-0.92], RR for HFrEF: 0.88 [0.82-0.95] and RR for HFpEF: 0.82 [0.75-0.90], P <0.001 in all cases), and cardiovascular mortality (RR for HF: 0.84 [0.76-0.92], RR for HFrEF: 0.87 [0.81-0.93] and RR for HFpEF: 0.88 [0.77-0.88], P <0.001 in all cases), less hospitalizations (RR for HF: 0.70 [0.65-0.78], RR for HFrEF: 0.78 [0.68-0.88] and RR for HFpEF: 0.61 [0.55-0.68], P <0.001 in all cases), and less 30-day readmissions (RR for HF: 0.67 [0.59-0.75], RR for HFrEF: 0.71 [0.63-0.79] and RR for HFpEF: 0.61 [0.55-0.69], P <0.001 in all cases), after adjustment for comorbidities, and other potential confounders. Analyses of recurrent hospitalizations gave larger SES benefits than time-to-first-event analyses. Conclusions: In this propensity-matched study, a high net annual household income is associated with an improved prognosis of patients with incident HFrEF and HFpEF.
Background: The liberal administration of hydroxychloroquine-sulphate (HCQ) to COVID-19 patients has raised concern regarding the risk of QTc prolongation and cardiac arrhythmias, particularly when prescribed with azithromycin. We evaluated the incidence of QTc prolongation among moderately and severely ill COVID-19 patients treated with HCQ and of the existence of concomitant alternative causes. Methods: All COVID-19 patients treated with HCQ (between Mar 1 and Apr 14, 2020) in a tertiary medical center were included. Clinical characteristics and relevant risk factors were collected from the electronic medical records. Individual patient QTc intervals were determined before and after treatment with HCQ. The primary outcome measure sought was a composite endpoint comprised of either an increase ≥ 60 milliseconds (ms) in the QTc interval compared with pretreatment QTc, and/or a maximal QTc interval >500 ms. Results: Ninety patients were included. Median age was 65 years (IQR 55-75) and 57 (63%) were male. Thirty-nine patients (43%) were severely or critically ill. Hypertension and obesity were common (n=23 each, 26%). QTc prolongation evolved in fourteen patients (16%). Age > 65 years, congestive heart failure, severity of disease, C-reactive protein level, hypokalemia and furosemide treatment, were all associated with QTc prolongation. Adjusted analysis showed that QTc prolongation was five times more likely with hypokalemia [OR 5, (95% CI, 1.3-20)], and three times more likely with furosemide treatment [OR 3 (95% CI, 1.01-13.7)]. Conclusion: In patients treated with HCQ, QTc prolongation was associated with the presence of traditional risk factors such as hypokalemia and furosemide treatment.
Objective: We aimed to investigate the demographic shifts in emergency service admissions, possible measures and room for improvement in emergency services during the Covid-19 pandemic. Methodology: Our study retrospectively analyzed the demographic features and clinical admission types of patients admitted to Batman District State Hospital Emergency Service at two different time periods, one prior to the Covid-19 pandemic and the other during the Covid-19 pandemic. The results were compared between the two periods designated as the pandemic period and the pre-pandemic period. Results: The number of patients admitted to emergency service was 47.681 in the pre-pandemic period and 9455 in the pandemic period (p<0.01). The number of patients admitted for trauma was 1247(2.61%) in the pre-pandemic period and 59(0.62%) in the pandemic period (p<0.01). The number of patients hospitalized to cardiology department or coronary care unit for acute coronary syndrome was 602(1.26%) in the pre-pandemic period and 29(0.3%) in the pandemic period (p<0.01). The number of patients hospitalized to neurological intensive care unit for acute cerebrovascular disease was 542(1.13%) in the pre-pandemic period and 22(0.2%) in the pandemic period (p<0.01). The number of patients hospitalized to pulmonary diseases department or intensive care unit for dyspnea was 622(1.21%) in the pre-pandemic period and 515 (5.4%) in the pandemic period (p <0.01). Conclusion: Measures taken to prevent the spread of Covid-19 infection have caused a significant drop in emergency service admissions. We are of the opinion that this will lead to an increase in deaths occurring at home, and we will soon encounter patients with worse prognosis and overcrowded emergency services. In order to prevent this problem, we believe that the public awareness about emergency conditions requiring emergency service admission should be heightened alongside of the ‘stay home’ calls.
Sore throat (acute pharyngitis) is globally one of the most frequent reasons for seeking healthcare. Its etiology is mostly viral. In 15-30% of cases, group A streptococci (GAS) are detected, which may cause acute rheumatic fever. We have done a worldwide systematic review to compare diagnostic and therapeutic guidelines across countries and regions. Previous reviews of sore throat guidelines were limited to specific regions and/or language; this is the first global review. Searches were performed in MEDLINE, EMBASE and COCHRANE (key words: sore throat, pharyngitis, tonsillitis or pharyngotonsillitis, and management, guidance, guideline or recommendation) and on the web sites of major health authorities and associated institutions from Africa, Asia, Europe, Middle East, North America, Oceania and South America. Thirty-six guidelines were identified from 26 countries. Most common are recommendations relying on the symptom- and age-based Centor or McIsaac scores. However, antibiotic treatment may be based on other symptomatic criteria; in the most extreme approach just sore throat in children. The recommendation of GAS-specific diagnostic tests is mainly limited to countries where such tests are readily available, although some countries choose not to use them. Penicillins are consistently recommended as first-line antibiotics. By contrast, guidance for symptomatic treatment is variable and mostly sparse or missing. African countries without sore throat guidelines and Asian countries bypassing them are afflicted by rising antibiotic resistance. The availability of sore throat guidelines varies considerably by region and country. Moreover, important divergence is found among the guidelines regarding diagnostic and treatment criteria. This may be explained by the historical background or adoption of external guidelines, rather than the local incidences of GAS infections or acute rheumatic fever. Absence of recommendations on symptomatic treatment in many guidelines is concerning, and raises issues about antimicrobial stewardship, as this is the mainstay of sore throat management, rather than antibiotics.
The COVID-19 pandemic has transformed lives across the world. In the UK there has been a public health driven policy of population ‘lockdown’ that had enormous personal and economic impact. We compare UK response/outcomes including excess deaths with European countries with similar levels of income/healthcare resources. We calibrate estimates of the economic costs as different %loss in GDP against possible benefits of avoiding life years lost, for different scenarios where local COVID-19 mortality/comorbidity rates were used to calculate the loss in life expectancy. We apply quality-adjusted life years (QALY) value of £30,000 (maximum under NICE guidelines). The implications for future lockdown easing policy in the UK are also evaluated. The spread of cases across European countries was extremely rapid. There was significant variation both in severity and timing of both implementation and subsequent reductions in social restrictions. There was less variation in the trajectory of mortality rates and excess deaths, which have fallen across all countries during May/June 2020. The average age at death and life expectancy loss for non-COVID-19 was 79.1 and 11.4years respectively while COVID-19 were 80.4 and 10.1years; including for life-shortening comorbidities and quality of life reduced this to 5QALY for each COVID-19 death. The lowest estimate for lockdown costs incurred was 50% higher than highest benefits from avoiding the worst mortality case scenario at full life expectancy tariff and in more realistic estimation they were over 50 times higher. Application to potential future scenarios showed in the best case a QALY value of £220k (7xNICE guideline) and in the worst-case £3.7m (125xNICE guideline) was needed to justify the continuation of the lockdown. The evidence suggests that the costs of continuing severe restrictions in the UK are so great relative to likely benefits in numbers of lives saved so that a substantial easing in restrictions is now warranted.
There is scarce information available in regards to the survival outcome of non-Hodgkin lymphoma (NHL) in South East Asia regions. Reports on the outcome of High dose therapy followed by autologous haematopoietic stem cell transplantation (AHSCT) were mainly from developed countries. In this study, we present the outcome of NHL patients treated with AHSCT from year 1997 to 2016 in two urban hospitals in Malaysia. A total of 140 patients were identified, majority of whom had B cell lymphoma (54.3%). Majority of patients (89.3%) were in complete remission at AHSCT. The overall survival (OS) and event-free survival (EFS) at 3 years were 70.7% and 62.1% respectively. The transplant-related mortality was 3.4%.
Background: The first case of COVID-19 in Israel was reported on February 21, 2020. Shaare Zedek (SZ), a 1000-bed tertiary care medical center in Jerusalem, Israel, cared for a significant number of these patients. While attention focused on COVID-19 patients, uninfected patients were admitted to decreasing numbers of available internal medicine (IM) beds as IM departments were converted to COVID-19 isolation wards. Due to the increase in COVID-19 patients, closure of IM wards, re-assignment of staff, and dynamic changes in available community placement options, we investigated the impact of the outbreak on IM patient not admitted for COVID-19. Methods: We reviewed IM admissions during March 15 – April 30, 2020 for patients without COVID-19. Characteristics assessed included number of admissions, age, length of stay, mortality rate, number of discharges, number discharged home, and functional status of the patients. Data was compared to the previous three years (2017 – 2019) during the same time period. Results: During March 15 – April 30, 2020 there were 409 patients admitted to IM compared to a mean of 557 over the previous three years. Fewer patients were admitted to the ED and the IM wards during the outbreak. There was no significant difference between the two groups with regards to gender, in-hospital mortality rate, number discharged, number discharged home, and patient functional level. Patients admitted during the outbreak to IM were younger (74.85 vs 76.86 years) and had a mean shorter hospital length of stay (5.12 vs 7.63 days) compared to the previous three years. Conclusion: While the characteristics of patients admitted to IM during the outbreak were similar, hospital length of stay was significantly shorter. Internal management processes, as well as patient preferences may have contributed to this observation. An infectious disease outbreak may have a significant effect on uninfected admitted patients.
Background: The coronavirus infection (COVID-19) was declared in January 2020 as a public health emergency of international concern. The Middle East and North Africa (MENA), like other parts of the world, suffered from several epidemics over the years. Pharmacists have vital roles to play to prevent the spread of this virus. Objectives: To assess the awareness of COVID-19 amongst pharmacists from countries located in the MENA countries, and to assess their perspectives of their role, barriers, and roles of the educational institutions and pharmaceutical associations in preparing them for their roles during the pandemic. Methods: An online survey was conducted to run a descriptive cross-sectional study in Jordan from 12th to 22th April 2020. The questionnaire was validated and put on Facebook for pharmacists’ recruitment and assessment of their awareness (20 questions with a score out of 20) about epidemics/pandemics and COVID-19, their perceived roles and barriers, and roles of the educational institutions and pharmaceutical associations. Data were analyzed using Statistical Package for the Social Science (SPSS). Results: Study participants (n= 2589) had a mean age of 29.3 (8.2) years and 1329 (51.5%) were females. Most of the participants were from Egypt 819 (40.8%), Followed by Jordan, Algeria, and Syria. As for the sources of information about coronavirus treatment among the study participants, 60.8% got their information from the social media. Fear as a consequence was identified by the majority of participants (87.7%). The majority of pharmacists identified positive roles for the pharmaceutical association and pharmaceutical associations. Conclusion: Pharmacists from the MENA countries believe they got enough education previously about epidemics/pandemics, and the majority follow on the latest coronavirus updates from social media. Fear was reported as the major barrier that requires resolution by the policymakers. Certain gaps in the awareness about COVID-19 were identified.
Aims: Lysosomal α-galactosidase A deficiency (Fabry disease (FD)) was considered an X-linked recessive disorder but is now viewed as a variable penetrance dominant trait. The prevalence of FD is 1 in 40000-117,000 but the exact frequency is disputed depending on ascertainment of late-onset cases and degree of female penetrance. Its prevalence in the general population, especially in patients with abnormal renal function is unclear. This study attempted to identify the prevalence of FD in patients with abnormal results identified from laboratory databases. Methods: Electronic laboratory databases were interrogated to identify from clinical biochemistry records patients with a phenotype of reduced estimated glomerular filtration rate categorised by age on one occasion or more over a 3-year time interval. Patients were recalled and a dried blood spot sample was collected for determination of α-galactosidase A activity by fluorimetric enzyme assay in men and mass spectrometry assays of α-galactosidase A and lyso-globotriaosylceramide (lyso-GL-3) concentrations in women. Results: Samples were obtained from 1084 patients identified with reduced renal function. No cases of FD were identified in 505 men. From 579 women one subject with reduced α-galactosidase activity (1.5 µmol/l/hr) and increased Lyso-GL-3 (5.5 ng/ml) was identified and shown to be heterozygous for a FD mutation (c.898C>T; p.L300F; Leu300Phe). It was later confirmed she was a relative of a known affected patient. Conclusions: Pathology databases hold routine information that can be used to identify patients with inherited errors of metabolism. Biochemical screening using reduced eGFR has a low yield for unidentified cases of Fabry Disease.
Aims: to test the hypothesis that a semi-supervised home physical exercise program improves the functional mobility and quality of life (QOL) of elderly in the community. Methods: This trial was conducted with elderly people (88% female), aged 60 years or older, sedentary and without cognitive decline. Elderly were randomly assigned to an intervention group - IG (home physical exercise and sleep hygiene) and a control group - CG (sleep hygiene). Were applied the International Questionnaire on Physical Activity; mental state mini-exam and the Timed Up and Go test (TUG) before and after the 12-week intervention period. Results: The IG showed an improvement in functional mobility, with a mean reduction in TUG execution time (p <0.01) and improvement in the QOL, (p <0.01) in WHOQOL-OLD. Conclusion: Semi-supervised physical home exercise is effective in improving the functional mobility and the QOL of sedentary elderly in the community. Trial Registration: Registro Brasileiro de Ensaios Clínicos (REBEC) Identifier: RBR-3cqzfy Keywords: Elderly; exercise; functional mobility; quality of life; community; physical activity; home exercise.