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M L Thompson

Publications and source records attributed to M L Thompson.

At least 19 recordsLinked to original sources
PubMed2006

Tuberculosis and silica exposure in South African gold miners.

AIMS: To examine the effect of silica exposure, in the absence of silicosis, on the prevalence of pulmonary tuberculosis (PTB), which is epidemic among South African gold miners. METHODS: Cross-sectional study of 520 gold miners over 37 years of age. Length of service, and cumulative and average dust and quartz exposure indices were derived for each miner. Chest radiographs were read for PTB by two NIOSH "B" readers. PTB was defined as a self-reported history of PTB or PTB on chest radiograph. Logistic regression was used to adjust for age, smoking, and silicosis. PTB effects of different exposure metrics for silica, scaled on their interquartile range (IQR), were compared. RESULTS: Means (ranges) were: age 46.7 (37.1-59.9) years; length of service 21.8 (6.3-34.5) years; average intensity of respirable quartz 0.053 (0-0.095) mg/m3. PTB prevalence was 19.4% (95% CI 16.0 to 22.8) on history alone, and 35.2% (95% CI 31.1 to 39.3) on history or on chest radiograph. Length of service was poorly predictive of PTB, while all exposure indices which included dust or quartz yielded prevalence odds ratios (PORs) of approximately 1.4 (95% CI approximately 1.1 to 1.8) for changes of one interquartile range in exposure. Controlling for silicosis--by adjustment or restriction--did not modify these results. Drillers and winch operators had the highest PTB prevalences and the highest dust and silica exposures. CONCLUSION: Older in-service gold miners in South Africa have a high prevalence of PTB, which is significantly associated with dust and silica exposure, even in the absence of silicosis. Limitations include a survivor workforce and the use of cumulative exposures based on current exposures. Dust control is an important component in control of the PTB epidemic in South African gold mines.

Adult↗
PubMed2003

Nuclear magnetic resonance and diffuse-reflectance infrared Fourier transform spectroscopy of biosolids-derived biocolloidal organic matter.

We extracted the acid-soluble portion of municipal biosolids, fractionated it by both molecular weight (MW) and hydrophobicity, and used various solid-state nuclear magnetic resonance (NMR) methods and diffuse-reflectance infrared Fourier transform (DRIFT) spectroscopy to characterize the fractions. Spectroscopic characterization of the MW components of the biosolids-derived organic matter fractions revealed the presence of functionally distinct groups of compounds. Quantitative 13C NMR, CH spectral editing, and several two-dimensional NMR experiments show that the high-MW hydrophilic fraction in particular is structurally simple, consisting predominantly of N-acetylated polysaccharides, perhaps derived from bacterial peptidoglycans. In the high-MW hydrophobic fraction, aromatic compounds were present in addition to the N-acetylated polysaccharides. Infrared spectroscopy confirmed that hydrophilic fractions were dominated by carbohydrates and indicated that the lower-MW fractions lacked amide moieties. Complementary interpretations of the DRIFT and NMR spectra improved our knowledge of the components separated by this fractionation scheme, allowing better characterization of biosolids organic matter. Moreover, fractionation based on both MW and hydrophobicity may prove useful in detailed characterization of the structure of biosolids-derived organic matter and other similarly heterogeneous natural organic matter in soils and sediments.

Colloids↗
PubMed2003

Uptake of 18fluorodeoxyglucose in the cystic fibrosis lung: a measure of lung inflammation?

Positron emission tomography is a three-dimensional imaging technique that measures physiological effects, including metabolism. 18Fluorodeoxyglucose has been extensively used as a tracer of cellular energy metabolism in the brain and in tumour detection. As neutrophils utilise glucose as an energy source during their respiratory burst, it was hypothesised that 18fluorodeoxyglucose uptake, by these cells, could be interpreted as a measure of neutrophil activation in cystic fibrosis (CF). Ten adult CF patients were given a bolus intravenous injection of 18fluorodeoxyglucose, followed by a 90-min dynamic mid-lung acquisition scan. Right-lung 18fluorodeoxyglucose uptake was assessed using a Patlak plot and values were converted to glucose utilisation. Three clinically inactive pulmonary sarcoidosis patients served as controls. From the 10 CF patients with baseline sputum neutrophils of 14 x 10(6) cells x mL(-1) who were investigated, seven were found to have sputum at a normal or slightly depressed glucose utilisation rate (mean 1.33 micromol x g(-1) x h(-1)) compared with a mean of 2.82 micromol x g(-1) x h(-1) for the sarcoidosis patients. In eight patients, receiving inhaled tobramycin therapy, no change in lung glucose utilisation or sputum neutrophil counts were found. Despite high-sputum neutrophil levels, lung glucose utilisation was not elevated in patients with cystic fibrosis.

Adult↗
PubMed2002

Correlation of poly(methylene)-rich amorphous aliphatic domains in humic substances with sorption of a nonpolar organic contaminant phenanthrene.

The structural makeup of natural organic matter plays a major role in regulating its capacity to retain nonionic hydrophobic organic compounds (HOCs). We used a model HOC--phenanthrene--to investigate the correlations between sorption capacity, specifically the modified Freundlich coefficient (K'f), and compositional data of humic acids, humins, and a peat obtained from quantitative 13C solid-state NMR spectroscopy. A positive correlation between K'f and the weight fraction of amorphous poly(methylene) in the sorbents was observed. In contrast, the correlation between phenanthrene sorption capacity and aromaticity or polarity indices of the sorbents was insignificant. The nonpolar aliphatic carbon fraction, excluding poly(methylene), was only partially correlated with K'f. Detailed NMR analyses of the sorbents using 1H inversion-recovery experiments showed that 10-nm diameter domains of branched nonpolar aliphatic groups, which account for 20-50% of all nonpolar aliphatic segments and may be associated with the poly(methylene), were responsible for the partial correlation. The correlation between K'f and the amorphous nonpolar aliphatic domains including amorphous poly(methylene) was strong. The rubbery, relatively low-density, and amorphous nonpolar aliphatic domains can be expected to offer an excellent environment for the sorption of phenanthrene by partitioning. These observations suggest that the domains of amorphous poly(methylene) and branched nonpolar aliphatics, which make up 2-9 wt % of the organic fraction in our samples, may serve as good descriptors for the potential of natural organic matter to retain HOCs in the natural environments.

Adsorption↗
PubMed2001

Sorption of phenanthrene by reference smectites.

Fate and behavior of nonionic hydrophobic organic compounds (HOCs) in the environment is mainly controlled by their interactions with various components of soils and sediments. Due to their large surface area and abundance in many soils, smectites may greatly influence the fate and transport of HOCs in the environment. We used phenanthrene as a probe to explore the potential of reference smectites to sorb HOCs from aqueous solution. Batch experiments were used to construct phenanthrene sorption isotherms, and possible sorption mechanisms were inferred from the shape of the isotherms. Our results demonstrate that smectites can retain large amounts of phenanthrene from water. Phenanthrene sorption capacities of the reference smectites investigated in this study were comparable to those of soil clays containing a considerable amount of organic matter. Hectorite exhibited the highest sorption affinity and capacity followed by Panther Creek montmorillonite. The lack of correlation between Freundlich sorption constants (K'f) and indices of charge or hydrophobicity suggests that sorption of phenanthrene by smectites is primarily a physical phenomenon. Capillary condensation into a network of nanoor micropores created by quasicrystals is likely to be a dominant mechanism of phenanthrene retention by smectites.

Adsorption↗
PubMed2001

Porphyrins with exocyclic rings. 16. Synthesis and spectroscopic characterization of fluoranthoporphyrins, a new class of highly conjugated porphyrin chromophores.

Porphyrins with fused aromatic rings are under detailed investigation due to their unique spectroscopic properties. To gain more insights into the effects due to ring annealation on the porphyrin chromophore, a series of fluoranthoporphyrins have been synthesized. Reaction of 3-nitrofluoranthene with isocyanoacetate esters in the presence of a phosphazene base afforded good yields of the fluorantho[2,3-c]pyrrole esters 8. Cleavage of the ester moiety with KOH in ethylene glycol afforded the parent heterocycle 9, and this condensed with 2 equiv of acetoxymethylpyrroles 10 in refluxing acetic acid-2-propanol to afford tripyrranes 11. Following cleavage of the tert-butyl ester protective groups with TFA, "3 + 1" condensation with pyrrole dialdehyde 12 gave the fluoranthoporphyrins 13 in good overall yields. In addition, reaction of tripyrrane 11 with acenaphthopyrrole dialdehyde 16 gave the mixed acenaphthofluoranthoporphyrin 17 in excellent yields. A difluoranthoporphyrin 18 was also prepared via a "2 + 2" MacDonald condensation. Reaction of fluoranthopyrrole 8a with dimethoxymethane in the presence of p-toluenesulfonic acid gave the symmetrical dipyrrylmethane 19, and following ester saponification, this was condensed with a dipyrrylmethane dialdehyde to afford the adj-difluoranthoporphyrin 18. The UV--vis spectra for these fluoranthoporphyrins gave a series of three broadened absorptions in the Soret band region, although the Q-bands were little effected by ring fusion. The nickel(II), copper(II), and zinc chelates were more unusual, showing strong absorptions near 600 nm. Difluoranthoporphyrin 18 showed many of the same spectroscopic features, although the presence of two ring fusions gave rise to an increase in the spectroscopic shifts. The mixed system 17 gave spectra that showed larger red shifts due to the acenaphthylene unit combined with the features due to the fluoranthene rings. This work further demonstrates the utility of aromatic ring fusion in altering the properties of porphyrinoid systems.

Fluorescent Dyes↗
PubMed2001

Test-retest reliability of an icon/calendar-based questionnaire used to assess occupational history.

BACKGROUND: Self-reported work histories can be critical for both epidemiologic and clinical purposes. However, the complexity of some work histories, such as those of migrant farm workers, can hamper recall, resulting in inaccurate reporting. Memory aids may reduce such error. This study assesses the reliability of work histories collected using such aids in the form of an icon/calendar-based questionnaire. METHODS: Thirty-one males engaged in farmwork and other manual labor for a median 28 years (range: 10-64) were interviewed twice, 8-14 months apart, about their lifetime employment. In each interview, subjects were asked about important life events, which were recorded with icons on a calendar. They were then asked to recount their work history, including for each job the tasks, crops or products handled, starting and ending dates, and location. This information was recorded, job-by-job, on the calendar with icons. RESULTS: Interquestionnaire agreement of cumulative reported employment duration (as measured by the correlation coefficient) was moderate to high across all time periods for certain crops (e.g., r = 0.69-0.92 for apple-related work), by location (e.g., r = 0.76-0.95 for Washington State), and for agricultural work in general (r = 0.67-0.94), but was lower for specific tasks. Agreement of job counts was high for total work history for certain crops (e.g., r = 0.93 for apple-related work), by location (e.g., r = 0.90 for Washington State), and for agricultural work in general (r = 0.89), but paradoxically decreased with proximity to the interview date. Agreement of both measures tended to be highest for those tasks and crops in which subjects reported spending the most time. Categorization of subjects into tertiles on the basis of either cumulative duration or counts produced results similar to those observed for job counts. CONCLUSIONS: The icon-calendar questionnaire is an effective tool for estimating cumulative duration of certain work categorizations among subjects with complex work histories.

Adolescent↗
PubMed2001

Comparability of data obtained from migrant farmworkers and their spouses on occupational history.

BACKGROUND: Epidemiologic studies, particularly case-control studies, often rely on proxy respondents to provide information about subjects' occupational histories. The quality of proxy-reported information in occupational histories has never been evaluated for migrant farmworkers. METHODS: We compared occupational histories self-reported by 31 farmworkers with those reported by their wives. The work histories were obtained using an icon/calendar-based questionnaire that was designed to facilitate recall for migrant farmworkers, who typically have complex work histories. RESULTS: The work histories provided by proxy respondents contained 32% fewer jobs and accounted for 24% fewer years than the self-reported histories. Correlations for lifetime duration of employment in different types of jobs were moderate to good for general agricultural jobs in Washington (0.70) and apple-related jobs (0.65), which were held by virtually all of the farmworkers; correlations were moderate to poor for less common jobs and for specific types of tasks. Agreement was better after marriage than before, and for jobs held in the current year compared to other time frames. Overall, the ability of the spouses to provide occupational histories for farmworkers was within the range observed in studies involving other occupations and industries. CONCLUSIONS: In studies involving farmworkers, when study subjects cannot be interviewed, spouses can provide useful information on occupational histories. However, the information should be used only for more generalized exposure assessments; it is most appropriate for estimating cumulative duration of agricultural work, or recent work, by place or for common crops.

Adult↗
PubMed2001

Neuropsychological test performance in a cognitively intact sample of older Japanese American adults.

The purpose of this paper was to present population-based data showing the effects of age on cognitive test performance in a sample of older Japanese American adults. In addition, the relative effects of education, gender, and primary spoken language were compared to effects that have been reported in the literature for majority culture older adults. Subjects included 201 non-demented Japanese American adults age 70 and older currently enrolled in the Kame Project, a prospective study of aging and dementia in King County, WA. Cognitive tests included the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological assessment battery, WAIS-R Digit Span and Digit Symbol subtests, Trail Making Test, Purdue Pegboard, and Finger Tapping. Older age was associated with significantly (p<0.05) lower scores on all tests; less than high school education was associated with lower scores on all tests except Digit Span, Finger Tapping, and the Purdue Pegboard. Women and English-speaking participants scored higher than men and Japanese speakers on various tests of memory, attention, and visuomotor ability. These data reinforce the importance of using appropriately corrected norms when interpreting results of cognitive screening tests with minority culture older adults.

Journal Article↗
PubMed2000

Medical care-seeking for menstrual symptoms.

Fifty-six female undergraduates completed questionnaires regarding their menstrual symptoms, social learning experiences, and illness representations. The results showed that, compared to non-care-seekers, participants who had sought medical care for their menstrual symptoms reported more symptoms that had been problematic since menarche. Consistent with previous research, care-seekers reported more reinforcement for adolescent menstrual illness behaviours than non-care-seekers. Care-seekers also reported their symptoms as more serious and more difficult to ignore. The perceived seriousness and severity of symptoms were both correlated with reinforcement for adolescent menstrual symptoms. Lay referral was also a reported factor in care-seekers. The results of the present data are discussed with respect to previous research on care-seeking for menstrual and other symptoms.

Adaptation, Psychological↗
PubMed2000

Primary human immunodeficiency virus type 1 infection: clinical manifestations among women in Mombasa, Kenya.

The occurrence of clinical manifestations associated with primary human immunodeficiency virus type 1 (HIV-1) infection was evaluated in a prospective cohort study of female sex workers in Mombasa, Kenya. Among 103 women who seroconverted to HIV-1, fever, vomiting, diarrhea, headache, arthralgia, myalgia, skin rash, swollen lymph nodes, extrainguinal lymphadenopathy, inguinal lymphadenopathy, and vaginal candidiasis were noted significantly more frequently at visits in which seroconversion first became evident. Eighty-one percent of seroconverting women had >/=1 of these 11 symptoms or signs. Among 44% of the women, the acute illness was severe enough to prevent them from working. Having >/=2 of 6 selected symptoms and signs yielded a sensitivity of 51%, specificity of 83%, positive likelihood ratio of 3.2, and negative likelihood ratio of 0.5 for acute HIV-1 infection. The recognition of primary HIV-1-infection illness in high-risk populations and subsequent risk-reduction counseling could potentially reduce secondary HIV-1 transmission during this highly infectious period.

Cohort Studies↗
PubMed2000

Combining diagnostic test results to increase accuracy.

When multiple diagnostic tests are performed on an individual or multiple disease markers are available it may be possible to combine the information to diagnose disease. We consider how to choose linear combinations of markers in order to optimize diagnostic accuracy. The accuracy index to be maximized is the area or partial area under the receiver operating characteristic (ROC) curve. We propose a distribution-free rank-based approach for optimizing the area under the ROC curve and compare it with logistic regression and with classic linear discriminant analysis (LDA). It has been shown that the latter method optimizes the area under the ROC curve when test results have a multivariate normal distribution for diseased and non-diseased populations. Simulation studies suggest that the proposed non-parametric method is efficient when data are multivariate normal.The distribution-free method is generalized to a smooth distribution-free approach to: (i) accommodate some reasonable smoothness assumptions; (ii) incorporate covariate effects; and (iii) yield optimized partial areas under the ROC curve. This latter feature is particularly important since it allows one to focus on a region of the ROC curve which is of most relevance to clinical practice. Neither logistic regression nor LDA necessarily maximize partial areas. The approaches are illustrated on two cancer datasets, one involving serum antigen markers for pancreatic cancer and the other involving longitudinal prostate specific antigen data.

Journal Article↗
PubMed2000

Utility of vibration sense testing for use in developing countries: comparison of extinction time on the tuning fork to vibration thresholds on the Vibratron II.

The measurement of vibration sense loss is a useful tool to detect early impacts of neurotoxic chemicals. Measurement methods are needed for developing countries that are culturally unbiased, and which can be used under field conditions where electricity may be unavailable. Extinction time on a 256 Hz tuning fork was compared to vibration threshold measured on the Vibratron II for precision and agreement amongst 306 fruit farm workers as part of a study investigating neurobehavioural impacts of organophosphates in South Africa in 1993. Simultaneous data were also available from a 1 g accelerometer attached to the post of the Vibratron for comparisons. Precision of the tuning fork and Vibratron II appeared comparable and CVs (2.5 to 8.9%) were lower than that reported in the literature. Agreement of the tuning fork with the Vibratron was moderate (Spearmans correlation coefficient of the order of 0.39 to 0.42) whereas agreement between Vibratron and Accelerometer was high (Spearmans correlation of coefficient of the order of 0.78 to 0.83). Height, age and schooling were predictors of vibration sense for the Vibratron and accelerometer but only schooling for extinction time on the tuning fork. Height modified the variability of the Vibratron and accelerometer. Delays in application of the tuning fork to the base of the medial malleolus of 3 seconds or more were associated with average increases in extinction time of 1.7 s. The tuning fork, as standardised in this study, represents a relatively quick, easy and low-technology device with good utility, that is relatively resistant to the usual confounders for vibration threshold measurement. Further studies to explore its validity in relation to other well-recognised methods for detection of subtle neurotoxic impacts should be encouraged.

Adult↗
PubMed1999

Cofactors for the acquisition of HIV-1 among heterosexual men: prospective cohort study of trucking company workers in Kenya.

OBJECTIVE: To determine the prevalence, incidence, and correlates of HIV-1 infection in a cohort of east African trucking company employees. METHODS: HIV-1-seronegative trucking company employees were enrolled in a prospective cohort study and evaluated at 3 monthly intervals for HIV-1 seroconversion, sexually transmitted diseases, and sexual behavior. RESULTS: The baseline seroprevalence of HIV-1 among 1500 trucking company employees was 17.8%. Among 752 HIV-1-seronegative men who were followed, the HIV-1 annual seroincidence was 3.1%. In univariate analysis, HIV-1 acquisition was associated with age under 25 years, 10 years or less of sexual activity, occupation as a driver/driver's assistant, occupational travel for more than 14 days per month, religion other than Christian or Muslim, uncircumcised status, sex with a prostitute, sex with a girlfriend/casual partner, extramarital sex, and enrollment seropositivity to Treponema pallidum, Haemophilus ducreyi, and Herpes simplex virus type 2 (all P values < or = 0.05). Using multivariate analysis, HIV-1 acquisition was independently associated with 10 years or less of sexual activity (hazard rate ratio (HRR) 2.0, 95% confidence interval (CI) 1.0-4.3), occupation as a driver/driver's assistant (HRR 3.9, 95% CI 1.7-9.0), religion other than Christian or Muslim (HRR 6.1, 95% CI 1.4-25.7), uncircumcised status (HRR 2.3, 95% CI 1.0-5.0), and unprotected sex with a prostitute (HRR 2.8, 95% CI 1.1-7.0). CONCLUSIONS: Trucking company employees had a high HIV-1 seroprevalence rate at enrollment and a high HIV-1 seroincidence during follow-up. Risk factors for HIV-1 seroconversion included years of sexual activity, occupation, religion, uncircumcised status, and unprotected sex with a prostitute. This population is an appropriate target for HIV-1 prevention trials and behavioral interventions.

Adolescent↗
PubMed1999

The utility of apolipoprotein E genotyping in the diagnosis of Alzheimer disease in a community-based case series.

CONTEXT: A recent collaborative study found that apolipoprotein E (APOE) genotype, in conjunction with the clinical diagnosis of Alzheimer disease (AD), was useful in improving diagnostic specificity (correctly not diagnosing AD) relative to the clinical diagnosis alone. Since these samples are particularly enriched with patients with AD and the APOE epsilon4 allele, results may not be generalizable to patients seen in the general medical community. OBJECTIVE: To evaluate the diagnostic utility of the APOE genotype in diagnosing AD in a community-based case series from the largest health maintenance organization in an urban area. DESIGN: We examined the effect of including APOE genotype on the diagnosis of AD in a community-based case series of patients presenting with memory complaints. PATIENTS: Clinical and neuropathologic diagnoses and APOE genotype were obtained from 132 patients who underwent evaluation for dementia and subsequent autopsy. MAIN OUTCOME MEASURES: Sensitivity, specificity, and positive and negative predictive values given various combinations of clinical diagnoses and the presence of an APOE epsilon4 allele. RESULTS: Of the 132 patients, 94 had neuropathologically confirmed AD, yielding a prevalence of 71%. The clinical diagnosis alone yielded a sensitivity of 84%, an estimated specificity of 50%, and positive and negative predictive values of 81% and 56%, respectively. The presence of an epsilon4 allele alone was associated with an estimated sensitivity of 59%, specificity of 71%, and positive and negative predictive values of 83% and 41%, respectively. Using the presence of clinical AD and an epsilon4 allele decreased the sensitivity to 49% and increased the specificity to 84%. The positive and negative predictive values were 88% and 40%, respectively. Alternatively, the clinical diagnosis of AD or the presence of an epsilon4 allele in individuals not meeting clinical criteria for AD increases the estimated sensitivity to 94% but decreases the specificity to 37%. The positive and negative predictive values were 79% and 70%, respectively. The changes in the sensitivity and specificity for the combined tests relative to clinical diagnosis alone offset each other. For lower prevalence communities, the positive predictive value will be much lower than those observed herein. CONCLUSIONS: Our findings do not support the use of APOE genotyping alone in the diagnosis of AD in the general medical community. Although the presence of an epsilon4 allele in older persons with clinical AD increased the probability of having AD and the absence of an epsilon4 allele in this group decreased the probability of having AD, the association is not strong enough in the differential diagnosis of non-Alzheimer dementia and AD.

Aged↗
PubMed1999

A preliminary statistical examination of the effects of uncertainty and variability on environmental regulatory criteria for ozone.

Basing the quantitative expression of environmental regulatory standards and associated compliance criteria on statistical principles has recently received attention in Europe, most visibly in a study by the UK Royal Commission on Environmental Pollution. These issues are timely for consideration in the USA, where a recent periodic review of National Ambient Air Quality Standards (NAAQS) has led to revision of the regulatory standards for ambient ozone and particulate matter. Salient statistical issues include accounting for errors of the first and second kind due to sampling and measurement error. These issues appear routine statistically and also may seem absent from regulations, but neither is necessarily the case. This paper is directed towards developing a methodology for examining the problem of dealing with uncertainty and variation in environmental regulations and compliance criteria. Our approach is illustrated through statistical analysis of the (old) 1 hour and the (new) 8 hour standards for ambient ozone, based on intensive monitoring in California's San Joaquin Valley during summer 1990 performed under the SARMAP Project. This paper presents preliminary findings based on quantifying measurement error or precision in terms of small-scale spatial and temporal variability, laying the groundwork for future work.

Air Pollutants↗
PubMed1999

Effect of circumcision on incidence of human immunodeficiency virus type 1 and other sexually transmitted diseases: a prospective cohort study of trucking company employees in Kenya.

To determine the effect of circumcision status on acquisition of human immunodeficiency virus (HIV) type 1 and other sexually transmitted diseases, a prospective cohort study of 746 HIV-1-seronegative trucking company employees was conducted in Mombasa, Kenya. During the course of follow-up, 43 men acquired HIV-1 antibodies, yielding an annual incidence of 3.0%. The annual incidences of genital ulcers and urethritis were 4.2% and 15.5%, respectively. In multivariate analysis, after controlling for demographic and behavioral variables, uncircumcised status was an independent risk factor for HIV-1 infection (hazard rate ratio [HRR=4.0; 95% confidence interval [CI], 1.9-8.3) and genital ulcer disease (HRR=2.5; 95% CI, 1.1-5.3). Circumcision status had no effect on the acquisition of urethral infections and genital warts. In this prospective cohort of trucking company employees, uncircumcised status was associated with increased risk of HIV-1 infection and genital ulcer disease, and these effects remained after controlling for potential confounders.

Adolescent↗