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PubMed1987

The impact of long-term therapy by a multidisciplinary team on the education, occupation and marital status of growth hormone deficient patients after termination of therapy.

Forty-two GH deficient patients (14 isolated GH deficiency (IGHD), 28 multiple pituitary hormone deficiencies (MPHD), 23 males and 19 females) were evaluated after termination of hGH therapy and achievement of final height. IGHD patients were found to score higher in intelligence quotients (IQ) than the MPHD patients. The educational and occupational achievements of all patients positively correlated with their IQ level. Three patients achieved only elementary education, 26 completed high school and 13 had higher education. Thirty patients who had completed their education were employed, whereas 12 continued to study. Seventeen of the male patients and five females served in the Army. Eight patients were married and half of the single patients reported having a stable relationship with the opposite sex. The hypopituitary patients did not differ in five out of seven subscales of the human services rehabilitation scale when compared to a normal control group. These results which vary from those previously reported demonstrate the importance of long-term psychosocial counselling initiated at the time of diagnosis as part of the therapeutic approach in hypopituitary patients.

Educational Status↗
PubMed1979

Polygamy and the evolution of human longevity.

An alternative to previous explanations of the rapid increase in man's longevity and intelligence during the several million years of his recent evolution from pre-hominid, clearly shorter-lived and less intelligent, primate ancestors is presented. The general thesis is that a very greatly accelerated rate of incorporation of favorable genes or gene combinations can be achieved in surprisingly few generations among social animals provided that dominant males become the patriarchs of many descendents by virtue of their partial or complete monopoly on available females. The conclusion is that man probably differs from his ancesters of 0.5 to 5 million years ago by many thousands of genes (both structural and regulatory) rather than the dozens or few hundreds that have been postulated on the basis of more classical treatments of selection pressures, gene frequency changes and mutation rates. The concepts developed here formally apply only to two alternative alleles, rather than to groups of genes which segregate independently, or to characters determined by multiple alleles. The appropriate mathematical treatment of the latter real situation is not readily visualized; nor is account taken of the likelihood that different tribes of pre-humans developed different specializations via the above mechanisms which were then (later) combined into an emerging human stock through matings between members of different tribes. The very great variability both in longevity and in intelligence between different races of animals such as dogs, which have been the objects of deliberate genetic selection by humans for particular heritable traits, may parallel our own recent history, even though the selection mechanism (deliberate human selection vs. polygamous dominance) is quite different in the two cases. The onset of civilizations consisting of amalgums between smaller, previously competing tribes, together with the humanitarian responsibilities to each other we share as a species, ironically has probably arrested further evolution of human longevity (and perhaps of intelligence) in the modern world. Possibly even retrogressive changes are occurring, except in those rare sub-populations in which special social and cultural practices tend to favor selective perpetuation of characteristics which are usually viewed as beneficial.

Alleles↗
PubMed1994

Masculinity, femininity, and marital satisfaction: an examination of theoretical models.

This study sought to investigate the relationship between masculinity, femininity, and marital satisfaction. A number of polynomial multiple regression analyses were performed in an effort to determine the validity of six theoretical models linking sex roles to marital satisfaction. These are the femininity model, masculinity model, sex-typed model, additive androgynous model, interactive androgynous model, and curvilinear model. The sample was composed of 117 couples who completed the Bem Sex-Role Inventory (Bem, 1974) and the Dyadic Adjustment Scale (Spanier, 1976). For men, the results showed that marital satisfaction was related to (a) their self-described levels of femininity and masculinity, (b) the level of self-described femininity of their wives, and (c) the presence of feminine qualities as well as a limited optimal level of masculine qualities which they perceived in their wives. For women, marital satisfaction was associated with (a) the number of self-described feminine qualities and (b) the level of masculinity, as well as an optimal level of femininity, which they perceived in their husbands. Furthermore, small actual-ideal discrepancies in levels of masculinity and femininity ascribed to partners constituted reliable predictors of marital satisfaction for both men and women.

Adult↗
PubMed1992

A method for assessing the quality of life of cancer patients: replication of the factor structure.

The psychometric properties of a method of measuring the quality of life of cancer patients based on multiple linear analogue scales have been assessed in a group of 294 patients with breast cancer attending one clinical unit. The method was found to be readily managed by patients although a small number of scales presented difficulties of understanding to patients and difficulties of analysis. The scales distinguished readily between patients of different disease and treatment status. Factor analysis revealed a 5 factor structure which we interpret as relating to physical activities of everyday living, emotional disturbance, alimentary disturbances, appearance and cosmetic problems and a fifth factor which is more difficult to interpret and includes impairment of speech, writing and concentration. We feel the essential factors determining quality of life in cancer patients have been demonstrated in this and our earlier studies and there is now a substantial level of agreement in the factors that have been identified by groups taking quite different approaches. The major factors determining quality of life in cancer patients are now known and should be assessed in clinical research and clinical trials. The method by which they should be assessed is not as yet so clear.

Adult↗
PubMed2002

Male sexual behaviour during wife's pregnancy and postpartum abstinence period in Oyo State, Nigeria.

The traditional proscription against sex for women during pregnancy, and particularly in the postpartum period, in south-west Nigeria leaves many men without sexual access to their wives for extended periods of time. This practice raises the question whether men abstain or seek other sexual partners. A community-based study was conducted using 3,204 married men from randomly selected local government areas of the state. These men had wives who had delivered a baby in the 36 months prior to the study. Information was obtained on their sexual practices before and during pregnancy and the postpartum period. Male sexual networking was not absent outside the pregnancy and the postpartum periods. However, during pregnancy, a higher percentage of men (43.7%) had other partners compared with the period outside pregnancy and postpartum (42.1%). The difference was not significant (p>0.05). Similarly, in the postpartum abstinence period, more men (48%) had other sexual partners when compared with the period outside pregnancy and postpartum (42.1%; p<0.001). Sexual networking with non-regular and multiple partners was also more commonly observed in the postpartum period than in pregnancy (11.9% vs 10.4%; p<0.05). Significantly more rural than urban men had multiple sexual partners when their wife was pregnant (p=0.01) or in postpartum abstinence (p<0.05). Condom use with regular partners was largely absent, and consistent condom use with extramarital partners was very low among urban and rural men (6.3% vs 1.7%). The vast majority of men were having unprotected vaginal sex. Logistic regression analysis showed that polygamous men, those under 30 years in the urban area, and men with low or no education were more likely to have sex with other women when their wife was pregnant. During a wife's postpartum abstinence period, men in higher status occupations, younger urban men (<49 years), those with more children, the polygamous, and men with a first wife under 40 years in urban area were more likely to have other partners. In light of the heterosexual mode of HIV transmission in Nigeria, there is a dire need to design and implement an intervention programme targeted at married men, which takes into consideration cultural practices. This will hopefully help check the course of the disease in a country thought to be on the verge of an HIV epidemic.

Age Distribution↗
PubMed1992

What do cancer patients' spouses know about the patients?

A large body of research shows that social support in general and of family members in particular plays an important role in determining cancer patients' quality of life. We assumed that the spouse's information about how the patient experiences the situation determines the spouse's ability to help. The present study was designed to examine how much the spouse knows about the attitudes and experiences of their husband or wife who is a cancer patient, and whether this knowledge depends on the questions' structure, disease duration, its severity, or level of patient's information about the disease and prognosis. A questionnaire with multiple-choice and open-ended questions assessing 13 domains (e.g., fears and worries concerning health, functioning in the family, and anxiety) was administered to patients and their partners. Subjects were 55 head-and-neck cancer patients, 40 men and 15 women, with disease stages I to IV, grade of tumors G1 to G3-4, and disease duration of 0.5 to 21 years. The results showed that correspondence between the patients' and their spouses' responses was very low, and was not affected by the structure of the questions or the disease's duration and severity. Correspondence was high only in patients informed about their disease. In the discussion, it was pointed out that when the patient is informed, communication channels in the family are opened and this brings about an increase in the spouses's information about the patient and hence in the spouse's ability to provide the patient the needed social support as a psychotherapeutic agent and a friend. The cancer nurse may play a crucial role in instituting the patient-spouse dialogue.

Adult↗
PubMedDate not supplied

Couples' adjustment to breast cancer and benign breast disease: a longitudinal analysis.

A comprehensive comparison of couples' adjustment to benign (n = 73 couples) and malignant breast disease (n = 58 couples) at the time of diagnosis and at two follow-up assessments at 60 days and 1 year is reported. Specific objectives were to: (a) compare the concurrent stress, resources, appraisal, and patterns of adjustment of couples in the benign and malignant groups; (b) compare the psychosocial responses of patients versus spouses; and (c) determine the amount of correspondence in levels of adjustment reported by patients and their husbands over time. Multiple instruments with reported reliability and validity were used to measure study variables: Smilkstein Stress Scale, Dyadic Adjustment Scale, Family APGAR, Social Support Questionnaire, Mishel Uncertainty in Illness Scale, Beck Hopelessness Scale, Brief Symptom Inventory, and Psychosocial Adjustment to Illness Scale. Mixed design analyses of covariance (ANCOVA) were used to assess differences between and among couples and examine changes in study variables over time. Significant differences were found in the resources, appraisal, and patterns of adjustment reported by couples in the benign and malignant groups. Couples facing breast cancer reported greater decreases in their marital and family functioning, more uncertain appraisals, and more adjustment problems associated with the illness. In addition, there was a high degree of correspondence between the levels of adjustment reported by women with breast cancer and their husbands over time. Couples who reported high distress or a high number of role problems at diagnosis were likely to remain highly distressed at 60 days and 1 year. Study findings underscore the importance of assisting couples, not just patients, to manage the adjustment difficulties associated with breast cancer.

Adaptation, Psychological↗
PubMed2002

Women who marry men with alcohol-use disorders.

BACKGROUND: Women who marry men with alcohol-use disorders (AUDs) might have unique characteristics that could affect the clinical course of their partner's AUD and the risk for problems in the offspring. Most data available on spouses of such men come from subjects in treatment, which might bias results to more severely impaired individuals. Our data were gathered as part of a prospective study of an original sample of 453 sons of alcoholics and controls who were originally selected as students or nonacademic staff at a university. METHODS: Personal interviews were performed with 327 women who were married to men who had been personally evaluated on multiple occasions over the prior 15 years. The data compare characteristics of the 235 women (71.9%) whose husbands had never developed alcohol abuse and dependence with the 92 (28.1%) for whom these disorders had been documented. RESULTS: The women who married men with an AUD were less likely to be homemakers, were more likely to meet criteria for alcoholism (especially abuse) themselves, were more likely to report use of illicit substances, and to be current smokers. However, spouses of men with AUDs in this highly functional sample had no higher risk for other major psychiatric disorders and did not report a higher rate of alcohol abuse or dependence or psychiatric conditions in their parents. CONCLUSIONS: The results demonstrate increased risks for the use of illicit substances and for AUDs in women married to alcoholics, despite the overall high level of functioning of the sample. This information may be relevant to enhancing our understanding of the environment in which their offspring are being raised. The descriptive aspects of the work might also help researchers and clinicians working with alcoholic families.

Adult↗
PubMed2001

Relationship functioning and home and work demands predict individual differences in diurnal cortisol patterns in women.

In 70 middle-class mothers of 2-year-old children, individual differences in mothers' morning cortisol levels, cortisol decreases across the day and average cortisol levels were predicted from demographic and medical control variables, maternal relationship functioning and home and work demands. For two days, salivary cortisol levels were measured in the morning immediately after wakeup, four times in the afternoon, and in the evening immediately prior to bedtime. Hierarchical linear modeling (HLM) growth curve analyses were used to estimate the intercept (early morning level), slope (steepness of decline in cortisol values across the day), and the average height of each mother's cortisol curve across the waking hours. HLM and multiple regression techniques were then used to predict individual differences in these parameters from the variables of interest. Time of day accounted for 72% of the variation in mothers' observed cortisol values across the day. After controlling for demographic and medical variables, positive relationship functioning was associated with higher morning cortisol levels and a steeper decline in cortisol across the day, while greater hours of maternal employment and a greater number of children in the household were associated with lower morning cortisol values and a less steep decline in cortisol levels across the day. Variables predicting higher morning values also predicted higher average cortisol levels, while variables predicting lower morning cortisol predicted lower average cortisol levels. The full model including selected control, relationship functioning and home and work demand variables accounted for 40% of the variance in mothers' morning cortisol values, 43% of the variance in cortisol slopes and 35% of the variability in mothers' average cortisol levels. This study presents the first evidence of associations between psychological variables and individual differences in the organization of cortisol levels across the waking day in normal adult women.

Adaptation, Psychological↗
PubMed2002

Interparental conflict and risk behaviors among Mexican American adolescents: a cognitive-emotional model.

This study used a cognitive-emotional model to examine the relations between multiple dimensions of interparental conflict and health risk behaviors among young adolescents. Participants were 151 Mexican American adolescents and their parents. At initial individual interviews, parents reported on conflict with their spouses, and adolescents reported on their parents' conflict, their appraisals of the conflict, their emotional distress, and their acculturation level. At 6-month follow-ups, adolescents reported on their risk behaviors, including substance use and sexual activity. In general, adolescents' acculturation level was not related to their risk behaviors. More frequent conflict, more conflict about the adolescent, more adolescent involvement in the conflict, and poor conflict resolution were related to greater emotional distress. More conflict about the adolescent, mothers being more demanding/dominating during conflict, and more adolescent involvement in the conflict were related to greater risk behaviors. Adolescents' cognitions mediated the link between two dimensions of parental conflict, frequency and resolution, and emotional distress. Adolescents' emotional distress mediated the association between adolescent involvement in parental conflict and adolescents' risk behaviors.

Acculturation↗
PubMedDate not supplied

Regional differences in stroke mortality and alcohol consumption in Japan.

The relationship between alcohol consumption and stroke mortality in 1975 in 46 prefectures of Japan was investigated. This was done by adjusting salt intake and several socio-economic factors, i.e., the annual per capita income, the number of persons who received public aid, the number of tatamis (a Japanese traditional floor unit) per household, the unemployment rate, and the unmarried or divorce rate, using a stepwise multiple regression analysis. As dependent variables, the sex-specific and age-adjusted mortality for the middle-aged (35-59 years) and for all ages due to stroke were used. For men, alcohol consumption was significantly related to age-adjusted stroke mortalities for the middle-aged and for all ages independent of salt intake and several socio-economic factors. Alcohol consumption was more strongly related to age-adjusted stroke mortality for the middle-aged than for all ages. For women alcohol was weakly correlated with the stroke mortality of the middle-aged. Salt intake was significantly correlated with stroke mortality for women but not for men. Furthermore, the male: female ratios of the age-adjusted stroke mortality for the middle aged and for all ages were analyzed as well, because alcohol is mostly consumed by men in Japan, and it was expected that the sex ratios would be well correlated to alcohol consumption. The results were as expected. Therefore, it was suggested that the regional difference in stroke mortality in Japan may be explained in part by that of alcohol consumption.

Adult↗
PubMed1981

[Psychic attitude of women to irreversible contraception (author's transl)].

Thirty-four of 100 women who had undergone officially sanctioned irreversible contraception at the Gynaecological Department of Wismar Regional Hospital were selected at random for follow-up investigation, two-and-a-half to one year after the intervention. The following psychological tests were taken: a standardised interview based on abridged psychopathological method, Freiburg personality inventory, record of complaints according to Kasielke, and the multiple-choice vocabulary test according to Lienert. Psychiatric examination was added on the basis of a structured psychopathological record system according to Grünes and Kühne. The following results were obtained from the study: All probands exhibited positive attitudes to the method of irreversible contraception. They said they would choose the same option, if they had to were asked again. They recommended the same decision to other women. Inner conflicts because of the irreversible nature of the intervention, problems of selfvalue, and impairment of partnership relations were not reported. Nor did any of the women wish refertilisation. The gynaecological intervention did in no single case turn out as source for neurotic developments or other psychiatrically relevant symptoms. However, the possibility of neurosis must be reckoned with, as it must with any other medical intervention. This risk may be effectively encountered by due consideration of the patient's personality, clarified indication, adequate information, and therapeutic support for the patient's effort to get to grips with the psychic problem. Hence, irreversible contraception can be an alternative, also for its psychic consequences, for women above 35 to whom safe reversible contraceptives cannot be applied for whatever reasons, although they have completed their own family planning.

Adult↗
PubMed1988

The effects of maternal smoking on fetal and infant mortality.

Although maternal cigarette smoking has been shown to reduce the birth weight of an infant, previous findings on the relation between smoking and fetal and infant mortality have been inconsistent. This study used the largest data base ever available (360,000 birth, 2,500 fetal death, and 3,800 infant death certificates for Missouri residents during 1979-1983) to assess the impact of smoking on fetal and infant mortality. Multiple logistic regression was used to estimate the joint effects of maternal smoking, age, parity, education, marital status, and race on total mortality (infant plus fetal deaths). Compared with nonsmoking women having their first birth, women who smoked less than one pack of cigarettes per day had a 25% greater risk of mortality, and those who smoked one or more packs per day had a 56% greater risk. Among women having their second or higher birth, smokers experienced 30% greater mortality than nonsmokers, but there was no difference by amount smoked. The prevalence of smoking in this population was 30%. It was estimated that if all pregnant women stopped smoking, the number of fetal and infant deaths would be reduced by approximately 10%. The higher rate of mortality among blacks compared with whites could not be attributed to differences in smoking or the other four maternal characteristics studied. In fact, the black-white difference was greater among low-risk women (e.g., married multiparas aged 20 and over with high education) than among high-risk women (e.g., unmarried teenagers with low education).

Adolescent↗
PubMed2001

[Weill Marchesani syndrome. Report of a case].

Weill Marchesani syndrome is a congenital disease that combines microspherophakia and skeletal abnormalities. The authors report a 19-year-old male, born of a consanguineous marriage, with a progressive decrease in visual acuity. The general examination showed a squat look, dwarfism, muscle hypertrophy, short hands and feet, and joint stiffness. The ophthalmological examination showed that visual acuity was limited to hand motion in the right eye despite correction and no perception of light in the left eye. Intraocular pressure was 36 mmHg in the right eye and 40 mmHg in the left eye. The anterior chamber was irregular with iridophakodonesis and microspherophakia of both lenses. The zonula was partially ruptured in the right eye. The iridocorneal angle was narrow. Fundus eye examination showed a pale optic disc with an excavation of 9/10 on the right. In the left eye, the optic disc was totally excavated. Cardiovascular check-up revealed rheumatic aortic valvular cardiopathy. The therapy consisted of combined surgery: phakophagia with anterior vitrectomy plus trabeculectomy operated on the right eye. Weill Marchesani syndrome is a rare congenital affection with a recessive autosomal transmission. The visual prognosis is dominated by secondary glaucoma due to pupillary blockage by the mobile eye lens. This observation illustrates the seriousness of spontaneous progression in Weill Marchesani syndrome, justifying the necessity of lens extraction before the onset of complications.

Abnormalities, Multiple↗
PubMed1995

Marital status and health care utilization.

BACKGROUND: Several studies have reported differences in health care utilization by marital status, but usually only controlling for age and sex. Our study aimed at answering the questions: 1) To what extent are differences in health care utilization by marital status due to confounding by socio-demographic variables other than age and sex? and 2) To what extent are these differences due to differences in health status by marital status? METHODS: For the analyses we used the baseline data from the Longitudinal Study on Socio-Economic Differences in the Utilization of Health Services. Our study population consisted of 2662 people from the Netherlands, aged 25-74 years. People with diabetes mellitus, chronic non-specific lung diseases, heart conditions and back complaints were overrepresented. Our measures for health care utilization were general practitioner consultation, specialist consultation, hospital admission and use of prescription medicines. Multiple logistic regression models were used to calculate odds ratios (OR) for health care utilization by marital status, controlling for the socio-demographic variables age, sex, educational level, degree of urbanization, religion and country of birth (question 1), and a number of health indicators (question 2). RESULTS: We found that educational level is an important confounder of the relationship between health care utilization and marital status. In addition differences in health status to a considerable extent explain the higher utilization of health services of widowed and divorced people, but not the lower utilization of the never married. After control for confounding and health status there still were unexplained differences in health care utilization by marital status: e.g. the divorced were more frequently hospitalized (OR = 1.53, 95% CI: 1.03-2.22) than married people. CONCLUSIONS: There are differences in health care utilization by marital status which are not due to confounding by other socio-demographic variables or differences in health status. Further investigation of these differences is necessary, and is likely to benefit from inclusion of socio-psychological variables. Living arrangements should also be included in these future analyses.

Adult↗
PubMed1994

Alzheimer's disease: the impact of the family on spouses, offspring, and inlaws.

This article reports the findings from a study designed to identify qualities of the multigeneration family system that affected the relationship between the demands of Alzheimer's disease on the family and the health and well-being of (a) spouses, (b) offspring, and (c) offspring's spouses or "inlaws." Members of 97 families of patients with Alzheimer's disease, recruited from four University-affiliated Alzheimer's Centers, completed detailed questionnaires and participated in a 45-minute telephone interview to assess care-strain, personal stress, appraisals of three major domains of family life (World View, Structure/Organization, and Emotion Management), and three health and well-being indices (Anxiety/Depression, Somatic Symptoms, and Well-Being). Multivariate multiple regression equations, run separately for each of the three groups of family respondents and each of the three family domains, indicated: (1) no significant associations between the severity of the elder's disease and family member health and well-being; (2) female family members reported poorer health and well-being than male family members; and (3) caregiver strain was negatively associated with family member health and well-being. Further, appraised family qualities were associated with the health and well-being of the three groups of respondents differently: directly for offspring, interactively with severity of patient disorder for inlaws, and not at all for spouses. The data suggested that some family qualities served a protective function, whereas others exacerbated the negative effects of caregiving by affecting personal health and well-being. The findings are interpreted in terms of the different roles and expectations for care-giving placed on spouses, offspring, and inlaws. It is suggested that programs of intervention for patients with Alzheimer's and other chronic diseases should focus on the multigeneration family as the context for care, rather than only on the primary caregiver.

Activities of Daily Living↗
PubMed1992

Low birth weight in relation to multiple induced abortions.

BACKGROUND: Most studies report that a single induced abortion does not increase risk for delivering a low birth weight infant in a subsequent pregnancy. However, the effect of multiple abortions has not been adequately evaluated. METHODS: This relationship was studied in 6541 White women who delivered their first child between 1984 and 1987. We compared the frequencies of low birth weight (less than 2500 g) among infants born to 1999 women without prior induced abortion and 1999 women with one abortion with the frequencies of low birth weight among infants born to women with two (n = 1850), three (n = 520), and four or more (n = 173) prior induced abortions. RESULTS: After adjustment for confounding variables, we found no linear relationship in risk of low birth weight among women with one (relative risk [RR] = 1.2, 95% confidence interval [CI] = 0.9-1.5), two (RR = 1.5, 95% CI = 1.1-2.0), three (RR = 1.3, 95% CI = 0.8-1.9), or four or more (RR = 1.6, 95% CI = 0.9-2.9) prior induced abortions. CONCLUSIONS: These findings confirm earlier reports of little or no evidence of harmful effects on birth weight by one or by two or more induced abortions. We further report that risk is not significantly elevated even in women with three, four, or more prior terminations of pregnancy when compared with women with one or two abortions.

Abortion, Induced↗
PubMed1997

Triplet births: trends and outcomes, 1971-94.

OBJECTIVES: This report describes changes in the number and ratio of live births in triplet and other higher order multiple deliveries from 1971 to 1994 by maternal race, age, education, and marital status. The report also examines the birth outcomes of triplets compared with singletons, including overall gestation specific, and birthweight specific infant mortality rates. METHODS: Birth data are obtained from the U.S. certificates of live birth. Mortality data were obtained from the Linked Birth and Infant Death Data Sets for the 1983-91 birth cohorts. Most analyses are based on triplet and other higher-order multiple births (quadruplet and quintuplet and greater births) in the aggregate. (Triplet births comprise about 92 percent of all higher order multiple births.) Triplet and other higher order birth ratios for most variables are computed by combining data for years 1982-84 and 1992-94, and for infant mortality by combining birth cohorts for years 1987-91. FINDINGS: Between 1971 and 1994 the number and ratio of triplet births quadrupled, rising from 1,034 to 4,594, and from 29.1 to 116.2 per 100,000 live births. Most of the increase was among births to white mothers, particularly among married and more educated mothers. Only about one-third of the increase in triplet birthing among white mothers between 1989 and 1994 could be attributed to changes in the maternal age distribution. Massachusetts reported the highest triplet birth ratio (215.9), more than twice the U.S. ratio (105.5). Other States with comparatively high ratios were New Hampshire, New Jersey, and Iowa. Nine of 10 triplets were born preterm compared with 1 of 10 singletons. The average triplet weighed 1,698 grams at birth, one-half that of the average singleton (3,358 grams). Triplets were about 12 times more likely to die during the first year of life as singletons, but had a survival advantage over singletons at lower gestations and birthweights.

Adult↗