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PubMed2003

The effects of higher hemoglobin levels on mortality and hospitalization in hemodialysis patients.

BACKGROUND: The introduction of recombinant human erythropoietin for the treatment of anemia of chronic renal failure provided the opportunity to correct anemia in this patient population. The optimal target hemoglobin for patients with end-stage renal disease (ESRD) remains controversial. A large database of hemodialysis patients was analyzed to determine whether increasing hemoglobin level above the current Kidney Dialysis Outcomes Quality Initiative (K/DOQI) recommendations was associated with increased risk of mortality and hospitalization. METHODS: A longitudinal study of hemodialysis patients in Fresenius Medical Care-North America facilities was performed. Selection was restricted to patients in the census for 6 consecutive months from July 1, 1998 through June 30, 2000. Patient mean hemoglobin and other covariates measured during the initial 6 months were related to survival, number of hospitalizations, and length of stay over the subsequent 6 months of follow-up. RESULTS: Patients with hemoglobin <9 g/dL had an adjusted relative risk of death of 2.11 compared to those patients with 11 </= hemoglobin < 12 g/dL (P < 0.0001). The adjusted relative risk of death was 0.84 for 12 </= hemoglobin < 13 g/dL (P = 0.007). These data suggest there is no increased risk of mortality associated with hemoglobin above the current recommended values. Both number of hospitalizations and length of stay decreased as hemoglobin increased. Patients with hemoglobin >/=13 g/dL had an adjusted length of stay of 9.6 days compared to 10.9 days for those with 11 </= hemoglobin < 12 g/dL (P < 0.0001). CONCLUSION: These data indicate the relative risk of death and hospitalization are inversely associated with hemoglobin levels, with no apparent additional risk associated with hemoglobin levels> 12 g/dL.

Adult↗
PubMed2003

Using publicly available directories to trace survey nonresponders and calculate adjusted response rates.

In population-based surveys, sample lists are often out of date by the time data collection begins. Consequently, response rates, and the perceived validity of the survey, may be compromised by the unknowing inclusion of ineligible subjects. A strategy to address this issue is ascertainment of survey nonrespondents' eligibility status, enabling post hoc adjustment of response rates. In 1995-1996, population surveys were carried out in two Ontario, Canada, communities. Despite intensive follow-up, the status of 8949 (18.6%) of the 48218 potential subjects in these surveys remained unknown. In response, 500 "unknowns" from each community were randomly selected for tracing by using publicly available telephone directories and, where applicable, city directories. These tracing efforts classified persons into one of three groups: "ineligible" (moved before the mailing), "true nonresponder" (present when the survey was mailed), and "remains unknown" (no directory listing found). Publicly available directories clarified the status of 76.0% of potential participants, reducing the proportion of "unknowns" from 18.6% to 4.6%. Applying the estimated proportions of "ineligibles" from each area resulted in response rates adjusted from 63.8% to 71.2% and from 72.8% to 74.9% in the survey areas. Publicly available directories were used to successfully trace the majority of survey nonresponders, thus strengthening confidence in the survey's results.

Aged↗
PubMed2006

Organizational characteristics associated with staff turnover in nursing homes.

PURPOSE: The association between certified nurse aide, licensed practical nurse, and registered nurse turnover and the organizational characteristics of nursing homes are examined. DESIGN AND METHODS: Hypotheses for eight organizational characteristics are examined (staffing levels, top management turnover, resident case mix, facility quality, ownership, chain membership, size, and Medicaid census), using Online Survey, Certification, and Reporting (known as OSCAR) data. Turnover information came from primary data collected from 854 facilities in six states (Missouri, Texas, Connecticut, New York, Pennsylvania, and New Jersey). RESULTS: The 1-year turnover rates were 56.4%, 39.7%, and 35.8% for certified nurse aides, licensed practical nurses, and registered nurses, respectively. The results consistently show that, for all caregivers, lower staffing levels, lower quality, for-profit ownership, and higher bed size are associated with higher turnover. Some differences also are found for different levels of turnover, but there are few differences among types of nursing staff. IMPLICATIONS: Given that turnover rates are problematic, this study gives us a better understanding of the phenomenon and at the same time helps us further understand the wide variation that is known to exist between nursing homes, based on their organizational characteristics.

Aged↗
PubMed1995

Preparing for health care reform and an LCME site visit: addressing the generalist-non-generalist imbalance.

PURPOSE: The purpose of the present study was to evaluate primary care outcomes for the Loma Linda University School of Medicine (LLUSM), using Association of American Medical Colleges (AAMC) data files. The two principal objectives were to estimate the percentages of LLUSM graduates who are practicing or will practice primary care medicine and to determine what information available on application to LLUSM is useful in predicting graduates' specialty choices (i.e., primary versus non-primary care). METHOD: In 1993-94 data were taken from several AAMC data files (available to all medical schools), including the Graduate Medical Education (GME) Tracking Census and the American Medical College Application Service (AMCAS) Applicant Master File. The second and fourth years after graduation were used as points of evaluation. Primary care (generalist) was defined as taking or having completed a residency in family practice, internal medicine, or pediatrics, and not having taken any fellowship training. RESULTS: Fourth year after graduation: 42.4% of the 1,064 LLUSM graduates (1983 to 1990) were training in or had completed residencies in family practice (19.8%), internal medicine (16.2%), or pediatrics (6.4%). Second year of GME: of the 1,365 LLUSM graduates (1983 to 1992), 49.3% were in the primary care pipeline (19.8% in family practice, 21.9% in internal medicine, and 7.6% in pediatrics). Two variables available on admission to medical school were associated with being in the primary care pipeline (second-year GME generalist): being a woman and being a member of a non-underrepresented minority. One variable was associated with being in the non-primary care pipeline: having a rural county code. Undergraduate grades and Medical College Admission Test scores were not good predictors. CONCLUSION: The AAMC data files, available to all medical schools, are useful for estimating and evaluating primary care outcomes.

Career Choice↗
PubMed1997

Recent upturn in mortality in rural Zimbabwe: evidence for an early demographic impact of HIV-1 infection?

OBJECTIVES: To describe recent mortality trends in rural Zimbabwe and to assess the impact of HIV-1 infection. METHOD: Comparative, cross-sectional, retrospective, demographic survey with 1-year follow-up. Parallel HIV-1 surveillance. Comparison of results with 1992 national census and vital registration data and results from mathematical model-based population projections. SETTING AND PARTICIPANTS: Residents of 929 (745 revisited in 1995) households in two rural areas of Manicaland Province, Zimbabwe, with contrasting HIV-1 prevalence: Honde and Rusitu valleys. Subjects gave information on parental survival for 2320 resident children. Female residents aged 13-49 years (n = 1237) provided information on birth histories and child survival. Consenting women attending local antenatal clinics (n = 487) provided blood samples for HIV-1 screening and demographic information. MAIN OUTCOME MEASURES: HIV-1 prevalence in pregnant women; per capita death registration rates; incidence of parental death for children aged under 8 years; infant mortality and age-specific death probabilities. RESULTS: HIV-1 prevalence was high in each study area. Death registration and age-specific mortality have begun to rise. The largest increases were seen in the area of higher HIV-1 prevalence (Honde) and among younger adults, particularly men. Incidence of parental death was observed to be rising. Increases in registered deaths were concentrated among HIV-1-associated causes. CONCLUSIONS: The observed increases in mortality by age, sex and cause of death were consistent with those expected early in a severe HIV-1 epidemic, on the basis of mathematical model projections and observations elsewhere in Africa. Further rises in mortality, particularly among women and young children, and consequent increases in orphanhood, are to be expected in rural areas of Zimbabwe.

Adolescent↗
PubMed1995

Using a Standard Staffing Index to allocate nursing staff.

The Standard Staffing Index (SSI) was established as a method to determine unit staffing needs and allocate staff effectively. Daily staffing is based on the SSI, the average patient acuity, and the unit census. This has resulted in time savings to determine staffing needs and accurate monitoring of staffing patterns and productivity by nurse managers. The SSI is based on specific patient needs as determined by regular evaluations and audits.

Academic Medical Centers↗
PubMed2003

Dioxin emissions from a solid waste incinerator and risk of non-Hodgkin lymphoma.

BACKGROUND: It is not clear whether low environmental doses of dioxin affect the general population. We previously detected a cluster of patients with non-Hodgkin lymphoma around a French municipal solid waste incinerator with high dioxin emissions. To explore the environmental route suggested by these findings, we carried out a population-based case-control study in the same area. METHODS: We compared 222 incident cases of non-Hodgkin lymphoma diagnosed between 1980 and 1995 and controls randomly selected from the 1990 population census, using a 10-to-1 match. Dioxin ground-level concentrations were modeled with a second-generation Gaussian-type dispersion model, yielding four dioxin exposure categories. The latter were linked to individual places of residence, using Geographic Information System technology. RESULTS: The risk of developing non-Hodgkin lymphoma was 2.3 times higher (95% confidence interval = 1.4-3.8) among individuals living in the area with the highest dioxin concentration than among those living in the area with the lowest dioxin concentration. No increased risk was found for the intermediate dioxin exposure categories. Adjustment for a wide range of socioeconomic characteristics at the block group level did not alter the results. CONCLUSION: Although emissions from incinerators are usually not regarded as an important source of exposure to dioxins compared with other background sources, our findings support the hypothesis that environmental dioxins increase the risk of non-Hodgkin lymphoma among the population living in the vicinity of a municipal solid waste incinerator.

Adolescent↗
PubMed2006

What are children's trusts? Early findings from a national survey.

BACKGROUND: The Children Act 2004 and National Service Framework for Children, Young People and Maternity Services require fuller integration of health, education and social services for children and young people in England and Wales. The UK government supported the establishment of 35 experimental children's trust pathfinders (henceforth called children's trusts) in England. METHODS: A questionnaire was completed by managers in all 35 children's trusts a year after their start. Children's trust documents were examined. Census and performance indicators were compared between children's trust areas and the rest of England. RESULTS: Children's trust areas had demographic and social characteristics typical of England. All children's trusts aimed to improve health, education and social services by greater managerial and service integration. All had boards representing the three sectors; other agencies' representation varied. Two-thirds of children's trusts had moved towards pooling budgets in at least some service areas. At this stage in their development, some had prioritized joint procurement or provision of services, with formal managerial structures, while others favoured an informal strategic planning, co-ordination and information sharing approach. The commonest priorities for services development were for disabled children (16 children's trusts), followed by early intervention (11) and mental health services (8). CONCLUSIONS: The diverse strategies adopted by these 35 children's trusts during their first year is due to their own characteristics and to the way government strategy developed during this period. Whilst some prioritized organizational development, joint financing and commissioning, and information sharing, others laid more emphasis on mechanisms for bringing front-line professionals closer together. Their experiences are of value to others deciding how best to integrate children's services.

Adolescent↗
PubMed2001

Increasingly inequitable distribution of general practitioners in Australia, 1986-96.

OBJECTIVE: To document trends in the distribution of general practitioners (GPs) in Australia between 1986 and 1996, adjusted for community need. METHODS: Data on the location of GPs, population size and crude mortality in statistical divisions (SD) were obtained from the Australian Bureau of Statistics Census of Population and Housing in 1986 and 1996. From these data, we calculated measures of distribution equality (number of people sharing each GP in each SD) and distribution equity (number of people sharing each GP divided by the crude mortality rate; the Robin Hood Index), and analysed temporal changes in the distribution of GPs. RESULTS: Nationally, the number of people sharing each GP fell 11% from 1,038 in 1986 to 921 in 1996. However, in 41 of 57 SDs (72%, p=0.01) the number of people sharing a GP actually increased over this time, and the average Robin Hood Index across SDs fell from 0.943 to 0.783 (p=0.004), indicating increasingly inequitable distribution. Comparing the Robin Hood Index values of all SDs ranked in pairs, the value fell in 53 of 57 (93%, p<0.001) paired SDs over the decade. These patterns demonstrate increasing inequity over the decade. The number of people sharing each GP was consistently and substantially lower in the capital city SDs and the Robin Hood Index values were consistently and substantially higher (overserved) compared with country SDs. CONCLUSIONS: Despite there being more GPs per capita in Australia, their distribution became increasingly unequal and inequitable between 1986 and 1996, such that rural and remote areas became increasingly poorly served.

Australia↗
PubMed2004

Exploring neighborhood-level variation in asthma and other respiratory diseases: the contribution of neighborhood social context.

OBJECTIVE: We explore differences in the prevalence of asthma and other respiratory diseases at the neighborhood level. In addition to traditional metrics of neighborhood structure (e.g., concentrated disadvantage, residential stability), we incorporate residents' evaluations of neighborhood context. We examine the extent to which indicators such as disorder (observable signs of physical and social decay) and collective efficacy (trust and shared expectations for beneficial community action) account for differences in the prevalence of asthma and other respiratory diseases. METHODS: We examine 338 Chicago neighborhoods, combining 3 data sources from the 1990s: 1) the Metropolitan Chicago Information Center Metro Survey; 2) the Decennial Census; and 3) the Project on Human Development in Chicago Neighborhoods Community Survey. We use a multilevel statistical approach to disentangle neighborhood- from individual-level effects. MEASUREMENTS: A survey-based response to whether a physician has diagnosed asthma, bronchitis, emphysema, or other breathing problems. RESULTS: Findings indicate that individual- and neighborhood-level factors are associated with asthma/breathing problems. At the individual level, female gender, smoking, and a weight problem are positively associated with asthma/breathing problems, while Latino ethnicity is protective. At the neighborhood level, collective efficacy is protective against asthma/breathing problems. Residential stability is positively associated only when levels of collective efficacy are controlled. CONCLUSIONS: Neighborhood context, particularly collective efficacy, may be an underlying factor that reduces vulnerability to asthma and other respiratory diseases. Collective efficacy may enhance the ability to garner health-relevant resources, eliminate environmental hazards that trigger asthma, and promote communication among residents which, in turn, enables dissemination of information relevant to respiratory ailments.

Adult↗
PubMed1996

Cognitive deficits in presumed minor head-injured patients.

OBJECTIVE: To determine the frequency of cognitive deficits in ED patients with presumed minor head injury and to identify factors in the initial history and physical examination predictive of cognitive deficits in these patients. METHODS: A prospective clinical study was performed over a nine-month period at a large community-based ED (60,000 patient annual census). Consecutive patients between 16 and 50 years of age who presented to the ED with a history of blunt trauma or a deceleration injury to the head and a Glasgow Coma Scale (GCS) score of 14 or 15 were included. Patients who were admitted to the hospital or who had an abnormal imaging study of the skull or brain also were excluded. Detailed history and physical examination findings were collected using a standardized data form. Cognitive testing was done at one week postinjury (Halstead-Reitan Neuropsychological Test Battery). RESULTS: Seventy patients were originally entered into the study, and 36 completed the follow-up. Those completing the study were more commonly employed and less likely to have used sensorium-altering drugs or ethanol. Of the 36 patients who completed the study, 42% had either mild or moderate cognitive deficits at one week postinjury. Abnormal cerebellar function during the initial visit was associated with the presence of cognitive deficits at follow-up (p = 0.004). However, only four of 15 (27%; 95% CI 8-55%) patients with a cognitive deficit had an abnormal cerebellar finding. CONCLUSION: Many patients with minor head injuries have cognitive deficits one week after injury. History and physical examination features are poor predictors of these deficits. Further studies are needed to evaluate the duration and final outcome of these cognitive deficits.

Adolescent↗
PubMed2006

Modeling the mental health workforce in Washington State: using state licensing data to examine provider supply in rural and urban areas.

CONTEXT: Ensuring an adequate mental health provider supply in rural and urban areas requires accessible methods of identifying provider types, practice locations, and practice productivity. PURPOSE: To identify mental health shortage areas using existing licensing and survey data. METHODS: The 1998-1999 Washington State Department of Health files on credentialed health professionals linked with results of a licensure renewal survey, 1990 US Census data, and the results of the 1990-1992 National Comorbidity Survey were used to calculate supply and requirements for mental health services in 2 types of geographic units in Washington state-61 rural and urban core health service areas and 13 larger mental health regions. Both the number of 9 types of mental health professionals and their full-time equivalents (FTEs) per 100,000 population measured supply in the health service areas and mental health regions. FINDINGS: Notable shortages of mental health providers existed throughout the state, especially in rural areas. Urban areas had 3 times the psychiatrist FTEs per 100,000 and more than 1.5 times the nonpsychiatrist mental health provider FTEs per 100,000 as rural areas. More than 80% of rural health service areas had at least 10% fewer psychiatrist FTEs and nonpsychiatrist mental health provider FTEs than the state ratio (10.4 FTEs per 100,000 and 306.5 FTEs per 100,000, respectively). Ten of the 13 mental health regions were more than 10% below the state ratio of psychiatrist FTEs per 100,000. CONCLUSIONS: States gathering a minimum database at licensure renewal can identify area-specific mental health care shortages for use in program planning.

Geography↗
PubMed2001

Oral cancer knowledge and opinions among Maryland nurse practitioners.

OBJECTIVES: As part of a Maryland statewide oral cancer needs assessment, a census of adult and family practice nurse practitioners was conducted to determine their knowledge of oral cancer risk factors, diagnostic procedures and related opinions. METHODS: Information was obtained through a pretested, 40-item, self-administered mail questionnaire of 389 nurse practitioners. A second complete mailing was sent three weeks after the initial mailing; two postal card reminders were mailed at 10 and 17 days after the second mailing, which yielded a response rate of 56 percent. RESULTS: Most nurse practitioners identified the use of tobacco, alcohol, and prior oral cancer lesions as real risk factors. But only 35 percent identified exposure to the sun as a risk for lip cancer. Respondents were not overly knowledgeable about the early signs of oral cancer, most common forms, or sites for oral cancer. Only 19 percent believed their knowledge of oral cancer was current. Nurse practitioners who reported having a continuing education course on oral cancer within the past two to five years were 3.1 times more likely to have a high score on knowledge of risk factors and 2.9 times more likely to have a high score on knowledge of both risk factors and of diagnostic procedures than were those who had never had a continuing education course. CONCLUSIONS: The reported knowledge of oral cancer, in conjunction with opinions about level of knowledge and training, point to a need for systematic educational updates in oral cancer prevention and early detection.

Adult↗
PubMed2006

The risk for multiple sclerosis in female nurse anaesthetists: a register based study.

BACKGROUND: Previous studies have suggested that exposure to organic solvents, including volatile anaesthetic agents, may be a risk factor for multiple sclerosis (MS), possibly in combination with genetic and other environmental factors. AIMS: To further investigate the role of volatile anaesthetic agents having similar acute toxic effects to other organic solvents. METHODS: Female nurse anaesthetists, other female nurses, and female teachers from middle and upper compulsory school levels were identified and retrieved from the 1985 census, Statistics Sweden. By means of the unique personal identity number in Sweden, these individuals were linked with the disability pension registers at The National Social Insurance Board and also with data on hospital care 1985-2000 at The National Board of Health and Welfare. RESULTS: The cumulative incidence rate ratio of MS was found to be increased in female nurse anaesthetists in relation to other nurses (statistically not significant) and teachers (statistically significant), respectively. CONCLUSIONS: These findings give some support to previous findings of an increased risk for MS in nurse anaesthetists. This is interesting in the context of previous observations of organic solvents in general as a potential risk factor in MS.

Adult↗
PubMedDate not supplied

Differential distribution of risk factors and outcome of acute coronary syndrome in Kuwait: three years' experience.

OBJECTIVE: To compare the distribution of risk factors and clinical outcome of acute coronary syndrome (ACS) between Kuwaiti and other Arab men living in Kuwait. SUBJECTS AND METHODS: The data for this study was collected from the computerized database at the Mubarak Al-Kabeer Hospital, Kuwait and the 1997-2000 census data for the State of Kuwait. 1,329 Arab men (666 Kuwaitis and 663 other Arabs) older than 25 years who were admitted between September 1997 and August 2000 with a diagnosis of ACS were included in the study. RESULTS: The rate of admission for the entire patient population was twofold higher for Kuwaiti (1.68/1,000) than other Arab men (0.72/1,000), (p < 0.001); the mean age of the Kuwaiti men was 56.7 +/- 11.9 years and other Arab men 53.0 +/- 10.5 years (p < 0.001). The prevalence of hypertension, diabetes, smoking and hypercholesterolemia for Kuwaiti men was 35.9, 56.9, 51.7 and 36.2%, respectively; the corresponding prevalence for other Arab men was 28.8, 42.7, 68.2 and 32.0%, the difference in the prevalence except for hypercholesterolemia was significant (p < 0.001). In Kuwaiti men younger than 55 years of age, the prevalence of hypertension, diabetes mellitus, smoking and hypercholesterolemia was 26.6, 49.5, 68.6 and 43.3%, respectively; the corresponding values for other Arab men was 22.3, 36.2, 77.7 and 43.3%; the difference in prevalence except for hypertension was significant (p < 0.001). The in-hospital mortality for the whole study was 6.2% (Kuwaiti) and 2.3% (other Arab men; p < 0.001); while that for men younger than 55 years was 2.7% (Kuwaiti) and 0.8% (other Arab men; p < 0.05). CONCLUSION: The rate of admission for the entire patient population with a diagnosis of ACS was twofold higher for Kuwaiti than other Arab men. Among all patients and also those less than 55 years, the prevalence of diabetes mellitus was consistently higher among Kuwaiti than other Arab men thereby probably leading to the higher admission rate and in-hospital mortality.

Adult↗
PubMedDate not supplied

Household and neighborhood contexts of intimate partner violence.

OBJECTIVES: Two sources of contextual risk on the prevalence and severity of intimate partner violence (IPV) are investigated: household economic condition and neighborhood disadvantage. There is debate about whether each context is an independent source of IPV risk and whether risks cumulate over contexts. METHODS: Data from the second wave of the National Survey of Families and Households are combined with tract level data from the 1990 U.S. Census. A sub-sample of co-resident couples with a child aged 5-17 in the household was selected for analysis (n=2,273). IPV is measured in three ways: as any physical violence reported by either partner in the year prior to the survey, as gendered violence in which both partners are identified as aggressors, and as severe violence in terms of injury and frequency. RESULTS: Regardless of how IPV is assessed, couples with IPV are more likely to present a vulnerable economic risk profile and to live in neighborhoods of high disadvantage. When economically vulnerable couples living in advantaged versus disadvantaged neighborhoods are compared, there are no significant differences in rates of IPV, regardless of the measure of IPV that is used. Neighborhood context matters, however, in comparisons among economically advantaged couples: rates of IPV are significantly higher among those in disadvantaged neighborhoods. CONCLUSIONS: The consistency of effect for economic vulnerability and its invariance across neighborhood settings suggests that reducing economic vulnerability is likely to have beneficial effects in both disadvantaged and non-disadvantaged neighborhoods.

Adolescent↗
PubMedDate not supplied

Counting women's work in the agricultural census of Nepal: a report.

Like many national statistical surveys, the Agricultural Census of Nepal does not reflect the actual contribution of women's work in agriculture. Inadequacies in conceptualization, definition of terms and data gathering methods result in undervaluation and underrepresentation of women's work. This study of 124 Newar households in the Lubhu Village Development Committee, Kathmandu Valley, provides a statistical representation of women's roles in agricultural operations and household activities by assessing the actual extent of their work. After analyzing the gender division of labor, the study concludes that women's work in agriculture and household activities is significantly higher than men's work.

Agriculture↗
PubMed2003

Physical activity, high density lipoprotein cholesterol and other lipids levels, in men and women from the ATTICA study.

BACKGROUND: Physical activity has long been associated with reduced risk of coronary heart disease (CHD). In this work we evaluated the effect of physical activity on lipid levels, in a sample of cardiovascular disease free people. METHODS: The ATTICA study is a population-based cohort that has randomly enrolled 2772 individuals, stratified by age-gender (according to the census 2001), from the greater area of Athens, during 2001-2002. Of them, 1376 were men (45 +/- 12 years old, range: 18-86) and 1396 women (45 +/- 13 years old, range: 18-88). We assessed the relationship between physical activity status (measured in kcal/min expended per day) and several lipids, after taking into account the effect of several characteristics of the participants. RESULTS: 578 (42%) men and 584 (40%) women were classified as physically active. Compared to sedentary physically active women had significantly lower levels of total serum cholesterol (p < 0.05), LDL (p < 0.05) and oxidized LDL cholesterol (p < 0.05), triglycerides (p < 0.05), apolipoprotein B (p < 0.05), and higher levels of HDL cholesterol (p < 0.05) and apolipoprotein A1 (p < 0.05). Similar associations were observed in men, but the benefits did not reach statistical significance. However, when we adjusted for age, smoking habits and body mass index, physical activity was only significantly associated with higher HDL-cholesterol (p < 0.05) and apolipoprotein A1 (p < 0.05) levels, in women, but not in men. CONCLUSIONS: Substantial independent increases in HDL-cholesterol and apolipoprotein A1 concentrations were observed in women, but not in men, in a Mediterranean cohort.

Journal Article↗