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Biomedical subjects

F D Gilliland

Publications and source records attributed to F D Gilliland.

At least 37 records · Page 2Linked to original sources
PubMed2000

Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study.

CONTEXT: Patients with prostate cancer and their physicians need knowledge of treatment options and their potential complications, but limited data on complications are available in unselected population-based cohorts of patients. OBJECTIVE: To measure changes in urinary and sexual function in men who have undergone radical prostatectomy for clinically localized prostate cancer. DESIGN: The Prostate Cancer Outcomes Study, a population-based longitudinal cohort study with up to 24 months of follow-up. SETTING: Population-based cancer registries in 6 geographic regions of the United States. PARTICIPANTS: A total of 1291 black, white, and Hispanic men aged 39 to 79 years who were diagnosed as having primary prostate cancer between October 1, 1994, and October 31, 1995, and who underwent radical prostatectomy within 6 months of diagnosis for clinically localized disease. MAIN OUTCOME MEASURES: Distribution of and change in urinary and sexual function measures reported by patients at baseline and 6, 12, and 24 months after diagnosis. RESULTS: At 18 or more months following radical prostatectomy, 8.4% of men were incontinent and 59.9% were impotent. Among men who were potent before surgery, the proportion of men reporting impotence at 18 or more months after surgery varied according to whether the procedure was nerve sparing (65.6% of non-nerve-sparing, 58.6% of unilateral, and 56.0% of bilateral nerve-sparing). At 18 or more months after surgery, 41.9% reported that their sexual performance was a moderate-to-large problem. Both sexual and urinary function varied by age (39.0% of men aged <60 years vs 15.3 %-21.7% of older men were potent at > or =18 months [P<.001]; 13.8% of men aged 75-79 years vs 0.7%-3.6% of younger men experienced the highest level of incontinence at > or =18 months [P = .03]), and sexual function also varied by race (38.4% of black men reported firm erections at > or =18 months vs 25.9% of Hispanic and 21.3% of white men; P = .001). CONCLUSIONS: Our study suggests that radical prostatectomy is associated with significant erectile dysfunction and some decline in urinary function. These results may be particularly helpful to community-based physicians and their patients with prostate cancer who face difficult treatment decisions.

Adult↗
PubMed2000

Radon progeny exposure and lung cancer risk among non-smoking uranium miners.

Studies of miners provide the basis for public health efforts to reduce residential radon progeny exposure. Because the preponderance of households do not have members who smoke indoors, studies of non-smoking miners contribute essential data for risk assessments for residential radon progeny exposure. We studied a cohort of 2,209 never-smokers who were underground uranium miners employed in the western U.S. from 1956 to the early 1990's and who participated in a screening program for lung cancer conducted by Saccomanno and colleagues. After determining the vital status and cause of death in the cohort, we conducted a nested case-control study of 55 lung cancer deaths in males and 3 age-matched controls for each case. The relative risk of lung cancer was 29.2 (95% CI 5.1, 167.2) for miners with greater than 1,450 WLM compared with those exposed to less than 80 WLM. Temporal factors affected risk, including average dose rate, which was inversely associated with lung cancer risk, and the length of time since last exposure, which was directly associated with decreased risk. As in studies of non-smokers and smokers combined, the exposure response relationship in never-smokers was consistent with a decreased slope at higher WLM, which resulted, in part, from an inverse dose rate effect.

Adult↗
PubMed2000

Validation study of retrospective recall of disease-targeted function: results from the prostate cancer outcomes study.

OBJECTIVES: This was an ancillary methodological study within the Prostate Cancer Outcomes Study (PCOS) to assess the validity of 6-month retrospective recall of prediagnostic disease-targeted function among men diagnosed with prostate cancer. METHODS: A convenience sample of 133 prostate cancer cases were administered a baseline questionnaire shortly after diagnosis that asked about prediagnostic urinary, sexual, and bowel function. They were surveyed again concerning the same items 6 months later and asked to recall their prediagnostic function. Reports of prediagnostic function obtained at baseline and 6 months are compared, as are measures of change derived from these reports. Percent agreement and weighted kappas are calculated to measure the extent of agreement. RESULTS: Over 70% of the men reported prediagnostic functioning at the highest level on 12 of 17 survey items. For each of these items, recall at 6 months was identical to the baseline survey response for > or =69% of the men. The values of the weighted kappas for changes computed with baseline reports (prospective) and changes computed with 6-month recall (retrospective) ranged from 0.396 to 0.919 for the 17 individual items. Intraclass correlations for the retrospective versus prospective changes in the multi-item function scores were 0.828 for urinary, 0.618 for bowel, and 0.692 for sexual function. CONCLUSIONS: At baseline, men recently diagnosed with prostate cancer report few disease-related problems before diagnosis, and a high percentage of men recall this accurately 6 months later. There is reasonably high agreement between baseline and 6-month estimates of prediagnostic function and between prospective and retrospective measures of change over 6 months.

Aged↗
PubMed2000

Uranium mining and lung cancer among Navajo men in New Mexico and Arizona, 1969 to 1993.

Navajo men who were underground miners have excess risk of lung cancer. To further characterize the long-term consequences of uranium mining in this high-risk population, we examined lung cancer incidence among Navajo men residing in New Mexico and Arizona from 1969 to 1993 and conducted a population-based case-control study to estimate the risk of lung cancer for Navajo uranium miners. Uranium mining contributed substantially to lung cancer among Navajo men over the 25-year period following the end of mining for the Navajo Nation. Sixty-three (67%) of the 94-incident lung cancers among Navajo men occurred in former uranium miners. The relative risk for a history of mining was 28.6 (95% confidence interval, 13.2-61.7). Smoking did not account for the strong relationship between lung cancer and uranium mining. The Navajo experience with uranium mining is a unique example of exposure in a single occupation accounting for the majority of lung cancers in an entire population.

Adult↗
PubMed2000

Maternal smoking during pregnancy, environmental tobacco smoke exposure and childhood lung function.

BACKGROUND: Exposure to environmental tobacco smoke (ETS) during childhood and in utero exposure to maternal smoking are associated with adverse effects on lung growth and development. METHODS: A study was undertaken of the associations between maternal smoking during pregnancy, exposure to ETS, and pulmonary function in 3357 school children residing in 12 Southern California communities. Current and past exposure to household ETS and exposure to maternal smoking in utero were assessed by a self-administered questionnaire completed by parents of 4th, 7th, and 10th grade students in 1993. Standard linear regression techniques were used to estimate the effects of in utero and ETS exposure on lung function, adjusting for age, sex, race, Hispanic ethnicity, height, weight, asthma, personal smoking, and selected household characteristics. RESULTS: In utero exposure to maternal smoking was associated with reduced peak expiratory flow rate (PEFR) (-3.0%, 95% CI -4.4 to -1.4), mean mid expiratory flow (MMEF) (-4.6%, 95% CI -7.0 to -2.3), and forced expiratory flow (FEF(75)) (-6.2%, 95% CI -9.1 to -3.1), but not forced expiratory volume in one second (FEV(1)). Adjusting for household ETS exposure did not substantially change these estimates. The reductions in flows associated with in utero exposure did not significantly vary with sex, race, grade, income, parental education, or personal smoking. Exposure to two or more current household smokers was associated with reduced MMEF (-4.1%, 95% CI -7.6 to -0. 4) and FEF(75) (-4.4%, 95% CI -9.0 to 0.4). Current or past maternal smoking was associated with reductions in PEFR and MMEF; however, after adjustment for in utero exposure, deficits in MMEF and FEF(75) associated with all measurements of ETS were substantially reduced and were not statistically significant. CONCLUSIONS: In utero exposure to maternal smoking is independently associated with decreased lung function in children of school age, especially for small airway flows.

Adolescent↗
PubMed2000

Effects of in utero and environmental tobacco smoke exposure on lung function in boys and girls with and without asthma.

To investigate whether the effects of in utero exposure to maternal smoking and environmental tobacco smoke (ETS) exposure on lung function vary by sex or asthma status, we examined medical history and tobacco smoke exposure data for 5,263 participants in the Children's Health Study. At study enrollment, parents or guardians of each subject completed a questionnaire, and lung function was measured spirometrically with maximum forced expiratory flow-volume maneuvers. To assess the in utero effects of maternal smoking and ETS exposure on lung function, we used regression splines that accounted for the nonlinear relationship between pulmonary function, height, and age. In utero exposure to maternal smoking was independently associated with deficits in lung function that were larger for children with asthma. Boys and girls with a history of in utero exposure to maternal smoking showed deficits in maximum midexpiratory flow (MMEF) and a decrease in the FEV(1)/FVC ratio. As compared with children without asthma, boys with asthma had significantly larger deficits from in utero exposure in FVC, MMEF, and FEV(1)/FVC, and girls with asthma had larger decreases in FEV(1)/FVC. The effect of ETS exposure varied by children's gender and asthma status. Deficits in flows associated with current ETS exposure were present in children with and without asthma but were significant only among children without asthma. Past ETS exposure was associated with reduced FEV(1), MMEF, and FEV(1)/FVC among boys with asthma. In contrast, past ETS exposure was associated with decreased flow rates in girls without asthma. In summary, both in utero exposure to maternal smoking and ETS exposure were associated with persistent deficits in lung function. The effects of in utero exposure were greatest among children with asthma.

Adolescent↗
PubMed2000

The positive yield of imaging studies in the evaluation of men with newly diagnosed prostate cancer: a population based analysis.

PURPOSE: We determine the positive yield of imaging studies performed on men with newly diagnosed prostate cancer. MATERIALS AND METHODS: A prospective, population based survey was conducted on 3,690 men with prostate cancer diagnosed between October 1, 1994 and October 31, 1995. Cases were identified by the rapid case ascertainment systems used in 6 geographic regions participating in the Surveillance, Epidemiology and End Results Program. Based on information captured in primary medical record reviews we estimated the positive yield of bone scans, computerized tomography (CT) and magnetic resonance imaging. RESULTS: The positive yield of bone scan and CT was less than 5% and 12%, respectively, for all men with prostate specific antigen (PSA) 4 to 20 ng./ml., and less than 2% and 9%, respectively, for those who also had a Gleason score of 6 or less. Only men with PSA greater than 50 ng./ml. and those with Gleason scores 8 to 10 and PSA greater than 20 ng./ml. had positive yields greater than 10% and 20% for bone scan and CT, respectively. CONCLUSIONS: Imaging studies designed to identify metastases and/or extracapsular extension in men with newly diagnosed prostate cancer frequently have a low positive yield. Wide variations exist in the use of imaging studies and are associated with tumor factors, such as Gleason score and serum PSA, and nontumor factors, such as state of residence. More extensive cost-effectiveness analyses are needed to define appropriate guidelines for ordering imaging studies to optimize the positive yield among men with newly diagnosed prostate cancer.

Aged↗
PubMed1999

Trends in incidence and treatment for ductal carcinoma in situ in Hispanic, American Indian, and non-Hispanic white women in New Mexico, 1973-1994.

BACKGROUND: Incidence rates of ductal carcinoma in situ (DCIS) breast carcinoma and the use of breast-conserving surgery (BCS) for its treatment show substantial geographic and ethnic variations nationwide. To the authors' knowledge, few studies have investigated incidence rates and treatment patterns in Hispanics and American Indians. METHODS: The authors used data from the population-based New Mexico Tumor Registry to describe trends in DCIS incidence rates between 1973-1994 and investigate patient and physician characteristics related to BCS in a multiethnic population between 1985-1994. Multiple logistic regression was used to evaluate patient and physician factors related to receiving BCS. RESULTS: Incidence rates for DCIS in Hispanics were approximately 50% lower compared with non-Hispanic whites. American Indians had the lowest incidence rate. Beginning in 1985, incidence rates for Hispanics and non-Hispanic whites showed a 21% annual increase. Between 1990-1994, incidence rates in American Indians increased more than twofold. BCS increased 5.8% per year between 1985-1994, with 50% of Hispanic and non-Hispanic white patients treated with BCS in 1994. The strongest factor associated with receiving BCS was geographic location of treatment (P < 0.001). The odds of receiving BCS were 5.8 times higher in the northern third of the state compared with the southern third. No significant variation in BCS was found by ethnicity, rural/urban residency, socioeconomic status, or physician characteristics. CONCLUSIONS: Incidence rates for DCIS increased substantially in all three ethnic groups. The use of BCS was associated most strongly with the location of treatment, most likely reflecting differences in physician practices and treatment recommendations. Further research is needed to investigate the increasing incidence rates of DCIS and the determinants of BCS for the treatment of DCIS.

Adolescent↗
PubMed1999

Preventive health care among rural American Indians in New Mexico.

BACKGROUND: Incidence of and mortality from cardiovascular disease, cancer, diabetes, and other chronic diseases are rapidly increasing among American Indians; however, the utilization of preventive services for these conditions is not well characterized in these ethnic groups. METHODS: We interviewed 1,273 American Indian adults in New Mexico, ages 18 years and older, by telephone regarding routine health checks, including blood pressure, blood cholesterol, mammograms, clinical breast exams, Pap smears, influenza and pneumonia vaccinations, and diabetes using items from the CDC Behavioral Risk Factor Surveillance System. RESULTS: We found that utilization of preventive service was surprisingly high among rural American Indians. Routine health checks and blood pressure checks within the past year were reported by more than 70% of the population. Blood cholesterol checks (41.1%) and pneumonia vaccinations (30.7%) were less commonly reported. Utilization of cancer screening for the most common women's cancers was also high. Most women reported ever having a Pap smear test (88.3%), a clinical breast examination (79.5%), and a mammogram (75.6%). The prevalence of diagnosed diabetes (8.8% overall and 26.4% for ages 50 years and older) greatly exceeds the nationwide prevalence. CONCLUSIONS: The utilization of preventive services delivered by a unique governmental partnership is high among American Indians in New Mexico and, except for cholesterol screening, is comparable with rates for the U.S. population. Because cardiovascular disease is on the rise, more attention to preventive services in this arena is warranted. The high and increasing prevalence of diagnosed diabetes suggests that aggressive diabetes screening and interventions are needed.

Adult↗
PubMed1999

Reduced telomere DNA content is correlated with genomic instability and metastasis in invasive human breast carcinoma.

Telomere shortening leads to genomic instability and has been correlated with poor outcome in several types of cancer. A recently described, robust titration assay was used to quantify telomere DNA content in frozen and paraffin-embedded specimens of 49 invasive human breast carcinomas, including tumors with normal or abnormal contents of genomic DNA, which produced regional, distant, or local disease. Telomere DNA contents ranged from 53% to 370% of the content in a reference DNA purified from normal placenta. Tumors were divided into three groups of approximately equal size based on increasing telomere DNA content. All of 16 tumors in the group with the least telomere DNA (Group I), were aneuploid compared to 9/17 tumors in the group with the most telomere DNA (Group III). The Chi-square test for trend indicated that tumors with the least telomere DNA were significantly more likely to be aneuploid than tumors with the most telomere DNA (p < 0.002). Twelve of 14 tumors in Group I also produced metastatic disease compared to 8/15 tumors in Group III. The Fischer Exact Test indicated that tumors with the least telomere DNA were significantly more likely to be metastatic than tumors with the most telomere DNA (p < 0.05). There was no association between telomere DNA content and patients' age, tumors' size, grade, stage, or fraction of cells in S-phase. The correlation of reduced telomere DNA content with aneuploidy and metastasis, both of which are associated with poor outcome in invasive breast carcinoma, implies that telomere DNA content also could have prognostic value.

Aneuploidy↗
PubMed1999

A population-based survey of prostate cancer testing in New Mexico.

Prostate cancer screening has increased dramatically in the past decade, but few studies have looked at population-based testing rates and the factors that influence testing. The objectives of our study were to estimate prostate cancer testing rates for New Mexican men 50 years or older and to identify patient factors associated with testing. We surveyed men using random-digit dialing. Subjects completed a 32-item questionnaire asking about prostate cancer testing; demographics; cancer knowledge, attitudes, and beliefs; health behaviors; and risks for prostate cancer. Associations between patient factors and testing were analyzed with multivariate logistic regression. Two hundred thirty-nine subjects (36% response rate) completed the survey; 95% had heard of prostate cancer and nearly 90% felt that testing was important. Forty-eight percent had been tested, most within the past year. Significant predictors for testing included receiving regular health care (odds ratio = 2.15, 95% CI = 1.07-4.33), being retired (OR = 2.49, 95 CI = 1.18-5.28), and having been diagnosed with prostatic hyperplasia (OR = 3.14, 95% CI = 1.30-7.59). Prostate cancer testing occurred frequently among New Mexican men. The study variables that were the most significant predictors of testing were all markers for access to health care.

Aged↗
PubMed1999

Effect of spirometer temperature on FEV1 in a longitudinal epidemiological study.

OBJECTIVES: To assess the magnitude of error in pulmonary function measurements introduced by variation in spirometer temperature under field conditions. In a large scale epidemiological study of school children, the influence was investigated of spirometer temperature on forced expiratory volume in 1 second (FEV1) measured with dry rolling seal volumetric spirometers and conventional body temperature, pressure, and saturation (BTPS) corrections. METHODS: Linear regression analyses were performed on data from 995 test-retest pairs on 851 different children, with 1-110 days between test and retest, and spirometer temperature differences between -13 degrees C and +9 degrees C. RESULTS: After adjusting for effects of growth (test-retest intervals) and circadian variation (changes in times of testing), differences in standard BTPS corrected FEV1 showed significant (p < 0.05) dependence on differences in spirometer temperature between tests (-0.24%/degree C). CONCLUSIONS: When spirometer temperatures vary widely, standard BTPS correction does not fully adjust for gas contraction. To improve accuracy of volume measurements in epidemiological studies, additional correction for variation in spirometer temperature should be considered.

Adolescent↗
PubMed1999

A theoretical basis for investigating ambient air pollution and children's respiratory health.

Acute respiratory health effects in children from exposure at current ambient levels of ozone are well documented; however, evidence for acute effects from other criteria pollutants such as nitrogen dioxide and respirable particles is inconsistent. Whether chronic effects result from long-term exposure to any of these pollutants during childhood is an important unresolved question. Establishing whether acute or chronic effects result from childhood exposure and identifying sensitive subgroups may require integration of biologic mechanisms of lung defenses, injury, and response into the study design and statistical models used in analyses. This review explores the theoretical basis for explaining such adverse effects in light of our contemporary understanding of mechanisms of lung injury and response at the cellular and molecular levels. The rapidly evolving understanding of the effects of air pollution on cellular and molecular levels presents an opportunity to develop and refine innovative biologically based hypotheses about the effects of childhood exposure. We hypothesize that children with low fruit and vegetable intake, low antioxidant levels, high polyunsaturated fat intake, or who have inherited certain alleles for genes involved in lung defenses and immune response regulation may be at increased risk for adverse effects. Because responses to air pollutants of interest are complex and involve a number of pathophysiologic processes, the magnitude of main effects of dietary factors, genes, and gene-environment interactions may be modest for individuals; however, each may make an important contribution to the population burden of preventable respiratory diseases.

Air Pollution↗
PubMed1999

Women uranium workers: a case study of perceived hazardous exposures and health effects.

An exploratory study of seventy-four women uranium workers employed in the western United States (miners, millers, truck haulers, and office workers) was conducted. These uranium industry workers were employed primarily during the 1970s and 1980s. It was found that approximately 60 percent perceived overall moderate to high levels of dust during their employment, and about 50 percent reported the likelihood of having past, present, or future health problems related to their uranium work. Two of the most-often-identified health problems were respiratory symptoms or illnesses and cancer. Issues regarding public policy, research, and worker rights are discussed.

Journal Article↗
PubMed1999

Predicting extracapsular extension of prostate cancer in men treated with radical prostatectomy: results from the population based prostate cancer outcomes study.

PURPOSE: We investigated whether clinical information routinely available in community practice could predict extracapsular extension of clinically localized prostate cancer in men undergoing radical prostatectomy. MATERIALS AND METHODS: We examined prostate cancer outcomes in a population based sample of 3,826 patients with primary prostate cancer in 6 regions of the United States covered by the Surveillance, Epidemiology, and End Results program. Stratified and weighted logistic regression was used to identify predictors of and probabilities for extracapsular extension of clinically localized tumors treated with radical prostatectomy. RESULTS: Nearly 47% of men undergoing radical prostatectomy had extraprostatic extension. The strongest predictors were elevated prostate specific antigen (PSA) greater than 20 versus less than 4 ng./ml. (odds ratio 5.88, 95% confidence interval 2.90 to 11.15), Gleason score greater than 8 versus less than 6 (1.73, 1.04 to 2.87) and age greater than 70 versus less than 50 years (1.91, 0.98 to 3.70). Ethnicity and region were not associated with increased risk of extraprostatic extension. A nomogram developed from our model predicts extracapsular extension ranging from 24% in men younger than 50 years with PSA less than 4 ng./ml. and a Gleason score of less than 7 to 85% in those 70 years old or older with PSA greater than 20 ng./ml. and a Gleason score of 8 or more. If prostatectomy were limited to patients with less than 60% probability of extraprostatic extension based on the nomogram, 95% of those with organ confined cancers would undergo definitive surgery and 18% of those with extracapsular extension would be spared the morbidity of surgery. CONCLUSIONS: In a population based analysis of prostate cancer practice patterns PSA, Gleason score and age are clinically useful predictors of extracapsular extension. Although extracapsular extension may be an imperfect predictor of cancer outcomes, our nomogram provides more realistic probabilities for extracapsular extension than those based on institutional series.

Aged↗
PubMed1998

Reproductive risk factors for breast cancer in Hispanic and non-Hispanic white women: the New Mexico Women's Health Study.

The authors conducted a population-based case-control study of breast cancer in Hispanic women in New Mexico. Hispanic and non-Hispanic white women with incident breast cancer, aged 30-74 years and diagnosed between 1992 and 1994, were identified by the New Mexico Tumor Registry. Controls were selected using random digit dialing and frequency matched by ethnicity, age, and region. Information on reproductive history, lactation, and other risk factors was collected through in-person interviews; 719 Hispanics and 836 non-Hispanic whites were included in the analysis. Conditional logistic regression was used to estimate relative risk of breast cancer for reproductive factors and to assess ethnic differences in effects. Older age at first full-term birth was associated with breast cancer among Hispanics; the odds ratio for women aged 27 years and older at first full-term birth compared with women 18 years or younger was 2.26 (95% confidence interval 1.17-4.38) compared with 1.60 (95% confidence interval 0.86-3.01) for non-Hispanic whites. Higher parity was associated with reduced risk of breast cancer for non-Hispanic whites, but not Hispanics (p < 0.008). Longer lactation was associated with reduced risk in premenopausal Hispanic women and premenopausal and postmenopausal non-Hispanic white women. Reproductive factors explained 17% of the ethnic difference in breast cancer incidence for postmenopausal women and none of the difference for premenopausal women.

Adult↗
PubMed1998

Trends in the survival of American Indian, Hispanic, and Non-Hispanic white cancer patients in New Mexico and Arizona, 1969-1994.

BACKGROUND: The burden of cancer mortality falls disproportionately on cancer patients belonging to ethnic minority groups. In the U.S., African American, Hispanic, and American Indian cancer patients are diagnosed at a more advanced stage and receive less appropriate treatment, resulting in poorer outcomes and higher mortality, than white cancer patients. The authors hypothesized that cancer control strategies based on earlier detection and more effective treatment may be most effective in increasing survival in groups with more advanced disease at diagnosis, less appropriate treatment, and lower survival. METHODS: Data collected by the New Mexico Tumor Registry, a member organization of the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute, afforded the authors an opportunity to investigate this hypothesis by studying trends in cancer survival for American Indians, Hispanics, and non-Hispanic whites. The authors examined temporal trends and ethnic disparities in survival for in situ and invasive incident cancer cases at 25 sites diagnosed from 1969 through 1994 in New Mexico residents and in American Indians residing in Arizona. RESULTS: The distribution of stage became more favorable and the percentage of patients receiving appropriate treatment increased for all three ethnic groups during the study period. Survival improved for patients with cancer at most sites in each ethnic group; however, because the increase in survival was greater for non-Hispanic whites than for American Indians or Hispanics, the number of sites associated with disparities in survival among non-Hispanic whites, American Indians, and Hispanics increased. Differences in the distribution of age, gender, stage at diagnosis, histologic grade, and treatment did not completely explain the improved survival or the ethnic disparities regarding survival. CONCLUSIONS: Increased cancer control efforts were associated with earlier diagnosis, more patients receiving appropriate therapy, and improved survival for non-Hispanic whites, American Indians, and Hispanics. However, the improvement was greatest for non-Hispanic whites, and disparities in survival results for the different ethnic groups widened over the period of study. Cancer control strategies need to address the specific social, cultural, and biologic prognostic factors that affect different ethnic groups if disparities in outcomes are to be reduced.

Arizona↗