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PubMed2006

REFINEMENT: a search framework for the identification of interferon-responsive elements in DNA sequences--a case study with ISRE and GAS.

Interferons (IFN) are a family of pleiotropic secreted proteins that play a key role in mediating antiviral and apoptotic responses, and in immune modulation. Interferons induce a large number of genes through activating the janus tyrosine kinase (JAK)-signal transducers and activators of transcription proteins (STAT) pathway, and the binding of transcription factors to upstream regions of the inducible genes (interferon-stimulated gene, ISG) at specific DNA regulatory elements known as interferon-stimulated response element (ISRE) and gamma-activated sequence (GAS). We have previously performed DNA micro-arrays on peripheral blood mononuclear cells (PBMC) treated with interferon-alpha in culture and showed that approximately 700 genes are significantly modulated (P < or = 0.001). In order to search for ISRE and GAS we have developed a framework called regulatory element finding with iteration and effective model refinement (REFINEMENT) using an existing program (HMMER) and a standard discriminating scoring technique. Although REFINEMENT uses existing programs, our framework itself is novel as it effectively discriminates occurrences using an iterative model refinement technique. REFINEMENT has detected either ISRE or GAS sequence in all of the genes shown to be induced at a P-value < or = 0.001. There were far more functional occurrences in ISRE than in GAS, suggesting that ISRE plays a greater role in response to interferon-alpha than GAS sequences. This method can be used to identify such sequences in any set of genes. REFINEMENT is non-commercial and is accessible at .

Base Sequence↗

PubMed2005

Effects of information and group structure on evolution of altruism: analysis of two-score model by covariance and contextual analyses.

An altruistic individual has to gamble on cooperation to a stranger because it does not know whether the stranger is trustworthy before direct interaction. Nowak and Sigmund (Nature 393 (1998a) 573; J. Theor. Biol. 194 (1998b) 561) presented a new theoretical framework of indirect reciprocal altruism by image scoring game where all individuals are informed about a partner's behavior from its image score without direct interaction. Interestingly, in a simplified version of the image scoring game, the evolutionarily stability condition for altruism became a similar form of Hamilton's rule, i.e. inequality that the probability of getting correct information is more than the ratio of cost to benefit. Since the Hamilton's rule was derived by evolutionarily stable analysis, the evolutionary meaning of the probability of getting correct information has not been clearly examined in terms of kin and group selection. In this study, we applied covariance analysis to the two-score model for deriving the Hamilton's rule. We confirmed that the probability of getting correct information was proportional to the bias of altruistic interactions caused by using information about a partner's image score. The Hamilton's rule was dependent on the number of game bouts even though the information reduced the risk of cooperation to selfish one at the first encounter. In addition, we incorporated group structure to the two-score model to examine whether the probability of getting correct information affect selection for altruism by group selection. We calculated a Hamilton's rule of group selection by contextual analysis. Group selection is very effective when either the probability of getting correct information or that of future interaction, or both are low. The two Hamilton's rules derived by covariance and contextual analyses demonstrated the effects of information and group structure on the evolution of altruism. We inferred that information about a partner's behavior and group structure can produce flexible pathways for the evolution of altruism.

Altruism↗

PubMed1998

A whole-genome radiation hybrid map of the dog genome.

A whole genome radiation hybrid (RH) map of the canine genome was constructed by typing 400 markers, including 218 genes and 182 microsatellites, on a panel of 126 radiation hybrid cell lines. Fifty-seven RH groups have been determined with lod scores greater than 6, and 180 framework landmarks were ordered with odds greater than 1000:1. Average spacing between adjacent markers is 23 cR5000, an estimated physical distance of 3.8 Mb. Fourteen groups have been assigned to 9 of the canine chromosomes, and a comparison of RH and genetic groups allowed the successful bridging of both types of data on one map composed of 31 RH and 13 syntenic RH groups. Comparison of canine, human, mouse, and pig maps underlined regions of conserved synteny. This integrated map, covering an estimated 80% of the dog genome, should prove a powerful tool for localizing and identifiying genes implicated in pathological and phenotypical traits.

Animals↗

PubMed2006

Lessons learned from clinical anthrax drills: evaluation of knowledge and preparedness for a bioterrorist threat in Israeli emergency departments.

STUDY OBJECTIVE: Emergency department (ED) physicians and nurses are considered critical sentinels of a bioterrorist attack. We designed a special hospital drill to test EDs' response to inhalational anthrax and assess the level of preparedness for anthrax bioterrorism. We hypothesized that the occurrence of such a drill in an ED would improve the knowledge of its physicians, even those who had not actually participated in the drill. METHODS: We conducted 23 drills at all Israeli general hospitals' EDs. An actor entered the walk-in triage area, simulating a febrile patient with lower respiratory complaints. A chest radiograph with mediastinal widening, as can be seen in early anthrax disease, was planted in the hospital's imaging results system. Patients were instructed to give additional epidemiologic clues, such as having a few friends with a similar syndrome. Either before or after the drills, we distributed multiple choice tests about diagnosis and management of anthrax to the 115 senior emergency physicians at these hospitals. RESULTS: In 91% of EDs, a decision to admit the patient was made. Sixty-one percent included anthrax in the differential diagnosis and activated the appropriate protocols. Only 43% contacted all relevant officials. Average score on the anthrax tests was 58 (of 100). Physicians who were tested before the drill (in their institution) achieved a mean score of 54.5, whereas those who were tested after their ED had been exercised achieved a mean score of 59.3. CONCLUSION: A national framework of drills on bioterrorism can help estimate and potentially augment national preparedness for bioterrorist threats. It is not, on its own, an effective educational tool. More emphasis should be given to formal accredited continuing medical education programs on bioterrorism, especially for emergency physicians and ED nurses, who will be in the front line of a bioterrorist attack.

Anthrax↗

PubMed2026

Direct and spillover hospitalisation patterns during climate hazards across regions of different health-system resilience levels in China: a nationwide retrospective analysis.

BACKGROUND: Health-system resilience serves as a key contributor in mitigating adverse health impacts during climate hazards. However, quantitative insights into resilience-associated health-care utilisation patterns and targeted adaptation policies remain scarce. We aimed to capture the spatiotemporal health impacts in disaster-exposed counties and their neighbouring counties in China during storms, floods, tropical cyclones, and blizzards or winter storms; understand the association between health-system resilience metrics and hazard-attributable hospitalisations; and develop evidence-based adaptation policies towards climate extremes. METHODS: In this retrospective, observational analysis of county-level aggregated hospitalisation data, we used a propensity score matching-difference-in-differences framework to assess the spatiotemporal changes of nine types of disease-specific hospitalisations in both disaster-exposed and neighbouring regions during storms, floods, tropical cyclones, and blizzards in China. We quantified the relative importance and health gains of health-system metrics during such hazards through random forest approach with interpretable partial dependence plots to derive evidence-based adaptation recommendations. FINDINGS: We included hospitalisation data from Jan 1, 2016 to Dec 31, 2023. In this period, 3241 county-hazard event combinations and 41 747 482 hospitalisations were recorded across 955 Chinese counties. The disaster-exposed regions experienced an initial decline in hospitalisation rates, followed by admission surges after disasters. For example, infectious disease admissions decreased by 11·92% (95% CI -10·53 to -13·31) during the flood-active period but increased by 7·68% (6·46-8·91) after 1-2 weeks of floods. Neighbouring zones were also affected through spillover effects, with infectious disease admissions increasing by 3·18% (1·76-4·61) after 1-2 weeks of the floods. Cardiovascular disease, injuries, infectious, respiratory, and mental disorders were more sensitive across all regions. Particularly for disaster-exposed counties, cardiovascular hospitalisations increased by 14·31% (7·34-21·29) during the tropical cyclone-active period. Notably, compared with low-resilience counties, high-resilience counties were associated with 19·48-30·03% smaller hazard-related relative changes in hospitalisation rates during the hazard-active period and 27·07-31·08% smaller hazard-related relative changes in hospitalisation rates in post-hazard periods. For instance, during the storm-active period, the increase in respiratory hospitalisations was 7·21% (0·67-13·75) in high-resilience counties versus 12·13% (5·20-19·05) in low-resilience counties. Health workforce (relative importance 14·58% during the hazard-active period and 13·80% during the post-hazard period) and service delivery (14·10% during the hazard-active period and 14·17% during the post-hazard period) were identified as key contributors of health-system resilience. Empirical synergistic effects were observed when combining interventions during the post-hazard period, with the combined effect of service delivery (individual contribution 8%) and workforce (individual contribution 4%) exceeding the sum of their individual contributions (16% reduction in cumulative excess admissions) by 33%. INTERPRETATION: Climate hazards are associated with substantial changes in hospitalisation rates in both disaster-exposed and neighbouring regions. Health-system resilience is essential in addressing disaster-health challenges. Targeted adaptation interventions should be context-appropriate and threshold-aware, thereby maximising the public health benefits relative to resilience-oriented investments in health systems. FUNDING: Gates Foundation and the National Natural Science Foundation of China.

Journal Article↗

PubMed2006

National survey of accommodations and alternate assessments for students who are deaf or hard of hearing in the United States.

This paper reports the results of the National Survey of Accommodations and Alternate Assessments for Students who are Deaf or Hard of Hearing in the United States (National Survey). This study focused on the use of accommodations and alternate assessments in statewide assessments used with students who are deaf or hard of hearing. A total of 258 participants responded to the survey, including 32 representing schools for the deaf, 168 from districtwide/school programs, and 58 from mainstreamed settings. These schools and programs served a total of nearly 12,000 students who are deaf or hard of hearing nationwide. The most prevalent accommodations used in 2003-2004 statewide standardized assessments in mathematics and reading were extended time, an interpreter for directions, and a separate room for test administration. Read aloud and signed question-response accommodations were often prevalent, used more often for mathematics than in reading assessments. Participants from mainstreamed settings reported a more frequent use of accommodations than those in schools for the deaf or districtwide/school programs. In contrast, schools for the deaf were most likely to have students participate in alternate assessments. The top three alternate assessment formats used across all settings were out-of-level testing, work samples, and portfolios. Using the National Survey results as a starting point, future research will need to investigate the validity of accommodations used with students who are deaf or hard of hearing. In the context of the No Child Left Behind Act of 2001 accountability policies, the accommodations and alternate assessment formats used with students who are deaf or hard of hearing may result in restrictions in how scores are integrated into state accountability frameworks.

Chi-Square Distribution↗

PubMed2026

Dissecting the shared genetic architecture between migraine subtypes and cardiovascular diseases: a multi-layered genomic analysis.

BACKGROUND: Epidemiological studies have linked migraine to an increased risk of cardiovascular disease (CVD); however, the shared genetic basis and putative causal relationships between migraine subtypes and cardiovascular traits remain poorly understood. METHODS: Leveraging large-scale GWAS summary statistics for migraine phenotypes (overall migraine, migraine with aura [MA], and migraine without aura [MO]) from FinnGen R12, along with seven cardiovascular diseases from publicly available consortia, we conducted a multi-layered genetic analysis. This integrative framework encompassed genetic correlation [linkage disequilibrium score regression (LDSC) and high-definition likelihood (HDL)], cross-trait meta-analysis (CPASSOC and PLACO), Bayesian colocalization, summary-data-based Mendelian randomization (SMR) using GTEx v8 eQTL data, and bidirectional two-sample Mendelian randomization (MR). RESULTS: Significant genetic correlations were identified between migraine and multiple cardiovascular traits, with hypertension and coronary artery disease (CAD) showing the most robust associations. MA exhibited broader genetic overlap with cardiovascular diseases than MO, including a notably stronger correlation with ischemic stroke, whereas MO demonstrated a stronger correlation with hypertension. Cross-trait meta-analysis identified 160 pleiotropic loci across 17 of 21 trait pairs. Colocalization analysis confirmed 32 loci harboring shared causal variants, mapped to 13 candidate genes, of which 7 (PHACTR1, LRP1, SOX7, ABO, FHOD3, MEI1, XKR6) were further validated by SMR as exhibiting tissue-specific regulatory effects. Among these, PHACTR1 displayed the broadest pleiotropic profile across migraine phenotypes and vascular diseases. After MR-PRESSO outlier removal, bidirectional MR identified 10 MR-supported associations, two of which (genetic liability to hypertension on overall migraine, and CAD on MA) survived Bonferroni correction, all free of detectable horizontal pleiotropy. Genetic liability to hypertension was associated with increased migraine risk (OR = 1.90, 95% CI 1.25-2.90, P = 2.64 × 10⁻³), atherosclerotic diseases showed subtype-specific effects (inverse for MO, positive for MA), and, in the reverse direction, migraine was associated with increased ischemic stroke risk. CONCLUSIONS: This study provides a comprehensive and systematic characterization of the shared genetic architecture between migraine subtypes and cardiovascular diseases. By identifying pleiotropic genes and bidirectional putative causal relationships with subtype-specific patterns, our findings carry implications for the development of targeted therapeutics and subtype-specific cardiovascular risk stratification.

Humans↗

PubMed1988

Nursing students' attitudes toward AIDS.

A study of 177 baccalaureate nursing students was conducted to explore their knowledge, fears, beliefs and other attitudes regarding AIDS. Lazarus' theory related to coping with threatening events provided the theoretical framework. Students with a high fear score were less willing to care for AIDS patients, had higher knowledge scores, and were more homophobic. While 96.6% of the students felt that AIDS patients are entitled to the same care as any other patient, 49% preferred not to care for AIDS patients. Thirty-six percent thought nursing students should not be assigned to care for AIDS patients. Most of the students (70.6%) got their information about AIDS from the media. Nursing faculty must respond by including current, correct information when instructing students about AIDS. Faculty also need to provide opportunities for students to ask questions and share their fears regarding AIDS.

Acquired Immunodeficiency Syndrome↗

PubMed2002

Assessing the clinical significance of single items relative to summated scores.

How many items are needed to measure an individual's quality of life (QOL)? This article describes the strengths and weaknesses of single items and summated scores (from multiple items) as QOL measures. We also address the use of single global measures vs multiple subindices as measures of QOL. The primary themes that recur throughout this article are the relationships between well-defined research objectives, the research setting, and the choice single item vs summated scores to measure QOL. The conceptual framework of the study, the conceptual fit with the measure, and the purpose of the assessment should all be considered when choosing a measure of QOL. No "gold standard" QOL measure can be recommended because no "one size fits all." Single items have the advantage of simplicity at the cost of detail. Multiple-item indices have the advantage of providing a complete profile of QOL component constructs at the cost of increased burden and of asking potentially irrelevant questions. The 2 types of indices are not mutually exclusive and can be used together in a single research study or in the clinical setting.

Chronic Disease↗

PubMed1994

Association between survival time and ordinal covariates.

An application of the method of rank correlation is proposed for testing independence between a censored survival time and an ordinal covariate. The test statistic counts the number of concordances minus the number of discordances at each time with event(s) and adds across times; it is expressible as a score statistic within the proportional hazards framework. The proposed test includes, as a special case, a generalization of Jonckheere's test against ordered alternatives and as applied to the analysis of categorical data, it can be seen as a generalization of the Mantel-Haenszel procedure.

Analysis of Variance↗

PubMed2002

Concept mapping assessment in medical education: a comparison of two scoring systems.

BACKGROUND: Concept mapping has the potential to measure important aspects of a student's evolving knowledge framework in a way that conventional examinations cannot. This is important because development of an elaborate and well-structured knowledge framework is a critical step toward becoming an expert in a particular field. Little is known about the best way to score concept maps in the setting of medical education. Therefore, as a preliminary step in addressing this question, we compared two different scoring systems for validity: a structural method based on the organization of a map's hierarchical structure and a relational method based, not on structure, but on the quality of each individual map component. METHODS: A total of 21 paediatric resident doctors completed concept map training, drew a preinstruction concept map about "seizures", completed a seizure education course, and then drew a postinstruction seizure map. Two raters using both structural and relational methods scored each map. RESULTS: Structural scores increased significantly after instruction and were higher in more experienced residents, but relational scores were not significantly different. Interrater scoring reliability for both methods ranged from moderate to strong, but was greater using the relational scoring method. CONCLUSIONS: These data suggest that scoring systems for evaluating concept maps in postgraduate medical education may need to account for structural features of maps, if scores are to reflect changes in the developing knowledge frameworks of resident doctors. More research to further evaluate reliability and validity is critical prior to any future use of concept mapping assessment in medical education.

California↗

PubMed2006

Assessing normative cut points through differential item functioning analysis: an example from the adaptation of the Middlesex Elderly Assessment of Mental State (MEAMS) for use as a cognitive screening test in Turkey.

BACKGROUND: The Middlesex Elderly Assessment of Mental State (MEAMS) was developed as a screening test to detect cognitive impairment in the elderly. It includes 12 subtests, each having a 'pass score'. A series of tasks were undertaken to adapt the measure for use in the adult population in Turkey and to determine the validity of existing cut points for passing subtests, given the wide range of educational level in the Turkish population. This study focuses on identifying and validating the scoring system of the MEAMS for Turkish adult population. METHODS: After the translation procedure, 350 normal subjects and 158 acquired brain injury patients were assessed by the Turkish version of MEAMS. Initially, appropriate pass scores for the normal population were determined through ANOVA post-hoc tests according to age, gender and education. Rasch analysis was then used to test the internal construct validity of the scale and the validity of the cut points for pass scores on the pooled data by using Differential Item Functioning (DIF) analysis within the framework of the Rasch model. RESULTS: Data with the initially modified pass scores were analyzed. DIF was found for certain subtests by age and education, but not for gender. Following this, pass scores were further adjusted and data re-fitted to the model. All subtests were found to fit the Rasch model (mean item fit 0.184, SD 0.319; person fit -0.224, SD 0.557) and DIF was then found to be absent. Thus the final pass scores for all subtests were determined. CONCLUSION: The MEAMS offers a valid assessment of cognitive state for the adult Turkish population, and the revised cut points accommodate for age and education. Further studies are required to ascertain the validity in different diagnostic groups.

Adolescent↗

PubMed1994

Lods, wrods, and mods: the interpretation of lod scores calculated under different models.

In this paper we examine the relationships among classical lod scores, "wrod" scores (lod scores calculated under the wrong genetic model), and "mod" scores (lod scores maximized over genetic model parameters). We compare the behavior of these scores when the state of nature is linkage to their behavior when the state of nature is no linkage. We describe sufficient conditions for mod scores to be valid and discuss their use to determine the correct genetic model. We show that lod scores represent a likelihood-ratio test for independence. We explain the "ascertainment-assumption-free" aspect of using mod scores to determine mode of inheritance and we set this aspect into a well-established statistical framework. Finally, we summarize practical guidelines for the use of mod scores.

Bias↗

PubMed2026

A contextual activity score (CAS) for inferring ADAR-associated transcriptional activity across RNA-seq, single-cell, and spatial transcriptomics.

BACKGROUND AND OBJECTIVE: Adenosine-to-inosine RNA editing, catalyzed by Adenosine Deaminases Acting on RNA (ADARs), is a widespread modification involved in neural function, immune regulation, and cancer. The Alu Editing Index (AEI) is the standard metric to estimate ADAR activity but requires raw sequencing reads and is poorly suited for single-cell and spatial transcriptomic data. This study aimed to develop an alternative framework for inferring ADAR-associated transcriptional activity from gene expression data across diverse transcriptomic technologies. METHODS: We developed the Contextual Activity Score (CAS), a framework based on transcriptional signatures from ADAR perturbation experiments. Context-specific signatures were generated for human neurons, mouse neurons, and cancer models to infer ADAR1 and ADAR2 activity. CAS was computed from normalized gene expression matrices using regulon-based enrichment analysis. Performance was evaluated by comparing with the Alu Editing Index across bulk RNA sequencing datasets, simulated sequencing depths, and library preparation protocols. RESULTS: CAS showed strong concordance with the Alu Editing Index across multiple datasets, while remaining robust to reduced sequencing depth and different library protocols. Unlike the Alu Editing Index, CAS can be applied to single-cell and spatial transcriptomic data and enables the independent assessment of ADAR2 activity. In cancer and neuronal contexts, CAS captured biologically meaningful variations in ADAR-associated transcriptional activity at sample, cell-type, and spatial levels. CONCLUSION: CAS provides a scalable approach applicable across multiple RNA-seq protocols for estimating ADAR-associated transcriptional activity using gene expression data. This method, implemented in an open-source R package for broad adoption, expands the ability to study ADAR-associated transcriptional activity across transcriptomic modalities where direct editing quantification is challenging, such as single-cell and spatial transcriptomics.

Adenosine Deaminase↗

PubMed2004

Base rates for panic and depression according to the Brief Patient Health Questionnaire: a population-based study.

BACKGROUND: Recently published studies analyzing sensitivity and specificity scores have demonstrated that the brief version of the Patient Health Questionnaire (PHQ [J. Am. Med. Assoc. 282 (1999) 1734]) is a useful tool for the detection of panic disorder and depression. METHODS: We aimed to get normative data for the brief PHQ in a representative population-based sample. Sociodemographic data and PHQ data from 2066 subjects were included. RESULTS: Base rates for PHQ criteria of major depression were 3.8% with the typical 1:2 ratio between males and females (frequency of minor depressive forms: 9.2%). Normative data for the depression total scores were reported. Marital status, education and family income were significantly associated with depression, even after controlling for age and sex. For panic disorder, base rates were 1.8%; age, gender, and marital status were significant predictors. Frequency for panic attacks as a less restrictively defined version were 4.5%. CONCLUSIONS: The normative data provide a framework for the interpretation of depression and panic scores of the PHQ.

Adolescent↗

PubMed1991

Developmental and family milieu correlates of resilience in urban children who have experienced major life stress.

Reports findings from interviews with parents of demographically-comparable groups of highly-stressed urban children with stress-resilient (SR) and stress-affected (SA) outcomes at ages 10-12. SR and SA children were compared on family milieu and child development variables assessed within a developmental framework. Compared to SAs, parents of SRs scored higher on variables reflecting parent perceptions of a nurturant caregiver-child relationship and self-views as effective caregivers, in the context of positive discipline practices, a child's positive early temperament, and support for primary caregivers. A discriminant function analysis identified seven variables that optimally differentiated the groups and correctly classified 86% of the Ss as SR or SA.

Adaptation, Psychological↗

PubMed2003

Power analysis in randomized clinical trials based on item response theory.

Patient relevant outcomes, measured using questionnaires, are becoming increasingly popular endpoints in randomized clinical trials (RCTs). Recently, interest in the use of item response theory (IRT) to analyze the responses to such questionnaires has increased. In this paper, we used a simulation study to examine the small sample behavior of a test statistic designed to examine the difference in average latent trait level between two groups when the two-parameter logistic IRT model for binary data is used. The simulation study was extended to examine the relationship between the number of patients required in each arm of an RCT, the number of items used to assess them, and the power to detect minimal, moderate, and substantial treatment effects. The results show that the number of patients required in each arm of an RCT varies with the number of items used to assess the patients. However, as long as at least 20 items are used, the number of items barely affects the number of patients required in each arm of an RCT to detect effect sizes of 0.5 and 0.8 with a power of 80%. In addition, the number of items used has more effect on the number of patients required to detect an effect size of 0.2 with a power of 80%. For instance, if only five randomly selected items are used, it is necessary to include 950 patients in each arm, but if 50 items are used, only 450 are required in each arm. These results indicate that if an RCT is to be designed to detect small effects, it is inadvisable to use very short instruments analyzed using IRT. Finally, the SF-36, SF-12, and SF-8 instruments were considered in the same framework. Since these instruments consist of items scored in more than two categories, slightly different results were obtained.

Health Status↗

PubMed2002

The use of Rasch measurement to improve the Oswestry classification scheme.

OBJECTIVES: To use Rasch measurement to assess and modify the original classification categories of the Oswestry Low Back Pain Disability Questionnaire (Oswestry), to examine the hypothesis that the items from the Oswestry form a unidimensional construct and a hierarchical representation of low back pain (LBP) disability, and to compare ordinal Likert resultant scores to interval Rasch scaled scores with disability categories serving as a framework. DESIGN: Rasch analysis model. Existing Oswestry admission data generated by FOTO were analyzed. SETTING: Statistical analysis of sample database. PARTICIPANTS: A sample of 942 patients with LBP referred for physical therapy between 1993 and 1994. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Construct validity; disability categories (as assessed by Likert and Rasch models); and fit statistics (infit, outfit as mean squares). RESULTS: All items from the Oswestry except the pain item fit the Rasch model. Construct validity of the scale using the Rasch model required the structure of the rating scale to be modified from 6 response levels to 4. A hierarchical representation of LBP disability was supported. A comparison of the disability categories based on Likert and Rasch scaling revealed them to be nonequivalent. The new scaling changed the disability categories for 44% of patients. CONCLUSION: Rasch analysis produced disability categories in the Oswestry that are linear and, therefore, useful for quantitatively assessing self-reported disability levels.

Adolescent↗