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1.
Clin Genitourin Cancer ; 18(2): e91-e102, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31917174

RESUMO

BACKGROUND: Disparities in bladder cancer survival by race/ethnicity and gender are likely related to differences in diagnosis. We assessed disparities in stage at diagnosis and potential contributing factors within a large, integrated delivery system. PATIENTS AND METHODS: We conducted a retrospective cohort study of 7244 patients with bladder cancer age ≥ 21 years diagnosed from January 2001 to June 2015 within Kaiser Permanente Southern California. Bivariate analyses compared stage at diagnosis - as well as comorbidities, health plan membership length, and health care utilization prior to diagnosis - by race/ethnicity, gender, and age. Multivariable generalized linear mixed models with urologist as a random effect were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for diagnosis of muscle-invasive bladder cancer (MIBC) versus non-muscle-invasive bladder cancer. RESULTS: In multivariable analyses, stage at diagnosis varied significantly by race/ethnicity (P < .001). Non-Hispanic black patients had significantly higher odds of being diagnosed with MIBC than non-Hispanic white patients (OR, 1.33; 95% CI, 1.05-1.67), whereas Asian patients had significantly lower odds (OR, 0.67; 95% CI, 0.49-0.91). Women were significantly more likely to be diagnosed with MIBC than men (OR, 1.40; 95% CI, 1.22-1.61). Non-Hispanic black women had the highest proportion (39%) of MIBC diagnoses. Among Hispanic and Asian patients, a greater proportion of diagnoses occurred at younger ages. CONCLUSIONS: Health care coverage within an equal-access system did not eliminate disparities in stage at diagnosis by race/ethnicity or gender. Studies are needed to identify etiologic factors and aspects of care delivery (eg, patient-physician interactions) that may affect the diagnostic process to inform efforts to improve health equity.

2.
Soc Sci Med ; 242: 112585, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31634808

RESUMO

BACKGROUND: Although homelessness and opioid overdose are major public health issues in the U.S., evidence is limited as to whether homelessness is associated with an increased risk of opioid overdose. OBJECTIVE: To compare opioid-related outcomes between homeless versus housed individuals in low-income communities. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis of individuals who had at least one ED visit or hospitalization in four states (Florida, Maryland, Massachusetts, and New York) in 2014. MEASUREMENTS: Risk of opioid overdose and opioid-related ED visits/hospital admissions were compared between homeless versus low-income housed individuals, adjusting for patient characteristics and hospital-specific fixed effects (effectively comparing homeless versus low-income housed individuals treated at the same hospital). We also examined whether risk of opioid-related outcomes varied by patients' sex and race/ethnicity. RESULTS: A total of 96,099 homeless and 2,869,230 low-income housed individuals were analyzed. Homeless individuals had significantly higher risk of opioid overdose (adjusted risk, 1.8% for homeless vs. 0.3% for low-income housed individuals; adjusted risk difference [aRD], +1.5%; 95%CI, +1.0% to +2.0%; p < 0.001) and opioid-related ED visit/hospital admission (10.4% vs. 1.5%; aRD, +8.9%; 95%CI, +7.2% to +10.6%; p < 0.001) compared to low-income housed individuals. Non-Hispanic White females had the highest risk among the homeless population, whereas non-Hispanic White males had the highest risk among the low-income housed population. LIMITATIONS: Individuals with no ED visit or hospitalization in 2014 were not included. CONCLUSION: Homeless individuals had disproportionately higher adjusted risk of opioid-related outcomes compared to low-income housed individuals treated at the same hospital. Among homeless individuals, non-Hispanic White females incurred the highest risk. These findings highlight the importance of recognizing the homeless population-especially the non-Hispanic White female homeless population-as a high-risk population for opioid overdose.

3.
Urology ; 131: 93-103, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31129191

RESUMO

OBJECTIVES: To examine treatment variability, disparities, and quality among newly diagnosed nonmuscle invasive bladder cancer (NMIBC) patients, and to identify factors associated with treatment use in a large, diverse integrated delivery system. METHODS: Retrospective cohort study of 5386 NMIBC patients diagnosed between January 2001 and June 2015 within Kaiser Permanente Southern California. Electronic health data were used to identify treatment outcomes and patient, provider, and tumor characteristics. Outcomes were use of (1) postoperative intravesical chemotherapy, (2) induction Bacille Calmette-Guérin (BCG) immunotherapy, and (3) any intravesical therapy. Multivariable odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using generalized linear mixed models with a binary outcome and urologist as a random effect. RESULTS: From 2001 to 2015, 41% of newly diagnosed NMIBC patients were treated with intravesical therapy. Postoperative chemotherapy use increased significantly over this period (OR per-year = 1.16, 95% CI: 1.07-1.25). BCG use was strongly associated with tumor characteristics: patients with high-grade or carcinoma in situ tumors were more likely to receive BCG (OR = 10.10, 95% CI: 8.39-12.16). Few treatment differences were found by sex or race/ethnicity, but were observed by age. Wide treatment variability across urologists was observed, with some urologists never using intravesical therapy as part of initial treatment while others almost always used it. Differences across urologists accounted for more variability in postoperative chemotherapy (intraclass correlation coefficient = 0.52) than BCG immunotherapy (intraclass correlation coefficient = 0.11) use. CONCLUSION: Substantial variability in initial treatment of NMIBC was observed across urologists, accounting for tumor, patient, and provider characteristics. Results suggest a considerable opportunity for quality improvement programs to reduce unwanted treatment variability and improve care for patients.


Assuntos
Adjuvantes Imunológicos/administração & dosagem , Antineoplásicos/administração & dosagem , Vacina BCG/administração & dosagem , Qualidade da Assistência à Saúde , Neoplasias da Bexiga Urinária/tratamento farmacológico , Administração Intravesical , Idoso , Idoso de 80 Anos ou mais , California , Estudos de Coortes , Prestação Integrada de Cuidados de Saúde , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Padrões de Prática Médica/estatística & dados numéricos , Estudos Retrospectivos , Neoplasias da Bexiga Urinária/patologia
4.
Obesity (Silver Spring) ; 27(4): 591-602, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30900410

RESUMO

OBJECTIVE: The aim of this work was to study weight loss and risk of cardiovascular disease (CVD) or death associated with longer-term phentermine use. METHODS: Using electronic health record data, 13,972 adults were identified with a first phentermine fill in 2010 to 2015, creating exposure categories according to a patient's duration of use (referent: ≤ 3 months). Multivariable linear models were used to compare percent weight loss across categories at 6, 12, and 24 months, and Cox proportional hazards models were used to compare risk of composite CVD or death, up to 3 years after starting phentermine. RESULTS: The cohort was 84% female and 45% white, with a mean (SD) baseline age 43.5 (10.7) years and BMI of 37.8 (7.2) kg/m2 . In multivariable models, longer-term users of phentermine experienced more weight loss; patients using continuously for > 12 months lost 7.4% more than the referent group at 24 months (P < 0.001). The composite CVD or death outcome was rare (0.3%, 41 events), with no significant difference in hazard ratios between groups. CONCLUSIONS: Greater weight loss without increased risk of incident CVD or death was observed in patients using phentermine monotherapy for longer than 3 months. Despite the limitations of the observational design, this study supports the effectiveness and safety of longer-term phentermine use for low-risk individuals.


Assuntos
Fármacos Antiobesidade/uso terapêutico , Doenças Cardiovasculares/induzido quimicamente , Doenças Cardiovasculares/epidemiologia , Obesidade/tratamento farmacológico , Fentermina/uso terapêutico , Adolescente , Adulto , Doenças Cardiovasculares/mortalidade , Causas de Morte , Estudos de Coortes , Registros Eletrônicos de Saúde/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Obesidade/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Perda de Peso/efeitos dos fármacos , Adulto Jovem
5.
Artigo em Inglês | MEDLINE | ID: mdl-30675373

RESUMO

Background: Diabetes and prediabetes are chronic conditions that affect over 40% of the US adult population combined. Regular physical activity can benefit people with diabetes through improved glucose control and can reduce the conversion of prediabetes to diabetes. Studies are needed in settings where people with these conditions can be identified and provided the skills and support to increase physical activity. The primary care setting meets this need, but there are insufficient high-quality trials to recommend this approach be broadly implemented. Methods: We conducted a randomized, 24-week pilot study in Southern California to assess the feasibility of using information technology systems available in primary care for identifying potential participants, test methods for obtaining physical activity clearance, conducting mail-based assessments, and delivering telephone-based motivational interviewing to increase physical activity. Eligibility criteria included age between 18 and 74 years, diabetes or prediabetes, and physically inactive based on a clinical assessment tool. At baseline and follow-up, physical activity was assessed by a 7-day accelerometry, cardiometabolic risk factors were collected from electronic medical records, and psychosocial factors were assessed from validated questionnaires administered through a mail survey. Participants were block randomized into intervention or usual care. Staff collecting outcome data were blinded to group assignment. Analysis of covariance was used to assess the difference at follow-up between the intervention and usual care, adjusting for baseline. Results: A total of 67 participants were randomized. Follow-up mail assessments were completed by 53 participants. Of 224 potential intervention calls, 194 were completed (87%). Psychosocial measures significantly improved in four of the five factors for physical activity motivation relative to participants in the usual care arm. The more internally focused factors for exercise self-regulation and outcome expectancies scores were significantly greater for participants in intervention compared with usual care. Moderate to vigorous physical activity improved in intervention participants relative to usual care, but the difference was not statistically significant. No adverse events were noted. Conclusions: The objectives of this pilot study were met. If a fully powered trial is successful, primary care settings with "behind-the-scenes" information technology support may be appropriate to increase physical activity among patients with prediabetes and diabetes. Trial registration: Exercise Promotion in Primary Care (EPPC), NCT03429088, registered on February 5, 2018.

6.
Am J Obstet Gynecol ; 219(2): 178.e1-178.e10, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29870739

RESUMO

BACKGROUND: Only 2 case-control studies have examined the associations between consumption of meat products and endometriosis risk with inconsistent results. Consumption of animal products has the potential to influence endometriosis risk through effects on steroid hormones levels. OBJECTIVE: We sought to determine whether higher intake of red meat, poultry, fish, and seafood are associated with risk of laparoscopically confirmed endometriosis. STUDY DESIGN: A total of 81,908 participants of the prospective Nurses' Health Study II were followed up from 1991 through 2013. Diet was assessed via food frequency questionnaire every 4 years. Cox proportional hazards models were used to calculate rate ratios and 95% confidence intervals. RESULTS: During 1,019,294 person-years of follow-up, 3800 cases of incident laparoscopically confirmed endometriosis were reported. Women consuming >2 servings/d of red meat had a 56% higher risk of endometriosis (95% confidence interval, 1.22-1.99; Ptrend < .0001) compared to those consuming ≤1 serving/wk. This association was strongest for nonprocessed red meats (rate ratio, 1.57; 95% confidence interval, 1.35-1.83 for ≥2 servings/d vs ≤1 servings/wk; Ptrend < .0001), particularly among women who had not reported infertility (Pinteraction = .0004). Women in the highest category of processed red meat intake also had a higher risk of endometriosis (rate ratio, 1.20; 95% confidence interval, 1.06-1.37 for ≥5 servings/wk vs <1 serving/mo; Ptrend = .02). Intakes of poultry, fish, shellfish, and eggs were unrelated to endometriosis risk. CONCLUSION: Our prospective analysis among premenopausal US nurses suggests that red meat consumption may be an important modifiable risk factor for endometriosis, particularly among women with endometriosis who had not reported infertility and thus were more likely to present with pain symptoms. Well-designed dietary intervention studies among women with endometriosis could help confirm this observation.


Assuntos
Dieta/estatística & dados numéricos , Endometriose/epidemiologia , Aves Domésticas , Carne Vermelha , Alimentos Marinhos , Adulto , Animais , Estudos de Coortes , Ovos , Feminino , Peixes , Humanos , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de Risco , Frutos do Mar , Estados Unidos/epidemiologia
7.
J Clin Hypertens (Greenwich) ; 20(3): 532-540, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29432662

RESUMO

Racial/ethnic disparities in the prevalence of diagnosed hypertension are persistent but may be partially explained by racial/ethnic differences in weight category and neighborhood socioeconomic status. The authors compared hypertension prevalence rates among 4 060 585 adults with overweight or obesity across 10 healthcare systems by weight category and neighborhood education level in geographically and racially diverse individuals. Data were obtained from electronic health records. Hypertension was defined as at least two outpatient visits or one inpatient hospitalization with a coded diagnosis. Logistic regression, adjusted for age, sex, and site, with two-way interactions between race/ethnicity and weight category or neighborhood education, was used to examine the association between hypertension and race/ethnicity, with whites as the reference. Results documented that odds ratios for hypertension prevalence were greater for blacks, American Indians/Alaskan Natives, Asians, and Native Hawaiians/other Pacific Islanders compared with whites and lower for Hispanics in similar weight categories and neighborhood education levels. Although two-way interactions were statistically significant, the magnitude of the odds of hypertension compared with whites did not substantially vary across weight or neighborhood education. Hypertension odds were almost double relative to whites for blacks and Native Hawaiians/other Pacific Islanders across most weight categories and all neighborhood education levels. Odds of hypertension were about 50% greater for Asians relative to whites across weight categories. Results suggest that other factors might be associated with racial/ethnic disparities in hypertension. More research is needed to understand the many factors that may contribute to variation in diagnosed hypertension across racial/ethnic groups with overweight or obesity.


Assuntos
Grupos Étnicos/classificação , Hipertensão/epidemiologia , Obesidade/epidemiologia , Sobrepeso/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Registros Eletrônicos de Saúde , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Prevalência , Classe Social , Estados Unidos/etnologia , Adulto Jovem
8.
J Assist Reprod Genet ; 34(6): 765-774, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28417349

RESUMO

PURPOSE: The purpose of the study was to determine whether diagnosis of endometriosis or endometriosis with endometrioma influences in vitro fertilization (IVF) outcomes in an ethnically diverse population. METHODS: Women undergoing a first IVF cycle (n = 717) between January 1, 2008 and December 31, 2009, at a university-affiliated infertility clinic, were retrospectively assessed for an endometriosis diagnosis. Differences in prevalence of endometriosis by ethnicity were determined, as well as differences in IVF success by ethnicity, with a focus on country of origin for Asian women. A multivariate model was generated to assess the relative contributions of country of origin and endometriosis to chance of clinical pregnancy with IVF. RESULTS: Endometriosis was diagnosed in 9.5% of participants; 3.5% also received a diagnosis of endometrioma. Endometriosis prevalence in Asian women was significantly greater than in Caucasians (15.7 vs. 5.8%, p < 0.01). Women of Filipino (p < 0.01), Indian (p < 0.01), Japanese (p < 0.01), and Korean (p < 0.05) origin specifically were more likely to have endometriosis than Caucasian women, although there was no difference in endometrioma presence by race/ethnicity. Oocyte quantity, embryo quality, and fertilization rates did not relate to endometriosis. Clinical pregnancy rates were significantly lower for Asian women, specifically in Indian (p < 0.05), Japanese (p < 0.05), and Korean (p < 0.05) women, compared to Caucasian women, even after controlling for endometriosis status. CONCLUSIONS: The prevalence of endometriosis appears to be higher in Filipino, Indian, Japanese, and Korean women presenting for IVF treatment than for Caucasian women; however, the discrepancy in IVF outcomes was conditionally independent of the presence of endometriosis. Future research should focus on improving pregnancy outcomes for Asian populations whether or not they are affected by endometriosis, specifically in the form of longitudinal studies where exposures can be captured prior to endometriosis diagnoses and infertility treatment.


Assuntos
Transferência Embrionária , Endometriose/epidemiologia , Fertilização In Vitro/métodos , Infertilidade Feminina/fisiopatologia , Grupo com Ancestrais do Continente Asiático , Endometriose/patologia , Feminino , Humanos , Infertilidade Feminina/epidemiologia , Infertilidade Feminina/etiologia , Oócitos/crescimento & desenvolvimento , Indução da Ovulação/métodos , Gravidez , Resultado da Gravidez
9.
Obesity (Silver Spring) ; 25(5): 850-856, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28440047

RESUMO

OBJECTIVE: To compare bariatric surgery outcomes according to preoperative mental illness category. METHODS: Electronic health record data from several US healthcare systems were used to compare outcomes of four groups of patients who underwent bariatric surgery in 2012 and 2013. These included the following: people with (1) no mental illness, (2) mild-to-moderate depression or anxiety, (3) severe depression or anxiety, and (4) bipolar, psychosis, or schizophrenia spectrum disorders. Groups were compared on weight loss trajectory using generalized estimating equations using B-spline bases and on all-cause emergency department visits and hospital days using zero-inflated Poisson and negative binomial regression up to 2 years after surgery. Models were adjusted for demographic and health covariates, including baseline healthcare use. RESULTS: Among 8,192 patients, mean age was 44.3 (10.7) years, 79.9% were female, and 45.6% were white. Fifty-seven percent had preoperative mental illness. There were no differences between groups for weight loss, but patients with preoperative severe depression or anxiety or bipolar, psychosis, or schizophrenia spectrum disorders had higher follow-up levels of emergency department visits and hospital days compared to those with no mental illness. CONCLUSIONS: In this multicenter study, mental illness was not associated with differential weight loss after bariatric surgery, but additional research could focus on reducing acute care use among these patients.


Assuntos
Cirurgia Bariátrica/métodos , Transtorno Depressivo Maior/complicações , Saúde Mental/tendências , Adulto , Estudos de Coortes , Registros Eletrônicos de Saúde , Feminino , Humanos , Masculino
10.
Prev Med Rep ; 4: 296-302, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27486558

RESUMO

Our objective was to compare patients' health care experiences, related to their weight, across racial and ethnic groups. In Summer 2015, we distributed a written survey with telephone follow-up to a random sample of 5400 racially/ethnically and geographically diverse U.S. adult health plan members with overweight or obesity. The survey assessed members' perceptions of their weight-related healthcare experiences, including their perception of their primary care provider, and the type of weight management services they had been offered, or were interested in. We used multivariable multinomial logistic regression to examine the relationship between race/ethnicity and responses to questions about care experience. Overall, 2811 members (53%) responded to the survey and we included 2725 with complete data in the analysis. Mean age was 52.7 years (SD 15.0), with 61.7% female and 48.3% from minority racial/ethnic groups. Mean BMI was 37.1 kg/m(2) (SD 8.0). Most (68.2%) respondents reported having previous discussions of weight with their provider, but interest in such counseling varied by race/ethnicity. Non-Hispanic blacks were significantly less likely to frequently avoid care (for fear of discussing weight/being weighed) than whites (OR 0.49, 95% CI 0.26-0.90). Relative to whites, respondents of other race/ethnicities were more likely to want weight-related discussions with their providers. Race/ethnicity correlates with patients' perception of discussions of weight in healthcare encounters. Clinicians should capitalize on opportunities to discuss weight loss with high-risk minority patients who may desire these conversations.

11.
JMIR Res Protoc ; 5(2): e87, 2016 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-27307352

RESUMO

BACKGROUND: The Patient-Centered Outcomes Research Institute (PCORI) created a new national network infrastructure to enable large-scale observational comparative effectiveness research across diverse clinical care settings. As part of testing the feasibility of this effort, each clinical data research network (CDRN) was required to construct cohorts of patients, including one of patients with overweight and obesity. OBJECTIVE: The aim of this paper is to report on the development of the Patient Outcomes Research to Advance Learning (PORTAL) overweight and obese cohort, which includes patients from 10 health plans located across the United States. METHODS: Information was gathered from each plan's electronic health records (EHR). Eligibility included 18 years of age or older, a valid height and weight in 2012 or 2013, and body mass index (BMI) greater than 22.9 kg/m(2). Pre-diabetes and diabetes status was defined using the American Diabetes Association (ADA) criteria, using lab values of glycated hemoglobin (HbA1c) or fasting glucose available in the EHR. Hypertension was identified from the International Classification of Diseases (ICD) diagnosis codes. Individuals were classified into BMI categories: healthy weight (23.0-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), obese class 1 (30.0-34.9 kg/m(2)), obese class 2 (35.0-39.9 kg/m(2)), obese class 3 (40.0-49.0 kg/m(2)), and obese class 4 (>50.0 kg/m(2)). RESULTS: A cohort of 5,293,458 non-pregnant adults was created. Weight status was 20.39% (1,079,289/5,293,458) healthy weight, 40.40% (2,138,520/5,293,458) overweight, 22.78% (1,205,866/5,293,458) obese class 1, 9.86% (521,872/5,293,458) obese class 2, 5.59% (295,786/5,293,458) obese class 3, and 0.98% (52,125/5,293,458) obese class 4. Race/ethnicity was 49.02% (2,594,776/5,293,458) non-Hispanic white, 22.89% (1,211,677/5,293,458) Hispanic, 10.40% (550,608/5,293,458) Asian, 10.83% (573,506/5,293,458) black, and 6.59% (348,830/5,293,458) other. About 34.33% (1,817,438/5,293,458) met the definition of hypertension, 20.49% (1,660,940/5,293,458) of individuals met the criteria for pre-diabetes, and 14.98% (793,069/5,293,458) met criteria for diabetes. Prevalence of pre-diabetes and diabetes varied across health plans to a greater extent than expected based on hypertension prevalence and BMI status variability. CONCLUSIONS: This large, race, ethnic, and geographically diverse cohort will be useful for future studies of rare exposures or outcomes and differences in health care practices.

12.
Matern Child Health J ; 18(7): 1610-8, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24307056

RESUMO

Healthy diet, physical activity and appropriate weight gain during pregnancy contribute to healthy birth outcomes. The Institute of Medicine recommends that women receive counseling about diet and exercise during preconception, pregnancy and postpartum periods. We sought to determine how often healthcare providers report counseling women of childbearing age about diet or exercise and if such rates vary by pregnancy, overweight/obesity status or physician specialty. We combined the 2005-2010 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to obtain nationally representative estimates of outpatient preventive care visits for women of child-bearing age (15-44 years). Accounting for survey design, we compared proportions of preventive visits that included diet/exercise counseling for pregnant women versus non-pregnant women and performed multivariable logistic regression models to estimate odds ratios. Providers reported counseling pregnant women about diet/exercise during 17.9 % of preventive care visits compared to 22.6 % of visits for non-pregnant women (P < 0.01, adj. OR 0.8, 95 % CI 0.7, 1.0). Overweight/obese pregnant (vs. non-pregnant) women were significantly less likely to receive diet/exercise counseling (adj. OR 0.7, CI 0.5, 0.9) as were women seen by OB/GYNs versus non-OB/GYNs (adj. OR 0.4, CI 0.3, 0.5). Our findings suggest that provider-reported diet/exercise counseling rates during preventive care visits for women of childbearing age vary by overweight/obesity and pregnancy statuses, as well as by provider specialty. Our data suggest that there may be missed opportunities to provide diet/exercise counseling and that increasing rates of counseling could result in improved maternal and infant health outcomes.


Assuntos
Dieta , Adulto , Aconselhamento , Feminino , Comportamentos Relacionados com a Saúde , Pesquisas sobre Serviços de Saúde , Promoção da Saúde , Humanos , Serviços de Saúde Materna , Atividade Motora , Gravidez , Serviços Preventivos de Saúde , Estados Unidos , Adulto Jovem
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