[Show abstract][Hide abstract] ABSTRACT: sec> Background Mammographic density (MD) is a strong intermediate risk factor for breast cancer (BC) and, having both genetic and environmental determinants, may account for the over 6-fold international variations in BC incidence rates. The International Pooling Project of Mammographic Density is a worldwide collaborative project of MD targeting populations spanning the BC incidence range. The aims of the project are to (i) describe international variations in overall and age-specific distributions of MD, (ii) assess whether international variations in MD are explained by variations in the distributions of individual-level determinants of this marker and (iii) examine whether international variations in MD correlate with corresponding BC incidence rates. Methods Each contributing study provided comparable data on MD risk factors and mammographic images from a random sample of 400 general population women, who had undergone screening mammography. Images were transferred in digitised screen-film, full-field or computed radiography digital DICOM format (raw or processed). Images were randomly allocated into batches for MD reading using the Cumulus 6 thresholding software, by experienced readers who were blinded to study and individual-level factors. Data on MD determinants were pooled and linked with MD readings. Results are calibrated according to type of digital image (raw to processed), and adjusted for image type. Results 22 countries and approximately 12,000 women are included, spanning populations with age-standardised BC incidence rates (ASR) of 25.8 (India) to 99 (The Netherlands) per 100,000 woman-years. To date, for 9,635 participants data have been pooled (results will be updated). The MD risk factors vary greatly across populations, for example: mean age at menarche (in years) was 14.3 (95% CI 14.1–14.5) in Korean women and 12.6 (12.5–12.8) in Mexican women; mean parity was 3.8 (3.6–4.1) in Egyptian women and 1.3 (1.1–1.4) in those from Hong Kong; and mean BMI (in kg/m2) was 33.7 (33.1–34.3) in Egyptian women compared to 22.3 (21.6–22.9) in those from India. Differences in MD according to these distributions will be presented. Discussion The international perspective of this study generated large exposure heterogeneity enabling a wider investigation of MD determinants and the extent to which MD is an intermediate marker of BC risk, both within and between populations. </sec
Journal of Epidemiology & Community Health 09/2015; 69(Suppl 1). DOI:10.1136/jech-2015-206256.99 · 3.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
Extraovarian sex hormone production plays an important role in estrogen biosynthesis in postmenopausal women. We examined possible associations between serum sex hormone level and polymorphisms in CYP19A1, HSD17B1, and HSD17B2. We also assessed possible interaction between these polymorphisms and current overweight.
We conducted a cross-sectional study. 785 Japanese natural postmenopausal women were randomly selected from the Japan Multi-Institutional Collaborative Cohort (J-MICC) Study database. Information on lifestyle factors was obtained from a self-administered questionnaire. Serum estrogens and androgens levels were measured by liquid chromatography-tandem mass spectrometry. Four tag SNPs (single nucleotide polymorphisms) of CYP19A1, one missense SNP of HSD17B1 and three tag SNPs of HSD17B2 were examined by Invader assay. A trend test was conducted using linear regression.
After adjustment for multiple comparisons, we found that rs4441215 and rs936306 in CYP19A1 and rs4888202 and rs2955160 in HSD17B2 were associated with differences in serum estrone level. Further, rs4441215 and rs936306 were associated with differences in serum estradiol level. None of these polymorphisms showed a significant interaction with current body mass index (BMI).
Our findings suggested that CYP19A1 and HSD17B2 polymorphisms might be associated with circulating sex hormone levels in Japanese postmenopausal women, independent of current BMI.
[Show abstract][Hide abstract] ABSTRACT: International reviews have concluded that consumption of fruit and vegetables might decrease the risk of lung cancer. However, the relevant epidemiological evidence still remains insufficient in Japan. Therefore, we performed a pooled analysis of data from four population-based cohort studies in Japan with >200,000 participants and >1,700 lung cancer cases. We computed study-specific hazard ratios by quintiles of vegetable and fruit consumption as assessed by food frequency questionnaires. Summary hazard ratios were estimated by pooling the study-specific hazard ratios with a fixed-effect model. In men, we found inverse associations between fruit consumption and the age- and area-adjusted risk of mortality or incidence of lung cancer. However, the associations were largely attenuated after adjustment for smoking and energy intake. The significant decrease in risk among men remained only for a moderate level of fruit consumption; the lowest summary hazard ratios were found in the third quintile of intake (mortality: 0.71, 95% confidence interval 0.60-0.84; incidence: 0.83, 95% confidence interval 0.70-0.98). This decrease in risk was mainly detected in ever smokers. Conversely, vegetable intake was positively correlated with the risk of incidence of lung cancer after adjustment for smoking and energy intake in men (trend P, 0.024); the summary hazard ratio for the highest quintile was 1.26 (95% confidence interval 1.05-1.50). However, a similar association was not detected for mortality from lung cancer. In conclusion, a moderate level of fruit consumption is associated with a decreased risk of lung cancer in men among the Japanese population. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
Cancer Science 05/2015; 106(8). DOI:10.1111/cas.12707 · 3.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Mammographic density, i.e., the radiographic appearance of the breast, is a strong predictor of breast cancer risk. To determine whether the association of breast density with breast cancer is modified by a first-degree family history of breast cancer (FHBC) in women of white and Asian ancestry, we analyzed data from four case-control studies conducted in the USA and Japan.
The study population included 1,699 breast cancer cases and 2,422 controls, of whom 45 % reported white (N = 1,849) and 40 % Asian (N = 1,633) ancestry. To standardize mammographic density assessment, a single observer re-read all mammograms using one type of interactive thresholding software. Logistic regression was applied to estimate odds ratios (OR) while adjusting for confounders.
Overall, 496 (12 %) of participants reported a FHBC, which was significantly associated with breast cancer risk in the adjusted model (OR 1.51; 95 % CI 1.23-1.84). There was a statistically significant interaction on a multiplicative scale between FHBC and continuous percent density (per 10 % density: p = 0.03). The OR per 10 % increase in percent density was higher among women with a FHBC (OR 1.30; 95 % CI 1.13-1.49) than among those without a FHBC (OR 1.14; 1.09-1.20). This pattern was apparent in whites and Asians. The respective ORs were 1.45 (95 % CI 1.17-1.80) versus 1.22 (95 % CI 1.14-1.32) in whites, whereas the values in Asians were only 1.24 (95 % CI 0.97-1.58) versus 1.09 (95 % CI 1.00-1.19).
These findings support the hypothesis that women with a FHBC appear to have a higher risk of breast cancer associated with percent mammographic density than women without a FHBC.
Cancer Causes and Control 03/2015; 26(4). DOI:10.1007/s10552-015-0551-2 · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The effects of smoking on breast cancer remain unclear. We assessed the associations of subject's or husband's smoking status with breast cancer incidence in a population-based prospective study in Japan. Subjects were 15,719 women aged 35 years or older. The follow-up was conducted from September, 1992 to March, 2008. Cancer incidence was mainly confirmed through regional population-based cancer registries. Breast cancer was defined as code C50 according to ICD-10. Lifestyles, including smoking status, were assessed with a self-administered questionnaire. Alcohol consumption was assessed with a validated food-frequency questionnaire. After multivariate adjustments for age, body mass index, alcohol consumption, physical activity, education, age at menarche, age at first delivery, menopausal status, number of children, and history of hormone replacement therapy, active smoking was not associated with the risk of breast cancer. Compared with never smokers whose husbands had never smoked, the risks of breast cancer were 1.98 (95% CI: 1.03 - 3.84) among never smokers whose husband was current smoker of 21 cigarettes per day or more. The increased risk of breast cancer among women having a smoking husband was pronounced among those who did not habitually consume alcohol. These results suggest that exposure to smoke from husband is a potential risk factor for breast cancer. The implication of alcohol drinking for the increased breast cancer risk from passive smoking is needed to be addressed in further studies.This article is protected by copyright. All rights reserved.
Cancer Science 01/2015; 106(4). DOI:10.1111/cas.12619 · 3.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although several experimental studies suggested that soy isoflavone intake inhibits the growth of stomach cancer, previous epidemiological studies have observed inconsistent results. We evaluated the associations of soy or isoflavone intake with stomach cancer incidence after considering several lifestyle factors, including salt intake, in a population-based prospective cohort study in Japan. Subjects were 14,219 men and 16,573 women aged 35 years or older in September 1992. Soy and isoflavone intakes, assessed with a validated food-frequency questionnaire, were controlled for the total energy intake. Cancer incidence was mainly confirmed through regional population-based cancer registries. Until March 2008, 441 men and 237 women developed stomach cancer. After adjustments for multiple confounders, a significantly decreased relative risk of stomach cancer was observed in the highest vs. lowest quartile of soy intake; the estimated hazard ratios were 0.71 (95% CI: 0.53, 0.96) for men (p for trend=0.039), and 0.58 (95% CI: 0.36, 0.94) for women (p for trend=0.003). Similar inverse associations between isoflavone intake and stomach cancer risk were also observed in women. Higher intake of non-fermented soy foods was significantly associated with a lower risk of stomach cancer (p for trend: 0.022 in men and 0.005 in women), whereas there was no significant association between the intake of fermented soy foods and a risk of stomach cancer. These results suggest that a high intake of soy isoflavone, mainly non-fermented soy foods, have a protective effect against stomach cancer. This article is protected by copyright. All rights reserved.
International Journal of Cancer 01/2015; 137(4). DOI:10.1002/ijc.29437 · 5.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: It has been hypothesized that alteration of hormone systems is involved in the carcinogenesis of acrylamide. The aim of the present study was to examine the cross-sectional associations between dietary acrylamide intake and sex hormone levels in premenopausal Japanese women. Methods: Study subjects were 393 women who had regular menstrual cycles less than 40 days long. Acrylamide intake was assessed with a food-frequency questionnaire and was based on acrylamide concentration reported from analyses of Japanese foods. We measured the plasma concentrations of estradiol, testosterone, dehydroepiandrosterone sulfate, sex hormone-binding globulin, follicle-stimulating hormone, luteinizing hormone, and prolactin. Results: After controlling for age, the phase of the menstrual cycle, and other covariates, acrylamide intake was statistically significantly inversely associated with total and free estradiol levels and statistically significantly positively associated with follicle-stimulating hormone level. Total and free estradiol levels were 18.2% and 19.3% lower, respectively, in women in the highest quartile of acrylamide intake than in those in the lowest quartile of intake. Follicle-stimulating hormone levels were 23.5% higher in women in the highest quartile of acrylamide intake than in those in the lowest quartile of intake. Conclusion: The data suggest that acrylamide intake may alter estradiol and follicle-stimulating hormone levels. Impact: High estradiol levels have been associated with an increased risk of breast cancer. Although the results need confirmation, they highlight the need to investigate the relationships among dietary acrylamide, sex hormones, and breast cancer risk.
[Show abstract][Hide abstract] ABSTRACT: Diets with a high glycaemic index (GI) or glycaemic load (GL) have been hypothesised to increase the risk of diabetes, CVD and some cancers. In the present study, the associations of dietary GI and GL with the risk of all-cause and cause-specific mortality were prospectively examined in a general population in Japan, where white rice is the main contributor of dietary GI and GL. A total of 28 356 residents of Takayama City, Japan, who responded to a self-administered questionnaire in 1992 were included in the present analyses. Dietary intake was assessed using a validated FFQ. Mortality was ascertained over 16 years. In men, dietary GI was found to be significantly inversely associated with the risk of all-cause and non-cancer, non-cardiovascular mortality; the hazard ratios (HR) for the highest v. lowest quartile were 0·80 (95 % CI 0·68, 0·95) and 0·64 (95 % CI 0·49, 0·84), respectively. Dietary GL was found to be significantly inversely associated with the risk of all-cause, cancer, and non-cancer, non-cardiovascular mortality; the HR for the highest v. lowest quartile were 0·71 (95 % CI 0·59, 0·86), 0·71 (95 % CI 0·52, 0·99) and 0·64 (95 % CI 0·48, 0·87), respectively. The results obtained for the GL derived from white rice, but not from other foods, closely mirrored those obtained for overall GL. In women, dietary GI was found to be significantly positively associated with the risk of cardiovascular mortality; the HR for the highest v. lowest quartile was 1·56 (95 % CI 1·15, 2·13). The results of the present study suggest potential favourable effects of dietary GI and GL on mortality in men, but an association between high GI and an increased risk of cardiovascular mortality in women.
British Journal Of Nutrition 10/2014; 112(12):1-8. DOI:10.1017/S0007114514003109 · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
The potential associations of diabetes mellitus with malignant neoplasms including liver cancer have become a great concern from both clinical and preventive perspectives. Although sufficient evidence for a positive association between diabetes and liver cancer already exists, it would be informative to summarize up-to-date epidemiologic data in Japan.
We systematically reviewed epidemiologic studies on diabetes and liver cancer among Japanese populations. Original data were obtained by searching the MEDLINE (PubMed) and Ichushi databases, complemented with manual searches. The evaluation was performed in terms of the magnitude of association in each study and the strength of evidence ('convincing', 'probable', 'possible' or 'insufficient'), together with biological plausibility.
We identified 19 cohort studies, one pooled-analysis of seven cohort studies, and seven case-control studies. Of 24 relative risk estimates of liver cancer for diabetes reported in those cohort studies, 17 showed a weak to strong positive association, six revealed no association and one demonstrated a weak inverse association (summary relative risk 2.10, 95% confidence interval 1.60-2.76). Ten relative risk estimates from the case-control studies showed a weak to strong positive association (n = 9) or no association (n = 1; summary relative risk 2.32, confidence interval 1.73-3.12). Overall, the summary relative risk became 2.18 (confidence interval 1.78-2.69). Heterogeneity in relative risks was significant for the difference in categories of study population (P = 0.01), but not in study type (P = 0.39) or sex (P = 0.33).
Diabetes mellitus 'probably' increases the risk of liver cancer among the Japanese population.
Japanese Journal of Clinical Oncology 08/2014; 44(10). DOI:10.1093/jjco/hyu108 · 2.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
The association between meat consumption and colorectal cancer remains inconsistent among Asians. The present study systematically evaluated and meta-analyzed epidemiologic studies on the association between consumption of total and specific meats and colorectal cancer risk among Japanese.
Original data were obtained from MEDLINE searched using PubMed or from searches of the Ichushi database, complemented with manual searches. The associations were evaluated based on the strength of evidence, the magnitude of association and biologic plausibility. A meta-analysis was performed according to total meat, red and processed meat as well as poultry and site-specific cancers.
Six cohort studies and 13 case-control studies were identified. In cohort studies, most investigations found no association between total meat consumption and colon/rectal cancer, and several studies showed a weak-to-moderate positive association of red meat and processed meat consumption with colon/rectal cancer. The majority of case-control studies showed no association between total meat consumption and colon and rectal cancer; however, several ones reported a weak-to-strong positive association of red and processed consumption with colon and rectal cancer. In meta-analysis, the summary relative risks (95% confidence interval) for the highest versus lowest categories of red meat consumption were 1.16 (1.001-1.34) and 1.21 (1.03-1.43) for colorectal and colon cancer, respectively, and those for processed meat consumption were 1.17 (1.02-1.35) and 1.23 (1.03-1.47) for colorectal and colon cancer, respectively. Poultry consumption was associated with lower risk of rectal cancer; summary relative risk (95% confidence interval) was 0.80 (0.67-0.96).
High consumption of red meat and processed meat possibly increases risk of colorectal cancer or colon cancer among the Japanese population.
Japanese Journal of Clinical Oncology 06/2014; 44(7):641-650. DOI:10.1093/jjco/hyu061 · 2.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives:
Having a lighter skin tone is highly valued among many Asian women. If skin colour is affected by smoking, women may be motivated to avoid tobacco or quit smoking. The present study examined the association of tobacco smoking with skin colour in Japanese women.
Information on smoking habits was obtained through a self-administered questionnaire completed by 939 Japanese women aged 20-74 in Gifu, Japan, during 2003-2006. Skin colour was examined on the inner side of the upper and lower arm and on the forehead using a Mexameter device (a narrow-band reflective spectrophotometer), which expressed results as a melanin index and erythema index.
Current smokers had higher melanin indices than never-smokers and former smokers for all measured sites. The number of cigarettes smoked per day, the years of smoking and pack-years were significantly positively associated with melanin indices for all measured sites after adjustments for age, body mass index, lifetime sun exposure, and room temperature and humidity. Smoking was also significantly associated with erythema indices on the inner upper and lower arms.
These data suggest that smoking is associated with a darker skin colour. If our findings are confirmed by further studies, they could be used in antismoking campaigns or by smoking cessation services.
Tobacco control 05/2014; 23(3):253-6. DOI:10.1136/tobaccocontrol-2012-050524 · 5.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Prospective evidence is inconsistent regarding the association between vegetable/fruit intake and the risk of gastric cancer.
In an analysis of original data from 4 population-based prospective cohort studies encompassing 191,232 participants, we used Cox proportional hazards regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of gastric cancer incidence according to vegetable and fruit intake and conducted a meta-analysis of HRs derived from each study.
During 2,094,428 person-years of follow-up, 2,995 gastric cancer cases were identified. After adjustment for potential confounders, we found a marginally significant decrease in gastric cancer risk in relation to total vegetable intake but not total fruit intake: the multivariate-adjusted HR (95% CI; P for trend) for the highest versus the lowest quintile of total vegetable intake was 0.89 (0.77-1.03; P for trend=0.13) among men and 0.83 (0.67-1.03; P for trend=0.40) among women. For distal gastric cancer, the multivariate HR for the highest quintile of total vegetable intake was 0.78 (0.63-0.97; P for trend=0.02) among men.
This pooled analysis of data from large prospective studies in Japan suggests that vegetable intake reduces gastric cancer risk, especially the risk of distal gastric cancer among men.
Annals of Oncology 03/2014; 25(6). DOI:10.1093/annonc/mdu115 · 7.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A positive association between body mass index (BMI) and breast cancer risk among postmenopausal women has been reported, and a weak inverse association has been suggested among premenopausal women from studies in the Western population. The effects of BMI on breast cancer have remained unclear among the Asian population, especially in premenopausal women.
We assessed the associations between BMI and breast cancer incidence by a pooled analysis from eight representative large-scale cohort studies in Japan. Cancer incidence was mainly confirmed through regional population-based cancer registries and/or through active patient notification from major local hospitals. Breast cancer was defined as code C50 according to ICD10. Pooled estimates of the hazard ratios (HRs) and 95% confidence interval (CIs) for breast cancer were calculated using random-effects models.
Analytic subjects were 183 940 women, 1783 of whom had breast cancer during 2 194 211 person-years of follow-up. A positive association between BMI and the risk of postmenopausal breast cancer was observed (trend P < 0.001). The HRs for premenopausal breast cancer were 1.05 (95% CI 0.56-1.99), 1.07 (95% CI 0.76-1.52), 0.91 (95% CI 0.64-1.30), 1.15 (95% CI 0.76-1.73), 1.45 (95% CI 0.71-2.94), and 2.25 (95% CI 1.10-4.60), respectively, in BMIs of <19, 19 to <21, 21 to <23, 25 to <27, 27 to <30, and ≥30 kg/m(2). These results were not substantially altered after excluding the patients who were diagnosed with breast cancer in the first 2 years of follow-up.
The increased risk of postmenopausal breast cancer among women with higher BMIs was confirmed in Japanese. A borderline-significant positive association between BMI and premenopausal breast cancer was observed, suggesting that body mass in Asian women might have opposite effects on breast cancer compared with Western women.
Annals of Oncology 02/2014; 25(2):519-24. DOI:10.1093/annonc/mdt542 · 7.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We reviewed epidemiological studies of soy intake and breast cancer among Japanese women. This report is one among a series of articles by our research group, which is evaluating the existing evidence concerning the association between health-related lifestyles and cancer.
Original data were obtained from MEDLINE searches using PubMed or from searches of the Ichushi database, complemented with manual searches. Evaluation of associations was based on the strength of evidence and the magnitude of association, together with biological plausibility.
Five cohort studies and six case-control studies were identified. Among the cohort studies, two studies observed that total soy intake (in terms of total amounts of soy foods or soy isoflavones) was associated with a moderate (0.5 ≤ relative risk ≤ 0.67 with statistical significance) or strong (relative risk ≤ 0.5 with statistical significance) risk reduction of breast cancer in postmenopausal women. Among the case-control studies, two studies reported a weak (0.67 ≤ odds ratio ≤ 1.5 with statistical significance or 0.5 ≤ odds ratio ≤ 0.67 without statistical significance) inverse association between total soy intake and the risk of breast cancer. In the former, this association was observed in all women combined-premenopausal and postmenopausal women-but in the latter, the association was confined to postmenopausal women. The associations of intakes of individual soy foods with the risk of breast cancer were generally null. There is some evidence that supports the biological plausibility of a protective effect of isoflavones on breast cancer risk.
We conclude that soy intake possibly decreases the risk of breast cancer among Japanese women.
Japanese Journal of Clinical Oncology 01/2014; 44(3). DOI:10.1093/jjco/hyt203 · 2.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Recently, profiles of plasma amino acids have been utilized to detect diseases including breast cancer. However, there is a possibility that the amino acid status may be associated with the risk of breast cancer. We investigated the relationship of plasma levels of amino acids with levels of sex hormones and insulin-like growth factor (IGF)-1, which are relevant to the etiology of premenopausal breast cancer, in normal premenopausal women.
Participants were 350 Japanese women who had regular menstrual cycles less than 40-day long. Fasting plasma samples were assayed for estradiol, testosterone, dehydroepiandrosterone sulfate, sex-hormone-binding globulin (SHBG), and IGF-1. A total of 20 amino acids in plasma were quantified by liquid chromatography-mass spectrometry. Information on lifestyle and reproductive factors was obtained using a self-administered questionnaire.
The plasma arginine level was significantly inversely correlated with plasma levels of total and free estradiol and IGF-1 after adjusting for age, body mass index, and phase of the menstrual cycle. Plasma leucine and tyrosine levels were significantly positively correlated with the free testosterone level. The ratio of plasma asparagine to the total amino acids was significantly positively correlated with SHBG level.
Plasma levels of some specific amino acids, such as arginine, leucine, tyrosine, and asparagine, were associated with the levels of sex hormones, SHBG, or IGF-1 in premenopausal women. However, the present cross-sectional study cannot provide a cause-effect relation. The implication of amino acids in the etiology of breast cancer needs to be addressed in future studies.
Cancer Causes and Control 11/2013; 25(2). DOI:10.1007/s10552-013-0316-8 · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There are few studies about the association between tinnitus and sleep disorders in the general population worldwide. This study assessed this association in a Japanese community.
A total of 14,027 participants 45 to 79 years of age who were in the Takayama Study responded to a self-administered questionnaire about tinnitus and sleep disorders.
Of this population, 13.3% of men and 10.6% of women had current tinnitus. The percentages of insomnia, respectively, among individuals with and without tinnitus were 28.1% in men and 36.1% in women and 18.8% in men and 21.5% in women. There were 1.7-fold (95% confidence interval [CI], 1.4 to 2.1) and 1.8-fold (95% CI, 1.5 to 2.2) increases in the odds ratios (ORs) of insomnia for those with tinnitus compared with those without tinnitus in men and women, respectively. Loud or very loud tinnitus was associated with 2.8-fold (95% CI, 1.8 to 4.3) and 3.3-fold (95% CI, 1.9 to 5.6) increases in the OR of insomnia in men and women, respectively. Even low (ie, quiet) or moderate tinnitus was significantly associated with insomnia. Difficulty initiating sleep, difficulty maintaining sleep, and a poor perceived quality of sleep were also significantly associated with tinnitus.
Insomnia and other sleep disorders were significantly associated with tinnitus in Japanese adults.
The Annals of otology, rhinology, and laryngology 11/2013; 122(11):701-6. DOI:10.1177/000348941312201107 · 1.09 Impact Factor