Lital Keinan-Boker

• MD, PhD, MPH
• Managing Director at University of Haifa

Background Disordered eating (DE) is highly prevalent among adolescents, though its definition varies. The association between DE and early pubertal maturation (EPM) remains underexplored in Israel, and has not been sufficiently examined using the widely-used SCOFF questionnaire. This study examines these associations in adolescents. Methods Parti...

Background: Self-rated health (SRH) has been shown to predict mortality across a lifespan. However, its predictive value might differ between populations. We compared the association between SRH and mortality in Israeli Jewish and Arab older adults (65+). Methods: A prospective cohort study was conducted among Jewish (n = 1463) and Arab (n = 298) p...

Background and Aims Knowledge is lacking on the relationship between greenness and mortality in cancer survivors who experience coronary artery disease (CAD), a cardio-oncologic population. We aimed to investigate the association between residential greenness exposure and all-cause mortality in a cardio-oncologic population. Methods Cancer survivo...

Background Collection of detailed dietary data is labor intensive and expensive, harmonization of existing data sets has been proposed as an effective tool for research questions in which individual studies are underpowered. Methods In this paper, we describe the methodology used to retrospectively harmonize nutritional data from multiple sources,...

Background Shigella is a leading cause of moderate-to-severe diarrhoea worldwide and diarrhoeal deaths in children in low- and-middle-income countries. Aim We investigated trends and characteristics of shigellosis and antimicrobial resistance of Shigella sonnei in Israel. Methods We analysed data generated by the Sentinel Laboratory-Based Surveil...

Background A new respiratory virus surveillance platform, based on nationwide hospital laboratory data, was established in Israel during the COVID-19 pandemic. Aim We aimed to evaluate the performance of this platform with respect to the detection of influenza and respiratory syncytial virus (RSV) from week 36 in 2020 to week 15 in 2023, and how i...

Background: Population-based cancer registries are the best source of information to measure cancer burden. However, little is done to use this information for individual cancer risk assessment. In this study, we aimed at identifying women at high risk of breast and ovarian cancer using data on family history of cancer from the Israel national canc...

In order to explore the association between meat consumption and gastrointestinal/colorectal cancer (CRC) risk and to estimate the Israeli population attributable fraction (PAF), we conducted a collaborative historical cohort study using the individual participant data of seven nutritional studies from the past 6 decades. We included healthy adult...

Aim COVID-19 infection may have long-lasting implications on mental health and cognitive functions. This study aimed to estimate the prevalence of post-COVID-19-related symptoms 13–18 months post-COVID-19 infection and to study the associations between past COVID-19 infection, poor mental health, and cognitive disturbances. Subject and methods Thi...

Background Knowledge is lacking on the relationship between greenness and all-cause mortality in cancer survivors who subsequently experience an acute coronary syndrome (ACS), a cardio-oncologic population. We aimed to investigate the association between residential greenness exposure and mortality in this cardio-oncologic population. Methods Canc...

Background Evidence suggests an inverse association between surrounding greenness and mortality among the general population and individuals with coronary heart disease (CHD). Little is known whether greenness-related mortality reduction differs between CHD and CHD-free individuals. Aim To compare associations of greenness and all-cause mortality...

Background Despite publications assuring no increased risk for acute cardiovascular events (excluding myocarditis) and sudden death following administration of COVID19 vaccines, these issues still stir much public ado. We assessed the risk for acute cardiovascular events that require hospitalization (excluding myocarditis) and for mortality in the...

Background Although studies have suggested that Holocaust survivors are more likely than their non‐Holocaust‐exposed counterparts to suffer from mental and chronic morbidity, methodology differences and potential confounders often compromise result replicability and external validity. We examined associations between Holocaust exposure and chronic...

Introduction The joint association of night-time sleep duration and daytime napping (siesta) with mortality remains elusive. We explored sleep patterns and long-term mortality in older adults and tested whether the relationship is modified by cognitive function. Methods We analysed data from 1519 participants in the National Health and Nutrition S...

Background: Shigella is a leading cause of moderate-to-severe diarrhea globally, with young children most affected. The burden of shigellosis drops increasingly with age, inferring the acquisition of natural immunity. We tested the hypothesis that IgG antibodies elicited against Shigella O-specific polysaccharide (O-SP) are correlates of age-acquir...

Background Environmental tobacco smoke (ETS) exposure in children can cause delayed lung development and lifelong cardiovascular damage. The aim of this study was to measure ETS exposure in children in Israel in 2020–2021 using urinary cotinine (UC) measurements and to assess correlates of ETS exposure, including parental smoking. Methods In the f...

Israel was the first country to launch COVID-19 boosters, in late July 2021, with strong public health messaging. The booster campaign reversed rising infection rates from the Delta variant and reduced hospitalizations and deaths. The US booster rollout was slower, and public health messaging was mixed. We used the Israeli experience to ask the cou...

Background Despite publications assuring no increased risk for acute cardiovascular events (excluding myocarditis) and sudden death following administration of COVID19 vaccines, this issue still stirs much public ado. We assessed the risk for acute cardiovascular events that require hospitalization in the short-term following administration of the...

Introduction: The association disclosed between COVID-19 infection and ischemic stroke (IS) raises concern. The exact risk periods, which were not consistent between studies, require further investigation. Methods: We linked between two national databases: the COVID-19 database and the Israeli National Stroke Registry. The self-controlled case s...

There is substantial public concern about the health risks of proximity to petrochemical industries. In the Haifa Bay Area (HBA), which contains Israel’s densest industrial area, these concerns have been strengthened by elevated cancer mortality rates since the late 1960s. We studied the association between adolescent exposure to industrial air pol...

Menopause occurs around midlife and is an inevitable component of women's aging. The study aimed to investigate the associations between the lifetime prevalence of menopausal symptoms and health-related characteristics among Israeli postmenopausal women aged 55-75 years. Additionally, this study aimed to estimate the use of hormone replacement ther...

Non-typhoidal salmonellosis (NTS) is one of the most common foodborne diseases worldwide. In this study, we aimed to analyze trends in the epidemiology of NTS in the last decade in Israel. Laboratory-confirmed cases of NTS at eight sentinel laboratories were reported to the Israel Sentinel Laboratory-Based Surveillance Network, integrated with the...

We assessed effectiveness of the BNT162b2 vaccine against infection with the B.1.1.529 (Omicron) variant (mostly BA.1 subvariant), among children 5-11 years of age in Israel. Using a matched case-control design, we matched SARS-CoV-2-positive children (cases) and SARS-CoV-2-negative children (controls) by age, sex, population group, socioeconomic s...

Background: Evidence regarding environmental exposure to green spaces and outcomes in coronary disease patients is lacking. We evaluated the association between residential exposure to greenness and mortality in patients undergoing percutaneous coronary interventions (PCI). Methods: Consecutive patients undergoing PCI at the Rabin Medical Center in...

Background: Childhood kidney failure is a rare condition with worldwide clinical variability. We used a nationwide multicenter analysis to study the pretransplant course of the entire Israeli pediatric kidney failure population over 30 years. Methods: In this nationwide, population-based, historical cohort study, we analyzed medical and demograp...

Background Food insecurity (FI) and poor health can turn into a vicious cycle with detrimental effects, especially in the elderly, however, few studies have examined the relationship between FI and health in this age group. Objective We investigated associations of FI with physical and mental health and health behaviors among community-dwelling el...

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) emerged in Israel in February 2020 and spread from then. In December 2020, the FDA approved an emergency use authorization of the Pfizer-BioNTech vaccine, and on 20 December, an immunization campaign began among adults in Israel. We characterized seropositivity for IgG anti-spike antibodi...

Background: Elevated intrascrotal temperature has been suggested as a risk factor for testicular cancer, which is the most common neoplasm among young men. Varicocoele was linked to increased intrascrotal temperature, but whether it is associated with testicular cancer is unclear. Objective: To explore the possible association between varicocoel...

Vaccine hesitancy (VH) is a major health threat to the efforts to tackle COVID-19 morbidity and mortality. This study’s objectives were to assess COVID-19 VH before and after vaccines' availability and to analyze the associations between COVID-19 VH and participants’ characteristics. A national cross-sectional telephone interview survey among Israe...

Background: The cancer burden in Israel is substantial. Recently calculated population attributable fractions (PAFs) for modifiable cancer risk factors in the US and the UK have indicated much room for prevention. Our aim was to estimate PAFs for selected modifiable cancer risk factors in Israel. Methods: Exposure data on selected modifiable risk f...

Irrigation with reclaimed wastewater is a growing practice aimed at conserving freshwater sources, especially in arid and semiarid regions. Despite the apparent advantages to water management, the practice of irrigation with reclaimed wastewater exposes the agroenvironment to contaminants of emerging concern (CECs). In this report, we estimated the...

Background There are limited data on whether primary diagnosis of meningioma may be associated with development of secondary primary cancer (SPC). Methods All meningioma cases (ICD-O-3 morphology codes 9530/0–9539/3) diagnosed in Jewish Israelis ≥ 20 years 1990 through 2015 registered in the Israel National Cancer Registry (INCR) were retrieved. A...

Protein consumption apparently plays a role in weight control. This cross-sectional study examined the association of protein consumption in Israeli adolescents with overweight/obesity. 7th–12th grade students participating in a national school-based survey (2015–2016) completed self-administered questionnaires, including a food frequency questionn...

Background: Two SARS-CoV-2 waves in Israel ended while a substantial number of individuals remained unvaccinated or partially vaccinated. The indirect protective effect of the first BNT162b2 vaccination campaign in Israel was evaluated between 22 December 2020 and 18 May 2021. Methods: The daily percentage of new PCR-confirmed SARS-CoV-2 cases a...

Importance: To our knowledge, the role of overall diet quality in successful aging has not been conclusively demonstrated. Objective: To prospectively examine the association between diet quality and longevity and successful aging in a population-based cohort of older adults. Design, setting, and participants: Participants in "Mabat Zahav" (th...

Background: Salmonella, Shigella, and Campylobacter are highly prevalent among children. Reports on risk factors of patients infected with all three pathogens, not simultaneously, are scarce. Objectives: To identify risk factors for multiple infection with Salmonella, Shigella, and Campylobacter in the same child. Methods: Using the Israel Sen...

Background Early reports on COVID-19 patient outcomes showed a marked fatality rate among patients requiring invasive mechanical ventilation (IMV). Objective Our aim was to compare case fatality rate (CFR) outcomes for patients requiring IMV due to severe acute respiratory syndrome (SARS)-associated coronavirus 2 (COVID-19), SARS-associated corona...

Background The COVID-19 pandemic presented new challenges for the existing respiratory surveillance systems, and adaptations were implemented. Systematic assessment of the syndromic and sentinel surveillance platforms during the pandemic is essential for understanding the value of each platform in the context of an emerging pathogen with rapid glob...

The Coronavirus disease 2019 (COVID-19) pandemic has introduced many mental stressors. This study aimed to evaluate the prevalence of depression and anxiety during the pandemic and characterize those at higher risk. We conducted a national cross-sectional telephone interview survey among Israeli adults from May to September 2020, between the first...

We estimated vaccine effectiveness (VE) of the BNT162b2 (Pfizer-BioNTech, https://www.pfizer.com) booster dose against SARS-CoV-2 infection and reduction of complications (hospitalization, severe disease, and death) among breakthrough cases in persons in Israel >16 years of age for <20 weeks. VE estimates reached 96.8% (95% CI 96.0%-97.5%) for pers...

Background: Guidelines for pandemic preparedness emphasize the role of sentinel and syndromic surveillance in monitoring pandemic spread. Objectives: To examine advantages and obstacles of utilizing a sentinel influenza surveillance system to monitor community severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) activity based on Israel'...

Background We aimed to build a basic daily mortality curve in Israel based on 20-year data accounting for long-term and annual trends, influenza-like illness (ILI) and climate factors among others, and to use the basic curve to estimate excess mortality during 65 weeks of the COVID-19 pandemic in 2020–2021 stratified by age groups. Methods Using d...

We analyzed data from a serological study performed on 2,765 samples from the Israeli National Sera Bank (INSB), established in 1997 in the Israel Center for Disease Control (ICDC) collected from children aged 0-<16 years during January 2020-March 2021. Trends in seropositivity rates to SARS-CoV-2 were evaluated using Joinpoint within specific age...

Women with the most extensive breast density, have a 4‐ to 6‐fold higher cancer risk than women with the lowest density. This cross‐sectional study evaluated associations of cumulative mammographic density in two distinct ethnic groups with the respective age‐specific breast cancer incidences in the population. The study compared four cohorts of 20...

Background Estimating real-world vaccine effectiveness is challenging since a variety of population factors can impact vaccine effectiveness. We aimed to assess the population-level reduction in cumulative SARS-CoV-2 cases, hospitalizations and mortality due to the BNT162b2 mRNA COVID-19 vaccination campaign in Israel during January-February, 2021....

PurposeMilk consumption is associated with increased height primarily in early childhood. However, in adolescents, data are scarce with inconsistent results. Since height is a proxy for overall health and well-being, this study evaluated the association of dairy intake with height in adolescents.Methods Students in 7th–12th grades, participating in...

Background Current guidelines are inconsistent regarding the follow-up of patients with 1–2 diminutive (1–5 mm) non-advanced adenomas (DNAAs). Aims To evaluate the risk of metachronous advanced neoplasia (AN), defined as cancer or advanced adenoma (AA), among patients with either normal colonoscopy or 1–2 DNAAs. Methods A retrospective cohort stu...

Background Several countries have recently transitioned from the trivalent inactivated influenza vaccine (TIV) to the quadrivalent inactivated influenza vaccine (QIV) in order to outweigh influenza B vaccine-mismatch. However, few studies thus far evaluated its benefits versus the TIV in a systematic manner. Our objective was to compare the QIV VE...

Until recently, children and adolescents were not eligible for COVID-19 vaccination. They may have been a considerable source of SARS-CoV-2 spread. We evaluated SARS-CoV-2 IgG antibody seroprevalence in Israeli children aged 0–15 years from January 2020 to March 2021. Seropositivity was 1.8–5.5 times higher than COVID-19 incidence rates based on PC...

Background Approximately 5.1 million Israelis had been fully immunized against coronavirus disease 2019 (Covid-19) after receiving two doses of the BNT162b2 messenger RNA vaccine (Pfizer–BioNTech) by May 31, 2021. After early reports of myocarditis during adverse events monitoring, the Israeli Ministry of Health initiated active surveillance. Meth...

Background: The rapid vaccination campaign against COVID-19 in Israel relied on the BNT162b2 vaccine. We performed a longitudinal analysis of multiple cohorts, using individual data, to evaluate the effectiveness of the vaccine against new and breakthrough cases. Methods: We estimated vaccine effectiveness (VE) for 27 consecutive cohorts, each c...

In Israel, the BNT162b2 vaccine against severe acute respiratory syndrome coronavirus 2 was approved for use in adolescents in June 2021, shortly before an outbreak of B.1.617.2 (Delta) variant-dominant infection. We evaluated short-term vaccine effectiveness and found the vaccine to be highly effective among this population in this setting.

Front-of-package labels (FOPL) are designed to simplify nutrition information and to help consumers make healthier food choices. The Israeli government has implemented new regulations requiring mandatory red warning FOPL for high levels of sodium, sugar, or saturated fats. A voluntary green positive FOPL for products fitting the national nutritiona...

Objectives: To evaluate the sex-specific effects of stimulants in children with Attention-Deficit/Hyperactivity Disorder (ADHD) on body mass index (BMI)-Z and Height-Z trajectories. Study design: A retrospective cohort study utilizing the database of Israel Clalit Health Services. Participants included 5-18-year-old insureds with documentation o...

Thyroid cancer (TC) constitutes more than 95% of all endocrine tumors. Differentiated thyroid carcinoma (DTC), which includes the papillary and follicular types, constitutes about 90% of all TCs and 2.1% of all cancers. The incidence of DTC has increased significantly worldwide, with papillary cancer leading this trend and being the most prevalent....

Haifa Bay Area (HBA) contains Israel’s principal industrial area, and there are substantial public concerns about health effects from its emissions. We aimed to examine associations between exposure to air pollution from HBA industrial area with prevalent asthma and other atopic diseases at age 17. This is a cross-sectional study. The study populat...

While vaccination is considered the most effective means to prevent influenza infection, its seasonal effectiveness varies, depending on the circulating influenza strains. Here, we characterized the circulation of influenza strains in October-2018 and March-2019 around the world. For this, we used nasopharyngeal samples collected from outpatient an...

Background: Evaluation of children's anthropometrics poses challenges due to age-related changes. The main focus is on height and weight. However, since weight is height-dependent, body mass index (BMI) is the best surrogate measurement of adiposity. Israel has not developed national growth tables; therefore, researchers and clinicians utilize eit...

This cohort study examines COVID-19 incidence rates in youths aged 0 to 19 before and after reopening schools in Israel.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) causes COVID-19 and is mostly person-to-person transmitted through respiratory droplets. The implications of the strategies implemented to prevent COVID-19 transmission on other infectious diseases are unclear. We aimed to appraise trends in the incidence of salmonellosis, shigellosis and...

Background Handgrip strength (HGS) is used to assess muscle strength, which is an important indicator of health status in older adults. Objective We evaluated associations of demographic, anthropometric, clinical, and nutritional factors with muscle strength in community-dwelling elderly adults. Methods This population-based cross-sectional study...

Background: Oral anticancer therapy (OACT) poses adherence-related challenges to patients while generating a setting in which both primary care physicians (PCPs) and oncologists are involved in the active treatment of cancer. Continuity of care (COC) was shown to be associated with medication adherence. While maintaining COC is a central role of t...

Background Gliomas manifest in a variety of histological phenotypes with varying aggressiveness. The etiology of glioma remains largely unknown. Taller stature in adulthood has been linked with glioma risk. The aim of this study was to discern whether this association can be detected in adolescence. Methods The cohort included 2,223,168 adolescent...

The Israel National Sera Bank (INSB) was established in 1997 in the Israel Center for Disease Control. The purpose of the INSB was to provide policymakers with data on the immunity status of the Israeli population against vaccine-preventable diseases, and on the extent and characteristics of exposure to emerging and re-emerging infectious diseases....

School reopening on May 2020 did not have a major effect on SARS-CoV-2 resurgence in Israel during June-July. Rather, the easing of restrictions on large-scale gatherings was primarily responsible for this resurgence, and the increased hospitalizations and mortality.

Background: The benefits of school reopening must be weighed against the morbidity and mortality risks and the impact of enhancing spread of COVID-19. We investigated the effects of school reopening and easing of social distancing restrictions on the dynamics of SARS-CoV-2 infections in Israel, between March-July 2020. Methods: We examined the n...

Introduction Congenital anomalies of the kidney and urinary tract (CAKUT) are the most common kidney diseases in childhood. Alterations in genes governing nephrogenesis may cause CAKUT, and in some cases may contribute to development of urinary tract (UT) tumors later in life. We aimed to assess the association between CAKUT and UT cancer in adulth...

Background: The Israel National Cancer Registry (INCR) was established in 1960. Reporting has been mandatory since 1982. All neoplasms of uncertain/unknown behavior, in situ and invasive malignancies (excluding basal and squamous cell carcinomas of the skin), and benign neoplasms of the brain and central nervous system (CNS) are reportable. Objec...

Abstract Background Disordered eating (DE), defined as unhealthy eating attitudes and behaviors, is considered a major public health problem among adolescents. Nevertheless, rates of DE among Arab and Jewish adolescents in Israel are still unknown. Furthermore, while previous studies have highlighted the role of frequent family meals as a protectiv...

Background The 2017–2018 influenza season in Israel was characterized by the predominance of influenza B Yamagata, with a lesser circulation of influenza A(H1N1)pdm09 and influenza A(H3N2). We estimated vaccine effectiveness (VE) of the inactivated influenza vaccine which was selected for use that season. Methods End-of-season VE and 95% confidenc...

Background Communication between health authorities and healthcare providers is an essential element of the response to public health emergencies. Although call centers can facilitate such communication, no published reports describing their outcomes exist. In advance of the expected COVID-19 outbreak in Israel, the Israel Center for Disease Contro...

Background Holocaust victims experienced extreme physical and mental stress that could lead to prolonged deficits in psychological and physiological well-being. We aimed to examine whether exposure to Holocaust conditions is associated with cognitive function and decline in a sample of old male adults with coronary heart disease (CHD). Methods The...

Background An Israeli national taskforce performed a multi-center clinical and analytical validation of seven serology assays to determine their utility and limitations for SARS-CoV-2 diagnosis. Methods Serology assays from Roche, Abbott, Diasorin, BioMerieux, Beckman-Coulter, Siemens, and an in-house RBD ELISA were included. Negative samples from...

Background Increasing cancer incidence among children alongside improved treatments has resulted in a growing number of pediatric cancer survivors. Despite childhood cancer survivors’ exposure to various factors that compromise kidney function, few studies have investigated the association between childhood cancer and future kidney disease. Method...

Introduction Israel ranks very high globally in performing bariatric surgery (BS) per capita. In the first phase of the COVID-19 pandemic the bariatric surgeons’ community faced many concerns and challenges, especially in light of a decree issued by the Ministry of Health (MOH) on March 22nd, to ban all elective surgery in public hospitals. The aim...

Introduction Less attention has been given to the detection and nutritional status and needs of obese frail/sarcopenic older subjects. The aim of this study was to characterize the nutritional composition in older (≥65 years), frail-prone, obese subjects (defined by either waist circumference [WC] or body mass index [BMI]). Methods A cross-section...

Background: We assessed in a nationwide cohort the association between adolescent BMI and early-onset (< 40 years) type 2 diabetes among Israelis of Ethiopian origin. Methods: Normoglycemic adolescents (range 16-20 years old), including 93,806 native Israelis (≥ 3rd generation in Israel) and 27,684 Israelis of Ethiopian origin, were medically as...

Background Pyelonephritis is the most common serious bacterial infection during childhood. The long-term importance of kidney scarring is unclear.Objective To assess the risk of end-stage kidney disease (ESKD) in adolescents and young adults with history of pyelonephritis.Study DesignA nationwide, population-based, historical cohort study, includin...

Background: Meningiomas are the most common primary central nervous system tumors. Potential risk factors include obesity, height, history of allergy/atopy, and autoimmune diseases, but findings are conflicting. This study sought to assess the role of the different risk factors in the development of meningioma in adolescents/young adults. Methods...

Background Diabetic kidney disease (DKD) is becoming increasingly common among children. We aimed to estimate the risk of end-stage renal disease (ESKD) and mortality among adolescents with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) and normal renal function compared with non-diabetics. We hypothesized that childhood onset T...

Background: We assessed in a nationwide cohort the association between adolescent BMI and early-onset (<40 years) type 2 diabetes among Israelis of Ethiopian origin. Methods: Normoglycemic adolescents (range 16-20 years old), including 93,806 native Israelis (≥3rd generation in Israel) and 27,684 Israelis of Ethiopian origin, were medically assesse...

Background: We assessed in a nationwide cohort the association between adolescent BMI and early-onset (<40 years) type 2 diabetes among Israelis of Ethiopian origin. Methods: Normoglycemic adolescents (range 16-20 years old), including 93,806 native Israelis (≥3 rd generation in Israel) and 27,684 Israelis of Ethiopian origin, were medically assess...

Background: The global incidence of thyroid cancer (TC) has risen considerably during the last three decades, while prognosis is generally favorable. We assessed the association between long-term all-cause mortality and cardiovascular risk factors in TC survivors compared to the general population. Methods: Individuals diagnosed with TC during 2001...

Background: The global incidence of thyroid cancer (TC) has risen considerably during the last three decades, while prognosis is generally favorable. We assessed the long-term all-cause mortality in TC survivors compared to the general population, and its association with cardiovascular risk factors. Methods: Individuals diagnosed with TC during 20...

Background: The global incidence of thyroid cancer (TC) has risen considerably during the last three decades, while prognosis is generally favorable. We assessed the long-term all-cause mortality in TC survivors compared to the general population, and its association with cardiovascular risk factors. Methods: Individuals diagnosed with TC during 20...

Objectives Respiratory Syncytial Virus (RSV) is a known cause of morbidity among young children, while RSV-related disease in the elderly is not fully recognized. Several RSV candidate vaccines for infants, pregnant women and adults are under development. We aimed to estimate nationwide age-specific hospitalizations and seasonal trends, to help det...

Background Individuals with coronary heart disease are considered susceptible to traffic-related air pollution exposure. Yet, cohort-based evidence on whether preexisting coronary heart disease modifies the association of traffic-related air pollution with health outcomes is lacking. Aim Using data of four Israeli cohorts, we compared associations...