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de Smith AJ, Jiménez-Morales S, Mejía-Aranguré JM. The genetic risk of acute lymphoblastic leukemia and its implications for children of Latin American origin. Front Oncol 2024; 13:1299355. [PMID: 38264740 PMCID: PMC10805326 DOI: 10.3389/fonc.2023.1299355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/12/2023] [Indexed: 01/25/2024] Open
Abstract
Acute lymphoblastic leukemia (ALL) is the most common cancer in children, and disproportionately affects children of Hispanic/Latino ethnicity in the United States, who have the highest incidence of disease compared with other racial/ethnic groups. Incidence of childhood ALL is similarly high in several Latin American countries, notably in Mexico, and of concern is the rising incidence of childhood ALL in some Hispanic/Latino populations that may further widen this disparity. Prior studies have implicated common germline genetic variants in the increased risk of ALL among Hispanic/Latino children. In this review, we describe the known disparities in ALL incidence as well as patient outcomes that disproportionately affect Hispanic/Latino children across the Americas, and we focus on the role of genetic variation as well as Indigenous American ancestry in the etiology of these disparities. Finally, we discuss future avenues of research to further our understanding of the causes of the disparities in ALL incidence and outcomes in children of Latin American origin, which will be required for future precision prevention efforts.
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Affiliation(s)
- Adam J. de Smith
- Center for Genetic Epidemiology, Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, Los Angeles, CA, United States
- USC Norris Comprehensive Cancer Center, University of Southern California Keck School of Medicine, Los Angeles, CA, United States
| | - Silvia Jiménez-Morales
- Laboratorio de Innovación y Medicina de Precisión, Núcleo A, Instituto Nacional de Medicina Genómica, Ciudad de México, Mexico
| | - Juan Manuel Mejía-Aranguré
- Laboratorio de Genómica Funcional del Cáncer, Instituto Nacional de Medicina Genómica, Ciudad de México, Mexico
- Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, Mexico
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Zang X, Feng L, Qin W, Wang W, Zang X. Using machine learning methods to analyze the association between urinary polycyclic aromatic hydrocarbons and chronic bowel disorders in American adults. CHEMOSPHERE 2024; 346:140602. [PMID: 37931709 DOI: 10.1016/j.chemosphere.2023.140602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/25/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023]
Abstract
The etiology of chronic bowel disorders is multifaceted, with environmental exposure to harmful substances potentially playing a significant role in their pathogenesis. However, research on the correlation between polycyclic aromatic hydrocarbons (PAHs) and chronic bowel disorders remains limited. Using data from the National Health and Nutrition Examination Survey (NHANES) conducted in 2009-2010, we investigated the relationship between 9 PAHs and chronic diarrhea and constipation in U.S. adults. We employed unsupervised methods such as clustering and Principal Component Analysis (PCA) to identify participants with similar exposure patterns. Additionally, we used supervised learning techniques, namely weighted quantile sum (WQS) and Bayesian kernel machine (BKMR) regressions, to assess the association between PAHs and the occurrence of chronic diarrhea and chronic constipation. PCA identified three principal components in the unsupervised analysis, explaining 86.5% of the total PAH variability. The first component displayed a mild association with chronic diarrhea, but no correlation with chronic constipation. Participants were divided into three clusters via K-means clustering, based on PAH concentrations. Clusters with higher PAH exposure demonstrated an increased odds ratio for chronic diarrhea, but no meaningful connection with chronic constipation. In the supervised analysis, the WQS regression underscored a positive relationship between the PAH mixture and chronic diarrhea, with three PAHs significantly impacting the mixture effect. The mixture index showed no correlation with chronic constipation. BKMR analysis illustrated a positive trend in the impact of four specific PAHs on chronic diarrhea, given other metabolites were fixed at their 50th percentiles. Our results suggest a clear association between higher PAH exposure and an increased risk of chronic diarrhea, but not chronic constipation. It also underscores the potential role of specific PAHs in contributing to the risk of chronic diarrhea.
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Affiliation(s)
- Xiaodong Zang
- Department of Pediatrics, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Liandong Feng
- Hubei Provincial Key Laboratory of Occurrence and Intervention of Rheumatic Diseases, Minda Hospital of Hubei Minzu University, Enshi, 445000, China
| | - Wengang Qin
- Department of Pediatrics, Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui, 230001, China
| | - Weilin Wang
- Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Xiaowei Zang
- College of Safety Science and Engineering, Nanjing Tech University, Nanjing, 211816, China.
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Smith MJ, Phillips RV, Luque-Fernandez MA, Maringe C. Application of targeted maximum likelihood estimation in public health and epidemiological studies: a systematic review. Ann Epidemiol 2023; 86:34-48.e28. [PMID: 37343734 DOI: 10.1016/j.annepidem.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/24/2023] [Accepted: 06/06/2023] [Indexed: 06/23/2023]
Abstract
PURPOSE The targeted maximum likelihood estimation (TMLE) statistical data analysis framework integrates machine learning, statistical theory, and statistical inference to provide a least biased, efficient, and robust strategy for estimation and inference of a variety of statistical and causal parameters. We describe and evaluate the epidemiological applications that have benefited from recent methodological developments. METHODS We conducted a systematic literature review in PubMed for articles that applied any form of TMLE in observational studies. We summarized the epidemiological discipline, geographical location, expertize of the authors, and TMLE methods over time. We used the Roadmap of Targeted Learning and Causal Inference to extract key methodological aspects of the publications. We showcase the contributions to the literature of these TMLE results. RESULTS Of the 89 publications included, 33% originated from the University of California at Berkeley, where the framework was first developed by Professor Mark van der Laan. By 2022, 59% of the publications originated from outside the United States and explored up to seven different epidemiological disciplines in 2021-2022. Double-robustness, bias reduction, and model misspecification were the main motivations that drew researchers toward the TMLE framework. Through time, a wide variety of methodological, tutorial, and software-specific articles were cited, owing to the constant growth of methodological developments around TMLE. CONCLUSIONS There is a clear dissemination trend of the TMLE framework to various epidemiological disciplines and to increasing numbers of geographical areas. The availability of R packages, publication of tutorial papers, and involvement of methodological experts in applied publications have contributed to an exponential increase in the number of studies that understood the benefits and adoption of TMLE.
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Affiliation(s)
- Matthew J Smith
- Inequalities in Cancer Outcomes Network, London School of Hygiene and Tropical Medicine, London, UK.
| | - Rachael V Phillips
- Division of Biostatistics, School of Public Health, University of California at Berkeley, Berkeley, CA
| | - Miguel Angel Luque-Fernandez
- Inequalities in Cancer Outcomes Network, London School of Hygiene and Tropical Medicine, London, UK; Department of Statistics and Operations Research, University of Granada, Granada, Spain
| | - Camille Maringe
- Inequalities in Cancer Outcomes Network, London School of Hygiene and Tropical Medicine, London, UK
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Pordanjani SR, Kavousi A, Mirbagheri B, Shahsavani A, Etemad K. Spatial analysis and geoclimatic factors associated with the incidence of acute lymphoblastic leukemia in Iran during 2006-2014: An environmental epidemiological study. ENVIRONMENTAL RESEARCH 2021; 202:111662. [PMID: 34273372 DOI: 10.1016/j.envres.2021.111662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 06/09/2021] [Accepted: 07/05/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVES The present study aims to determine the cumulative incidence rate of acute lymphoblastic leukemia (ALL), the degree of spatial autocorrelation and clustering of ALL, the hotspot and coldspots of ALL and geoclimatic conditions affecting the incidence of ALL in Iran and to draw a comparison between global and local regression models. MATERIALS AND METHODS In this ecological study, an exploratory-etiologic multiple-group method has been adopted to investigate all children under 15 years of age with ALL in Iran during 2006-2014. Data analysis was performed using Mann Whitney U, Pearson correlation coefficients (PCCs), Global Moran's I, Optimized hotspot analysis (OHSA), Global Poisson regression (GPR), Geographically Weighted Poisson Regression (GWPR) at a significant level of α = 0.05. RESULTS The cumulative incidence rate of ALL was estimated at 21,315 per 100,000 Iranian children under 15 years of age. The value of Global Moran's I index was estimated 0.338 and significant (<0.001 P-value). Coldspots were observed in north and northwest of Iran and hotspots were identified in south, southwest and mid-east of Iran. In the present study, Max Temperature of Warmest Month (MTWM) and Direct Normal Irradiation (DNI) were risk factors and Precipitation of the Coldest Quarter (PCQ) and Altitude (AL) were protective factors in the incidence of ALL, even though the non-stationarity of local coefficients and local t-values was clear. GWPR, by capturing and applying spatial heterogeneity and spatial autocorrelation, had a greater performance and goodness of fit than GPR. DISCUSSION ALL has created spatial clusters in Iran. The incidence of ALL is the result of synergistic interaction between environmental, infectious, geographical and genetic risk factors. It is recommended to use of local models in ecological studies.
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Affiliation(s)
- Sajjad Rahimi Pordanjani
- Epidemiology, Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran; Epidemiology, Department of Epidemiology and Biostatistics, Semnan University of Medical Sciences, Semnan, Iran.
| | - Amir Kavousi
- Workplace Health Promotion Research Center, Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Babak Mirbagheri
- Center for Remote Sensing and GIS Research, Faculty of Earth Sciences, Shahid Beheshti University, Tehran, Iran.
| | - Abbas Shahsavani
- Air Quality Health and Climate Change Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Environmental Health Engineering, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Koorosh Etemad
- Epidemiology, Department of Epidemiology, School of Public Health and Safety Shahid Beheshti, University of Medical Sciences, Tehran, Iran.
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Pordanjani SR, Kavousi A, Mirbagheri B, Shahsavani A, Etemad K. Identification of high-risk and low-risk clusters and estimation of the relative risk of acute lymphoblastic leukemia in provinces of Iran during 2006-2014 period: A geo-epidemiological study. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2021; 26:18. [PMID: 34084197 PMCID: PMC8106411 DOI: 10.4103/jrms.jrms_662_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 01/08/2020] [Accepted: 09/18/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND The present study was conducted to determine the epidemiological status, identify high-risk and low-risk clusters, and estimate the relative risk (RR) of acute lymphoblastic leukemia (ALL) in provinces of Iran. MATERIALS AND METHODS This is an ecological study carried out using an Exploratory Multiple-Group design on 3769 children under 15 years of age with ALL from 2006 to 2014. Data analysis was performed using Mann-Whitney U, Global Moran's I and Kuldorff's purely spatial scan statistic tests at a significance level of 0.05. RESULTS The average annual incidence rate of ALL during 2006-2014 period was 2.25/100,000 children under 15 years of age. The most likely high-risk cluster with log-likelihood ratio (LLR) =327.47 is located in the southwestern part of Iran with a radius of 294.93 km and a centrality of 30.77 N and 50.83 E, which contained 1276 patients with a RR of 2.56. It includes Fars, Bushehr, Kohgiluyeh and Boyer-Ahmad, Khuzestan and Chahar Mahall and Bakhtiari provinces. On the other hand, the most likely low-risk cluster with 517 patients, and a RR 0.49 and LLR = 227.03 was identified in the northwestern part of Iran with a radius of 270.38 km and a centrality of 37.25 N and 49.49 E. It includes Zanjan, Qazvin, Gilan and East Azerbaijan, Ardabil, Alborz and Tehran provinces. CONCLUSION High-risk clusters were observed in Southwestern, central, and eastern Iran, while low-risk clusters were identified in Northern and Western Iran.
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Affiliation(s)
- Sajjad Rahimi Pordanjani
- Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Kavousi
- Workplace Health Promotion Research Center, Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Babak Mirbagheri
- Center for Remote Sensing and GIS Research, Faculty of Earth Sciences, Shahid Beheshti University, Tehran, Iran
| | - Abbas Shahsavani
- Environmental and Occupational Hazards Control Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Environmental Health Engineering, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Koorosh Etemad
- Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Marron M, Brackmann LK, Kuhse P, Christianson L, Langner I, Haug U, Ahrens W. Vaccination and the Risk of Childhood Cancer-A Systematic Review and Meta-Analysis. Front Oncol 2021; 10:610843. [PMID: 33552984 PMCID: PMC7862764 DOI: 10.3389/fonc.2020.610843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/07/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Infections may play a role in the etiology of childhood cancer and immunizations may be protective because vaccinations stimulate the immune system. Observational studies reported inconsistent associations between vaccination and risk of childhood cancer. Since a synthesis of the evidence is lacking, we conducted a meta-analysis stratified by histological and site-specific cancer. METHODS We performed a systematic review (CRD42020148579) following PRISMA guidelines and searched for literature in MEDLINE, Embase, and the Science Citation Index databases. We identified in three literature databases 7,594 different articles of which 35 met the inclusion criteria allowing for 27 analyses of 11 cancer outcomes after exposure to nine different types of vaccinations. We calculated summary odds ratios (ORs) and 95% confidence intervals (CIs) using random effects models. RESULTS We observed four inverse associations between childhood leukemia and certain vaccines as well as the number of vaccinations: OR 0.49 (95% CI = 0.32 to 0.74) for leukemia death after bacillus Calmette-Guérin vaccination; OR 0.76 (95% CI = 0.65 to 0.90) for acute lymphoblastic leukemia after Haemophilus influenzae type b vaccination; OR 0.57 (95% CI = 0.36 to 0.88) for leukemia; and OR 0.62 (95% CI = 0.46 to 0.85) for acute lymphoblastic leukemia after three or more vaccinations of any type. All other conducted analyses did not show any associations. DISCUSSION The results are consistent with the hypothesis that vaccinations reduce the risk of childhood leukemia. However, the robustness and validity of these results is limited due to the small number, substantial heterogeneity, and methodological limitations of available studies.
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Affiliation(s)
- Manuela Marron
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Department Epidemiological Methods and Etiological Research, Bremen, Germany
| | - Lara Kim Brackmann
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Department Epidemiological Methods and Etiological Research, Bremen, Germany
| | - Pia Kuhse
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Department Epidemiological Methods and Etiological Research, Bremen, Germany
| | - Lara Christianson
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Library, Bremen, Germany
| | - Ingo Langner
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Department Clinical Epidemiology, Bremen, Germany
| | - Ulrike Haug
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Department Clinical Epidemiology, Bremen, Germany
- University of Bremen, Faculty of Human and Health Sciences, Bremen, Germany
| | - Wolfgang Ahrens
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Department Epidemiological Methods and Etiological Research, Bremen, Germany
- University of Bremen, Faculty of Mathematics and Computer Science, Bremen, Germany
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Qiu KY, Xu HG, Luo XQ, Mai HR, Liao N, Yang LH, Zheng MC, Wan WQ, Wu XD, Liu RY, Chen QW, Chen HQ, Sun XF, Jiang H, Long XJ, Chen GH, Li XY, Li CG, Huang LB, Ling YY, Lin DN, Wen C, Kuang WY, Feng XQ, Ye ZL, Wu BY, He XL, Li QR, Wang LN, Kong XL, Xu LH, Li CK, Fang JP. Prognostic Value and Outcome for ETV6/RUNX1-Positive Pediatric Acute Lymphoblastic Leukemia: A Report From the South China Children's Leukemia Group. Front Oncol 2021; 11:797194. [PMID: 34988026 PMCID: PMC8722219 DOI: 10.3389/fonc.2021.797194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/29/2021] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To analyzed the outcome of ETV6/RUNX1-positive pediatric acute B lymphoblastic leukemia (B-ALL) with the aim of identifying prognostic value. METHOD A total of 2,530 pediatric patients who were diagnosed with B-ALL were classified into two groups based on the ETV6/RUNX1 status by using a retrospective cohort study method from February 28, 2008, to June 30, 2020, at 22 participating ALL centers. RESULTS In total, 461 (18.2%) cases were ETV6/RUNX1-positive. The proportion of patients with risk factors (age <1 year or ≥10 years, WB≥50×109/L) in ETV6/RUNX1-positive group was significantly lower than that in negative group (P<0.001), while the proportion of patients with good early response (good response to prednisone, D15 MRD < 0.1%, and D33 MRD < 0.01%) in ETV6/RUNX1-positive group was higher than that in the negative group (P<0.001, 0.788 and 0.004, respectively). Multivariate analysis of 2,530 patients found that age <1 or ≥10 years, SCCLG-ALL-2016 protocol, and MLL were independent predictor of outcome but not ETV6/RUNX1. The EFS and OS of the ETV6/RUNX1-positive group were significantly higher than those of the negative group (3-year EFS: 90.11 ± 4.21% vs 82 ± 2.36%, P<0.0001, 3-year OS: 91.99 ± 3.92% vs 88.79 ± 1.87%, P=0.017). Subgroup analysis showed that chemotherapy protocol, age, prednisone response, and D15 MRD were important factors affecting the prognosis of ETV6/RUNX1-positive children. CONCLUSIONS ETV6/RUNX1-positive pediatric ALL showed an excellent outcome but lack of independent prognostic significance in South China. However, for older patients who have the ETV6/RUNX1 fusion and slow response to therapy, to opt for more intensive treatment.
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Affiliation(s)
- Kun-yin Qiu
- Children’s Medical Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Hong-gui Xu
- Children’s Medical Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xue-qun Luo
- Department of Paediatrics, Sun Yat-sen University First Affiliated Hospital, Guangzhou, China
| | - Hui-rong Mai
- Department of Hematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, China
| | - Ning Liao
- Department of Paediatrics, Guangxi Medical University First Affiliated Hospital, Nanning, China
| | - Li-hua Yang
- Department of Paediatrics, Southern Medical University Zhujiang Hospital, Guangzhou, China
| | - Min-cui Zheng
- Department of Hematology, Hunan Children’s Hospital, Changsha, China
| | - Wu-qing Wan
- Department of Paediatrics, Second Xiangya Hospital of Central South University, Changsha, China
| | - Xue-dong Wu
- Department of Paediatrics, Southern Medical University Nanfang Hospital, Guangzhou, China
| | - Ri-yang Liu
- Department of Paediatrics, Huizhou Central People’s Hospital, Huizhou, China
| | - Qi-wen Chen
- Department of Paediatrics, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hui-qin Chen
- Department of Paediatrics, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiao-fei Sun
- Department of Paediatrics, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Hua Jiang
- Department of Hematology, Guangzhou Women and Children’s Medical Center, Guangzhou, China
| | - Xing-jiang Long
- Department of Paediatrics, Liuzhou People’s Hospital, Liuzhou, China
| | - Guo-hua Chen
- Department of Paediatrics, Huizhou First People’s Hospital, HuiZhou, China
| | - Xin-yu Li
- Children’s Medical Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Chang-gang Li
- Department of Hematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, China
| | - Li-bin Huang
- Department of Paediatrics, Sun Yat-sen University First Affiliated Hospital, Guangzhou, China
| | - Ya-yun Ling
- Department of Paediatrics, Guangxi Medical University First Affiliated Hospital, Nanning, China
| | - Dan-na Lin
- Department of Paediatrics, Southern Medical University Zhujiang Hospital, Guangzhou, China
| | - Chuan Wen
- Department of Paediatrics, Second Xiangya Hospital of Central South University, Changsha, China
| | - Wen-yong Kuang
- Department of Hematology, Hunan Children’s Hospital, Changsha, China
| | - Xiao-qin Feng
- Department of Paediatrics, Southern Medical University Nanfang Hospital, Guangzhou, China
| | - Zhong-lv Ye
- Department of Paediatrics, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Bei-yan Wu
- Department of Paediatrics, The First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Xiang-lin He
- Department of Paediatrics, Hunan Provincial People’s Hospital, Changsha, China
| | - Qiao-ru Li
- Department of Paediatrics, Zhongshan People’s Hospital, Zhongshan, China
| | - Li-na Wang
- Department of Paediatrics, Guangzhou First People’s Hospital, Guangzhou, China
| | - Xian-ling Kong
- Department of Paediatrics, Boai Hospital of Zhongshan, Zhongshan, China
| | - Lu-hong Xu
- Children’s Medical Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Chi-kong Li
- Department of Paediatrics, Hong Kong Children Hospital and Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Jian-pei Fang
- Children’s Medical Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- *Correspondence: Jian-pei Fang,
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Leonard SA, Kennedy CJ, Carmichael SL, Lyell DJ, Main EK. An Expanded Obstetric Comorbidity Scoring System for Predicting Severe Maternal Morbidity. Obstet Gynecol 2020; 136:440-449. [PMID: 32769656 DOI: 10.1097/aog.0000000000004022] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To develop and validate an expanded obstetric comorbidity score for predicting severe maternal morbidity that can be applied consistently across contemporary U.S. patient discharge data sets. METHODS Discharge data from birth hospitalizations in California during 2016-2017 were used to develop the score. The outcomes were severe maternal morbidity, defined using the Centers for Disease Control and Prevention index, and nontransfusion severe maternal morbidity (excluding cases where transfusion was the only indicator of severe maternal morbidity). We selected 27 potential patient-level risk factors for severe maternal morbidity, identified using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. We used a targeted causal inference approach integrated with machine learning to rank the risk factors based on adjusted risk ratios (aRRs). We used these results to assign scores to each comorbidity, which sum to a single numeric score. We validated the score in California and national data sets and compared the performance to that of a previously developed obstetric comorbidity index. RESULTS Among 919,546 births, the rates of severe maternal morbidity and nontransfusion severe maternal morbidity were 168 and 74 per 10,000 births, respectively. The highest risk comorbidity was placenta accreta spectrum (aRR of 30.5 for severe maternal morbidity and 54.7 for nontransfusion severe maternal morbidity) and the lowest was gestational diabetes mellitus (aRR of 1.06 for severe maternal morbidity and 1.12 for nontransfusion severe maternal morbidity). Normalized scores based on the aRR were developed for each comorbidity, which ranged from 1 to 59 points for severe maternal morbidity and from 1 to 36 points for nontransfusion severe maternal morbidity. The overall performance of the expanded comorbidity scores was good (C-statistics were 0.78 for severe maternal morbidity and 0.84 for nontransfusion severe maternal morbidity in California data and 0.82 and 0.87, respectively, in national data) and improved on prior comorbidity indices developed for obstetric populations. Calibration plots showed good concordance between predicted and actual risks of the outcomes. CONCLUSION We developed and validated an expanded obstetric comorbidity score to improve comparisons of severe maternal morbidity rates across patient populations with different comorbidity case mixes.
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Affiliation(s)
- Stephanie A Leonard
- Departments of Obstetrics and Gynecology and Pediatrics and the California Maternal Quality Care Collaborative, Stanford University, Stanford, and the Division of Epidemiology and Biostatistics and the Berkeley Institute for Data Science, University of California, Berkeley, Berkeley, California
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