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Wu K, Sun Q, Liu D, Lu J, Wen D, Zang X, Gao L. Genetically predicted circulating levels of cytokines and the risk of oral cavity and pharyngeal cancer: a bidirectional mendelian-randomization study. Front Genet 2024; 14:1321484. [PMID: 38274108 PMCID: PMC10808506 DOI: 10.3389/fgene.2023.1321484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 12/26/2023] [Indexed: 01/27/2024] Open
Abstract
Background: Epidemiological research has established associations between various inflammatory cytokines and the occurrence of oral cancer and oropharyngeal cancer (OCPC). We performed a Mendelian randomization (MR) analysis to systematically investigate the causal relationship between inflammatory cytokines and OCPC. Methods: We performed a bidirectional two-sample MR analysis using OCPC from 12 studies (6,034 cases and 6,585 controls) and genome-wide association study (GWAS) results for 41 serum cytokines from 8,293 Finns, respectively. Inverse variance weighting was used as the primary MR method and four additional MR methods (MR Egger, Weighted median, Simple mode, Weighted mode) were used to examine genetic associations between inflammatory traits and OCPC, and Cochran's Q test, MR-Egger intercept, leave-one-out analysis, funnel plot, and multivariate MR (MVMR) analysis were used to assess the MR results. Results: The results suggested a potential association between high gene expression of Macrophage inflammatory protein-1α (MIP1α/CCL3) and an increased risk of OCPC (Odds Ratio (OR): 1.71, 95% Confidence Interval (CI): 1.09-2.68, p = 0.019). Increasing the expression levels of the interleukin-7 (IL-7) gene by 1 standard deviation reduced the risk of OCPC (OR: 0.64, 95%CI: 0.48-0.86, p = 0.003). In addition, multivariate Mendelian randomization analysis also showed the same results (MIP1α/CCL3, OR: 1.002, 95% CI: 0.919-1.092, p = 0.044; IL-7, OR: 0.997, 95% CI: 0.994-0.999, p = 0.011). Conversely, there was a positive correlation between genetic susceptibility to OCPC and an increase in Interleukin-4 (IL-4) (OR: 1.04, 95%CI: 1.00-1.08, p = 0.027). Conclusion: Our study systematically assessed the association between inflammatory cytokines and the risk of OCPC. We identified two upstream regulatory factors (IL-7 and CCL3) and one downstream effector factor (IL-4) that were associated with OCPC, offering potential avenues for the development of novel treatments.
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Affiliation(s)
- Kehan Wu
- Department of Oral and Maxillofacial Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Qianhui Sun
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Dongxu Liu
- Department of Oral and Maxillofacial Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Jiayi Lu
- Department of Oral and Maxillofacial Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Deyu Wen
- Department of Oral and Maxillofacial Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Xiyan Zang
- Department of Oral and Maxillofacial Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Li Gao
- Department of Oral and Maxillofacial Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
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Zhang X, Gleber-Netto FO, Wang S, Jin KW, Yang DM, Gillenwater AM, Myers JN, Ferrarotto R, Pickering CR, Xiao G. A Deep Learning Onion Peeling Approach to Measure Oral Epithelium Layer Number. Cancers (Basel) 2023; 15:3891. [PMID: 37568707 PMCID: PMC10416878 DOI: 10.3390/cancers15153891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/27/2023] [Accepted: 07/01/2023] [Indexed: 08/13/2023] Open
Abstract
Head and neck squamous cell carcinoma (HNSCC), specifically in the oral cavity (oral squamous cell carcinoma, OSCC), is a common, complex cancer that significantly affects patients' quality of life. Early diagnosis typically improves prognoses yet relies on pathologist examination of histology images that exhibit high inter- and intra-observer variation. The advent of deep learning has automated this analysis, notably with object segmentation. However, techniques for automated oral dysplasia diagnosis have been limited to shape or cell stain information, without addressing the diagnostic potential in counting the number of cell layers in the oral epithelium. Our study attempts to address this gap by combining the existing U-Net and HD-Staining architectures for segmenting the oral epithelium and introducing a novel algorithm that we call Onion Peeling for counting the epithelium layer number. Experimental results show a close correlation between our algorithmic and expert manual layer counts, demonstrating the feasibility of automated layer counting. We also show the clinical relevance of oral epithelial layer number to grading oral dysplasia severity through survival analysis. Overall, our study shows that automated counting of oral epithelium layers can represent a potential addition to the digital pathology toolbox. Model generalizability and accuracy could be improved further with a larger training dataset.
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Affiliation(s)
- Xinyi Zhang
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA (S.W.); (D.M.Y.)
| | - Frederico O. Gleber-Netto
- Department of Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (A.M.G.); (J.N.M.)
| | - Shidan Wang
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA (S.W.); (D.M.Y.)
| | - Kevin W. Jin
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA (S.W.); (D.M.Y.)
| | - Donghan M. Yang
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA (S.W.); (D.M.Y.)
| | - Ann M. Gillenwater
- Department of Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (A.M.G.); (J.N.M.)
| | - Jeffrey N. Myers
- Department of Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (A.M.G.); (J.N.M.)
| | - Renata Ferrarotto
- Department of Thoracic Head & Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | | | - Guanghua Xiao
- Quantitative Biomedical Research Center, Peter O’Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA (S.W.); (D.M.Y.)
- Department of Bioinformatics, The University of Texas Southwestern Medical Center, Dallas, TX 76104, USA
- Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, TX 76104, USA
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Chen G, Xie J, Liu D, Zhang X, Tang A. Causal effects of education attainment on oral and oropharyngeal cancer: New evidence from a meta-analysis and Mendelian randomization study. Front Public Health 2023; 11:1132035. [PMID: 37124787 PMCID: PMC10130402 DOI: 10.3389/fpubh.2023.1132035] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/28/2023] [Indexed: 05/02/2023] Open
Abstract
Objectives Higher educational attainment (EA) has proven to be beneficial for preventing and treating various types of cancers. Currently, there is little evidence on the association between EA and prevention of oral cavity and pharyngeal cancer (OCPC). Methods Several databases were searched until October 1, 2022, and a meta-analysis was performed. A Mendelian randomization (MR) study was conducted with EA (i.e., the exposure) data derived from the Social Science Genetic Association Consortium and 6,034 cases of OCPC (i.e., outcome) selected from the Integrative Epidemiology Unit genome-wide association study. Five methods were used to evaluate the causality between EA and OCPC. The leave-one-out sensitivity test, MR-Egger regression, and multivariable MR (MVMR) analysis were applied to evaluate the MR results. Results The meta-analysis included 36 eligible studies. EA was significantly and negatively associated with OCPC risk (odds ratio [OR]: 0.439, 95% confidence interval [CI]: 0.383-0.503, P < 0.001). MR analysis revealed that the risk of OCPC, oropharyngeal cancer, and oral cavity cancer decreased with an increase in education (OR: 0.349, 95% CI: 0.222-0.548, P < 0.001; OR: 0.343, 95% CI: 0.198-0.597; P < 0.001; OR: 0.342, 95% CI: 0.195-0.601, P < 0.001, respectively). Even after correcting for mediators, high EA still significantly reduced the risk of OCPC (OR: 0.361, 95% CI: 0.281-0.463, P < 0.001). Conclusion Both the meta-analysis and MR results demonstrated that high levels of EA can reduce the risk of OCPC in the general population.
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Affiliation(s)
- Gui Chen
- Department of Otolaryngology Head and Neck Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- State Key Laboratory of Respiratory Disease, Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Junyang Xie
- State Key Laboratory of Respiratory Disease, Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Di Liu
- Department of Otolaryngology Head and Neck Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiaowen Zhang
- State Key Laboratory of Respiratory Disease, Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
- Xiaowen Zhang
| | - Anzhou Tang
- Department of Otolaryngology Head and Neck Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- *Correspondence: Anzhou Tang
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Matos S, Boakye EA, Crosby D, Sharma A. Prevalence and Factors Associated With Oral Cavity and Pharyngeal Cancer Screening in a Rural Population. OTO Open 2021; 5:2473974X211065018. [PMID: 34926974 PMCID: PMC8671683 DOI: 10.1177/2473974x211065018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/13/2021] [Indexed: 11/23/2022] Open
Abstract
Objective (1) To quantify the prevalence of provider recommendation and receipt of oral cavity and pharyngeal cancer (OCPC) screening and (2) to examine the factors associated with OCPC screening recommendation and receipt among adults. Study Design Cross-sectional. Setting Rural counties in central Illinois. Methods This study among adults (N = 145) was conducted between January 1 and June 30, 2017. The outcomes of interest were provider recommendation and receipt of OCPC screening. Multivariable logistic regression models were used to examine the association between (1) sociodemographic, health care access and utilization, and OCPC risk factors and (2) provider recommendation and receipt of OCPC screening. Results The prevalence of provider recommendation and receipt of OCPC screening was 12.4% and 28.3%, respectively. Approximately 15% of current smokers, 13% of participants who consume alcohol, and 10% of participants with ≥5 lifetime sexual partners had received an OCPC screening recommendation. OCPC screening rates were 19% for current smokers, 30% for those who consume alcohol, and 32% for those with ≥5 lifetime sexual partners. In the adjusted analyses, respondents with ≥5 partners (adjusted odds ratio, 3.10 [95% CI, 1.25-7.66]) had a higher odds of receiving OCPC screening than those with <5. There were no significant associations between other OCPC risk factors and provider recommendation and receipt of OCPC screening. Conclusion OCPC screening recommendation and receipt were low; only number of lifetime sexual partners was associated with OCPC screening receipt. Our findings suggest that rural populations may be vulnerable to late-stage diagnosis of OCPC, and interventions to help improve screening rates are warranted.
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Affiliation(s)
- Sophia Matos
- School of Medicine, Southern Illinois University, Springfield, Illinois, USA
| | - Eric Adjei Boakye
- Department of Population Science and Policy, School of Medicine, Southern Illinois University, Springfield, Illinois, USA
- Simmons Cancer Institute, School of Medicine, Southern Illinois University, Springfield, Illinois, USA
| | - Dana Crosby
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Southern Illinois University, Springfield, Illinois, USA
| | - Arun Sharma
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Southern Illinois University, Springfield, Illinois, USA
- Arun Sharma, MD, MS, School of Medicine, Southern Illinois University, 720 Bond St, Springfield, IL 62702, USA.
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Kawakita D, Lee YCA, Turati F, Parpinel M, Decarli A, Serraino D, Matsuo K, Olshan AF, Zevallos JP, Winn DM, Moysich K, Zhang ZF, Morgenstern H, Levi F, Kelsey K, McClean M, Bosetti C, Garavello W, Schantz S, Yu GP, Boffetta P, Chuang SC, Hashibe M, Ferraroni M, La Vecchia C, Edefonti V. Dietary fiber intake and head and neck cancer risk: A pooled analysis in the International Head and Neck Cancer Epidemiology consortium. Int J Cancer 2017; 141:1811-1821. [PMID: 28710831 PMCID: PMC5797849 DOI: 10.1002/ijc.30886] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 06/13/2017] [Accepted: 06/27/2017] [Indexed: 12/21/2022]
Abstract
The possible role of dietary fiber in the etiology of head neck cancers (HNCs) is unclear. We used individual-level pooled data from ten case-control studies (5959 cases and 12,248 controls) participating in the International Head and Neck Cancer Epidemiology (INHANCE) consortium, to examine the association between fiber intake and cancer of the oral cavity/pharynx and larynx. Odds Ratios (ORs) and their 95% Confidence Intervals (CIs) were estimated using unconditional multiple logistic regression applied to quintile categories of non-alcohol energy-adjusted fiber intake and adjusted for tobacco and alcohol use and other known or putative confounders. Fiber intake was inversely associated with oral and pharyngeal cancer combined (OR for 5th vs. 1st quintile category = 0.49, 95% CI: 0.40-0.59; p for trend <0.001) and with laryngeal cancer (OR = 0.66, 95% CI: 0.54-0.82, p for trend <0.001). There was, however, appreciable heterogeneity of the estimated effect across studies for oral and pharyngeal cancer combined. Nonetheless, inverse associations were consistently observed for the subsites of oral and pharyngeal cancers and within most strata of the considered covariates, for both cancer sites. Our findings from a multicenter large-scale pooled analysis suggest that, although in the presence of between-study heterogeneity, a greater intake of fiber may lower HNC risk.
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Affiliation(s)
- Daisuke Kawakita
- Branch of Medical Statistics, Biometry and Epidemiology “G. A. Maccacaro”, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, via G. Venezian, 1, 20133 Milano, Italy
- epartment of Otorhinolaryngology, Head and Neck Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-0001, Japan
- Division of Molecular Medicine, Aichi Cancer Center Research Institute, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Yuan-Chin Amy Lee
- Division of Public Health, Department of Family & Preventive Medicine and Huntsman Cancer Institute, University of Utah School of Medicine, 375 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Federica Turati
- Branch of Medical Statistics, Biometry and Epidemiology “G. A. Maccacaro”, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, via G. Venezian, 1, 20133 Milano, Italy
| | - Maria Parpinel
- Department of Medical and Biological Sciences, University of Udine, Piazzale M. Kolbe, 4, 33100 Udine, Italy
| | - Adriano Decarli
- Branch of Medical Statistics, Biometry and Epidemiology “G. A. Maccacaro”, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, via G. Venezian, 1, 20133 Milano, Italy
- Branch of Medical Statistics, Biometry and Bioinformatics, Fondazione IRCSS Istituto Nazionale Tumori di Milano, via G. Venezian, 1, 20133, Milano, Italy
| | - Diego Serraino
- Epidemiology and Biostatistics Unit, CRO Aviano National Cancer Institute, IRCCS, via F. Gallini, 2, 33081 Aviano (PN), Italy
| | - Keitaro Matsuo
- Division of Molecular Medicine, Aichi Cancer Center Research Institute, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Andrew F. Olshan
- University of North Carolina School of Public Health, Chapel Hill, NC, USA
| | - Jose P. Zevallos
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, 170 Manning Drive, Campus Box # 7070, Chapel Hill, NC 27599-7070, USA
| | - Deborah M. Winn
- Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD 20892-9764, USA
| | | | - Zuo-Feng Zhang
- Department of Epidemiology, UCLA School of Public Health, 71-225 CHS, Box 951772, Los Angeles, CA 90095-1772, USA
| | - Hal Morgenstern
- Departments of Epidemiology and Environmental Health Sciences, School of Public Health and Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Fabio Levi
- Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital (CHUV), Route de la Corniche 10, 1010 Lausanne, Switzerland
| | - Karl Kelsey
- Department of Epidemiology and Pathology and Laboratory Medicine, Brown University, 70 Ship Street, G-E3, Providence, RI 02912, USA
| | - Michael McClean
- Department of Environmental Health, Boston University School of Public Health, 715 Albany Street, Talbot 4W Boston, MA 02118, USA
| | - Cristina Bosetti
- Department of Epidemiology, IRCCS - Istituto di Ricerche Farmacologiche ‘Mario Negri’, via G. La Masa, 19, 20156 Milano, Italy
| | - Werner Garavello
- Department of Otorhinolaryngology, School of Medicine and Surgery, University of Milano - Bicocca, via Pergolesi, 20052 Monza, Italy
| | - Stimson Schantz
- Department of Otolaryngology, New York Eye and Ear Infirmary, 310 E. 14th Street, New York, NY 10003, USA
| | - Guo-Pei Yu
- Medical Informatics Center, Peking University, Peking, China
| | - Paolo Boffetta
- The Tisch Cancer Institute and Institute of Translational Epidemiology, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, New York, NY 10029, USA
| | - Shu-Chun Chuang
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Mia Hashibe
- Division of Public Health, Department of Family & Preventive Medicine and Huntsman Cancer Institute, University of Utah School of Medicine, 375 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Monica Ferraroni
- Branch of Medical Statistics, Biometry and Epidemiology “G. A. Maccacaro”, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, via G. Venezian, 1, 20133 Milano, Italy
| | - Carlo La Vecchia
- Branch of Medical Statistics, Biometry and Epidemiology “G. A. Maccacaro”, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, via G. Venezian, 1, 20133 Milano, Italy
| | - Valeria Edefonti
- Branch of Medical Statistics, Biometry and Epidemiology “G. A. Maccacaro”, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, via G. Venezian, 1, 20133 Milano, Italy
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Suárez E, González L, Díaz-Toro EC, Calo WA, Bermúdez F, Ortiz AP. Incidence of oral cavity and pharyngeal cancers by anatomical sites in population-based registries in Puerto Rico and the United States of America. P R Health Sci J 2013; 32:175-81. [PMID: 24397214 PMCID: PMC4994517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Puerto Rico's (PR) epidemiological data on each oral cavity and pharynx cancer (OCPC) site is yet largely unexplored. Our aim was to compare OCPC incidence in PR, by anatomical site, with that of non-Hispanic whites (NHW), non-Hispanic blacks (NHB), and Hispanic (USH) individuals in the USA. METHODS Data from the Surveillance Epidemiology and End Results program and the PR Central Cancer Registry were collected and analyzed. Age-standardized rates, percent changes, and standardized rate ratios were estimated with 95% confidence intervals. RESULTS Although declining incidence rates were observed for most anatomical sites in most racial/ethnic groups and in both sexes, the incidence of oropharynx cancers slightly increased for cancers in the oropharynx among PR women, both in the base of tongue and soft palate/other oropharynx (p>0.05). The incidence of soft palate/other oropharynx cancers in PR men was about 2.8 times higher than in USH men (p<0.05) and about 1.4 times higher than in NHW men but 21% lower than in NHB men (p>0.05). Significant interactions terms formed with racial/ethnic group and age were shown in various sites. The largest differences between sexes were consistently noted in PR. CONCLUSION Further research in PR should assess the effect of the HPV infection, as well as of other risk factors, in OCPC incidence by anatomical site in younger populations. These data could explain more precisely the reasons for the differences observed in this study, particularly among sexes in PR.
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Affiliation(s)
- Erick Suárez
- Department of Biostatistics and Epidemiology, Graduate School of Public Health, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico.
| | - Lorena González
- Research Design, Biostatistics, and Clinical Research Ethics, Puerto Rico Clinical and Translational Research Consortium, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico. UPR/MDACC Partnership in Excellence in Cancer Research Program, School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Elba C Díaz-Toro
- Department of Restorative Sciences, School of Dental Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - William A Calo
- Center for Health Promotion and Prevention Research, University of Texas, School of Public Health, Houston, Texas, USA
| | - Francisco Bermúdez
- Department of Surgical Sciences, School of Dental Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Ana P Ortiz
- Department of Biostatistics and Epidemiology, Graduate School of Public Health, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
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