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1.
J Pediatr Hematol Oncol ; 46(2): e202-e204, 2024 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-38181327

RESUMO

Polyethylene glycol-asparaginase (PEGAsp) is an established component of acute leukemia therapy. Hypersensitivity reactions to PEGAsp occur in 10% to 15% of patients, with polyethylene glycol suggested as the antigenic culprit. As coronavirus disease 2019 (COVID-19) mRNA vaccines contain polyethylene glycol, the safety of administration of these vaccines to patients with prior PEGAsp hypersensitivity has been questioned. Between December 21, 2020 and March 3, 2022, 66 patients with acute leukemia and PEGAsp allergy received COVID-19 vaccination. No patients (0/66 0%, 95% CI: 0%-5.4%) experienced an allergic reaction to the vaccine. COVID-19 mRNA vaccination appears to be safe in pediatric and young adult patients with acute lymphoblastic leukemia with PEGAsp allergy.


Assuntos
Asparaginase , Vacinas contra COVID-19 , Hipersensibilidade a Drogas , Polietilenoglicóis , Criança , Humanos , Antineoplásicos/efeitos adversos , Asparaginase/efeitos adversos , COVID-19/prevenção & controle , Vacinas contra COVID-19/efeitos adversos , Hipersensibilidade a Drogas/etiologia , Escherichia coli , Polietilenoglicóis/efeitos adversos , Leucemia-Linfoma Linfoblástico de Células Precursoras/tratamento farmacológico , Vacinação/efeitos adversos
2.
Cancers (Basel) ; 15(23)2023 Nov 23.
Artigo em Inglês | MEDLINE | ID: mdl-38067252

RESUMO

The optimization of outcomes for pediatric cancer patients relies on the successful advancement of supportive care to ease the treatment burden and mitigate the long-term impacts of cancer therapy. Advancing pediatric supportive care requires research prioritization as well as the development and implementation of innovations. Like the prevailing theme throughout pediatric oncology, there is a clear need for personalized or precision approaches that are consistent, evidence-based, and guided by clinical practice guidelines. By incorporating technology and datasets, we can address questions which may not be feasible to explore in clinical trials. Now is the time to listen to patients' voices by using patient-reported outcomes (PROs) to ensure that their contributions and experiences inform clinical care plans. Furthermore, while the extrapolation of knowledge and approaches from adult populations may suffice in the absence of pediatric-specific evidence, there is a critical need to specifically understand and implement elements of general and developmental pediatrics like growth, nutrition, development, and physical activity into care. Increased research funding for pediatric supportive care is critical to address resource availability, equity, and disparities across the globe. Our patients deserve to enjoy healthy, productive lives with optimized and enriched supportive care that spans the spectrum from diagnosis to survivorship.

3.
J Hosp Med ; 18(6): 509-518, 2023 06.
Artigo em Inglês | MEDLINE | ID: mdl-37143201

RESUMO

BACKGROUND: Late recognition of in-hospital deterioration is a source of preventable harm. Emergency transfers (ET), when hospitalized patients require intensive care unit (ICU) interventions within 1 h of ICU transfer, are a proximal measure of late recognition associated with increased mortality and length of stay (LOS). OBJECTIVE: To apply diagnostic process improvement frameworks to identify missed opportunities for improvement in diagnosis (MOID) in ETs and evaluate their association with outcomes. DESIGN, SETTINGS, AND PARTICIPANTS: A single-center retrospective cohort study of ETs, January 2015 to June 2019. ET criteria include intubation, vasopressor initiation, or ≥ $\ge \phantom{\rule{}{0ex}}$ 60 mL/kg fluid resuscitation 1 h before to 1 h after ICU transfer. The primary exposure was the presence of MOID, determined using SaferDx. Cases were screened by an ICU and non-ICU physician. Final determinations were made by an interdisciplinary group. Diagnostic process improvement opportunities were identified. MAIN OUTCOME AND MEASURES: Primary outcomes were in-hospital mortality and posttransfer LOS, analyzed by multivariable regression adjusting for age, service, deterioration category, and pretransfer LOS. RESULTS: MOID was identified in 37 of 129 ETs (29%, 95% confidence interval [CI] 21%-37%). Cases with MOID differed in originating service, but not demographically. Recognizing the urgency of an identified condition was the most common diagnostic process opportunity. ET cases with MOID had higher odds of mortality (odds ratio 5.5; 95% CI 1.5-20.6; p = .01) and longer posttransfer LOS (rate ratio 1.7; 95% CI 1.1-2.6; p = .02). CONCLUSION: MOID are common in ETs and are associated with increased mortality risk and posttransfer LOS. Diagnostic improvement strategies should be leveraged to support earlier recognition of clinical deterioration.


Assuntos
Deterioração Clínica , Unidades de Terapia Intensiva Pediátrica , Criança , Humanos , Estudos Retrospectivos , Unidades de Terapia Intensiva , Tempo de Internação , Mortalidade Hospitalar
4.
Transplant Cell Ther ; 29(3): 207.e1-207.e5, 2023 03.
Artigo em Inglês | MEDLINE | ID: mdl-36610491

RESUMO

Institutions that perform hematopoietic cell transplantation (HCT) are required by law to report standardized, structured data on transplantation outcomes. A key post-transplantation outcome is engraftment, the time between HCT infusion and reemergence of circulating neutrophils and platelets. At our center, we found that manual chart abstraction for engraftment data was highly error-prone. We developed a custom R/Shiny application that automatically calculates engraftment dates and displays them in an intuitive format to augment the manual chart review. Our hypothesis was that use of the application to assist with calculating and reporting engraftment dates would be associated with a decreased error rate. The study was conducted at a single tertiary care institution. The application was developed in a collaborative, multidisciplinary fashion by members of an embedded cellular therapy informatics team. Retrospective validation of the application's accuracy was conducted on all malignant HCTs from February 2016 to December 2020 (n = 198). Real-world use of the application was evaluated prospectively from April 2021 through April 2022 (n = 53). The Welch 2-sample t test was used to compare error rates preimplementation and postimplementation. Data were visualized using p charts, and standard special cause variation rules were applied. The accuracy of reported data postdeployment increased dramatically; the engraftment error rate decreased from 15% to 3.8% for neutrophils (P = .003) and from 28% to 1.9% for platelets (P < .001). This study demonstrates the effective deployment of a custom R/Shiny application that was associated with significantly reduced error rates in HCT engraftment reporting for operational, research, and regulatory purposes. Users reported subjective satisfaction with the application and that it addressed difficulties with the legacy manual process. Identifying and correcting erroneous data in engraftment reporting could lead to a more efficient and accurate nationwide assessment of transplantation success. Furthermore, we show that it is possible and practical for academic medical centers to create and support embedded informatics teams that can quickly build applications for clinical operations in a manner compliant with regulatory requirements.


Assuntos
Transplante de Células-Tronco Hematopoéticas , Estudos Retrospectivos , Transplante Homólogo , Sistema de Registros , Automação
5.
Pediatr Blood Cancer ; 70(2): e30128, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-36495256

RESUMO

In this commentary, we highlight the central role that data standards play in facilitating data-driven efforts to advance research in pediatric oncology. We discuss the current state of data standards for pediatric oncology and propose five steps to achieve an improved future state with benefits for clinicians, researchers, and patients.


Assuntos
Neoplasias , Criança , Humanos , Neoplasias/terapia , Oncologia , Previsões , Pacientes , Enfermagem Oncológica
6.
Pediatr Blood Cancer ; 69(4): e29579, 2022 04.
Artigo em Inglês | MEDLINE | ID: mdl-35044081

RESUMO

Implementation science (IS) has garnered attention within oncology, and most prior IS work has focused on adult, not pediatric, oncology. This narrative review broadly characterizes IS for pediatric oncology. It includes studies through 2020 using the following search terms in PubMed, Ovid Medline, and Cochrane: "implementation science," "pediatric," "childhood," "cancer," and "oncology." Systematic review was not performed due to the limited number of heterogeneous studies. Of 216 articles initially reviewed, nine were selected as specific to IS and pediatric oncology. All nine examined oncologic supportive care, cancer prevention, or cancer control. The supportive care focus is potentially due to the presence of cooperative study groups such as the Children's Oncology Group, which efficiently drive cancer-directed therapy changes through clinical trials. Future IS within pediatric oncology should embrace this ecosystem and focus on cancer control interventions that benefit patients across multiple cancer types and patients treated outside cooperative group studies.


Assuntos
Ciência da Implementação , Neoplasias , Adulto , Criança , Ecossistema , Humanos , Oncologia , Neoplasias/prevenção & controle
7.
AMIA Jt Summits Transl Sci Proc ; 2021: 585-594, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34457174

RESUMO

Many diseases have been linked with birth seasonality, and these fall into four main categories: mental, cardiovascular, respiratory and women's reproductive health conditions. Informatics methods are needed to uncover seasonally varying infectious diseases that may be responsible for the increased birth month-dependent disease risk observed. We have developed a method to link seasonal infectious disease data from the USA to birth month dependent disease data from humans and canines. We also include seasonal air pollution and climate data to determine the seasonal factors most likely involved in the response. We test our method with osteosarcoma, a rare bone cancer. We found the Lyme disease incidence was the most strongly correlated significant factor in explaining the birth month-osteosarcoma disease pattern (R=0.418, p=2.80X10-23), and this was true across all populations observed: canines, pediatric, and adult populations.


Assuntos
Doenças Transmissíveis , Osteossarcoma , Algoritmos , Animais , Criança , Cães , Feminino , Humanos , Informática , Osteossarcoma/epidemiologia , Estações do Ano
9.
Artigo em Inglês | MEDLINE | ID: mdl-32438697

RESUMO

(1) Background: Cardio-metabolic diseases (CMD), including cardiovascular disease, stroke, and diabetes, have numerous common individual and environmental risk factors. Yet, few studies to date have considered how these multiple risk factors together affect CMD disparities between Blacks and Whites. (2) Methods: We linked daily fine particulate matter (PM2.5) measures with survey responses of participants in the Southern Community Cohort Study (SCCS). Generalized linear mixed modeling (GLMM) was used to estimate the relationship between CMD risk and social-demographic characteristics, behavioral and personal risk factors, and exposure levels of PM2.5. (3) Results: The study resulted in four key findings: (1) PM2.5 concentration level was significantly associated with reported CMD, with risk rising by 2.6% for each µg/m3 increase in PM2.5; (2) race did not predict CMD risk when clinical, lifestyle, and environmental risk factors were accounted for; (3) a significant variation of CMD risk was found among participants across states; and (4) multiple personal, clinical, and social-demographic and environmental risk factors played a role in predicting CMD occurrence. (4) Conclusions: Disparities in CMD risk among low social status populations reflect the complex interactions of exposures and cumulative risks for CMD contributed by different personal and environmental factors from natural, built, and social environments.


Assuntos
Poluentes Atmosféricos , Poluição do Ar , Doenças Cardiovasculares , Material Particulado , Poluentes Atmosféricos/toxicidade , Doenças Cardiovasculares/epidemiologia , Estudos de Coortes , Centros Comunitários de Saúde , Exposição Ambiental , Feminino , Disparidades nos Níveis de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Material Particulado/toxicidade , Fatores de Risco
10.
BMC Res Notes ; 13(1): 88, 2020 Feb 21.
Artigo em Inglês | MEDLINE | ID: mdl-32085812

RESUMO

OBJECTIVE: Bipartite graphs are widely used to model relationships between pairs of heterogeneous data types. Maximal bicliques are foundational structures in such graphs, and their enumeration is an important task in systems biology, epidemiology and many other problem domains. Thus, there is a need for an efficient, general purpose, publicly available tool to enumerate maximal bicliques in bipartite graphs. The statistical programming language R is a logical choice for such a tool, but until now no R package has existed for this purpose. Our objective is to provide such a package, so that the research community can more easily perform this computationally demanding task. RESULTS: Biclique is an R package that takes as input a bipartite graph and produces a listing of all maximal bicliques in this graph. Input and output formats are straightforward, with examples provided both in this paper and in the package documentation. Biclique employs a state-of-the-art algorithm previously developed for basic research in functional genomics. This package, along with its source code and reference manual, are freely available from the CRAN public repository at https://cran.r-project.org/web/packages/biclique/index.html.


Assuntos
Algoritmos , Software , Fatores de Tempo
11.
Support Care Cancer ; 28(4): 1659-1666, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31286235

RESUMO

PURPOSE: Malnutrition related to undernutrition in pediatric oncology patients is associated with worse outcomes including increased morbidity and mortality. At a tertiary pediatric center, traditional malnutrition screening practices were ineffective at identifying cancer patients at risk for undernutrition and needing nutrition consultation. METHODS: To efficiently identify undernourished patients, an automated malnutrition screen using anthropometric data in the electronic health record (EHR) was implemented. The screen utilized pediatric malnutrition (undernutrition) indicators from the 2014 Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition with corresponding structured EHR elements. The time periods before (January 2016-August 2017) and after (September 2017-August 2018) screen implementation were compared. Process metrics including nutrition consults, timeliness of nutrition assessments, and malnutrition diagnoses documentation were assessed using statistical process control charts. Outcome metrics including change in nutritional status at least 3 months after positive malnutrition screen were assessed with the Cochran-Armitage trend test. RESULTS: After automated malnutrition screen implementation, all process metrics demonstrated center line shifts indicating special cause variation. For patient admissions with a positive screen for malnutrition of any severity level, no significant improvement in status of malnutrition was observed after 3 months (P = .13). Sub-analysis of patient admissions with screen-identified severe malnutrition noted improvement in degree of malnutrition after 3 months (P = .02). CONCLUSIONS: Select 2014 Consensus Statement indicators for pediatric malnutrition can be implemented as an automated screen using structured EHR data. The automated screen efficiently identifies oncology patients at risk of malnutrition and may improve clinical outcomes.


Assuntos
Registros Eletrônicos de Saúde/estatística & dados numéricos , Desnutrição/diagnóstico , Avaliação Nutricional , Estado Nutricional/fisiologia , Adolescente , Criança , Pré-Escolar , Consenso , Atenção à Saúde , Dietética , Humanos , Lactente , Programas de Rastreamento/métodos , Neoplasias/terapia , Melhoria de Qualidade
13.
BMC Bioinformatics ; 20(Suppl 15): 503, 2019 Dec 24.
Artigo em Inglês | MEDLINE | ID: mdl-31874625

RESUMO

BACKGROUND: Cluster analysis is a core task in modern data-centric computation. Algorithmic choice is driven by factors such as data size and heterogeneity, the similarity measures employed, and the type of clusters sought. Familiarity and mere preference often play a significant role as well. Comparisons between clustering algorithms tend to focus on cluster quality. Such comparisons are complicated by the fact that algorithms often have multiple settings that can affect the clusters produced. Such a setting may represent, for example, a preset variable, a parameter of interest, or various sorts of initial assignments. A question of interest then is this: to what degree do the clusters produced vary as setting values change? RESULTS: This work introduces a new metric, termed simply "robustness", designed to answer that question. Robustness is an easily-interpretable measure of the propensity of a clustering algorithm to maintain output coherence over a range of settings. The robustness of eleven popular clustering algorithms is evaluated over some two dozen publicly available mRNA expression microarray datasets. Given their straightforwardness and predictability, hierarchical methods generally exhibited the highest robustness on most datasets. Of the more complex strategies, the paraclique algorithm yielded consistently higher robustness than other algorithms tested, approaching and even surpassing hierarchical methods on several datasets. Other techniques exhibited mixed robustness, with no clear distinction between them. CONCLUSIONS: Robustness provides a simple and intuitive measure of the stability and predictability of a clustering algorithm. It can be a useful tool to aid both in algorithm selection and in deciding how much effort to devote to parameter tuning.


Assuntos
Algoritmos , Biometria , Análise por Conglomerados , Perfilação da Expressão Gênica
14.
J Natl Cancer Inst Monogr ; 2019(54): 127-131, 2019 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-31532530

RESUMO

Recognition and treatment of malnutrition in pediatric oncology patients is crucial because it is associated with increased morbidity and mortality. Nutrition-relevant data collected from cancer clinical trials and nutrition-specific studies are insufficient to drive high-impact nutrition research without augmentation from additional data sources. To date, clinical big data resources are underused for nutrition research in pediatric oncology. Health-care big data can be broadly subclassified into three clinical data categories: administrative, electronic health record (including clinical data research networks and learning health systems), and mobile health. Along with -omics data, each has unique applications and limitations. We summarize the potential use of clinical big data to drive pediatric oncology nutrition research and identify key scientific gaps. A framework for advancement of big data utilization for pediatric oncology nutrition research is presented and focuses on transdisciplinary teams, data interoperability, validated cohort curation, data repurposing, and mobile health applications.


Assuntos
Big Data , Oncologia , Ciências da Nutrição , Pediatria , Pesquisa , Registros Eletrônicos de Saúde , Humanos , Oncologia/métodos , Metabolômica/métodos , Nutrigenômica/métodos , Pediatria/métodos , Vigilância em Saúde Pública , Telemedicina
15.
Algorithms ; 12(1)2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31448059

RESUMO

Let k denote an integer greater than 2, let G denote a k-partite graph, and let S denote the set of all maximal k-partite cliques in G. Several open questions concerning the computation of S are resolved. A straightforward and highly-scalable modification to the classic recursive backtracking approach of Bron and Kerbosch is first described and shown to run in O(3 n/3) time. A series of novel graph constructions is then used to prove that this bound is best possible in the sense that it matches an asymptotically tight upper limit on |S|. The task of identifying a vertex-maximum element of S is also considered and, in contrast with the k = 2 case, shown to be NP-hard for every k ≥ 3. A special class of k-partite graphs that arises in the context of functional genomics and other problem domains is studied as well and shown to be more readily solvable via a polynomial-time transformation to bipartite graphs. Applications, limitations, potentials for faster methods, heuristic approaches, and alternate formulations are also addressed.

16.
Pediatr Blood Cancer ; 66(9): e27876, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31207054

RESUMO

BACKGROUND: Widespread implementation of electronic health records (EHR) has created new opportunities for pediatric oncology observational research. Little attention has been given to using EHR data to identify patients with pediatric hematologic malignancies. METHODS: This study used EHR-derived data in a pediatric clinical data research network, PEDSnet, to develop and evaluate a computable phenotype algorithm to identify pediatric patients with leukemia and lymphoma who received treatment with chemotherapy. To guide early development, multiple computable phenotype-defined cohorts were compared to one institution's tumor registry. The most promising algorithm was chosen for formal evaluation and consisted of at least two leukemia/lymphoma diagnoses (Systematized Nomenclature of Medicine codes) within a 90-day period, two chemotherapy exposures, and three hematology-oncology provider encounters. During evaluation, the computable phenotype was executed against EHR data from 2011 to 2016 at three large institutions. Classification accuracy was assessed by masked medical record review with phenotype-identified patients compared to a control group with at least three hematology-oncology encounters. RESULTS: The computable phenotype had sensitivity of 100% (confidence interval [CI] 99%, 100%), specificity of 99% (CI 99%, 100%), positive predictive value (PPV) and negative predictive value (NPV) of 100%, and C-statistic of 1 at the development institution. The computable phenotype performance was similar at the two test institutions with sensitivity of 100% (CI 99%, 100%), specificity of 99% (CI 99%, 100%), PPV of 96%, NPV of 100%, and C-statistic of 0.99. CONCLUSION: The EHR-based computable phenotype is an accurate cohort identification tool for pediatric patients with leukemia and lymphoma who have been treated with chemotherapy and is ready for use in clinical studies.


Assuntos
Algoritmos , Registros Eletrônicos de Saúde , Leucemia/tratamento farmacológico , Linfoma/tratamento farmacológico , Sistema de Registros , Adolescente , Pré-Escolar , Feminino , Humanos , Masculino
17.
Pediatr Blood Cancer ; 66(8): e27795, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31069926

RESUMO

BACKGROUND: Little is known about the specific information parents of children with cancer search for online. Understanding the content of parents' searches over time could offer insight into what matters most to parents and identify knowledge gaps that could inform more comprehensive approaches to family education and support. METHODS: We describe parents' health-related Google searches starting six months before cancer diagnosis and extending through the date of study enrollment, which was at least one month after initiating cancer treatment. Searches were obtained retrospectively and grouped into health-related and non-health-related categories. The median time to parent enrollment from date of cancer diagnosis was 264 days. RESULTS: Parents searched for health-related topics more frequently than the general population (13% vs 5%). Health-related searches increased in the months preceding the child's cancer diagnosis and most commonly pertained to symptoms and logistics, "directions to hospital." Health-related search volume peaked about a month after cancer diagnosis when general health-related searches were present in addition to cancer-specific searches. Eighteen percent of health-related searches were cancer specific, and of these cancer-specific searches, 54% pertained to support, for example "cancer quote for son." CONCLUSIONS: Google search content offers insight into what matters to parents of cancer patients. Understanding search content could inform more comprehensive approaches to family education and support initiatives.


Assuntos
Troca de Informação em Saúde/estatística & dados numéricos , Conhecimentos, Atitudes e Prática em Saúde , Internet/estatística & dados numéricos , Oncologia/estatística & dados numéricos , Neoplasias/diagnóstico , Pais/educação , Adulto , Criança , Tomada de Decisões , Feminino , Humanos , Masculino , Estudos Retrospectivos , Inquéritos e Questionários
19.
J Med Internet Res ; 20(1): e6, 2018 01 08.
Artigo em Inglês | MEDLINE | ID: mdl-29311051

RESUMO

BACKGROUND: In the United States, cancer is common, with high morbidity and mortality; cancer incidence varies between states. Online searches reflect public awareness, which could be driven by the underlying regional cancer epidemiology. OBJECTIVE: The objective of our study was to characterize the relationship between cancer incidence and online Google search volumes in the United States for 6 common cancers. A secondary objective was to evaluate the association of search activity with cancer-related public events and celebrity news coverage. METHODS: We performed a population-based, retrospective study of state-level cancer incidence from 2004 through 2013 reported by the Centers for Disease Control and Prevention for breast, prostate, colon, lung, and uterine cancers and leukemia compared to Google Trends (GT) relative search volume (RSV), a metric designed by Google to allow interest in search topics to be compared between regions. Participants included persons in the United States who searched for cancer terms on Google. The primary measures were the correlation between annual state-level cancer incidence and RSV as determined by Spearman correlation and linear regression with RSV and year as independent variables and cancer incidence as the dependent variable. Temporal associations between search activity and events raising public awareness such as cancer awareness months and cancer-related celebrity news were described. RESULTS: At the state level, RSV was significantly correlated to incidence for breast (r=.18, P=.001), prostate (r=-.27, P<.001), lung (r=.33, P<.001), and uterine cancers (r=.39, P<.001) and leukemia (r=.13, P=.003) but not colon cancer (r=-.02, P=.66). After adjusting for time, state-level RSV was positively correlated to cancer incidence for all cancers: breast (P<.001, 95% CI 0.06 to 0.19), prostate (P=.38, 95% CI -0.08 to 0.22), lung (P<.001, 95% CI 0.33 to 0.46), colon (P<.001, 95% CI 0.11 to 0.17), and uterine cancers (P<.001, 95% CI 0.07 to 0.12) and leukemia (P<.001, 95% CI 0.01 to 0.03). Temporal associations in GT were noted with breast cancer awareness month but not with other cancer awareness months and celebrity events. CONCLUSIONS: Cancer incidence is correlated with online search volume at the state level. Search patterns were temporally associated with cancer awareness months and celebrity announcements. Online searches reflect public awareness. Advancing understanding of online search patterns could augment traditional epidemiologic surveillance, provide opportunities for targeted patient engagement, and allow public information campaigns to be evaluated in ways previously unable to be measured.


Assuntos
Internet/normas , Neoplasias/epidemiologia , Ferramenta de Busca/métodos , Conscientização , Humanos , Incidência , Estudos Retrospectivos , Estados Unidos
20.
Environ Dis ; 2(2): 33-44, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29152601

RESUMO

OBJECTIVES: The aim is to identify exposures associated with lung cancer mortality and mortality disparities by race and gender using an exposome database coupled to a graph theoretical toolchain. METHODS: Graph theoretical algorithms were employed to extract paracliques from correlation graphs using associations between 2162 environmental exposures and lung cancer mortality rates in 2067 counties, with clique doubling applied to compute an absolute threshold of significance. Factor analysis and multiple linear regressions then were used to analyze differences in exposures associated with lung cancer mortality and mortality disparities by race and gender. RESULTS: While cigarette consumption was highly correlated with rates of lung cancer mortality for both white men and women, previously unidentified novel exposures were more closely associated with lung cancer mortality and mortality disparities for blacks, particularly black women. CONCLUSIONS: Exposures beyond smoking moderate lung cancer mortality and mortality disparities by race and gender. POLICY IMPLICATIONS: An exposome approach and database coupled with scalable combinatorial analytics provides a powerful new approach for analyzing relationships between multiple environmental exposures, pathways and health outcomes. An assessment of multiple exposures is needed to appropriately translate research findings into environmental public health practice and policy.

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