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  1. Article ; Online: The accuracy of absolute differential abundance analysis from relative count data.

    Roche, Kimberly E / Mukherjee, Sayan

    PLoS computational biology

    2022  Volume 18, Issue 7, Page(s) e1010284

    Abstract: Concerns have been raised about the use of relative abundance data derived from next generation sequencing as a proxy for absolute abundances. For example, in the differential abundance setting, compositional effects in relative abundance data may give ... ...

    Abstract Concerns have been raised about the use of relative abundance data derived from next generation sequencing as a proxy for absolute abundances. For example, in the differential abundance setting, compositional effects in relative abundance data may give rise to spurious differences (false positives) when considered from the absolute perspective. In practice however, relative abundances are often transformed by renormalization strategies intended to compensate for these effects and the scope of the practical problem remains unclear. We used simulated data to explore the consistency of differential abundance calling on renormalized relative abundances versus absolute abundances and find that, while overall consistency is high, with a median sensitivity (true positive rates) of 0.91 and specificity (1-false positive rates) of 0.89, consistency can be much lower where there is widespread change in the abundance of features across conditions. We confirm these findings on a large number of real data sets drawn from 16S metabarcoding, expression array, bulk RNA-seq, and single-cell RNA-seq experiments, where data sets with the greatest change between experimental conditions are also those with the highest false positive rates. Finally, we evaluate the predictive utility of summary features of relative abundance data themselves. Estimates of sparsity and the prevalence of feature-level change in relative abundance data give reasonable predictions of discrepancy in differential abundance calling in simulated data and can provide useful bounds for worst-case outcomes in real data.
    MeSH term(s) High-Throughput Nucleotide Sequencing ; RNA-Seq
    Language English
    Publishing date 2022-07-11
    Publishing country United States
    Document type Journal Article ; Research Support, U.S. Gov't, Non-P.H.S. ; Research Support, Non-U.S. Gov't
    ZDB-ID 2193340-6
    ISSN 1553-7358 ; 1553-734X
    ISSN (online) 1553-7358
    ISSN 1553-734X
    DOI 10.1371/journal.pcbi.1010284
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  2. Article ; Online: The accuracy of absolute differential abundance analysis from relative count data.

    Kimberly E Roche / Sayan Mukherjee

    PLoS Computational Biology, Vol 18, Iss 7, p e

    2022  Volume 1010284

    Abstract: Concerns have been raised about the use of relative abundance data derived from next generation sequencing as a proxy for absolute abundances. For example, in the differential abundance setting, compositional effects in relative abundance data may give ... ...

    Abstract Concerns have been raised about the use of relative abundance data derived from next generation sequencing as a proxy for absolute abundances. For example, in the differential abundance setting, compositional effects in relative abundance data may give rise to spurious differences (false positives) when considered from the absolute perspective. In practice however, relative abundances are often transformed by renormalization strategies intended to compensate for these effects and the scope of the practical problem remains unclear. We used simulated data to explore the consistency of differential abundance calling on renormalized relative abundances versus absolute abundances and find that, while overall consistency is high, with a median sensitivity (true positive rates) of 0.91 and specificity (1-false positive rates) of 0.89, consistency can be much lower where there is widespread change in the abundance of features across conditions. We confirm these findings on a large number of real data sets drawn from 16S metabarcoding, expression array, bulk RNA-seq, and single-cell RNA-seq experiments, where data sets with the greatest change between experimental conditions are also those with the highest false positive rates. Finally, we evaluate the predictive utility of summary features of relative abundance data themselves. Estimates of sparsity and the prevalence of feature-level change in relative abundance data give reasonable predictions of discrepancy in differential abundance calling in simulated data and can provide useful bounds for worst-case outcomes in real data.
    Keywords Biology (General) ; QH301-705.5
    Subject code 551
    Language English
    Publishing date 2022-07-01T00:00:00Z
    Publisher Public Library of Science (PLoS)
    Document type Article ; Online
    Database BASE - Bielefeld Academic Search Engine (life sciences selection)

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  3. Article: Enhancing radiotherapy response via intratumoral injection of the TLR9 agonist CpG to stimulate CD8 T cells in an autochthonous mouse model of sarcoma.

    Su, Chang / Kent, Collin L / Pierpoint, Matthew / Floyd, Warren / Luo, Lixia / Wiliams, Nerissa T / Ma, Yan / Peng, Brian / Lazarides, Alexander L / Subramanian, Ajay / Himes, Jonathan E / Perez, Vincent M / Hernansaiz-Ballesteros, Rosa D / Roche, Kimberly E / Modliszewski, Jennifer L / Selitsky, Sara R / Mari Shinohara / Wisdom, Amy J / Moding, Everett J /
    Mowery, Yvonne M / Kirsch, David G

    bioRxiv : the preprint server for biology

    2024  

    Abstract: Radiation therapy is frequently used to treat cancers including soft tissue sarcomas. Prior studies established that the toll-like receptor 9 (TLR9) agonist cytosine-phosphate-guanine oligodeoxynucleotide (CpG) enhances the response to radiation therapy ( ...

    Abstract Radiation therapy is frequently used to treat cancers including soft tissue sarcomas. Prior studies established that the toll-like receptor 9 (TLR9) agonist cytosine-phosphate-guanine oligodeoxynucleotide (CpG) enhances the response to radiation therapy (RT) in transplanted tumors, but the mechanism(s) remain unclear. Here, we used CRISPR/Cas9 and the chemical carcinogen 3-methylcholanthrene (MCA) to generate autochthonous soft tissue sarcomas with high tumor mutation burden. Treatment with a single fraction of 20 Gy RT and two doses of CpG significantly enhanced tumor response, which was abrogated by genetic or immunodepletion of CD8+ T cells. To characterize the immune response to RT + CpG, we performed bulk RNA-seq, single-cell RNA-seq, and mass cytometry. Sarcomas treated with 20 Gy and CpG demonstrated increased CD8 T cells expressing markers associated with activation and proliferation, such as Granzyme B, Ki-67, and interferon-γ. CpG + RT also upregulated antigen presentation pathways on myeloid cells. Furthermore, in sarcomas treated with CpG + RT, TCR clonality analysis suggests an increase in clonal T-cell dominance. Collectively, these findings demonstrate that RT + CpG significantly delays tumor growth in a CD8 T cell-dependent manner. These results provide a strong rationale for clinical trials evaluating CpG or other TLR9 agonists with RT in patients with soft tissue sarcoma.
    Language English
    Publishing date 2024-01-04
    Publishing country United States
    Document type Preprint
    DOI 10.1101/2024.01.03.573968
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  4. Article ; Online: Universal gut microbial relationships in the gut microbiome of wild baboons.

    Roche, Kimberly E / Bjork, Johannes R / Dasari, Mauna R / Grieneisen, Laura / Jansen, David / Gould, Trevor J / Gesquiere, Laurence R / Barreiro, Luis B / Alberts, Susan C / Blekhman, Ran / Gilbert, Jack A / Tung, Jenny / Mukherjee, Sayan / Archie, Elizabeth A

    eLife

    2023  Volume 12

    Abstract: Ecological relationships between bacteria mediate the services that gut microbiomes provide to their hosts. Knowing the overall direction and strength of these relationships is essential to learn how ecology scales up to affect microbiome assembly, ... ...

    Abstract Ecological relationships between bacteria mediate the services that gut microbiomes provide to their hosts. Knowing the overall direction and strength of these relationships is essential to learn how ecology scales up to affect microbiome assembly, dynamics, and host health. However, whether bacterial relationships are generalizable across hosts or personalized to individual hosts is debated. Here, we apply a robust, multinomial logistic-normal modeling framework to extensive time series data (5534 samples from 56 baboon hosts over 13 years) to infer thousands of correlations in bacterial abundance in individual baboons and test the degree to which bacterial abundance correlations are 'universal'. We also compare these patterns to two human data sets. We find that, most bacterial correlations are weak, negative, and universal across hosts, such that shared correlation patterns dominate over host-specific correlations by almost twofold. Further, taxon pairs that had inconsistent correlation signs (either positive or negative) in different hosts always had weak correlations within hosts. From the host perspective, host pairs with the most similar bacterial correlation patterns also had similar microbiome taxonomic compositions and tended to be genetic relatives. Compared to humans, universality in baboons was similar to that in human infants, and stronger than one data set from human adults. Bacterial families that showed universal correlations in human infants were often universal in baboons. Together, our work contributes new tools for analyzing the universality of bacterial associations across hosts, with implications for microbiome personalization, community assembly, and stability, and for designing microbiome interventions to improve host health.
    MeSH term(s) Animals ; Humans ; Gastrointestinal Microbiome ; Papio/genetics ; Microbiota ; Bacteria/genetics ; RNA, Ribosomal, 16S/genetics
    Chemical Substances RNA, Ribosomal, 16S
    Language English
    Publishing date 2023-05-09
    Publishing country England
    Document type Journal Article ; Research Support, N.I.H., Extramural ; Research Support, U.S. Gov't, Non-P.H.S. ; Research Support, Non-U.S. Gov't
    ZDB-ID 2687154-3
    ISSN 2050-084X ; 2050-084X
    ISSN (online) 2050-084X
    ISSN 2050-084X
    DOI 10.7554/eLife.83152
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  5. Article ; Online: Morbidity after secondary cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy for ovarian cancer: An analysis of a randomized phase II trial.

    Praiss, Aaron M / Zhou, Qin / Iasonos, Alexia / Moukarzel, Lea / Dessources, Kimberly / Soldan, Krysten / Su, Katy / Sonoda, Yukio / Roche, Kara Long / Gardner, Ginger J / Troso-Sandoval, Tiffany / Tew, William P / Grisham, Rachel N / Chi, Dennis S / O'Cearbhaill, Roisin E / Zivanovic, Oliver

    Gynecologic oncology

    2023  Volume 171, Page(s) 23–30

    Abstract: Objective: To assess postoperative complications after secondary cytoreductive surgery (SCS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC), we conducted an exploratory analysis of patients with platinum-sensitive recurrent ovarian ... ...

    Abstract Objective: To assess postoperative complications after secondary cytoreductive surgery (SCS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC), we conducted an exploratory analysis of patients with platinum-sensitive recurrent ovarian cancer enrolled in a randomized phase II trial.
    Methods: Complications occurring within 30 days of surgery were graded using Common Terminology Criteria for Adverse Events (CTCAE) version 5.0; only hemoglobin and platelet levels were assessed. Patients were grouped by CTCAE grade ≥ 3 and < 3 complications.
    Results: Among 83 eligible patients, 33 (40%) had grade ≥ 3 complications and 50 (60%) had grade < 3 complications; anemia and abdominal infections were the most common. There were no perioperative mortalities. Time to initiation of postoperative chemotherapy for patients with grade ≥ 3 and grade < 3 events was 34 days (range, 18-60) and 31 days (range, 21-43), respectively (P = .017). Median progression-free survival (PFS) did not significantly differ between patients with grade ≥ 3 and grade < 3 complications (11.2 months [95% CI: 9.3-14.4] vs 14.9 months [95% CI: 11.3-16.5], respectively; P = .186), nor did median overall survival (OS) (46.9 months [95% CI: 34-NE] vs 68.2 months [95% CI: 52.1-NE], respectively; P = .053).
    Conclusion: Postoperative complications following SCS with or without HIPEC were associated with slight delays in chemotherapy initiation but did not significantly impact oncologic outcomes.
    MeSH term(s) Humans ; Female ; Hyperthermic Intraperitoneal Chemotherapy/adverse effects ; Cytoreduction Surgical Procedures/adverse effects ; Combined Modality Therapy ; Hyperthermia, Induced/adverse effects ; Ovarian Neoplasms/drug therapy ; Ovarian Neoplasms/surgery ; Carcinoma, Ovarian Epithelial/surgery ; Carcinoma, Ovarian Epithelial/drug therapy ; Morbidity ; Postoperative Complications/epidemiology ; Postoperative Complications/etiology ; Antineoplastic Combined Chemotherapy Protocols/adverse effects
    Language English
    Publishing date 2023-02-16
    Publishing country United States
    Document type Clinical Trial, Phase II ; Randomized Controlled Trial ; Journal Article ; Research Support, N.I.H., Extramural
    ZDB-ID 801461-9
    ISSN 1095-6859 ; 0090-8258
    ISSN (online) 1095-6859
    ISSN 0090-8258
    DOI 10.1016/j.ygyno.2023.02.003
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  6. Article ; Online: Universal gut microbial relationships in the gut microbiome of wild baboons

    Kimberly E Roche / Johannes R Bjork / Mauna R Dasari / Laura Grieneisen / David Jansen / Trevor J Gould / Laurence R Gesquiere / Luis B Barreiro / Susan C Alberts / Ran Blekhman / Jack A Gilbert / Jenny Tung / Sayan Mukherjee / Elizabeth A Archie

    eLife, Vol

    2023  Volume 12

    Abstract: Ecological relationships between bacteria mediate the services that gut microbiomes provide to their hosts. Knowing the overall direction and strength of these relationships is essential to learn how ecology scales up to affect microbiome assembly, ... ...

    Abstract Ecological relationships between bacteria mediate the services that gut microbiomes provide to their hosts. Knowing the overall direction and strength of these relationships is essential to learn how ecology scales up to affect microbiome assembly, dynamics, and host health. However, whether bacterial relationships are generalizable across hosts or personalized to individual hosts is debated. Here, we apply a robust, multinomial logistic-normal modeling framework to extensive time series data (5534 samples from 56 baboon hosts over 13 years) to infer thousands of correlations in bacterial abundance in individual baboons and test the degree to which bacterial abundance correlations are ‘universal’. We also compare these patterns to two human data sets. We find that, most bacterial correlations are weak, negative, and universal across hosts, such that shared correlation patterns dominate over host-specific correlations by almost twofold. Further, taxon pairs that had inconsistent correlation signs (either positive or negative) in different hosts always had weak correlations within hosts. From the host perspective, host pairs with the most similar bacterial correlation patterns also had similar microbiome taxonomic compositions and tended to be genetic relatives. Compared to humans, universality in baboons was similar to that in human infants, and stronger than one data set from human adults. Bacterial families that showed universal correlations in human infants were often universal in baboons. Together, our work contributes new tools for analyzing the universality of bacterial associations across hosts, with implications for microbiome personalization, community assembly, and stability, and for designing microbiome interventions to improve host health.
    Keywords gut microbiota ; microbiome community dynamics ; correlations between bacteria ; universality ; personalization ; longitudinal data analysis ; Medicine ; R ; Science ; Q ; Biology (General) ; QH301-705.5
    Subject code 612
    Language English
    Publishing date 2023-05-01T00:00:00Z
    Publisher eLife Sciences Publications Ltd
    Document type Article ; Online
    Database BASE - Bielefeld Academic Search Engine (life sciences selection)

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  7. Article ; Online: Sorting Five Human Tumor Types Reveals Specific Biomarkers and Background Classification Genes.

    Roche, Kimberly E / Weinstein, Marvin / Dunwoodie, Leland J / Poehlman, William L / Feltus, Frank A

    Scientific reports

    2018  Volume 8, Issue 1, Page(s) 8180

    Abstract: We applied two state-of-the-art, knowledge independent data-mining methods - Dynamic Quantum Clustering (DQC) and t-Distributed Stochastic Neighbor Embedding (t-SNE) - to data from The Cancer Genome Atlas (TCGA). We showed that the RNA expression ... ...

    Abstract We applied two state-of-the-art, knowledge independent data-mining methods - Dynamic Quantum Clustering (DQC) and t-Distributed Stochastic Neighbor Embedding (t-SNE) - to data from The Cancer Genome Atlas (TCGA). We showed that the RNA expression patterns for a mixture of 2,016 samples from five tumor types can sort the tumors into groups enriched for relevant annotations including tumor type, gender, tumor stage, and ethnicity. DQC feature selection analysis discovered 48 core biomarker transcripts that clustered tumors by tumor type. When these transcripts were removed, the geometry of tumor relationships changed, but it was still possible to classify the tumors using the RNA expression profiles of the remaining transcripts. We continued to remove the top biomarkers for several iterations and performed cluster analysis. Even though the most informative transcripts were removed from the cluster analysis, the sorting ability of remaining transcripts remained strong after each iteration. Further, in some iterations we detected a repeating pattern of biological function that wasn't detectable with the core biomarker transcripts present. This suggests the existence of a "background classification" potential in which the pattern of gene expression after continued removal of "biomarker" transcripts could still classify tumors in agreement with the tumor type.
    MeSH term(s) Biomarkers, Tumor/genetics ; Cluster Analysis ; Computational Biology ; Female ; Gene Expression Profiling ; Humans ; Male ; Neoplasm Staging ; Neoplasms/classification ; Neoplasms/genetics ; Neoplasms/pathology
    Chemical Substances Biomarkers, Tumor
    Language English
    Publishing date 2018-05-25
    Publishing country England
    Document type Journal Article
    ZDB-ID 2615211-3
    ISSN 2045-2322 ; 2045-2322
    ISSN (online) 2045-2322
    ISSN 2045-2322
    DOI 10.1038/s41598-018-26310-x
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  8. Article ; Online: An intrinsic oscillator drives the blood stage cycle of the malaria parasite

    Smith, Lauren M / Motta, Francis C / Chopra, Garima / Moch, J Kathleen / Nerem, Robert R / Cummins, Bree / Roche, Kimberly E / Kelliher, Christina M / Leman, Adam R / Harer, John / Gedeon, Tomas / Waters, Norman C / Haase, Steven B

    Science (New York, N.Y.)

    2020  Volume 368, Issue 6492, Page(s) 754–759

    Abstract: The blood stage of the infection of the malaria ... ...

    Abstract The blood stage of the infection of the malaria parasite
    MeSH term(s) Animals ; Circadian Clocks/genetics ; Circadian Clocks/physiology ; Erythrocytes/parasitology ; Gene Expression ; Genes, Protozoan/physiology ; Host-Parasite Interactions/genetics ; Host-Parasite Interactions/physiology ; Life Cycle Stages ; Malaria, Falciparum/blood ; Malaria, Falciparum/parasitology ; Mice ; Plasmodium falciparum/genetics ; Plasmodium falciparum/growth & development ; Transcriptome
    Language English
    Publishing date 2020-04-10
    Publishing country United States
    Document type Journal Article ; Research Support, N.I.H., Extramural ; Research Support, U.S. Gov't, Non-P.H.S.
    ZDB-ID 128410-1
    ISSN 1095-9203 ; 0036-8075
    ISSN (online) 1095-9203
    ISSN 0036-8075
    DOI 10.1126/science.aba4357
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  9. Article ; Online: Sorting Five Human Tumor Types Reveals Specific Biomarkers and Background Classification Genes

    Kimberly E. Roche / Marvin Weinstein / Leland J. Dunwoodie / William L. Poehlman / Frank A. Feltus

    Scientific Reports, Vol 8, Iss 1, Pp 1-

    2018  Volume 12

    Abstract: Abstract We applied two state-of-the-art, knowledge independent data-mining methods – Dynamic Quantum Clustering (DQC) and t-Distributed Stochastic Neighbor Embedding (t-SNE) – to data from The Cancer Genome Atlas (TCGA). We showed that the RNA ... ...

    Abstract Abstract We applied two state-of-the-art, knowledge independent data-mining methods – Dynamic Quantum Clustering (DQC) and t-Distributed Stochastic Neighbor Embedding (t-SNE) – to data from The Cancer Genome Atlas (TCGA). We showed that the RNA expression patterns for a mixture of 2,016 samples from five tumor types can sort the tumors into groups enriched for relevant annotations including tumor type, gender, tumor stage, and ethnicity. DQC feature selection analysis discovered 48 core biomarker transcripts that clustered tumors by tumor type. When these transcripts were removed, the geometry of tumor relationships changed, but it was still possible to classify the tumors using the RNA expression profiles of the remaining transcripts. We continued to remove the top biomarkers for several iterations and performed cluster analysis. Even though the most informative transcripts were removed from the cluster analysis, the sorting ability of remaining transcripts remained strong after each iteration. Further, in some iterations we detected a repeating pattern of biological function that wasn’t detectable with the core biomarker transcripts present. This suggests the existence of a “background classification” potential in which the pattern of gene expression after continued removal of “biomarker” transcripts could still classify tumors in agreement with the tumor type.
    Keywords Medicine ; R ; Science ; Q
    Subject code 572
    Language English
    Publishing date 2018-05-01T00:00:00Z
    Publisher Nature Portfolio
    Document type Article ; Online
    Database BASE - Bielefeld Academic Search Engine (life sciences selection)

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  10. Article ; Online: The Importance of Incorporating Proportional Alignment in Adult Cervical Deformity Corrections Relative to Regional and Global Alignment: Steps Toward Development of a Cervical-Specific Score.

    Passias, Peter G / Williamson, Tyler K / Pierce, Katherine E / Schoenfeld, Andrew J / Krol, Oscar / Imbo, Bailey / Joujon-Roche, Rachel / Tretiakov, Peter / Ahmad, Salman / Bennett-Caso, Claudia / Mir, Jamshaid / Dave, Pooja / McFarland, Kimberly / Owusu-Sarpong, Stephane / Lebovic, Jordan A / Janjua, Muhammad Burhan / de la Garza-Ramos, Rafael / Vira, Shaleen / Diebo, Bassel /
    Koller, Heiko / Protopsaltis, Themistocles S / Lafage, Renaud / Lafage, Virginie

    Spine

    2023  Volume 49, Issue 2, Page(s) 116–127

    Abstract: Study design/setting: Retrospective single-center study.: Background: The global alignment and proportion score is widely used in adult spinal deformity surgery. However, it is not specific to the parameters used in adult cervical deformity (ACD).: ...

    Abstract Study design/setting: Retrospective single-center study.
    Background: The global alignment and proportion score is widely used in adult spinal deformity surgery. However, it is not specific to the parameters used in adult cervical deformity (ACD).
    Purpose: Create a cervicothoracic alignment and proportion (CAP) score in patients with operative ACD.
    Methods: Patients with ACD with 2-year data were included. Parameters consisted of relative McGregor's Slope [RMGS = (MGS × 1.5)/0.9], relative cervical lordosis [RCL = CL - thoracic kyphosis (TK)], Cervical Lordosis Distribution Index (CLDI = C2 - Apex × 100/C2 - T2), relative pelvic version (RPV = sacral slope - pelvic incidence × 0.59 + 9), and a frailty factor (greater than 0.33). Cutoff points were chosen where the cross-tabulation of parameter subgroups reached a maximal rate of meeting the Optimal Outcome. The optimal outcome was defined as meeting Good Clinical Outcome criteria without the occurrence of distal junctional failure (DJF) or reoperation. CAP was scored between 0 and 13 and categorized accordingly: ≤3 (proportioned), 4-6 (moderately disproportioned), >6 (severely disproportioned). Multivariable logistic regression analysis determined the relationship between CAP categories, overall score, and development of distal junctional kyphosis (DJK), DJF, reoperation, and Optimal Outcome by 2 years.
    Results: One hundred five patients with operative ACD were included. Assessment of the 3-month CAP score found a mean of 5.2/13 possible points. 22.7% of patients were proportioned, 49.5% moderately disproportioned, and 27.8% severely disproportioned. DJK occurred in 34.5% and DJF in 8.7%, 20.0% underwent reoperation, and 55.7% achieved Optimal Outcome. Patients severely disproportioned in CAP had higher odds of DJK [OR: 6.0 (2.1-17.7); P =0.001], DJF [OR: 9.7 (1.8-51.8); P =0.008], reoperation [OR: 3.3 (1.9-10.6); P =0.011], and lower odds of meeting the optimal outcome [OR: 0.3 (0.1-0.7); P =0.007] by 2 years, while proportioned patients suffered zero occurrences of DJK or DJF.
    Conclusion: The regional alignment and proportion score is a method of analyzing the cervical spine relative to global alignment and demonstrates the importance of maintaining horizontal gaze, while also matching overall cervical and thoracolumbar alignment to limit complications and maximize clinical improvement.
    MeSH term(s) Adult ; Humans ; Lordosis/diagnostic imaging ; Lordosis/surgery ; Retrospective Studies ; Kyphosis/surgery ; Neck ; Cervical Vertebrae/diagnostic imaging ; Cervical Vertebrae/surgery
    Language English
    Publishing date 2023-10-05
    Publishing country United States
    Document type Journal Article
    ZDB-ID 752024-4
    ISSN 1528-1159 ; 0362-2436
    ISSN (online) 1528-1159
    ISSN 0362-2436
    DOI 10.1097/BRS.0000000000004843
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