1
|
Cheng Y, Ruan X, Lu X, Yang Y, Wang Y, Yan S, Sun Y, Yan F, Jiang L, Liu T. Accounting for the impact of rare variants on causal inference with RARE: a novel multivariable Mendelian randomization method. Brief Bioinform 2025; 26:bbaf214. [PMID: 40370099 PMCID: PMC12078940 DOI: 10.1093/bib/bbaf214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2024] [Revised: 04/10/2025] [Accepted: 04/20/2025] [Indexed: 05/16/2025] Open
Abstract
Mendelian randomization (MR) method utilizes genetic variants as instrumental variables to infer the causal effect of an exposure on an outcome. However, the impact of rare variants on traits is often neglected, and traditional MR assumptions can be violated by correlated horizontal pleiotropy (CHP) and uncorrelated horizontal pleiotropy (UHP). To address these issues, we propose a multivariable MR approach, an extension of the standard MR framework: MVMR incorporating Rare variants Accounting for multiple Risk factors and shared horizontal plEiotropy (RARE). In the simulation studies, we demonstrate that RARE effectively detects the causal effects of exposures on outcome with accounting for the impact of rare variants on causal inference. Additionally, we apply RARE to study the effects of high density lipoprotein and low density lipoprotein on type 2 diabetes and coronary atherosclerosis, respectively, thereby illustrating its robustness and effectiveness in real data analysis.
Collapse
Affiliation(s)
- Yu Cheng
- Research Center of Biostatistics and Computational Pharmacy, China Pharmaceutical University, #639 Longmian Ave, Jiangning District, Nanjing 211100, Jiangsu, China
- Department of Bioinformatics and Computational Biology, The University of Texas, M.D. Anderson Cancer Center, #7007 Bertner Ave, Texas Medical Center, Houston 77030, TX, United States
| | - Xinjia Ruan
- Research Center of Biostatistics and Computational Pharmacy, China Pharmaceutical University, #639 Longmian Ave, Jiangning District, Nanjing 211100, Jiangsu, China
| | - Xiaofan Lu
- Department of Cancer and Functional Genomics, Institute of Genetics and Molecular and Cellular Biology, CNRS/INSERM/UNISTRA, #10142 BP, Illkirch 67400, Bas-Rhin, France
| | - Yuqing Yang
- Research Center of Biostatistics and Computational Pharmacy, China Pharmaceutical University, #639 Longmian Ave, Jiangning District, Nanjing 211100, Jiangsu, China
| | - Yuhang Wang
- Research Center of Biostatistics and Computational Pharmacy, China Pharmaceutical University, #639 Longmian Ave, Jiangning District, Nanjing 211100, Jiangsu, China
| | - Shangjin Yan
- High School Affiliated to Nanjing Normal University, #37 Chahar Road, Gulou District, Nanjing 210003, Jiangsu, China
| | - Yuzhe Sun
- Department of Biochemistry, Vassar college, Poughkeepsie, NY 12604, United States
| | - Fangrong Yan
- Research Center of Biostatistics and Computational Pharmacy, China Pharmaceutical University, #639 Longmian Ave, Jiangning District, Nanjing 211100, Jiangsu, China
| | - Liyun Jiang
- Research Center of Biostatistics and Computational Pharmacy, China Pharmaceutical University, #639 Longmian Ave, Jiangning District, Nanjing 211100, Jiangsu, China
| | - Tiantian Liu
- Research Center of Biostatistics and Computational Pharmacy, China Pharmaceutical University, #639 Longmian Ave, Jiangning District, Nanjing 211100, Jiangsu, China
| |
Collapse
|
2
|
Li X, Sun L, Wu X, Qiu M, Ma X. Cathepsins and their role in gynecological cancers: Evidence from two-sample Mendelian randomization analysis. Medicine (Baltimore) 2025; 104:e41653. [PMID: 40068078 PMCID: PMC11902974 DOI: 10.1097/md.0000000000041653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2024] [Revised: 02/05/2025] [Accepted: 02/06/2025] [Indexed: 03/14/2025] Open
Abstract
Prior studies have reported connections between cathepsins (CTS) and gynecological cancers; however, the exact causal links are yet to be fully understood. Leveraging publicly accessible genome-wide association study summary datasets, we performed a two-sample bidirectional Mendelian randomization (MR) and multivariate MR (MVMR) analysis, with the inverse variance weighted (IVW) method as the primary approach. MR analysis demonstrated inverse associations between CTSB and cervical cancer (IVW: odds ratio [OR] = 0.9995, 95% confidence interval [CI] = 0.9991-0.9999, P = .0418), CTSE and ovarian cancer (IVW: OR = 0.9197, 95% CI = 0.8505-0.9944, P = .0358), CTSZ and ovarian cancer (IVW: OR = 0.9449, 95% CI = 0.8938-0.9990, P = .0459), CTSE and high grade serous ovarian cancer (IVW: OR = 0.8939, 95% CI = 0.8248-0.9689, P = .0063), and CTSZ and high grade serous ovarian cancer (IVW: OR = 0.9269, 95% CI = 0.8667-0.9913, P = .0268). A positive correlation was identified between CTSH and clear cell ovarian cancer (IVW: OR = 1.1496, 95% CI = 1.0368-1.2745, P = .0081). Nevertheless, subsequent adjustment for the false discovery rate revealed that none of the P-values retained statistical significance (PFDR > 0.05). MVMR analysis results elucidated that CTSZ was inversely associated with cervical cancer (IVW: OR = 0.9988, 95% CI = 0.9981-0.9996, P = .0022). Moreover, a positive association was noted between CTSF and cervical cancer (IVW: OR = 1.0007, 95% CI = 1.0000-1.0014, P = .0364), and similarly, between CTSS and cervical cancer (IVW: OR = 1.0005, 95% CI = 1.0000-1.0011, P = .0490). CTSO exhibited a positive association with non-endometrioid endometrial cancer (IVW: OR = 1.4405, 95% CI = 1.1864-1.7490, P < .001), and CTSH was positively associated with clear cell ovarian cancer (IVW: OR = 1.1167, 95% CI = 1.0131-1.2310, P = .0263). The MVMR analysis findings reveal that CTSZ emerges as a protective element against cervical cancer, whereas CTSF and CTSS represent risk factors for this disease. CTSO stands out as a risk factor for non-endometrioid endometrial cancer, and CTSH acts as a risk factor for clear cell ovarian cancer. This study elucidates causative connections between CTS and gynecological cancers, providing innovative insights for diagnostic and therapeutic optimization.
Collapse
Affiliation(s)
- Xiaoying Li
- Department of Gynecology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Lingyi Sun
- Department of Gynecology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaoting Wu
- Department of Gynecology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Meng Qiu
- Department of Gynecology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Xiuli Ma
- Department of Gynecology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| |
Collapse
|
3
|
Gerring ZF, Thorp JG, Treur JL, Verweij KJH, Derks EM. The genetic landscape of substance use disorders. Mol Psychiatry 2024; 29:3694-3705. [PMID: 38811691 PMCID: PMC11541208 DOI: 10.1038/s41380-024-02547-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 03/21/2024] [Accepted: 03/28/2024] [Indexed: 05/31/2024]
Abstract
Substance use disorders represent a significant public health concern with considerable socioeconomic implications worldwide. Twin and family-based studies have long established a heritable component underlying these disorders. In recent years, genome-wide association studies of large, broadly phenotyped samples have identified regions of the genome that harbour genetic risk variants associated with substance use disorders. These regions have enabled the discovery of putative causal genes and improved our understanding of genetic relationships among substance use disorders and other traits. Furthermore, the integration of these data with clinical information has yielded promising insights into how individuals respond to medications, allowing for the development of personalized treatment approaches based on an individual's genetic profile. This review article provides an overview of recent advances in the genetics of substance use disorders and demonstrates how genetic data may be used to reduce the burden of disease and improve public health outcomes.
Collapse
Affiliation(s)
- Zachary F Gerring
- Translational Neurogenomics Laboratory, Mental Health and Neuroscience, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Jackson G Thorp
- Translational Neurogenomics Laboratory, Mental Health and Neuroscience, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Jorien L Treur
- Department of Psychiatry, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Karin J H Verweij
- Department of Psychiatry, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Eske M Derks
- Translational Neurogenomics Laboratory, Mental Health and Neuroscience, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia.
| |
Collapse
|
4
|
Jin J, Qi G, Yu Z, Chatterjee N. Mendelian randomization analysis using multiple biomarkers of an underlying common exposure. Biostatistics 2024; 25:1015-1033. [PMID: 38459704 PMCID: PMC11879930 DOI: 10.1093/biostatistics/kxae006] [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: 02/28/2023] [Revised: 11/16/2023] [Accepted: 02/05/2024] [Indexed: 03/10/2024] Open
Abstract
Mendelian randomization (MR) analysis is increasingly popular for testing the causal effect of exposures on disease outcomes using data from genome-wide association studies. In some settings, the underlying exposure, such as systematic inflammation, may not be directly observable, but measurements can be available on multiple biomarkers or other types of traits that are co-regulated by the exposure. We propose a method for MR analysis on latent exposures (MRLE), which tests the significance for, and the direction of, the effect of a latent exposure by leveraging information from multiple related traits. The method is developed by constructing a set of estimating functions based on the second-order moments of GWAS summary association statistics for the observable traits, under a structural equation model where genetic variants are assumed to have indirect effects through the latent exposure and potentially direct effects on the traits. Simulation studies show that MRLE has well-controlled type I error rates and enhanced power compared to single-trait MR tests under various types of pleiotropy. Applications of MRLE using genetic association statistics across five inflammatory biomarkers (CRP, IL-6, IL-8, TNF-α, and MCP-1) provide evidence for potential causal effects of inflammation on increasing the risk of coronary artery disease, colorectal cancer, and rheumatoid arthritis, while standard MR analysis for individual biomarkers fails to detect consistent evidence for such effects.
Collapse
Affiliation(s)
- Jin Jin
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe St, Baltimore, MD 21205, United States
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104-6021, United States
| | - Guanghao Qi
- Department of Biomedical Engineering, Johns Hopkins University, 720 Rutland Avenue, Baltimore, MD 21205, United States
- Department of Biostatistics, University of Washington, 3980 15th Avenue NE, Seattle, WA 98195-1617, United States
| | - Zhi Yu
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, 415 Main St Cambridge, MA 02142, United States
| | - Nilanjan Chatterjee
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe St, Baltimore, MD 21205, United States
- Department of Oncology, School of Medicine, Johns Hopkins University, 733 N Broadway, Baltimore, MD 21205, United States
| |
Collapse
|
5
|
Zhang L, Xiong Y, Zhang J, Feng Y, Xu A. Systematic proteome-wide Mendelian randomization using the human plasma proteome to identify therapeutic targets for lung adenocarcinoma. J Transl Med 2024; 22:330. [PMID: 38576019 PMCID: PMC10993587 DOI: 10.1186/s12967-024-04919-z] [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: 11/07/2023] [Accepted: 01/21/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Lung adenocarcinoma (LUAD) is the predominant histological subtype of lung cancer and the leading cause of cancer-related mortality. Identifying effective drug targets is crucial for advancing LUAD treatment strategies. METHODS This study employed proteome-wide Mendelian randomization (MR) and colocalization analyses. We collected data on 1394 plasma proteins from a protein quantitative trait loci (pQTL) study involving 4907 individuals. Genetic associations with LUAD were derived from the Transdisciplinary Research in Cancer of the Lung (TRICL) study, including 11,245 cases and 54,619 controls. We integrated pQTL and LUAD genome-wide association studies (GWASs) data to identify candidate proteins. MR utilizes single nucleotide polymorphisms (SNPs) as genetic instruments to estimate the causal effect of exposure on outcome, while Bayesian colocalization analysis determines the probability of shared causal genetic variants between traits. Our study applied these methods to assess causality between plasma proteins and LUAD. Furthermore, we employed a two-step MR to quantify the proportion of risk factors mediated by proteins on LUAD. Finally, protein-protein interaction (PPI) analysis elucidated potential links between proteins and current LUAD medications. RESULTS We identified nine plasma proteins significantly associated with LUAD. Increased levels of ALAD, FLT1, ICAM5, and VWC2 exhibited protective effects, with odds ratios of 0.79 (95% CI 0.72-0.87), 0.39 (95% CI 0.28-0.55), 0.91 (95% CI 0.72-0.87), and 0.85 (95% CI 0.79-0.92), respectively. Conversely, MDGA2 (OR, 1.13; 95% CI 1.08-1.19), NTM (OR, 1.12; 95% CI 1.09-1.16), PMM2 (OR, 1.35; 95% CI 1.18-1.53), RNASET2 (OR, 1.15; 95% CI 1.08-1.21), and TFPI (OR, 4.58; 95% CI 3.02-6.94) increased LUAD risk. Notably, none of the nine proteins showed evidence of reverse causality. Bayesian colocalization indicated that RNASET2, TFPI, and VWC2 shared the same variant with LUAD. Furthermore, NTM and FLT1 demonstrated interactions with targets of current LUAD medications. Additionally, FLT1 and TFPI are currently under evaluation as therapeutic targets, while NTM, RNASET2, and VWC2 are potentially druggable. These findings shed light on LUAD pathogenesis, highlighting the tumor-promoting effects of RNASET2, TFPI, and NTM, along with the protective effects of VWC2 and FLT1, providing a significant biological foundation for future LUAD therapeutic targets. CONCLUSIONS Our proteome-wide MR analysis highlighted RNASET2, TFPI, VWC2, NTM, and FLT1 as potential drug targets for further clinical investigation in LUAD. However, the specific mechanisms by which these proteins influence LUAD remain elusive. Targeting these proteins in drug development holds the potential for successful clinical trials, providing a pathway to prioritize and reduce costs in LUAD therapeutics.
Collapse
Affiliation(s)
- Long Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yajun Xiong
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jie Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yuying Feng
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Aiguo Xu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| |
Collapse
|
6
|
Zhong S, Yang W, Zhang Z, Xie Y, Pan L, Ren J, Ren F, Li Y, Xie H, Chen H, Deng D, Lu J, Li H, Wu B, Chen Y, Peng F, Puduvalli VK, Sai K, Li Y, Cheng Y, Mou Y. Association between viral infections and glioma risk: a two-sample bidirectional Mendelian randomization analysis. BMC Med 2023; 21:487. [PMID: 38053181 PMCID: PMC10698979 DOI: 10.1186/s12916-023-03142-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 10/30/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Glioma is one of the leading types of brain tumor, but few etiologic factors of primary glioma have been identified. Previous observational research has shown an association between viral infection and glioma risk. In this study, we used Mendelian randomization (MR) analysis to explore the direction and magnitude of the causal relationship between viral infection and glioma. METHODS We conducted a two-sample bidirectional MR analysis using genome-wide association study (GWAS) data. Summary statistics data of glioma were collected from the largest meta-analysis GWAS, involving 12,488 cases and 18,169 controls. Single-nucleotide polymorphisms (SNPs) associated with exposures were used as instrumental variables to estimate the causal relationship between glioma and twelve types of viral infections from corresponding GWAS data. In addition, sensitivity analyses were performed. RESULTS After correcting for multiple tests and sensitivity analysis, we detected that genetically predicted herpes zoster (caused by Varicella zoster virus (VZV) infection) significantly decreased risk of low-grade glioma (LGG) development (OR = 0.85, 95% CI: 0.76-0.96, P = 0.01, FDR = 0.04). No causal effects of the other eleven viral infections on glioma and reverse causality were detected. CONCLUSIONS This is one of the first and largest studies in this field. We show robust evidence supporting that genetically predicted herpes zoster caused by VZV infection reduces risk of LGG. The findings of our research advance understanding of the etiology of glioma.
Collapse
Affiliation(s)
- Sheng Zhong
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China
| | - Wenzhuo Yang
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China
| | - Zhiyun Zhang
- Department of Plastic Surgery, The First Hospital of Jilin University, Changchun, 130000, People's Republic of China
| | - Yangyiran Xie
- Vanderbilt University School of Medicine, Vanderbilt University, 1161 21St Ave S # D3300, Nashville, TN, 37232, USA
| | - Lin Pan
- Clinical College, Jilin University, Street Xinmin 828, Changchun, People's Republic of China
| | - Jiaxin Ren
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Chang Chun, People's Republic of China
| | - Fei Ren
- Clinical College, Jilin University, Street Xinmin 828, Changchun, People's Republic of China
| | - Yifan Li
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China
| | - Haoqun Xie
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China
| | - Hongyu Chen
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China
| | - Davy Deng
- Dana Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA
| | - Jie Lu
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China
| | - Hui Li
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Chang Chun, People's Republic of China
| | - Bo Wu
- Department of Orthopaedics, The First Hospital of Jilin University, No.71, Street Xinmin Road, Chaoyang District, Changchun, Jilin, People's Republic of China
| | - Youqi Chen
- Clinical College, Jilin University, Street Xinmin 828, Changchun, People's Republic of China
| | - Fei Peng
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Vinay K Puduvalli
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, People's Republic of China
| | - Ke Sai
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China.
| | - Yunqian Li
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, People's Republic of China.
| | - Ye Cheng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, People's Republic of China.
| | - Yonggao Mou
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, People's Republic of China.
| |
Collapse
|
7
|
Cheng Q, Zhang X, Chen LS, Liu J. Mendelian randomization accounting for complex correlated horizontal pleiotropy while elucidating shared genetic etiology. Nat Commun 2022; 13:6490. [PMID: 36310177 PMCID: PMC9618026 DOI: 10.1038/s41467-022-34164-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/17/2022] [Indexed: 12/25/2022] Open
Abstract
Mendelian randomization (MR) harnesses genetic variants as instrumental variables (IVs) to study the causal effect of exposure on outcome using summary statistics from genome-wide association studies. Classic MR assumptions are violated when IVs are associated with unmeasured confounders, i.e., when correlated horizontal pleiotropy (CHP) arises. Such confounders could be a shared gene or inter-connected pathways underlying exposure and outcome. We propose MR-CUE (MR with Correlated horizontal pleiotropy Unraveling shared Etiology and confounding), for estimating causal effect while identifying IVs with CHP and accounting for estimation uncertainty. For those IVs, we map their cis-associated genes and enriched pathways to inform shared genetic etiology underlying exposure and outcome. We apply MR-CUE to study the effects of interleukin 6 on multiple traits/diseases and identify several S100 genes involved in shared genetic etiology. We assess the effects of multiple exposures on type 2 diabetes across European and East Asian populations.
Collapse
Affiliation(s)
- Qing Cheng
- grid.443347.30000 0004 1761 2353Center of Statistical Research, School of Statistics, Southwestern University of Finance and Economics, Chengdu, Sichuan China ,grid.428397.30000 0004 0385 0924Centre for Quantitative Medicine, Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Xiao Zhang
- grid.428397.30000 0004 0385 0924Centre for Quantitative Medicine, Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Lin S. Chen
- grid.170205.10000 0004 1936 7822Department of Public Health Sciences, The University of Chicago, Chicago, IL USA
| | - Jin Liu
- Centre for Quantitative Medicine, Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore.
| |
Collapse
|