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Brunwasser SM, Warner AK, Rosas-Salazar C, Wu P. Advancing birth cohort studies using administrative and other research-independent data repositories: Opportunities and challenges. J Allergy Clin Immunol 2025:S0091-6749(25)00383-5. [PMID: 40222617 DOI: 10.1016/j.jaci.2025.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2024] [Revised: 03/11/2025] [Accepted: 04/03/2025] [Indexed: 04/15/2025]
Abstract
The birth cohort study design is an essential epidemiologic tool for investigating the developmental origins of health and disease. Birth cohorts have greatly improved the etiologic understanding of asthma and allergic diseases, setting the stage for advancements in translational interventions. Increasingly, investigators leverage data repositories that have been compiled and maintained independently of research investigations (administrative data) to establish large birth cohorts or to augment data generated through active participant interaction. In many cases, administrative data can greatly enhance the capacity of birth cohorts to achieve their scientific goals. However, investigators must be wary of common pitfalls and carefully consider whether administrative data are well suited to the scientific inquiry. This article reviews the strengths and challenges of using administrative data and the pragmatic solutions that have been developed to optimize their use in birth cohorts. As birth cohorts continue to play an important role in understanding the etiology of early-life disease, unleashing the power of administrative data will greatly assist in this scientific process.
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Affiliation(s)
- Steven M Brunwasser
- Department of Psychology, Rowan University, Glassboro, NJ; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
| | | | | | - Pingsheng Wu
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tenn.
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Nowell WB, Barnes EL, Venkatachalam S, Kappelman MD, Curtis JR, Merkel PA, Shaw DG, Larson K, Greisz J, George MD. Racial and Ethnic Distribution of Rheumatic Diseases in Health Systems of the National Patient-Centered Clinical Research Network. J Rheumatol 2023; 50:1503-1508. [PMID: 37657793 DOI: 10.3899/jrheum.2022-1300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE To evaluate the relative prevalence of 8 rheumatic and musculoskeletal diseases (RMDs) across racial and ethnic groups within the National Patient-Centered Clinical Research Network (PCORnet). METHODS Electronic health records from participating PCORnet institutions and systems from January 1, 2013, to December 31, 2018, were used to identify adult patients with ≥ 2 diagnosis codes for rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), osteoporosis (OP), granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA), giant cell arteritis (GCA), and Takayasu arteritis (TAK). Among those with race and ethnicity data available, we compared prevalence of RMDs by race and ethnicity. RESULTS Data from 28,059,546 patients were available for analysis. RA was more common in patients who were American Indian or Alaska Native vs White, with a prevalence of 11.57 vs 10.11/1000 (odds ratio [OR] 1.15, 95% CI 1.09-1.22). SLE was more common in patients who were Black or African American (6.73/1000), American Indian or Alaska Native (3.82/1000), and Asian (3.39/1000) vs White (2.80/1000; OR 2.43, 95% CI 2.39-2.46; OR 1.39, 95% CI 1.25-1.53; OR 1.26, 95% CI 1.21-1.31, respectively). SLE was more common in patients who were Hispanic vs non-Hispanic (prevalence 3.93 vs 3.45/1000, OR 1.14, 95% CI 1.12-1.16). TAK was more common in patients who were Asian vs White (prevalence 0.05 vs 0.04/1000, OR 1.43, 95% CI 1.00-2.03). OP, RA, and the vasculitides were all more common in patients who were White vs Black or African American. CONCLUSION These data provide important information on the prevalence of RMDs by race and ethnicity in the United States. PCORnet can be used as a reliable data source to study RMDs within a large representative population.
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Affiliation(s)
- William Benjamin Nowell
- W.B. Nowell, PhD, MSW, S. Venkatachalam, PhD, MPH, Global Healthy Living Foundation, Upper Nyack, New York;
| | - Edward L Barnes
- E.L. Barnes, MD, MPH, M.D. Kappelman, MD, MPH, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Shilpa Venkatachalam
- W.B. Nowell, PhD, MSW, S. Venkatachalam, PhD, MPH, Global Healthy Living Foundation, Upper Nyack, New York
| | - Michael D Kappelman
- E.L. Barnes, MD, MPH, M.D. Kappelman, MD, MPH, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Jeffrey R Curtis
- J.R. Curtis, MD, MS, MPH, Illumination Health, Hoover, and University of Alabama at Birmingham, Birmingham, Alabama
| | - Peter A Merkel
- P.A. Merkel, MD, MPH, J. Greisz, MD, M.D. George, MD, MSCE, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dianne G Shaw
- D.G. Shaw, MA, K. Larson, MA, Vasculitis Foundation, Kansas City, Missouri, USA
| | - Kalen Larson
- D.G. Shaw, MA, K. Larson, MA, Vasculitis Foundation, Kansas City, Missouri, USA
| | - Justin Greisz
- P.A. Merkel, MD, MPH, J. Greisz, MD, M.D. George, MD, MSCE, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael D George
- P.A. Merkel, MD, MPH, J. Greisz, MD, M.D. George, MD, MSCE, University of Pennsylvania, Philadelphia, Pennsylvania
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Stunkel L. Big Data in Neuro-Ophthalmology: International Classification of Diseases Codes. J Neuroophthalmol 2022; 42:1-5. [PMID: 35067628 DOI: 10.1097/wno.0000000000001522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Leanne Stunkel
- John F. Hardesty, MD Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, St. Louis, Missouri; and Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
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Predictive Value of International Classification of Diseases Codes for Idiopathic Intracranial Hypertension in a University Health System. J Neuroophthalmol 2022; 42:6-10. [DOI: 10.1097/wno.0000000000001563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Khushzad F, Kumar R, Muminovic I, Moss HE. Predictive Value of International Classification of Diseases Codes for Idiopathic Intracranial Hypertension in a University Health System. J Neuroophthalmol 2021; 41:e679-e683. [PMID: 34788247 PMCID: PMC8600052 DOI: 10.1097/wno.0000000000000992] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Misclassification bias is introduced into medical claims-based research because of reliance on diagnostic coding rather than full medical record review. We sought to characterize this bias for idiopathic intracranial hypertension (IIH) and evaluate strategies to reduce it. METHODS A retrospective review of medical records was conducted using a clinical data warehouse containing medical records and administrative data from an academic medical center. Patients with 1 or more instances of International Classification of Diseases (ICD)-9 or -10 codes for IIH (348.2 or G93.2) between 1989 and 2017 and original results of neuroimaging (head CT or MRI), lumbar puncture, and optic nerve examination were included in the study. Diagnosis of IIH was classified as definite, probable, possible, or inaccurate based on review of medical records. The positive predictive value (PPV) for IIH ICD codes was calculated for all subjects, subjects with an IIH code after all testing was completed, subjects with high numbers of IIH ICD codes and codes spanning longer periods, subjects with IIH ICD codes associated with expert encounters (ophthalmology, neurology, or neurosurgery), and subjects with acetazolamide treatment. RESULTS Of 1,005 patients with ICD codes for IIH, 103 patients had complete testing results and were included in the study. PPV of ICD-9/-10 codes for IIH was 0.63. PPV in restricted samples was 0.82 (code by an ophthalmologist n = 57), 0.70 (acetazolamide treatment n = 87), and 0.72 (code after all testing, n = 78). High numbers of code instances and longer duration between the first and last code instance also increased the PPV. CONCLUSIONS An ICD-9 or -10 code for IIH had a PPV of 63% for probable or definite IIH in patients with necessary diagnostic testing performed at a single institution. Coding accuracy was improved in patients with an IIH ICD code assigned by an ophthalmologist. Use of coding algorithms considering treatment providers, number of codes, and treatment is a potential strategy to reduce misclassification bias in medical claims-based research on IIH. However, these are associated with a reduced sample size.
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Affiliation(s)
- Fareshta Khushzad
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
| | - Riya Kumar
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
| | - Irma Muminovic
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
| | - Heather E. Moss
- Department of Ophthalmology, Stanford University, Palo Alto, CA, USA
- Department of Neurology & Neurological Sciences, Stanford University, Palo Alto, CA, USA
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Marrie RA, Ekuma O, Wijnands JMA, Kingwell E, Zhu F, Zhao Y, Fisk JD, Evans C, Tremlett H. Identifying optic neuritis and transverse myelitis using administrative data. Mult Scler Relat Disord 2018; 25:258-264. [PMID: 30144696 DOI: 10.1016/j.msard.2018.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 08/11/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We aimed to validate administrative case definitions to identify individuals with optic neuritis (ON) or transverse myelitis (TM), and to distinguish which of these individuals had a monophasic presentation versus multiple sclerosis (MS). METHODS Using population-based administrative (health claims) data from Manitoba, Canada, we developed case definitions for ON and TM, and distinguished individuals who had monophasic presentations (ON-nonMS, TM-nonMS) versus those later diagnosed with MS (ON-MS, TM-MS). We compared performance of these case definitions to diagnoses based on medical records review in a reference cohort (n = 1251) using sensitivity, specificity, positive predictive value and negative predictive value. We estimated the annual incidence of these conditions for a three-year period (2011-2013). RESULTS When compared to medical records, using ≥1 physician visit, the case definition for ON had good sensitivity (88.5%), and specificity (82.7%) whereas the case definition for TM had low sensitivity (25.9%) and higher specificity (89.0%). Findings for the other case definitions tested were: ON-MS (sensitivity: 84.1%, specificity: 83.9%), ON-nonMS (sensitivity: 66.7%, specificity 98.5%), TM-MS (sensitivity: 22.2%, specificity: 90.4%), and TM-nonMS (sensitivity: 3.7%, specificity: 99.7%). After applying the ON and TM case definitions to administrative data, the average annual incidence of ON over the period 2011-2013 was 75.9 per 100,000 person-years (95%CI: 72.8, 79.1) and of TM was 18.3 per 100,000 person-years (95%CI: 16.8, 19.8). CONCLUSION Administrative data can be used to identify individuals with incident ON and TM, and to distinguish those with monophasic syndromes from those with an incident presentation of MS.
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Affiliation(s)
- Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
| | - Okechukwu Ekuma
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg MB, Canada.
| | - José M A Wijnands
- Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, Canada.
| | - Elaine Kingwell
- Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, Canada.
| | - Feng Zhu
- Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, Canada.
| | - Yinshan Zhao
- Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, Canada.
| | - John D Fisk
- Departments of Psychiatry, Psychology & Neuroscience, and Medicine, Dalhousie University, Halifax, NS, Canada.
| | - Charity Evans
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada.
| | - Helen Tremlett
- Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, Canada.
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Delate T, Jones AE, Clark NP, Witt DM. Assessment of the coding accuracy of warfarin-related bleeding events. Thromb Res 2017; 159:86-90. [PMID: 29035718 DOI: 10.1016/j.thromres.2017.10.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 09/13/2017] [Accepted: 10/04/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Using International Classification of Diseases, 9th edition (ICD-9) diagnosis codes to identify potential warfarin-related bleeding events from administrative datasets is highly efficient but may be prone to identifying non-events. The objective of this study was to evaluate the ability of bleeding-related ICD-9 codes to identify true bleeding events in patients who were receiving warfarin therapy at the time of hospitalization. METHODS This was a cross-sectional study conducted in an integrated healthcare delivery system. Anticoagulated patients aged ≥18years and hospitalized between January 1, 2014 and March 31, 2014 were identified using administrative data queries. All hospitalizations were manually chart reviewed by a trained abstractor blinded to hospitalization diagnoses to assess for true bleeding events. Identification of the presence or lack of bleeding-related ICD-9 diagnosis code(s) for each hospitalization was then performed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each ICD-9 code present. RESULTS There were 486 hospitalizations in 468 anticoagulated patients with 57 true bleeding events identified. Patients had a mean age of 73.4years and 50% were female. For codes in the principal position, sensitivity, specificity, PPV, and NPV were 7.0%, 99.8%, 80.0%, and 89.0%, respectively. For codes in any position, sensitivity, specificity, PPV, and NPV were 94.7%, 90.9%, 58.1%, and 99.2%, respectively. For major bleeding, sensitivity, specificity, PPV, and NPV were 100%, 83.1%, 14.0%, and 100%, respectively. CONCLUSIONS While the absence of a bleeding ICD-9 code reliably ruled-out hospitalization for warfarin-related bleeding, bleeding ICD-9 codes in the principal position were rarely used and undesirable false positive rates were identified when ICD-9 codes when recorded in any position and for major bleeding. Manual chart review is recommended to validate bleeding events from administrative data.
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Affiliation(s)
- Thomas Delate
- Pharmacy Department, Kaiser Permanente Colorado, 16601 East Centretech Parkway, Aurora, CO 80011, United States.
| | - Aubrey E Jones
- Pharmacy Department, Kaiser Permanente Colorado, 16601 East Centretech Parkway, Aurora, CO 80011, United States
| | - Nathan P Clark
- Pharmacy Department, Kaiser Permanente Colorado, 16601 East Centretech Parkway, Aurora, CO 80011, United States
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, 30 2000 E, Salt Lake City, UT 84112, United States
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Smith MG, Royer J, Mann JR, McDermott S. Using Administrative Data to Ascertain True Cases of Muscular Dystrophy: Rare Disease Surveillance. JMIR Public Health Surveill 2017; 3:e2. [PMID: 28082256 PMCID: PMC5269556 DOI: 10.2196/publichealth.6720] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 11/29/2016] [Accepted: 12/19/2016] [Indexed: 12/14/2022] Open
Abstract
Background Administrative records from insurance and hospital discharge data sources are important public health tools to conduct passive surveillance of disease in populations. Identifying rare but catastrophic conditions is a challenge since approaches for maximizing valid case detection are not firmly established. Objective The purpose of our study was to explore a number of algorithms in which International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and other administrative variables could be used to identify cases of muscular dystrophy (MD). Methods We used active surveillance to identify possible cases of MD in medical practices in neurology, genetics, and orthopedics in 5 urban South Carolina counties and to identify the cases that had diagnostic support (ie, true cases). We then developed an algorithm to identify cases based on a combination of ICD-9-CM codes and administrative variables from a public (Medicaid) and private insurer claims-based system and a statewide hospital discharge dataset (passive surveillance). Cases of all types of MD and those with Duchenne or Becker MD (DBMD) that were common to both surveillance systems were examined to identify the most specific administrative variables for ascertainment of true cases. Results Passive statewide surveillance identified 3235 possible cases with MD in the state, and active surveillance identified 2057 possible cases in 5 actively surveilled counties that included 2 large metropolitan areas where many people seek medical care. There were 537 common cases found in both the active and passive systems, and 260 (48.4%) were confirmed by active surveillance to be true cases. Of the 260 confirmed cases, 70 (26.9%) were recorded as DBMD. Conclusions Accuracy of finding a true case in a passive surveillance system was improved substantially when specific diagnosis codes, number of times a code was used, age of the patient, and specialty provider variables were used.
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Affiliation(s)
- Michael G Smith
- Bureau of Maternal and Child HealthDivision of Research and PlanningSouth Carolina Department of Health and Environmental ControlColumbia, SCUnited States
| | - Julie Royer
- South Carolina Budget and Control BoardRevenue and Fiscal Affairs OfficeColumbia, SCUnited States
| | - Joshua R Mann
- Department of Preventive MedicineUniversity of Mississippi Medical CenterJackson, MSUnited States
| | - Suzanne McDermott
- Department of Epidemiology and BiostatisticsUniversity of South CarolinaColumbia, SCUnited States
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Okubo Y, Nochioka K, Sakakibara H, Hataya H, Terakawa T, Testa M, Sundel RP. Nationwide epidemiological survey of childhood IgA vasculitis associated hospitalization in the USA. Clin Rheumatol 2016; 35:2749-2756. [PMID: 27596741 DOI: 10.1007/s10067-016-3402-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/28/2016] [Accepted: 08/29/2016] [Indexed: 12/18/2022]
Abstract
At the national level, IgA vasculitis-related hospitalizations among children in the USA are scarce. Furthermore, nationwide epidemiology and hospital course of children with IgA vasculitis have not been fully described in the USA, and disparities by race/ethnicity remain unknown. Hospital discharge records of patients aged 19 years or younger were obtained from the 2003, 2006, 2009, and 2012 Kids' Inpatient Database, and they were weighted to estimate the annual hospitalization rates with respect to age, gender, and race/ethnicity in the USA. Annual hospitalization rates were calculated using weighted case estimates and US census data. Negative binomial regression was used to ascertain the factors associated with length of hospital stay. Total annual hospitalization rates showed a significant decreasing trend, ranging from 2.45 per 100,000 children in 2003 to 1.89 per 100,000 children in 2012 (p < 0.001). The peak ages of the hospitalized children with IgA vasculitis were 2 and 7 years, and male-to-female ratios were 1.38-1.44. Factors associated with length of hospital stay were patients' ages (10-14 and 15-19 years), race/ethnicity (Hispanic, Asian, and Pacific Islander), comorbid electrolyte abnormality, GI hemorrhage, intussusception, renal symptoms, and GI symptoms. The annual hospitalization rates for IgA vasculitis are declining in the USA across multiple age groups. GI and renal manifestations are associated with increased length of hospital stay.
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Affiliation(s)
- Yusuke Okubo
- Harvard T.H. Chan School of Public Health, Boston, MA, USA. .,Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan. .,Harvard School of Public Health, 158 Longwood Avenue, Boston, MA, 02115, USA.
| | | | - Hiroshi Sakakibara
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroshi Hataya
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Toshiro Terakawa
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Marcia Testa
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Robert P Sundel
- Division of Immunology, Boston Children's Hospital, Boston, MA, USA
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Esposito S, Prada E, Mastrolia MV, Tarantino G, Codecà C, Rigante D. Autoimmune/inflammatory syndrome induced by adjuvants (ASIA): clues and pitfalls in the pediatric background. Immunol Res 2014; 60:366-375. [PMID: 25395340 DOI: 10.1007/s12026-014-8586-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The development and increasing diffusion of new vaccinations and global immunization protocols have aroused burning debates about safety of adjuvants and their immunogenicity-enhancing effect in vaccines. Shoenfeld and Agmon-Levin have grouped under the term "autoimmune/inflammatory syndrome induced by adjuvants" (ASIA) a complex of variable signs and symptoms that may occur after a previous exposure to different adjuvants and also external environmental triggers, even eliciting specific overt immune-mediated disorders. This entity subsumes five medical conditions: post-vaccination phenomena, gulf war syndrome, macrophagic myofasciitis syndrome, siliconosis, and sick building syndrome, but the relevance and magnitude of the syndrome in the pediatric age is fundamentally limited to post-vaccination autoimmune or inflammatory disorders. The occurrence of vaccine-triggered phenomena represents a diagnostic challenge for clinicians and a research conundrum for many investigators. In this paper, we will analyze the general features of ASIA and focus on specific post-vaccination events in relation with the pediatric background. In the presence of a favorable genetic background, many autoimmune/inflammatory responses can be triggered by adjuvants and external factors, showing how the man himself might breach immune tolerance and drive many pathogenetic aspects of human diseases. Nonetheless, the elective application of ASIA diagnostic criteria to the pediatric population requires further assessment and evaluations. Additional studies are needed to help clarify connections between innate or adaptive immunity and pathological and/or protective autoantibodies mostly in the pediatric age, as children and adolescents are mainly involved in the immunization agendas related to vaccine-preventable diseases.
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Affiliation(s)
- Susanna Esposito
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via Commenda 9, 20122, Milan, Italy,
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