some offhand observations about the treatment of skewness in pediatric echo reference data.
- Skewness:
- 1. asymmetry in a frequency distribution.
- 2. a measure of such asymmetry.
Underlying the use of z-scores is an assumption about the symmetric nature of the distribution: the use of "Z" is because the normal distribution is also known as the "Z distribution". However, as noted elsewhere[1, 2], cardiac growth data are skewed to the right. Here are a few examples that I find remarkable.
Left Atrial Diameter
Neilan et al.[3] examined the nature of the relationship of body size to cardiac structures using the left atrial diameter as measured in over 15,000 normal patients. Their plot of LA diameter against body weight—and the underlying rightward skew—can be examined here: left atrial diameter vs. body weight. Although the chart is presented in the source article with logarithmic axes, "back transforming" the axes into natural units reveals the magnitude and direction of the skew.
Left Ventricular Mass
Using the LMS technique to deliberately account for skew (and non-constant variance), Foster et al.[4] provide the data used to construct the following curves: left ventricular mass vs. height (I used ±1.65 for the upper and lower bounds). Interestingly, while the LMS method handles the skew and variance in a discrete (although smoothed) fashion, applying a log transformation appears to control both phenomenon as well.
Fetal Data
Comparing the recently published[5] fetal echo z-score data with the earlier reference[6] reveals one obvious difference: the Boston data is modeled as having a normal distribution, with no obvious skew. What, I wonder, happens if the underlying data really does have rightward skew, but is modeled as a normal distribution? Hmm...
References
- Sluysmans T and Colan SD (2009). Structural Measurements and Adjustment for Growth. In Wyman Lai [et al.] (Eds.), Echocardiography in Pediatric and Congenital Heart Disease: From Fetus to Adult
. Oxford: Wiley-Blackwell
- Abbott RD, Gutgesell HP. Effects of heteroscedasticity and skewness on prediction in regression: modeling growth of the human heart.
- Neilan TG, Pradhan AD, Weyman AE. Derivation of a size-independent variable for scaling of cardiac dimensions in a normal adult population.
- Foster BJ, Mackie AS, Mitsnefes M, Ali H, Mamber S, Colan SD. A novel method of expressing left ventricular mass relative to body size in children.
- McElhinney DB, Marshall AC, Wilkins-Haug LE, Brown DW, Benson CB, Silva V, Marx GR, Mizrahi-Arnaud A, Lock JE, Tworetzky W. Predictors of technical success and postnatal biventricular outcome after in utero aortic valvuloplasty for aortic stenosis with evolving hypoplastic left heart syndrome.
- Schneider C, McCrindle BW, Carvalho JS, Hornberger LK, McCarthy KP, Daubeney PE. Development of Z-scores for fetal cardiac dimensions from echocardiography.
