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Hu Y, Geere M, Awan M, Leavitt AD, Brown LE, Pearson HJ, Gandelman JS, Kogan SC. Dapsone-induced methemoglobinemia and hemolysis in a woman without G6PD deficiency presenting with idiopathic urticaria. Hematology 2022; 27:1253-1258. [PMID: 36444994 PMCID: PMC9788447 DOI: 10.1080/16078454.2022.2149943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/23/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The appearance of bite cells associated with methemoglobinemia can be caused by oxidizing drugs such as dapsone in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency or high drug serum levels. Bite cells are often pathognomonic for oxidant injury in patients with G6PD deficiency and suggest active hemolysis. CASE PRESENTATION We report a case of a woman with no prior history of G6PD deficiency who presented with anemia, methemoglobinemia and bite cells on peripheral blood smear after dapsone therapy for new onset idiopathic urticaria. Laboratory tests for G6PD, blood count and liver function were within normal limits prior to initiation of therapy. During the patient's hospital course, moderate methemoglobinemia and anemia were identified despite mildly increased serum G6PD level. These pathologies were reversed upon stopping dapsone therapy. CONCLUSION This case highlights the potential for therapeutic levels of dapsone to induce side effects in patients without G6PD deficiency and highlights the importance of routine blood monitoring for anemia and hemolysis during the course of drug therapy.
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Affiliation(s)
- Yang Hu
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
- Medical Scientist Training Program, University of Wisconsin School of Medicine and Public Health, Madison, WI. USA
| | - Mimansa Geere
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Maham Awan
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Andrew D. Leavitt
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Laura E. Brown
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Hadley J. Pearson
- Department of Dermatology, University of California San Francisco, San Francisco, CA, USA
| | - Jocelyn S. Gandelman
- Department of Dermatology, University of California San Francisco, San Francisco, CA, USA
| | - Scott C. Kogan
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
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2
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Gandelman JS, Kim EY, Grzegorczyk AM, Zejnullahu K, Edson RS. Mycoplasma pneumoniae-Induced Rash and Mucositis in a Previously Healthy Man: A Case Report and Brief Review of the Literature. Open Forum Infect Dis 2020; 7:ofaa437. [PMID: 33094121 PMCID: PMC7568429 DOI: 10.1093/ofid/ofaa437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/11/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
We describe a case of a 33-year-old-male with Mycoplasma pneumoniae-induced rash and mucositis and review the literature on this newly described syndrome.
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Affiliation(s)
- Jocelyn S Gandelman
- Department of Internal Medicine, California Pacific Medical Center, San Francisco, California, USA
| | - Elizabeth Y Kim
- Department of Internal Medicine, California Pacific Medical Center, San Francisco, California, USA
| | - Anne M Grzegorczyk
- Department of Internal Medicine, California Pacific Medical Center, San Francisco, California, USA
- Division of Hospital Medicine, California Pacific Medical Center, San Francisco, California, USA
| | - Kreshnik Zejnullahu
- Department of Internal Medicine, California Pacific Medical Center, San Francisco, California, USA
- Division of Hospital Medicine, California Pacific Medical Center, San Francisco, California, USA
| | - Randall S Edson
- Department of Internal Medicine, California Pacific Medical Center, San Francisco, California, USA
- Division of Infectious Diseases, California Pacific Medical Center, San Francisco, California, USA
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3
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Gandelman JS, Khan OA, Shuey MM, Neal JE, McNeer E, Dickson A, Barnado A, Wang L, Anandi P, Dupont WD, Stein CM, Chung CP. Increased Incidence of Resistant Hypertension in Patients With Systemic Lupus Erythematosus: A Retrospective Cohort Study. Arthritis Care Res (Hoboken) 2020; 72:534-543. [PMID: 30875459 DOI: 10.1002/acr.23880] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 03/05/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To compare the risk of resistant hypertension (RHTN) in patients with systemic lupus erythematosus (SLE) and in controls without SLE, and to define factors associated with RHTN in patients with SLE. METHODS We studied 1,044 patients with SLE and 5,241 control subjects using de-identified electronic health records from a tertiary care center. SLE was defined as ≥4 International Classification of Diseases, Ninth Revision codes for SLE and antinuclear antibody titer ≥1:160. RHTN was defined as uncontrolled blood pressure on 3 antihypertensive medications or requiring 4 or more antihypertensives to attain control. First, we compared the risk of RHTN between groups. Second, we examined the association between RHTN and all-cause mortality in patients with SLE. RESULTS RHTN was nearly twice as prevalent in patients with SLE compared to control subjects (10.2% and 5.3%, respectively), with an incidence rate of 10.2 versus 6.1 cases per 1,000 person-years of observation (hazard ratio [HR] 1.72 [95% confidence interval 1.28-2.30]; P < 0.001, adjusted for age, sex, race, baseline end-stage renal disease [ESRD], creatinine, and calendar year). In patients with SLE, we found associations between RHTN and black race, lower renal function, hypercholesterolemia, and increased inflammatory markers. RHTN was associated with a significantly higher mortality risk (HR 2.91, P = 0.0005) after adjustment for age, sex, race, calendar year, creatinine, baseline ESRD, and number of visits. CONCLUSION Patients with SLE have a higher risk of RHTN compared to frequency-matched controls, independent of multiple covariates. RHTN is an important comorbidity for clinicians to recognize in SLE, because it is associated with a higher risk of mortality.
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Affiliation(s)
| | - Omair A Khan
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | - Alyson Dickson
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - April Barnado
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Li Wang
- Vanderbilt University Medical Center, Nashville, Tennessee
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4
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Chen F, Dellalana LE, Gandelman JS, Vain A, Jagasia MH, Tkaczyk ER. Correction: Non-invasive measurement of sclerosis in cutaneous cGVHD patients with the handheld device Myoton: a cross-sectional study. Bone Marrow Transplant 2020; 55:992. [DOI: 10.1038/s41409-020-0780-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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5
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Reese T, Dickson AL, Shuey MM, Gandelman JS, Barnado A, Barker KA, Neal JE, Khan OA, Dupont WD, Stein CM, Chung CP. Increased blood pressure visit-to-visit variability in patients with systemic lupus erythematosus: association with inflammation and comorbidity burden. Lupus 2019; 28:954-960. [PMID: 31221051 DOI: 10.1177/0961203319856988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Blood pressure visit-to-visit variability is a novel risk factor for deleterious long-term cardiac and renal outcomes in the general population. We hypothesized that patients with systemic lupus erythematosus (SLE) have greater blood pressure visit-to-visit variability than control subjects and that blood pressure visit-to-visit variability is associated with a higher comorbidity burden. METHODS We studied 899 patients with SLE and 4172 matched controls using de-identified electronic health records from an academic medical center. We compared blood pressure visit-to-visit variability measures in patients with SLE and control subjects and examined the association between blood pressure visit-to-visit variability and patients' characteristics. RESULTS Patients with SLE had higher systolic blood pressure visit-to-visit variability 9.7% (7.8-11.8%) than the control group 9.2% (7.4-11.2%), P < 0.001 by coefficient of variation. Additional measures of systolic blood pressure visit-to-visit variability (i.e. standard deviation, average real variation, successive variation and maximum measure-to-measure change) were also significantly higher in patients with SLE than in control subjects. In patients with SLE, blood pressure visit-to-visit variability correlated significantly with age, creatinine, CRP, triglyceride concentrations and the Charlson comorbidity score (all P < 0.05). Hydroxychloroquine use was associated with reduced blood pressure visit-to-visit variability (P < 0.001), whereas the use of antihypertensives, cyclophosphamide, mycophenolate mofetil and corticosteroids was associated with increased blood pressure visit-to-visit variability (P < 0.05). CONCLUSION Patients with SLE had higher blood pressure visit-to-visit variability than controls, and this increased blood pressure visit-to-visit variability was associated with greater Charlson comorbidity scores, several clinical characteristics and immunosuppressant medications. In particular, hydroxychloroquine prescription was associated with lower blood pressure visit-to-visit variability.
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Affiliation(s)
- T Reese
- 1 Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - A L Dickson
- 1 Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - M M Shuey
- 1 Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J S Gandelman
- 2 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - A Barnado
- 1 Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - K A Barker
- 1 Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J E Neal
- 3 Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - O A Khan
- 3 Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - W D Dupont
- 3 Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C M Stein
- 1 Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,4 Department of Pharmacology, Vanderbilt University, Nashville, TN, USA
| | - C P Chung
- 1 Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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6
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Gandelman JS, Song DJ, Chen H, Engelhardt BG, Chen YB, Clark WB, Giver CR, Waller EK, Jung DK, Jagasia M. A Prospective Trial of Extracorporeal Photopheresis for Chronic Graft-versus-Host Disease Reveals Significant Disease Response and No Association with Frequency of Regulatory T Cells. Biol Blood Marrow Transplant 2018; 24:2373-2380. [DOI: 10.1016/j.bbmt.2018.06.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 06/28/2018] [Indexed: 12/18/2022]
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7
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Dellalana LE, Chen F, Vain A, Gandelman JS, Põldemaa M, Chen H, Tkaczyk ER. Reproducibility of the durometer and myoton devices for skin stiffness measurement in healthy subjects. Skin Res Technol 2018; 25:289-293. [PMID: 30414198 DOI: 10.1111/srt.12646] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/29/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clinical assessment of skin stiffness is unreliable in many applications. The durometer, an industrial device to measure hardness, has previously been applied in scleroderma. The Myoton is a noninvasive handheld device for assessing soft tissue biomechanical parameters. MATERIALS AND METHODS We evaluated the reproducibility of both devices in six healthy subjects in the volar forearm, dorsal forearm, upper arm, shin, and calf bilaterally. The intraclass correlation coefficient (ICC) was used as a measure of reproducibility among three observers. RESULTS The interobserver intraclass correlation coefficient (ICC) of overall stiffness for the Myoton was 0.74 [95% confidence interval (CI) 0.45-1.00] and 0.71 [0.39-1.00] for the durometer. Coefficient of variation (CV) for the Myoton was 6.4% [range 1.3-12.1] and 7.6% [range 4.4-13.8] for the durometer. Myoton and durometer values had a Pearson correlation of 0.69. The intraobserver Myoton ICC was 0.89 [0.74-1.00] and CV 3.1% [range 1.6-5.0]. The 95% confidence minimal detectable change by the Myoton for a single observer is 32.4 N/m, which is 7.6% of the average subject's overall stiffness. CONCLUSION The Myoton demonstrated high reproducibility, particularly in the overall stiffness parameter, and merits further investigation to assess disease progression and treatment efficacy.
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Affiliation(s)
- Laura E Dellalana
- Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee.,Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Fuyao Chen
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Arved Vain
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee.,University of Tartu Institute of Physics, Tartu, Estonia
| | | | | | - Heidi Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eric R Tkaczyk
- Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee.,Vanderbilt University School of Medicine, Nashville, Tennessee.,Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
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8
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Steinl GK, Gandelman JS, Katzman PJ, Ru Y, Guillet R, Pressman E, Cooper EM, O'Brien KO. Umbilical Cord Coiling in High-risk Pregnancies: Associations With Determinants of Adverse Birth Outcomes and Iron Status. Pediatr Dev Pathol 2018; 21:537-547. [PMID: 29652240 DOI: 10.1177/1093526618770318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Abnormal umbilical cord coiling has been associated with adverse neonatal outcomes, but the etiology of these findings remains poorly characterized. This study was undertaken to examine associations between cord coiling and maternal iron (Fe) status and to identify potential determinants of hypo- and hypercoiling in 2 higher risk obstetric groups: pregnant adolescents (≤18 years, n = 92) and adult women carrying twins (n = 49), triplets (n = 11), or quadruplets (n = 1). Umbilical cords were classified as hypo-, normo-, or hypercoiled using digital photographs to assess gross appearance. Hypocoiling and hypercoiling were observed in 44% (n = 86/195) and 13% (n = 26/195) of the combined study population. The prevalence of hypocoiling among women carrying multiples was over 3-fold higher than the prevalence in singleton pregnancies based on the published data. Within the entire study population, hypocoiling was associated with a lower gestational age at birth when compared to normocoiling and hypercoiling (36.3 ± 3.6 weeks [n = 86] vs 37.8 ± 2.7 [n = 83], P < .01, and 38.2 ± 2.6 [n = 26], P < .01, respectively), whereas hypercoiling was associated with significantly lower serum ferritin when compared to normocoiling ( P < .01) and hypocoiling ( P < .001). In the multiples cohort only, hypercoiling was significantly associated with multiparity ( P < .01) and lower birth weight ( P < .05). Further studies are needed to identify the determinants and consequences of cord coiling.
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Affiliation(s)
- Gabrielle K Steinl
- 1 Division of Nutritional Sciences, Cornell University, Ithaca, New York
| | | | - Philip J Katzman
- 2 School of Medicine, University of Rochester, Rochester, New York
| | - Yuan Ru
- 1 Division of Nutritional Sciences, Cornell University, Ithaca, New York
| | - Ronnie Guillet
- 2 School of Medicine, University of Rochester, Rochester, New York
| | - Eva Pressman
- 2 School of Medicine, University of Rochester, Rochester, New York
| | | | - Kimberly O O'Brien
- 1 Division of Nutritional Sciences, Cornell University, Ithaca, New York
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9
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Doxie DB, Greenplate AR, Gandelman JS, Diggins KE, Roe CE, Dahlman KB, Sosman JA, Kelley MC, Irish JM. BRAF and MEK inhibitor therapy eliminates Nestin-expressing melanoma cells in human tumors. Pigment Cell Melanoma Res 2018; 31:708-719. [PMID: 29778085 PMCID: PMC6188784 DOI: 10.1111/pcmr.12712] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 04/18/2018] [Accepted: 05/14/2018] [Indexed: 02/06/2023]
Abstract
Little is known about the in vivo impacts of targeted therapy on melanoma cell abundance and protein expression. Here, 21 antibodies were added to an established melanoma mass cytometry panel to measure 32 cellular features, distinguish malignant cells, and characterize dabrafenib and trametinib responses in BRAFV600mut melanoma. Tumor cells were biopsied before neoadjuvant therapy and compared to cells surgically resected from the same site after 4 weeks of therapy. Approximately 50,000 cells per tumor were characterized by mass cytometry and computational tools t-SNE/viSNE, FlowSOM, and MEM. The resulting single-cell view of melanoma treatment response revealed initially heterogeneous melanoma tumors were consistently cleared of Nestin-expressing melanoma cells. Melanoma cell subsets that persisted to week 4 were heterogeneous but expressed SOX2 or SOX10 proteins and specifically lacked surface expression of MHC I proteins by MEM analysis. Traditional histology imaging of tissue microarrays from the same tumors confirmed mass cytometry results, including persistence of NES- SOX10+ S100β+ melanoma cells. This quantitative single-cell view of melanoma treatment response revealed protein features of malignant cells that are not eliminated by targeted therapy.
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Affiliation(s)
- Deon B. Doxie
- Department of Cell and Developmental Biology, Vanderbilt University, School of Medicine, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Allison R. Greenplate
- Department of Cell and Developmental Biology, Vanderbilt University, School of Medicine, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jocelyn S. Gandelman
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kirsten E. Diggins
- Department of Cell and Developmental Biology, Vanderbilt University, School of Medicine, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Caroline E. Roe
- Department of Cell and Developmental Biology, Vanderbilt University, School of Medicine, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kimberly B. Dahlman
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey A. Sosman
- Department of Medicine, Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mark C. Kelley
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Hematology-Oncology, Northwestern University, Feinberg School of Medicine, Evanston, IL, USA
| | - Jonathan M. Irish
- Department of Cell and Developmental Biology, Vanderbilt University, School of Medicine, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
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10
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Chen F, Dellalana LE, Gandelman JS, Vain A, Jagasia MH, Tkaczyk ER. Non-invasive measurement of sclerosis in cutaneous cGVHD patients with the handheld device Myoton: a cross-sectional study. Bone Marrow Transplant 2018; 54:616-619. [PMID: 30287938 DOI: 10.1038/s41409-018-0346-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/23/2018] [Accepted: 09/05/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Fuyao Chen
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
| | - Laura E Dellalana
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jocelyn S Gandelman
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arved Vain
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA.,Institute of Physics, University of Tartu, Tartu, Estonia
| | - Madan H Jagasia
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric R Tkaczyk
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA. .,Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA. .,Dermatology Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA.
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11
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Gandelman JS, Byrne MT, Mistry AM, Polikowsky HG, Diggins KE, Chen H, Lee SJ, Arora M, Cutler C, Flowers M, Pidala J, Irish JM, Jagasia MH. Machine learning reveals chronic graft- versus-host disease phenotypes and stratifies survival after stem cell transplant for hematologic malignancies. Haematologica 2018; 104:189-196. [PMID: 30237265 PMCID: PMC6312024 DOI: 10.3324/haematol.2018.193441] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 08/17/2018] [Indexed: 12/13/2022] Open
Abstract
The application of machine learning in medicine has been productive in multiple fields, but has not previously been applied to analyze the complexity of organ involvement by chronic graft-versus-host disease. Chronic graft-versus-host disease is classified by an overall composite score as mild, moderate or severe, which may overlook clinically relevant patterns in organ involvement. Here we applied a novel computational approach to chronic graft-versus-host disease with the goal of identifying phenotypic groups based on the subcomponents of the National Institutes of Health Consensus Criteria. Computational analysis revealed seven distinct groups of patients with contrasting clinical risks. The high-risk group had an inferior overall survival compared to the low-risk group (hazard ratio 2.24; 95% confidence interval: 1.36-3.68), an effect that was independent of graft-versus-host disease severity as measured by the National Institutes of Health criteria. To test clinical applicability, knowledge was translated into a simplified clinical prognostic decision tree. Groups identified by the decision tree also stratified outcomes and closely matched those from the original analysis. Patients in the high- and intermediate-risk decision-tree groups had significantly shorter overall survival than those in the low-risk group (hazard ratio 2.79; 95% confidence interval: 1.58-4.91 and hazard ratio 1.78; 95% confidence interval: 1.06-3.01, respectively). Machine learning and other computational analyses may better reveal biomarkers and stratify risk than the current approach based on cumulative severity. This approach could now be explored in other disease models with complex clinical phenotypes. External validation must be completed prior to clinical application. Ultimately, this approach has the potential to reveal distinct pathophysiological mechanisms that may underlie clusters. Clinicaltrials.gov identifier: NCT00637689.
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Affiliation(s)
- Jocelyn S Gandelman
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, TN.,Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN.,Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Michael T Byrne
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Akshitkumar M Mistry
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Hannah G Polikowsky
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Kirsten E Diggins
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN.,Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Corey Cutler
- Stem Cell/Bone Marrow Transplantation Program, Dana-Farber Cancer Institute, Boston, MA
| | - Mary Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Joseph Pidala
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jonathan M Irish
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN .,Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Madan H Jagasia
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, TN .,Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
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12
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Gandelman JS, Zic J, Dewan AK, Lee SJ, Flowers M, Cutler C, Pidala J, Chen H, Jagasia MH, Tkaczyk ER. The Anatomic Distribution of Skin Involvement in Patients with Incident Chronic Graft-versus-Host Disease. Biol Blood Marrow Transplant 2018; 25:279-286. [PMID: 30219700 DOI: 10.1016/j.bbmt.2018.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/06/2018] [Indexed: 01/15/2023]
Abstract
Little is known about the anatomic distribution of cutaneous chronic graft-versus-host disease (cGVHD). Using data from the cGVHD Consortium Improving Outcomes Assessment Study, we describe the frequency and extent of erythema and superficial and deep sclerosis in 8 anatomic sites in patients with incident disease (ie, new cGVHD diagnosis within 3 months of study entry) receiving systemic therapy. Of 339 patients with incident disease, 182 (54%) had skin involvement. When an extremity was involved, the same type of disease was present contralaterally in 92% of cases, revealing a high level of symmetry. As anticipated, erythema was the most common incident feature; however, sclerotic skin involvement at the time of cGVHD diagnosis was more common than has been suggested by previous studies. Erythema occurred in 155 (85%) and sclerosis in 53 (29%) of the patients with skin involvement (46% and 16%, respectively, of the entire cohort of 339 incident cGVHD cases). Erythema was least common on the lower extremities (n = 71; 39% of patients with skin involvement). Moveable sclerosis was rare on the head, neck, and scalp (n = 4; 2%). Deep sclerosis did not occur in this region, and instead was most likely to occur on the upper extremities (n = 14; 8%) and lower extremities (n = 14; 8%). More than one-half of patients with erythema (n = 107; 58.7%) had diffuse involvement (4 or more of 8 sites involved), compared with less than one-third of those with sclerosis (n = 16; 30.2%).
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Affiliation(s)
- Jocelyn S Gandelman
- Department of Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee; Vanderbilt University School of Medicine, Nashville, Tennessee
| | - John Zic
- Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anna K Dewan
- Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mary Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Corey Cutler
- Stem Cell/Bone Marrow Transplantation Program, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joseph Pidala
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madan H Jagasia
- Vanderbilt University School of Medicine, Nashville, Tennessee; Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eric R Tkaczyk
- Department of Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee; Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee.
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13
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Shuey MM, Gandelman JS, Chung CP, Nian H, Yu C, Denny JC, Brown NJ. Characteristics and treatment of African-American and European-American patients with resistant hypertension identified using the electronic health record in an academic health centre: a case-control study. BMJ Open 2018; 8:e021640. [PMID: 29950471 PMCID: PMC6020960 DOI: 10.1136/bmjopen-2018-021640] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To identify patients with hypertension with resistant and controlled blood pressure (BP) using electronic health records (EHRs) in order to elucidate practices in the real-world clinical treatment of hypertension and to enable future genetic studies. DESIGN Using EHRs, we developed and validated algorithms to identify patients with resistant and controlled hypertension. SETTING An academic medical centre in Nashville, Tennessee. POPULATION European-American (EA) and African-American (AA) patients with hypertension. MAIN OUTCOME MEASURES Demographic characteristics: race, age, gender, body mass index, outpatient BPs and the history of diabetes mellitus, chronic kidney disease stage 3, ischaemic heart disease, transient ischaemic attack, atrial fibrillation and sleep apnoea. MEDICATION TREATMENT All antihypertensive medication classes prescribed to a patient at the time of classification and ever prescribed following classification. RESULTS The algorithms had performance metrics exceeding 92%. The prevalence of resistant hypertension in the total hypertensive population was 7.3% in EA and 10.5% in AA. At diagnosis, AA were younger, heavier, more often female and had a higher incidence of type 2 diabetes and higher BPs than EA. AA with resistant hypertension were more likely to be treated with vasodilators, dihydropyridine calcium channel blockers and alpha-2 agonists while EA were more likely to be treated with angiotensin receptor blockers, renin inhibitors and beta blockers. Mineralocorticoid receptor antagonists use was increased in patients treated with more than four antihypertensive medications compared with patients treated with three (12.4% vs 2.6% in EA, p<0.001; 12.3% vs 2.8% in AA, p<0.001). The number of patients treated with a mineralocorticoid receptor antagonist increased to 37.4% in EA and 41.2% in AA over a mean follow-up period of 7.4 and 8.7 years, respectively. CONCLUSIONS Clinical treatment of resistant hypertension differs in EA and AA patients. These results demonstrate the feasibility of identifying resistant hypertension using an EHR.
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Affiliation(s)
- Megan M Shuey
- Department of Pharmacology, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jocelyn S Gandelman
- Department of Medicine, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Cecilia P Chung
- Department of Medicine, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Hui Nian
- Department of Biostatistics, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Joshua C Denny
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Nancy J Brown
- Department of Pharmacology, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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14
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Chen F, Saknite I, Gandelman JS, Vain A, Vaughan LA, Clifton C, Logue M, Byrne MT, Kassim AA, Savani BN, Jagasia M, Tkaczyk E. Sclerotic Chronic Graft-Versus-Host Disease Severity Can be Assessed via Biomechanical Properties of Skin. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Gandelman JS, Byrne MT, Mistry AM, Polikowsky H, Diggins KE, Chen H, Lee SJ, Arora M, Cutler C, Flowers ME, Irish JM, Jagasia M. Machine Learning Reveals Patient Phenotypes and Stratifies Outcomes in Chronic Graft-Versus Host Disease. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Song DJ, Gandelman JS, Chen YB, Clark WB, Engelhardt BG, Giver CR, Waller EK, Jagasia M. High Completion Rate of ECP Treatment in Patients with Chronic Graft-Versus-Host Disease Despite Unique Barriers: Lessons Learned From a Prospective Multicenter Trial. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Diggins KE, Gandelman JS, Roe CE, Irish JM. Generating Quantitative Cell Identity Labels with Marker Enrichment Modeling (MEM). Curr Protoc Cytom 2018; 83:10.21.1-10.21.28. [PMID: 29345329 PMCID: PMC5774653 DOI: 10.1002/cpcy.34] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Multiplexed single-cell experimental techniques like mass cytometry measure 40 or more features and enable deep characterization of well-known and novel cell populations. However, traditional data analysis techniques rely extensively on human experts or prior knowledge, and novel machine learning algorithms may generate unexpected population groupings. Marker enrichment modeling (MEM) creates quantitative identity labels based on features enriched in a population relative to a reference. While developed for cell type analysis, MEM labels can be generated for a wide range of multidimensional data types, and MEM works effectively with output from expert analysis and diverse machine learning algorithms. MEM is implemented as an R package and includes three steps: (1) calculation of MEM values that quantify each feature's relative enrichment in the population, (2) reporting of MEM labels as a heatmap or as a text label, and (3) quantification of MEM label similarity between populations. The protocols here show MEM analysis using datasets from immunology and oncology. These MEM implementations provide a way to characterize population identity and novelty in the context of computational and expert analyses. © 2018 by John Wiley & Sons, Inc.
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Affiliation(s)
- Kirsten E. Diggins
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jocelyn S. Gandelman
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Caroline E. Roe
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan M. Irish
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
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