1
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Pach J, Valido K, Belzer A, Leventhal JS. The Use of Biologic Agents for the Treatment of Cutaneous Immune-Related Adverse Events from Immune Checkpoint Inhibitors: A Review of Reported Cases. Am J Clin Dermatol 2024:10.1007/s40257-024-00866-z. [PMID: 38767827 DOI: 10.1007/s40257-024-00866-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/22/2024]
Abstract
Cutaneous immune-related adverse events encompass a spectrum of dermatological manifestations, including lichenoid reactions, psoriasiform eruptions, eczematous dermatitis, immunobullous disorders, granulomatous reactions, pruritus, vitiligo, and severe cutaneous adverse reactions such as Stevens-Johnson syndrome. The conventional approach to treating high-grade or refractory cutaneous immune-related adverse events has involved high-dose systemic corticosteroids. However, their use is limited owing to the potential disruption of antitumor responses and associated complications. To address this, corticosteroid-sparing targeted immunomodulators have been explored as therapeutic alternatives. Biologic agents, commonly employed for non-cutaneous immune-related adverse events such as colitis, are increasingly recognized for their efficacy in treating various patterns of cutaneous immune-related adverse events, including psoriasiform, immunobullous, and Stevens-Johnson syndrome-like reactions. This review consolidates findings from the English-language literature, highlighting the use of biologic agents in managing diverse cutaneous immune-related adverse event patterns, also encompassing maculopapular, eczematous, and lichenoid eruptions, pruritus, and transient acantholytic dermatosis (Grover disease). Despite the established efficacy of these agents, further research is necessary to explore their long-term effects on antitumor responses.
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Affiliation(s)
- Jolanta Pach
- Yale University School of Medicine, New Haven, CT, USA
| | - Kailyn Valido
- Yale University School of Medicine, New Haven, CT, USA
| | - Annika Belzer
- Yale University School of Medicine, New Haven, CT, USA
| | - Jonathan S Leventhal
- Department of Dermatology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
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2
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Belzer A, Pach JJ, Valido K, Leventhal JS. The Impact of Dermatologic Adverse Events on the Quality of Life of Oncology Patients: A Review of the Literature. Am J Clin Dermatol 2024; 25:435-445. [PMID: 38366030 DOI: 10.1007/s40257-024-00847-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 02/18/2024]
Abstract
Dermatologic adverse events resulting from oncologic therapy are common and negatively impact patients' quality of life. Dermatologic adverse events include toxicity of the skin, oral mucosa, nails, and hair and are seen with cytotoxic chemotherapy, targeted therapy, immunotherapy, and radiation therapy, with distinct patterns of dermatologic adverse events by drug class. Here, we review the literature on the impact of dermatologic adverse events on quality of life. Studies on quality of life in patients with cancer have relied on scales such as the Dermatologic Life Quality Index and Skindex to demonstrate the association between dermatologic adverse events and declining quality of life. This relationship is likely due to a variety of factors, including physical discomfort, changes to body image, decreased self-esteem, and an effect on social interactions. Addressing such quality-of-life concerns for patients with cancer is critical, not only for patients' well-being but also because decreased satisfaction with treatment can lead to discontinuation of treatment or dose reduction. Prophylactic treatment and early management of dermatologic adverse events by experienced dermatologists can alleviate the negative effects on quality of life and allow continuation of life-prolonging treatment.
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Affiliation(s)
- Annika Belzer
- Yale University School of Medicine, New Haven, CT, USA
| | | | - Kailyn Valido
- Yale University School of Medicine, New Haven, CT, USA
| | - Jonathan S Leventhal
- Department of Dermatology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
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3
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Oyeyemi DM, Chan E, Montano M, Belzer A, Ogbuagu O, Zapata H, Tuan JJ. Acute cytomegalovirus proctitis and epididymitis acquired via sexual transmission in an immunocompetent patient: a case report. J Med Case Rep 2023; 17:489. [PMID: 37946248 PMCID: PMC10636986 DOI: 10.1186/s13256-023-04216-1] [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: 06/30/2023] [Accepted: 10/13/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND We present a case report of an immunocompetent host with presumed sexually transmitted cytomegalovirus proctitis and epididymitis, where there currently is a sparsity of published data. CASE PRESENTATION A 21-year-old previously healthy Caucasian individual was admitted for severe rectal and testicular pain in the setting of proctitis and epididymitis. Serology and rectal pathology confirmed acute primary cytomegalovirus infection. CONCLUSIONS This report details his diagnostic workup and highlights cytomegalovirus as a rare cause of sexually transmitted disease among immunocompetent persons.
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Affiliation(s)
- Deborah M Oyeyemi
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Elizabeth Chan
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Mason Montano
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Annika Belzer
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Onyema Ogbuagu
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Section of Infectious Disease, Yale University School of Medicine, 135 College St., Suite 323, New Haven, CT, 06510, USA
| | - Heidi Zapata
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Section of Infectious Disease, Yale University School of Medicine, 135 College St., Suite 323, New Haven, CT, 06510, USA
| | - Jessica J Tuan
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
- Section of Infectious Disease, Yale University School of Medicine, 135 College St., Suite 323, New Haven, CT, 06510, USA.
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4
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Belzer A, Leasure AC, Cohen JM, Perkins SH. The association of cutaneous squamous cell carcinoma and basal cell carcinoma with solid organ transplantation: a cross-sectional study of the All Of Us Research Program. Int J Dermatol 2023; 62:e564-e566. [PMID: 37144784 DOI: 10.1111/ijd.16700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/23/2023] [Accepted: 04/10/2023] [Indexed: 05/06/2023]
Affiliation(s)
| | | | - Jeffrey M Cohen
- Department of Dermatology, Yale School of Medicine, New Haven, CT, USA
| | - Sara H Perkins
- Department of Dermatology, Yale School of Medicine, New Haven, CT, USA
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5
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Belzer A, Parker ER. Climate Change, Skin Health, and Dermatologic Disease: A Guide for the Dermatologist. Am J Clin Dermatol 2023:10.1007/s40257-023-00770-y. [PMID: 37336870 DOI: 10.1007/s40257-023-00770-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 06/21/2023]
Abstract
Climate change has a pervasive impact on health and is of clinical relevance to every organ system. Climate change-related factors impact the skin's capacity to maintain homeostasis, leading to a variety of cutaneous diseases. Stratospheric ozone depletion has led to increased risk of melanoma and keratinocyte carcinomas due to ultraviolet radiation exposure. Atopic dermatitis, psoriasis, pemphigus, acne vulgaris, melasma, and photoaging are all associated with rising levels of air pollution. Elevated temperatures due to global warming induce disruption of the skin microbiome, thereby impacting atopic dermatitis, acne vulgaris, and psoriasis, and high temperatures are associated with exacerbation of skin disease and increased risk of heat stroke. Extreme weather events due to climate change, including floods and wildfires, are of relevance to the dermatologist as these events are implicated in cutaneous injuries, skin infections, and acute worsening of inflammatory skin disorders. The health consequences as well as the economic and social burden of climate change fall most heavily on vulnerable and marginalized populations due to structural disparities. As dermatologists, understanding the interaction of climate change and skin health is essential to appropriately manage dermatologic disease and advocate for our patients.
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Affiliation(s)
- Annika Belzer
- Yale University School of Medicine, New Haven, CT, USA
| | - Eva Rawlings Parker
- Department of Dermatology, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, 719 Thompson Lane, Suite 26-300, Nashville, TN, 37204, USA.
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7
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Belzer A, Pach J, Mortlock RD, Clune J, Olino K, Sznol M, Bhatia A, Burtness B, Christensen S, Leventhal JS. Evaluating the medical management of locally advanced and metastatic basal cell carcinoma: A single institutional retrospective analysis investigating efficacy, safety, and tolerability. JAAD Int 2023; 11:174-175. [PMID: 37252181 PMCID: PMC10213716 DOI: 10.1016/j.jdin.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
Affiliation(s)
- Annika Belzer
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Jolanta Pach
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Ryland D. Mortlock
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - James Clune
- Department of Plastic Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Kelly Olino
- Department of Surgical Oncology, Yale School of Medicine, New Haven, Connecticut
| | - Mario Sznol
- Department of Internal Medicine and Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - Aarti Bhatia
- Department of Internal Medicine and Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - Barbara Burtness
- Department of Internal Medicine and Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - Sean Christensen
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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8
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Belzer A, Mortlock RD, Olamiju B, Olino K, Cohen JM, Leventhal JS. The spectrum of cutaneous immune-related adverse events in patients with skin of color. J Am Acad Dermatol 2023; 88:1156-1158. [PMID: 36470309 PMCID: PMC10838520 DOI: 10.1016/j.jaad.2022.11.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/06/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Annika Belzer
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Ryland D Mortlock
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Brianna Olamiju
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Kelly Olino
- Department of Surgical Oncology, Yale School of Medicine, New Haven, Connecticut
| | - Jeffrey M Cohen
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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9
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Belzer A, Mortlock RD, Pach J, Cohen JM, Leventhal JS. The effect of baseline eczema or psoriasis on the morphology of cutaneous immune-related adverse events due to immune checkpoint inhibitor therapy. J Am Acad Dermatol 2023; 88:1198-1200. [PMID: 36634749 PMCID: PMC10121758 DOI: 10.1016/j.jaad.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/28/2022] [Accepted: 01/02/2023] [Indexed: 01/11/2023]
Affiliation(s)
- Annika Belzer
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Ryland D Mortlock
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Jolanta Pach
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Jeffrey M Cohen
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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10
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Belzer A, Swallow MA, Gowen M, Suozzi KC. Picosecond neodymium-doped yttrium-aluminum-garnet laser therapy for pigmentation due to lichen planus pigmentosus in a patient with skin of color. JAAD Case Rep 2023; 34:45-47. [PMID: 36936863 PMCID: PMC10018222 DOI: 10.1016/j.jdcr.2023.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Affiliation(s)
| | | | - Michael Gowen
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Kathleen C. Suozzi
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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11
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Belzer A, Becerra C, Clune J, Malik M, Leventhal JS, Cowper SE, Johnson RL. Histopathologic features and immunohistochemistry findings to assist the dermatopathologist in differentiating melanocytic matrical carcinoma from melanoma. J Cutan Pathol 2023; 50:471-474. [PMID: 36645720 DOI: 10.1111/cup.14376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/13/2022] [Accepted: 12/01/2022] [Indexed: 01/17/2023]
Affiliation(s)
- Annika Belzer
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Carla Becerra
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - James Clune
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mohsin Malik
- Dermatology Physicians of Connecticut, Shelton, Connecticut, USA
| | | | - Shawn E Cowper
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Rebecca L Johnson
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
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12
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Belzer A, Nguyen MO, Talsania A, Haldas J, Smith J, Leventhal JS. Spectrum of Dermatologic Adverse Events Associated With Amivantamab Use. JAMA Dermatol 2023; 159:109-111. [PMID: 36416832 PMCID: PMC9685543 DOI: 10.1001/jamadermatol.2022.4466] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 08/03/2022] [Indexed: 11/24/2022]
Abstract
This case series describes the different dermatologic adverse events that patients experienced while using amivantamab.
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Affiliation(s)
- Annika Belzer
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Michael O. Nguyen
- Department of Dermatology, University of California, Irvine School of Medicine, Irvine
| | - Ashita Talsania
- Department of Medical Oncology, Yale School of Medicine, New Haven, Connecticut
| | - Jason Haldas
- Department of Medical Oncology, Yale School of Medicine, New Haven, Connecticut
| | - Janellen Smith
- Department of Dermatology, University of California, Irvine School of Medicine, Irvine
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13
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Belzer A, Leasure AC, Damsky W, Cohen JM. The association of anxiety with granuloma annulare: a case-control study of the National Institutes of Health 'All of Us' research programme. Br J Dermatol 2022; 188:558-560. [PMID: 36715356 DOI: 10.1093/bjd/ljac114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/22/2022] [Accepted: 12/17/2022] [Indexed: 01/22/2023]
Abstract
Dear Editor, Granuloma annulare (GA) is an inflammatory skin disease that has been associated with diabetes, dyslipidaemia, hypothyroidism and autoimmune disorders.1,2 The annualized incidence and prevalence of GA in the USA are approximately 0.04% and 0.06%, respectively (with a female predominance).3 GA is clinically classified as localized (75% of cases), generalized or subcutaneous.4 There is a body of evidence supporting an association between several inflammatory dermatoses, such as psoriasis, and mental health conditions.5 Improvement of depression and anxiety following treatment of certain inflammatory dermatoses has also been described.5 It has been postulated that this association may, in part, relate to proinflammatory cytokines, which have been proposed to mechanistically connect inflammatory dermatoses and mental health conditions.6 A recent nested case-control study demonstrated a significant association of GA with depression, insomnia, opioid dependence and post-traumatic stress disorder.7 This study aims to investigate whether an association exists between GA and anxiety.
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Affiliation(s)
| | | | - William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, CT, USA.,Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Jeffrey M Cohen
- Department of Dermatology, Yale School of Medicine, New Haven, CT, USA
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Belzer A, Ramachandran V, Meehan SA, Pomeranz MK, Matatova M. A rare case of pruritic papular eruption of human immunodeficiency virus in a patient without a diagnosis of acquired immunodeficiency syndrome. JAAD Case Rep 2022; 32:23-25. [PMID: 36606203 PMCID: PMC9807780 DOI: 10.1016/j.jdcr.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Annika Belzer
- Yale School of Medicine, New Haven, Connecticut,Correspondence to: Annika Belzer, BS, 188 Willow St, Apartment No. 2, New Haven, CT 06511.
| | - Vignesh Ramachandran
- Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, New York
| | - Shane A. Meehan
- Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, New York,Department of Pathology, NYU Langone Health, New York, New York
| | - Miriam K. Pomeranz
- Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, New York
| | - Marina Matatova
- Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, New York
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15
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Belzer A, Rosenbach M, Parker ER, Barbieri JS, Nelson CA. Reducing the carbon footprint of travel to an international dermatology conference: a case study of the Medical Dermatology Society's Carbon Footprint Program. Int J Dermatol 2022. [DOI: 10.1111/ijd.16497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/14/2022] [Accepted: 10/26/2022] [Indexed: 11/15/2022]
Affiliation(s)
| | - Misha Rosenbach
- Department of Dermatology Perelman School of Medicine at the University of Pennsylvania Philadelphia PA USA
| | - Eva R. Parker
- Department of Dermatology, Center for Biomedical Ethics and Society Vanderbilt University Medical Center Nashville TN USA
| | - John S. Barbieri
- Department of Dermatology, Brigham and Women's Hospital Harvard Medical School Boston MA USA
| | - Caroline A. Nelson
- Department of Dermatology Yale University School of Medicine New Haven CT USA
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Ahearn EL, Belzer A, Cohen SR, Leventhal JS, Deverapalli SC. Psoriasiform and lichenoid eruptions as a potential harbinger of bullous dermatoses in the setting of immune checkpoint inhibitors: a case series. Int J Dermatol 2022. [PMID: 36271737 DOI: 10.1111/ijd.16464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/15/2022] [Accepted: 10/07/2022] [Indexed: 11/30/2022]
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Belzer A, Weiss E, Etaee F, Bunick CG, Damsky W, Nelson CA. Stenotrophomonas maltophilia, a Pathogen of Increasing Relevance to Dermatologists: A Case Report and Review of the Literature. Antibiotics (Basel) 2022; 11:antibiotics11101398. [PMID: 36290055 PMCID: PMC9598652 DOI: 10.3390/antibiotics11101398] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/08/2022] [Accepted: 10/09/2022] [Indexed: 12/01/2022] Open
Abstract
Stenotrophomonas maltophilia is a Gram-negative bacillus that causes skin and soft tissue infections (SSTI), as well as bacteremia, pneumonia, and urinary tract infections. S. maltophilia infections are typically nosocomial and are often transmitted through water sources. Although historically described in immunocompromised hosts, S. maltophilia prevalence is increasing in both immunocompromised and immunocompetent populations. In light of high morbidity and mortality, it is critical that dermatologists are aware of this organism because of the limited options for therapy. Here, we describe a case of a S. maltophilia abscess with bacteremia in a patient with chronic lymphocytic leukemia and aplastic anemia that was successfully treated with trimethoprim-sulfamethoxazole. We also review the current standard of care and propose an algorithm for the treatment of S. maltophilia infection.
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Affiliation(s)
| | - Emma Weiss
- Department of Dermatology, Yale School of Medicine, New Haven, CT 06510, USA
| | - Farshid Etaee
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06510, USA
| | - Christopher G. Bunick
- Department of Dermatology, Yale School of Medicine, New Haven, CT 06510, USA
- Program in Translational Biomedicine, Yale School of Medicine, New Haven, CT 06510, USA
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, CT 06510, USA
| | - Caroline A. Nelson
- Department of Dermatology, Yale School of Medicine, New Haven, CT 06510, USA
- Correspondence:
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Siegel ER, Zhuo H, Sinha P, Papolos AI, Ni SA, Vessel K, Belzer A, Minus EB, Calfee CS, Matthay MA, Wick KD. Ventilatory Ratio Is a Valuable Prognostic Indicator in an Observational Cohort of Patients With ARDS. Respir Care 2022; 67:1075-1081. [PMID: 35641002 PMCID: PMC9994339 DOI: 10.4187/respcare.09854] [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] [Indexed: 11/05/2022]
Abstract
BACKGROUND How indices specific to respiratory compromise contribute to prognostication in patients with ARDS is not well characterized in general clinical populations. The primary objective of this study was to identify variables specific to respiratory failure that might add prognostic value to indicators of systemic illness severity in an observational cohort of subjects with ARDS. METHODS Fifty subjects with ARDS were enrolled in a single-center, prospective, observational cohort. We tested the contribution of respiratory variables (oxygenation index, ventilatory ratio [VR], and the radiographic assessment of lung edema score) to logistic regression models of 28-d mortality adjusted for indicators of systemic illness severity (the Acute Physiology and Chronic Health Evaluation [APACHE] III score or severity of shock as measured by the number of vasopressors required at baseline) using likelihood ratio testing. We also compared a model utilizing APACHE III with one including baseline number of vasopressors by comparing the area under the receiver operating curve (AUROC). RESULTS VR significantly improved model performance by likelihood ratio testing when added to APACHE III (P = .036) or the number of vasopressors at baseline (P = .01). Number of vasopressors required at baseline had similar prognostic discrimination to the APACHE III. A model including the number of vasopressors and VR (AUROC 0.77 [95% CI 0.64-0.90]) was comparable to a model including APACHE III and VR (AUROC 0.81 [95% CI 0.68-0.93]; P for comparison = .58.). CONCLUSIONS In this observational cohort of subjects with ARDS, the VR significantly improved discrimination for mortality when combined with indicators of severe systemic illness. The number of vasopressors required at baseline and APACHE III had similar discrimination for mortality when combined with VR. VR is easily obtained at the bedside and offers promise for clinical prognostication.
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Affiliation(s)
- Emily R Siegel
- School of Medicine, University of California, San Francisco, San Francisco, California
| | - Hanjing Zhuo
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Pratik Sinha
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, Missouri
| | - Alexander I Papolos
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Siyuan A Ni
- Department of Pulmonology, Mills-Peninsula Medical Center, Burlingame, California
| | - Kathryn Vessel
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Annika Belzer
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Emily B Minus
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Carolyn S Calfee
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California; Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California; and Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
| | - Michael A Matthay
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California; Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California; and Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
| | - Katherine D Wick
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California.
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Belzer A, Leasure AC, Damsky W. 35151 The association of major depressive disorder and anxiety with granuloma annulare: A case-control study of the NIH All of Us database. J Am Acad Dermatol 2022. [DOI: 10.1016/j.jaad.2022.06.498] [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: 10/14/2022]
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20
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Belzer A, Bosenberg MW, Leventhal JS. 34811 Treatment of underlying monoclonal gammopathy of clinical significance (MGCS) with lenalidomide for IVIG-resistant scleromyxedema. J Am Acad Dermatol 2022. [DOI: 10.1016/j.jaad.2022.06.521] [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: 11/26/2022]
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21
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Belzer A, Ko C, Leventhal J. 003 Atypical bullous pemphigoid due to radiation therapy. J Invest Dermatol 2022. [DOI: 10.1016/j.jid.2022.05.057] [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: 11/29/2022]
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22
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Belzer A, McNiff JM, Leventhal JS. Skin eruption involving bilateral breasts following radiation therapy for invasive ductal carcinoma of the left breast. Int J Womens Dermatol 2022; 8:e016. [PMID: 35619675 PMCID: PMC9112382 DOI: 10.1097/jw9.0000000000000016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/06/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
| | - Jennifer M. McNiff
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Jonathan S. Leventhal
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
- *Corresponding author. E-mail address: (J.S. Leventhal)
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23
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Belzer A, Silber A, Mehra S, Gilani S, Leventhal JS. Mucosal haemangioma in the setting of treatment with trastuzumab emtansine (T-DM1). Br J Dermatol 2022; 187:e168. [PMID: 35633104 DOI: 10.1111/bjd.21654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Andrea Silber
- Department of Medical Oncology, Yale School of Medicine, New Haven, CT, USA
| | - Saral Mehra
- Department of Otolaryngology, Yale School of Medicine, New Haven, CT, USA
| | - Syed Gilani
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
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24
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Belzer A, Yeagle EM, Kohlenberg LK, Solberg M, Gudbranson E, Budge M, Batchelor HM, Fitzpatrick SE, Zhao A, Armengol VD, Hassan SF, Shum M, Bia M, Bia F, Desai NR, Kahn PA. Medical Student Patient Outreach to Ensure Continuity of Care During the COVID-19 Pandemic. Telemed Rep 2021; 2:56-63. [PMID: 35720754 PMCID: PMC9049823 DOI: 10.1089/tmr.2020.0030] [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] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/25/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND In response to the COVID-19 pandemic, the Yale New Haven Health System began rescheduling nonurgent outpatient appointments as virtual visits in March 2020. While Yale New Haven Health expanded its telemedicine infrastructure to accommodate this shift, many appointments were delayed and patients faced considerable uncertainty. OBJECTIVE Medical students created the Medical Student Task Force (MSTF) to help ensure continuity of care by calling patients whose appointments were delayed during this transition to telemedicine. METHODS Eighty-five student volunteers called 3765 internal medicine patients with canceled appointments, completing screening for 2197 patients. Volunteers screened for health care needs, assessed preferences for future appointments, and offered emotional support and information about COVID-19. Urgent or emergent patient concerns were triaged and escalated to providers. In this analysis, we used a mixed-methods approach: call information and provider responses were analyzed quantitatively, and patient feedback was analyzed qualitatively via thematic analysis. RESULTS Ninety-one percent of patients screened found the MSTF calls helpful. Twenty-one percent of patients reported health concerns, with 1% reporting urgent concerns escalated to and addressed by providers. Themes of patient comments included gratitude for outreach and social contact, utility of calls, and well-wishes for health care workers. CONCLUSIONS By calling patients whose appointments had been canceled during a rapid transition to telemedicine, the MSTF helped bridge a potential gap in care by offering patients communication with their care teams, information, and support. We propose that this model could be used in other care systems urgently transitioning to outpatient telemedicine, whether during ongoing outbreaks of COVID-19 or other public health emergencies.
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Affiliation(s)
- Annika Belzer
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | | | - Mariana Budge
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Sarah E. Fitzpatrick
- Yale School of Medicine, New Haven, Connecticut, USA
- Medical Scientist Training Program (MD-PhD), Yale School of Medicine, New Haven, Connecticut, USA
| | - Anna Zhao
- Yale School of Medicine, New Haven, Connecticut, USA
- Medical Scientist Training Program (MD-PhD), Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | - May Shum
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Margaret Bia
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Frank Bia
- Medical Scientist Training Program (MD-PhD), Yale School of Medicine, New Haven, Connecticut, USA
| | - Nihar R. Desai
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Peter A. Kahn
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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25
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Charruyer A, Weisenberger T, Li H, Khalifa A, Schroeder AW, Belzer A, Ghadially R. Decreased p53 is associated with a decline in asymmetric stem cell self-renewal in aged human epidermis. Aging Cell 2021; 20:e13310. [PMID: 33524216 PMCID: PMC7884041 DOI: 10.1111/acel.13310] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/26/2020] [Accepted: 12/01/2020] [Indexed: 12/17/2022] Open
Abstract
With age, the epidermis becomes hypoplastic and hypoproliferative. Hypoproliferation due to aging has been associated with decreased stem cell (SC) self‐renewal in multiple murine tissues. The fate of SC self‐renewal divisions can be asymmetric (one SC, one committed progenitor) or symmetric (two SCs). Increased asymmetric SC self‐renewal has been observed in inflammatory‐mediated hyperproliferation, while increased symmetric SC self‐renewal has been observed in cancers. We analyzed SC self‐renewal divisions in aging human epidermis to better understand the role of SCs in the hypoproliferation of aging. In human subjects, neonatal to 78 years, there was an age‐dependent decrease in epidermal basal layer divisions. The balance of SC self‐renewal shifted toward symmetric SC self‐renewal, with a decline in asymmetric SC self‐renewal. Asymmetric SC divisions maintain epidermal stratification, and this decrease may contribute to the hypoplasia of aging skin. P53 decreases in multiple tissues with age, and p53 has been shown to promote asymmetric SC self‐renewal. Fewer aged than adult ALDH+CD44+ keratinocyte SCs exhibited p53 expression and activity and Nutlin‐3 (a p53 activator) returned p53 activity as well as asymmetric SC self‐renewal divisions to adult levels. Nutlin‐3 increased Notch signaling (NICD, Hes1) and DAPT inhibition of Notch activation prevented Nutlin‐3 (p53)‐induced asymmetric SC self‐renewal divisions in aged keratinocytes. These studies indicate a role for p53 in the decreased asymmetric SC divisions with age and suggest that in aged keratinocytes, Notch is required for p53‐induced asymmetric SC divisions.
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Affiliation(s)
- Alexandra Charruyer
- Department of Dermatology UC San Francisco San Francisco California USA
- Department of Dermatology VA Medical Center San Francisco California USA
| | - Tracy Weisenberger
- Department of Dermatology UC San Francisco San Francisco California USA
- Department of Dermatology VA Medical Center San Francisco California USA
| | - Hang Li
- Department of Dermatology UC San Francisco San Francisco California USA
- Department of Dermatology VA Medical Center San Francisco California USA
| | - Ayman Khalifa
- Department of Dermatology UC San Francisco San Francisco California USA
- Department of Dermatology VA Medical Center San Francisco California USA
- Faculty of science Zagazig University Zagazig Egypt
| | | | - Annika Belzer
- Department of Dermatology UC San Francisco San Francisco California USA
- Department of Dermatology VA Medical Center San Francisco California USA
- Yale School of Medicine New Haven Connecticut USA
| | - Ruby Ghadially
- Department of Dermatology UC San Francisco San Francisco California USA
- Department of Dermatology VA Medical Center San Francisco California USA
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26
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Zachary CMB, Belzer A, Fackler NP, Shiu J, Smith J, Ghadially R. Facial psoriasis in a mask-like distribution. JAAD Case Rep 2021; 7:128-130. [PMID: 33426251 PMCID: PMC7777451 DOI: 10.1016/j.jdcr.2020.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Cameron M B Zachary
- Georgetown University School of Medicine, Washington, DC.,Department of Dermatology, University of California, Irvine, California
| | - Annika Belzer
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Nathan P Fackler
- Georgetown University School of Medicine, Washington, DC.,Department of Dermatology, University of California, Irvine, California
| | - Jessica Shiu
- Department of Dermatology, University of California, Irvine, California
| | - Janellen Smith
- Department of Dermatology, University of California, Irvine, California
| | - Ruby Ghadially
- Department of Dermatology, University of California, San Francisco, California
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27
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Belzer A, Olamiju B, Antaya RJ, Odell ID, Bia M, Perkins SH, Cohen JM. A novel medical student initiative to enhance provision of teledermatology in a resident continuity clinic during the COVID-19 pandemic: a pilot study. Int J Dermatol 2020; 60:128-129. [PMID: 33226121 PMCID: PMC7753449 DOI: 10.1111/ijd.15322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 10/23/2020] [Accepted: 11/02/2020] [Indexed: 12/01/2022]
Affiliation(s)
| | | | - Richard J Antaya
- Department of Dermatology, Yale School of Medicine, New Haven, CT, USA
| | - Ian D Odell
- Department of Dermatology, Yale School of Medicine, New Haven, CT, USA
| | - Margaret Bia
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sara H Perkins
- Department of Dermatology, Yale School of Medicine, New Haven, CT, USA
| | - Jeffrey M Cohen
- Department of Dermatology, Yale School of Medicine, New Haven, CT, USA
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28
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Anderson BJ, Calfee CS, Liu KD, Reilly JP, Kangelaris KN, Shashaty MGS, Lazaar AL, Bayliffe AI, Gallop RJ, Miano TA, Dunn TG, Johansson E, Abbott J, Jauregui A, Deiss T, Vessel K, Belzer A, Zhuo H, Matthay MA, Meyer NJ, Christie JD. Plasma sTNFR1 and IL8 for prognostic enrichment in sepsis trials: a prospective cohort study. Crit Care 2019; 23:400. [PMID: 31818332 PMCID: PMC6902425 DOI: 10.1186/s13054-019-2684-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/22/2019] [Indexed: 01/07/2023]
Abstract
Background Enrichment strategies improve therapeutic targeting and trial efficiency, but enrichment factors for sepsis trials are lacking. We determined whether concentrations of soluble tumor necrosis factor receptor-1 (sTNFR1), interleukin-8 (IL8), and angiopoietin-2 (Ang2) could identify sepsis patients at higher mortality risk and serve as prognostic enrichment factors. Methods In a multicenter prospective cohort study of 400 critically ill septic patients, we derived and validated thresholds for each marker and expressed prognostic enrichment using risk differences (RD) of 30-day mortality as predictive values. We then used decision curve analysis to simulate the prognostic enrichment of each marker and compare different prognostic enrichment strategies. Measurements and main results An admission sTNFR1 concentration > 8861 pg/ml identified patients with increased mortality in both the derivation (RD 21.6%) and validation (RD 17.8%) populations. Among immunocompetent patients, an IL8 concentration > 94 pg/ml identified patients with increased mortality in both the derivation (RD 17.7%) and validation (RD 27.0%) populations. An Ang2 level > 9761 pg/ml identified patients at 21.3% and 12.3% increased risk of mortality in the derivation and validation populations, respectively. Using sTNFR1 or IL8 to select high-risk patients improved clinical trial power and efficiency compared to selecting patients with septic shock. Ang2 did not outperform septic shock as an enrichment factor. Conclusions Thresholds for sTNFR1 and IL8 consistently identified sepsis patients with higher mortality risk and may have utility for prognostic enrichment in sepsis trials.
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Affiliation(s)
- Brian J Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA.
| | - Carolyn S Calfee
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Kathleen D Liu
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - John P Reilly
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Kirsten N Kangelaris
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Aili L Lazaar
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,GlaxoSmithKline R&D, Brentford, UK
| | | | - Robert J Gallop
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Department of Mathematics, West Chester University, West Chester, USA
| | - Todd A Miano
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Thomas G Dunn
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Erik Johansson
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Jason Abbott
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Alejandra Jauregui
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Thomas Deiss
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Kathryn Vessel
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Annika Belzer
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Hanjing Zhuo
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Michael A Matthay
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Nuala J Meyer
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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29
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Papolos AI, Schiller NB, Belzer A, Zhuo H, Gotts JE, Bibby D, Calfee CS, Matthay MA. Pulmonary Dead Space Monitoring: Identifying Subjects With ARDS at Risk of Developing Right Ventricular Dysfunction. Respir Care 2019; 64:1101-1108. [PMID: 31138736 DOI: 10.4187/respcare.06544] [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: 12/17/2022]
Abstract
BACKGROUND ARDS is a highly morbid condition characterized by diffuse pulmonary inflammation, which results in hypoxemic respiratory failure. Approximately 25% of patients with ARDS develop right ventricular dysfunction, with cor pulmonale being a common final pathway in a significant number of non-survivors. ARDS-related right ventricular dysfunction occurs due to acute elevation in ventricular afterload caused by mechanisms that are associated with increased pulmonary dead space fraction. Thus, we hypothesized that changes in pulmonary dead space fraction may reflect changes in pulmonary hemodynamics. METHODS This was a prospective single-center study of 21 subjects with ARDS who underwent serial determination of pulmonary dead space fraction and pulmonary hemodynamics via transthoracic echocardiography. Linear mixed-effects modeling was performed to test for an association between a change in pulmonary dead space and a change in pulmonary hemodynamics. RESULTS The tricuspid regurgitation velocity to right ventricular outflow track velocity time integral ratio, an echocardiographic surrogate for pulmonary vascular resistance, increased by 0.16 Wood units (Coefficient 0.16, 95% CI 0.09-0.23; P < .001), and the tricuspid regurgitation pressure gradient increased by 3.7 mm Hg (Coefficient 3.7, 95% CI 1.74-5.63, P < .001) for every 10% increase in pulmonary dead space fraction. CONCLUSIONS Increases in the pulmonary dead space fraction were associated with relative increases in both the tricuspid regurgitation velocity to right ventricular outflow track velocity time integral ratio and the tricuspid regurgitation pressure gradient, which likely contributed to the high incidence of ARDS-related right ventricular dysfunction encountered in clinical practice. Pulmonary dead space monitoring may serve as a clinical indicator to identify patients with ARDS at risk of developing right ventricular dysfunction and acute cor pulmonale.
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Affiliation(s)
- Alexander I Papolos
- University of California San Francisco Medical Center at Parnassus, Department of Medicine.
| | - Nelson B Schiller
- University of California San Francisco Medical Center at Parnassus, Department of Medicine
| | | | - Hanjing Zhuo
- University of California San Francisco Medical Center at Parnassus, Department of Medicine
| | - Jeffery E Gotts
- University of California San Francisco Medical Center at Parnassus, Department of Medicine
| | - Dwight Bibby
- University of California San Francisco Medical Center at Parnassus, Department of Medicine
| | - Carolyn S Calfee
- University of California San Francisco Medical Center at Parnassus, Department of Medicine
| | - Michael A Matthay
- University of California San Francisco Medical Center at Parnassus, Department of Medicine
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30
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Kalantar KL, Moazed F, Christenson SC, Wilson J, Deiss T, Belzer A, Vessel K, Caldera S, Jauregui A, Bolourchi S, DeRisi JL, Calfee CS, Langelier C. Metagenomic comparison of tracheal aspirate and mini-bronchial alveolar lavage for assessment of respiratory microbiota. Am J Physiol Lung Cell Mol Physiol 2019; 316:L578-L584. [PMID: 30652494 DOI: 10.1152/ajplung.00476.2018] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Accurate and informative microbiological testing is essential for guiding diagnosis and management of pneumonia in patients who are critically ill. Sampling of tracheal aspirate (TA) is less invasive compared with mini-bronchoalveolar lavage (mBAL) and is now recommended as a frontline diagnostic approach in patients who are mechanically ventilated, despite the historical belief that TA was suboptimal due to contamination from oral microbes. Advancements in metagenomic next-generation sequencing (mNGS) now permit assessment of airway microbiota without a need for culture and, as such, provide an opportunity to examine differences between mBAL and TA at a resolution previously unachievable. Here, we engaged shotgun mNGS to assess quantitatively the airway microbiome in matched mBAL and TA specimens from a prospective cohort of critically ill adults. We observed moderate differences between sample types across all subjects; however, we found significant compositional similarity in subjects with bacterial pneumonia, whose microbial communities were characterized by dominant pathogens. In contrast, in patients with noninfectious acute respiratory illnesses, significant differences were observed between sample types. Our findings suggest that TA sampling provides a similar assessment of airway microbiota as more invasive testing by mBAL in patients with pneumonia.
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Affiliation(s)
- Katrina L Kalantar
- Department of Biochemistry and Biophysics, University of California , San Francisco, California
| | - Farzad Moazed
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of California , San Francisco, California
| | - Stephanie C Christenson
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of California , San Francisco, California
| | - Jenny Wilson
- Department of Emergency Medicine, Stanford University , Stanford, California
| | - Thomas Deiss
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of California , San Francisco, California
| | - Annika Belzer
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of California , San Francisco, California
| | - Kathryn Vessel
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of California , San Francisco, California
| | - Saharai Caldera
- Chan Zuckerberg Biohub, San Francisco, California.,Division of Infectious Diseases, Department of Medicine, University of California , San Francisco, California
| | - Alejandra Jauregui
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of California , San Francisco, California
| | - Samaneh Bolourchi
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of California , San Francisco, California
| | - Joseph L DeRisi
- Department of Biochemistry and Biophysics, University of California , San Francisco, California.,Chan Zuckerberg Biohub, San Francisco, California
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of California , San Francisco, California
| | - Charles Langelier
- Division of Infectious Diseases, Department of Medicine, University of California , San Francisco, California
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