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Scott MKD, Quinn K, Li Q, Carroll R, Warsinske H, Vallania F, Chen S, Carns MA, Aren K, Sun J, Koloms K, Lee J, Baral J, Kropski J, Zhao H, Herzog E, Martinez FJ, Moore BB, Hinchcliff M, Denny J, Kaminski N, Herazo-Maya JD, Shah NH, Khatri P. Increased monocyte count as a cellular biomarker for poor outcomes in fibrotic diseases: a retrospective, multicentre cohort study. Lancet Respir Med 2019; 7:497-508. [PMID: 30935881 PMCID: PMC6529612 DOI: 10.1016/s2213-2600(18)30508-3] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 11/14/2018] [Accepted: 11/27/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND There is an urgent need for biomarkers to better stratify patients with idiopathic pulmonary fibrosis by risk for lung transplantation allocation who have the same clinical presentation. We aimed to investigate whether a specific immune cell type from patients with idiopathic pulmonary fibrosis could identify those at higher risk of poor outcomes. We then sought to validate our findings using cytometry and electronic health records. METHODS We first did a discovery analysis with transcriptome data from the Gene Expression Omnibus at the National Center for Biotechnology Information for 120 peripheral blood mononuclear cell (PBMC) samples of patients with idiopathic pulmonary fibrosis. We estimated percentages of 13 immune cell types using statistical deconvolution, and investigated the association of these cell types with transplant-free survival. We validated these results using PBMC samples from patients with idiopathic pulmonary fibrosis in two independent cohorts (COMET and Yale). COMET profiled monocyte counts in 45 patients with idiopathic pulmonary fibrosis from March 12, 2010, to March 10, 2011, using flow cytometry; we tested if increased monocyte count was associated with the primary outcome of disease progression. In the Yale cohort, 15 patients with idiopathic pulmonary fibrosis (with five healthy controls) were classed as high risk or low risk from April 28, 2014, to Aug 20, 2015, using a 52-gene signature, and we assessed whether monocyte percentage (measured by cytometry by time of flight) was higher in high-risk patients. We then examined complete blood count values in the electronic health records (EHR) of 45 068 patients with idiopathic pulmonary fibrosis, systemic sclerosis, hypertrophic cardiomyopathy, or myelofibrosis from Stanford (Jan 01, 2008, to Dec 31, 2015), Northwestern (Feb 15, 2001 to July 31, 2017), Vanderbilt (Jan 01, 2008, to Dec 31, 2016), and Optum Clinformatics DataMart (Jan 01, 2004, to Dec 31, 2016) cohorts, and examined whether absolute monocyte counts of 0·95 K/μL or greater were associated with all-cause mortality in these patients. FINDINGS In the discovery analysis, estimated CD14+ classical monocyte percentages above the mean were associated with shorter transplant-free survival times (hazard ratio [HR] 1·82, 95% CI 1·05-3·14), whereas higher percentages of T cells and B cells were not (0·97, 0·59-1·66; and 0·78, 0·45-1·34 respectively). In two validation cohorts (COMET trial and the Yale cohort), patients with higher monocyte counts were at higher risk for poor outcomes (COMET Wilcoxon p=0·025; Yale Wilcoxon p=0·049). Monocyte counts of 0·95 K/μL or greater were associated with mortality after adjusting for forced vital capacity (HR 2·47, 95% CI 1·48-4·15; p=0·0063), and the gender, age, and physiology index (HR 2·06, 95% CI 1·22-3·47; p=0·0068) across the COMET, Stanford, and Northwestern datasets). Analysis of medical records of 7459 patients with idiopathic pulmonary fibrosis showed that patients with monocyte counts of 0·95 K/μL or greater were at increased risk of mortality with lung transplantation as a censoring event, after adjusting for age at diagnosis and sex (Stanford HR=2·30, 95% CI 0·94-5·63; Vanderbilt 1·52, 1·21-1·89; Optum 1·74, 1·33-2·27). Likewise, higher absolute monocyte count was associated with shortened survival in patients with hypertrophic cardiomyopathy across all three cohorts, and in patients with systemic sclerosis or myelofibrosis in two of the three cohorts. INTERPRETATION Monocyte count could be incorporated into the clinical assessment of patients with idiopathic pulmonary fibrosis and other fibrotic disorders. Further investigation into the mechanistic role of monocytes in fibrosis might lead to insights that assist the development of new therapies. FUNDING Bill & Melinda Gates Foundation, US National Institute of Allergy and Infectious Diseases, and US National Library of Medicine.
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Affiliation(s)
- Madeleine K D Scott
- Institute for Immunity, Transplantation, and Infection, Stanford University School of Medicine, Stanford, CA, USA; Division for Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA; Department of Biophysics, Stanford University School of Medicine, Stanford, CA, USA
| | - Katie Quinn
- Division for Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Qin Li
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Robert Carroll
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hayley Warsinske
- Institute for Immunity, Transplantation, and Infection, Stanford University School of Medicine, Stanford, CA, USA; Division for Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Francesco Vallania
- Institute for Immunity, Transplantation, and Infection, Stanford University School of Medicine, Stanford, CA, USA; Division for Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Shirley Chen
- Institute for Immunity, Transplantation, and Infection, Stanford University School of Medicine, Stanford, CA, USA; Division for Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Mary A Carns
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kathleen Aren
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jiehuan Sun
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Kimberly Koloms
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jungwha Lee
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jessika Baral
- Institute for Immunity, Transplantation, and Infection, Stanford University School of Medicine, Stanford, CA, USA
| | - Jonathan Kropski
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Hongyu Zhao
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Erica Herzog
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Fernando J Martinez
- Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Bethany B Moore
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Monique Hinchcliff
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joshua Denny
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Naftali Kaminski
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Jose D Herazo-Maya
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Nigam H Shah
- Division for Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Purvesh Khatri
- Institute for Immunity, Transplantation, and Infection, Stanford University School of Medicine, Stanford, CA, USA; Division for Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
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Hinchcliff M, Toledo DM, Taroni JN, Wood TA, Franks JM, Ball MS, Hoffmann A, Amin SM, Tan AU, Tom K, Nesbeth Y, Lee J, Ma M, Aren K, Carns MA, Pioli PA, Whitfield ML. Mycophenolate Mofetil Treatment of Systemic Sclerosis Reduces Myeloid Cell Numbers and Attenuates the Inflammatory Gene Signature in Skin. J Invest Dermatol 2018; 138:1301-1310. [PMID: 29391252 DOI: 10.1016/j.jid.2018.01.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/08/2017] [Accepted: 01/04/2018] [Indexed: 12/12/2022]
Abstract
Fewer than half of patients with systemic sclerosis demonstrate modified Rodnan skin score improvement during mycophenolate mofetil (MMF) treatment. To understand the molecular basis for this observation, we extended our prior studies and characterized molecular and cellular changes in skin biopsies from subjects with systemic sclerosis treated with MMF. Eleven subjects completed ≥24 months of MMF therapy. Two distinct skin gene expression trajectories were observed across six of these subjects. Three of the six subjects showed attenuation of the inflammatory signature by 24 months, paralleling reductions in CCL2 mRNA expression in skin and reduced numbers of macrophages and myeloid dendritic cells in skin biopsies. MMF cessation at 24 months resulted in an increased inflammatory score, increased CCL2 mRNA and protein levels, modified Rodnan skin score rebound, and increased numbers of skin myeloid cells in these subjects. In contrast, three other subjects remained on MMF >24 months and showed a persistent decrease in inflammatory score, decreasing or stable modified Rodnan skin score, CCL2 mRNA reductions, sera CCL2 protein levels trending downward, reduction in monocyte migration, and no increase in skin myeloid cell numbers. These data summarize molecular changes during MMF therapy that suggest reduction of innate immune cell numbers, possibly by attenuating expression of chemokines, including CCL2.
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Affiliation(s)
- Monique Hinchcliff
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Diana M Toledo
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Jaclyn N Taroni
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Tammara A Wood
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Jennifer M Franks
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Michael S Ball
- Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Aileen Hoffmann
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sapna M Amin
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ainah U Tan
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kevin Tom
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Jungwha Lee
- Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Madeleine Ma
- Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kathleen Aren
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mary A Carns
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Patricia A Pioli
- Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Michael L Whitfield
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.
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Hinchcliff ME, Beaumont JL, Carns MA, Podlusky S, Thavarajah K, Varga J, Cella D, Chang RW. Longitudinal evaluation of PROMIS-29 and FACIT-dyspnea short forms in systemic sclerosis. J Rheumatol 2014; 42:64-72. [PMID: 25362656 DOI: 10.3899/jrheum.140143] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [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]
Abstract
OBJECTIVE To assess the sensitivity of the Patient-Reported Outcomes Measurement Information System 29-item Health Profile (PROMIS-29) and the Functional Assessment of Chronic Illness Therapy-Dyspnea 10-item short form (FACIT-Dyspnea) for measuring change in health status and dyspnea in systemic sclerosis (SSc). METHODS One hundred patients with SSc completed the PROMIS-29, FACIT-Dyspnea, and traditional instruments [Medical Research Council Dyspnea Score, St. George's Respiratory Questionnaire (SGRQ), Health Assessment Questionnaire-Disability Index (HAQ-DI), and Medical Outcomes Study Short Form-36 (SF-36)] at baseline and 1-year visits. PROMIS-29, FACIT-Dyspnea, and traditional instrument change scores were compared across composite modified Medsger Disease Severity and modified Rodnan Skin score (mRSS) change groups. RESULTS Moderately high Spearman correlation coefficients were observed between FACIT-Dyspnea and SGRQ (r = 0.57), FACIT-Dyspnea functional limitations and SF-36 physical component summary (PCS; r = 0.51), PROMIS-29 physical functioning and HAQ-DI (r = 0.50), and SF-36 PCS (r = 0.52) change scores. In most validity comparisons, PROMIS-29, FACIT-Dyspnea, HAQ-DI, and SF-36 scores performed similarly. While PROMIS-29 covers more content areas than SF-36 (e.g., sleep), it may do so at the expense of responsiveness of its 4-item physical function scale as compared to the multiitem-derived SF-36 PCS. Statistically significant increases in SF-36 role physical (p = 0.01) and physical component scale (p = 0.016), but not PROMIS-29, were observed in patients with mRSS improvement. CONCLUSION PROMIS-29 and FACIT-Dyspnea are valid instruments to measure health status and dyspnea in patients with SSc. In physical function assessment, longer PROMIS short forms or computer adaptive testing should be considered to improve responsiveness to the effect of skin disease changes on physical function in patients with SSc.
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Affiliation(s)
- Monique E Hinchcliff
- From the Department of Medicine, Division of Rheumatology, Department of Medical Social Sciences, and the Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine, Chicago, Illinois; Center for Lung Health, Henry Ford Hospital, Detroit, Michigan, USA.M.E. Hinchcliff, MD, MS, Assistant Professor of Medicine; M.A. Carns, MS; S. Podlusky, BA, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; J.L. Beaumont, MS, Statistical Analyst/Programmer, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; K. Thavarajah, MD, MS, Clinical Assistant Professor of Medicine, Center for Lung Health, Henry Ford Hospital; J. Varga, MD, Professor of Medicine, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine; D. Cella, PhD, Professor of Medicine, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; R.W. Chang, MD, MPH, Professor of Medicine, Department of Medicine, Division of Rheumatology, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine.
| | - Jennifer L Beaumont
- From the Department of Medicine, Division of Rheumatology, Department of Medical Social Sciences, and the Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine, Chicago, Illinois; Center for Lung Health, Henry Ford Hospital, Detroit, Michigan, USA.M.E. Hinchcliff, MD, MS, Assistant Professor of Medicine; M.A. Carns, MS; S. Podlusky, BA, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; J.L. Beaumont, MS, Statistical Analyst/Programmer, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; K. Thavarajah, MD, MS, Clinical Assistant Professor of Medicine, Center for Lung Health, Henry Ford Hospital; J. Varga, MD, Professor of Medicine, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine; D. Cella, PhD, Professor of Medicine, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; R.W. Chang, MD, MPH, Professor of Medicine, Department of Medicine, Division of Rheumatology, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine
| | - Mary A Carns
- From the Department of Medicine, Division of Rheumatology, Department of Medical Social Sciences, and the Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine, Chicago, Illinois; Center for Lung Health, Henry Ford Hospital, Detroit, Michigan, USA.M.E. Hinchcliff, MD, MS, Assistant Professor of Medicine; M.A. Carns, MS; S. Podlusky, BA, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; J.L. Beaumont, MS, Statistical Analyst/Programmer, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; K. Thavarajah, MD, MS, Clinical Assistant Professor of Medicine, Center for Lung Health, Henry Ford Hospital; J. Varga, MD, Professor of Medicine, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine; D. Cella, PhD, Professor of Medicine, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; R.W. Chang, MD, MPH, Professor of Medicine, Department of Medicine, Division of Rheumatology, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine
| | - Sofia Podlusky
- From the Department of Medicine, Division of Rheumatology, Department of Medical Social Sciences, and the Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine, Chicago, Illinois; Center for Lung Health, Henry Ford Hospital, Detroit, Michigan, USA.M.E. Hinchcliff, MD, MS, Assistant Professor of Medicine; M.A. Carns, MS; S. Podlusky, BA, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; J.L. Beaumont, MS, Statistical Analyst/Programmer, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; K. Thavarajah, MD, MS, Clinical Assistant Professor of Medicine, Center for Lung Health, Henry Ford Hospital; J. Varga, MD, Professor of Medicine, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine; D. Cella, PhD, Professor of Medicine, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; R.W. Chang, MD, MPH, Professor of Medicine, Department of Medicine, Division of Rheumatology, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine
| | - Krishna Thavarajah
- From the Department of Medicine, Division of Rheumatology, Department of Medical Social Sciences, and the Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine, Chicago, Illinois; Center for Lung Health, Henry Ford Hospital, Detroit, Michigan, USA.M.E. Hinchcliff, MD, MS, Assistant Professor of Medicine; M.A. Carns, MS; S. Podlusky, BA, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; J.L. Beaumont, MS, Statistical Analyst/Programmer, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; K. Thavarajah, MD, MS, Clinical Assistant Professor of Medicine, Center for Lung Health, Henry Ford Hospital; J. Varga, MD, Professor of Medicine, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine; D. Cella, PhD, Professor of Medicine, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; R.W. Chang, MD, MPH, Professor of Medicine, Department of Medicine, Division of Rheumatology, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine
| | - John Varga
- From the Department of Medicine, Division of Rheumatology, Department of Medical Social Sciences, and the Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine, Chicago, Illinois; Center for Lung Health, Henry Ford Hospital, Detroit, Michigan, USA.M.E. Hinchcliff, MD, MS, Assistant Professor of Medicine; M.A. Carns, MS; S. Podlusky, BA, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; J.L. Beaumont, MS, Statistical Analyst/Programmer, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; K. Thavarajah, MD, MS, Clinical Assistant Professor of Medicine, Center for Lung Health, Henry Ford Hospital; J. Varga, MD, Professor of Medicine, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine; D. Cella, PhD, Professor of Medicine, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; R.W. Chang, MD, MPH, Professor of Medicine, Department of Medicine, Division of Rheumatology, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine
| | - David Cella
- From the Department of Medicine, Division of Rheumatology, Department of Medical Social Sciences, and the Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine, Chicago, Illinois; Center for Lung Health, Henry Ford Hospital, Detroit, Michigan, USA.M.E. Hinchcliff, MD, MS, Assistant Professor of Medicine; M.A. Carns, MS; S. Podlusky, BA, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; J.L. Beaumont, MS, Statistical Analyst/Programmer, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; K. Thavarajah, MD, MS, Clinical Assistant Professor of Medicine, Center for Lung Health, Henry Ford Hospital; J. Varga, MD, Professor of Medicine, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine; D. Cella, PhD, Professor of Medicine, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; R.W. Chang, MD, MPH, Professor of Medicine, Department of Medicine, Division of Rheumatology, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine
| | - Rowland W Chang
- From the Department of Medicine, Division of Rheumatology, Department of Medical Social Sciences, and the Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine, Chicago, Illinois; Center for Lung Health, Henry Ford Hospital, Detroit, Michigan, USA.M.E. Hinchcliff, MD, MS, Assistant Professor of Medicine; M.A. Carns, MS; S. Podlusky, BA, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; J.L. Beaumont, MS, Statistical Analyst/Programmer, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; K. Thavarajah, MD, MS, Clinical Assistant Professor of Medicine, Center for Lung Health, Henry Ford Hospital; J. Varga, MD, Professor of Medicine, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine; D. Cella, PhD, Professor of Medicine, Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine; R.W. Chang, MD, MPH, Professor of Medicine, Department of Medicine, Division of Rheumatology, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, and the Institute for Public Health and Medicine
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