The European Community Study Group on diagnostic criteria for Sjögren's syndrome. Sensitivity and specificity of tests for ocular and oral involvement in Sjögren's syndrome

Sonoelastographic Modalities in the Evaluation of Salivary Gland Characteristics in Sjögren's Syndrome

The purpose of this study was to investigate salivary tissue assessment with various sonoelastographic modalities (real-time tissue elastography, Virtual Touch imaging and quantification) in patients with Sjögren's syndrome as compared with an appropriate control group. The sonoelastographic modalities were evaluated in 50 patients with primary Sjögren's syndrome (pSS). Patients underwent high-resolution ultrasonography of the submandibular and parotid glands. Results of B-mode, real-time tissue elastography, Virtual Touch imaging-each graded with the appropriate scoring system-and Virtual Touch quantification were compared with those for 50 patients with sicca symptoms who did not fulfill the American-European consensus group criteria. In B-mode, 34 of 50 parotid glands in patients with pSS and 8 of 50 in the control group had abnormal findings (p < 0.001). Compared with 9 of 50 control patients, 38 of 50 patients with pSS had abnormal findings in submandibular gland B-mode (p < 0.001). With real-time tissue elastography, there was a trend toward higher scores for parotid glands in the pSS group (p = 0.238), whereas scores for submandibular glands in the control group were higher (p = 0.107). Virtual Touch imaging did not indicate any difference (p = 0.647 and p = 0.658). In Virtual Touch quantification, values for parotid (mean: 2.99 m/s) and submandibular glands (mean: 2.54 m/s) in the pSS group were higher than those for parotid (mean: 2.16 m/s) and submandibular (mean: 2.04 m/s) glands in the control group (p < 0.001 and p = 0.008). Glandular stiffness, measured by Virtual Touch quantification, was significantly higher in patients with Sjögreńs syndrome than in patients with sicca symptoms.

Current Approach to Dry Eye Disease

Dry eye disease (DED) is a multifactorial disease of the tears and ocular surface that causes tear film instability with potential damage to the ocular surface. The prevalence of dry eye in the world population ranges from 6 to 34 %. It is more common in those aged over 50, and affects mainly women. Since the introduction of the Schirmer's test in 1903, other tests have been developed to evaluate dry eye, such as biomicroscopy, the tear film breakup time (BUT), vital dyes (lissamine green and rose bengal), fluorescein, leaf fern test, corneal sensitivity test, conjunctiva impression cytology, optical coherence tomography (OCT), and tear osmolarity measurement. Although there is no gold standard, it is advisable to combine at least two tests. Strategies for treating DED have recently been modified and include patient education, tear substitute, corticosteroids, secretagogues, fatty acids, immunomodulators, occlusion of lacrimal puncta surgery and, tarsorrhaphy. Biological therapy and new topical immunomodulators such as tacrolimus, tofacitinib and IL-1 receptor inhibitor are being tested. In this review, the evaluation tests for dry eye are compared and the main studies on treatment are presented, with emphasis on studies in patients with Sjögren's syndrome. The authors propose an approach for the management of dry eye.

Somatostatin receptor scintigraphy in patients with rheumatoid arthritis and secondary Sjögren's syndrome treated with Infliximab: a pilot study

Background

Human T lymphocytes infiltrating tissues in autoimmune diseases are known to express somatostatin receptors amongst other activation markers. In this study, we evaluated whether somatostatin receptor scintigraphy (SRS) using a radiolabelled somatostatin analogue (^99mTc-EDDA/tricine-HYNIC-tyr(3)-octreotide (^99mTc-EDDA/HYNIC-TOC)) is able to detect the presence of immune-mediated processes in patients with rheumatoid arthritis and secondary Sjögren’s syndrome. We also aimed to evaluate whether positivity to SRS was predictive of therapeutic response and if SRS could be used for monitoring the efficacy of immunomodulatory treatment.

Methods

Eighteen patients with rheumatoid arthritis and secondary Sjögren’s syndrome not responding to conventional treatment were recruited for treatment with infliximab, a monoclonal antibody against TNF-α. All patients had complete blood cell count, renal and liver function tests, measurements of ESR, CRP, ANA, ENA, and anti-dsDNA antibodies, functional salivary gland scintigraphy, labial biopsy, and ophthalmologic assessment with Schirmer’s test and tear film break-up time (BUT). Diagnosis was made according to the revised criteria of the American-European Consensus Group. All patients underwent SRS at baseline and after 3–6 months of therapy with infliximab. Eleven out of 18 had repeat SRS images. Images of the salivary glands and major joints were acquired 3 h after injection of 370 MBq of ^99mTc-EDDA/HYNIC-TOC. Image analysis was performed semi-quantitatively.

Results

All patients showed uptake of ^99mTc-EDDA/HYNIC-TOC in the joints. Salivary glands also showed variable radiopharmaceutical uptake in 12 out of 18 patients, but all patients showed presence of lymphocytic infiltration at labial salivary gland biopsy. All patients, who repeated the study after treatment, showed significant reduction of somatostatin uptake in the joints but not in the salivary glands.

Conclusions

SRS using ^99mTc-EDDA/HYNIC-TOC may be a useful imaging tool to assess disease activity and extent in patients with rheumatoid arthritis and may help to detect secondary Sjögren’s syndrome. It may also aid therapy decision-making with anti-TNFα antibodies in the joints but not in salivary glands.

Progress in tear microdesiccate analysis by combining various transmitted-light microscope techniques

Background

Tear desiccation on a glass surface followed by transmitted-light microscopy has served as diagnostic test for dry eye. Four distinctive morphological domains (zones I, II, III and transition band) have been recently recognized in tear microdesiccates. Physicochemical dissimilarities among those domains hamper comprehensive microscopic examination of tear microdesiccates. Optimal observation conditions of entire tear microdesiccates are now investigated. One-μl aliquots of tear collected from individual healthy eyes were dried at ambient conditions on microscope slides. Tear microdesiccates were examined by combining low-magnification objective lenses with transmitted-light microscopy (brightfield, phase contrasts Ph1,2,3 and darkfield).

Results

Fern-like structures (zones II and III) were visible with all illumination methods excepting brightfield. Zone I was the microdesiccate domain displaying the most noticeable illumination-dependent variations, namely transparent band delimited by an outer rim (Ph1, Ph2), homogeneous compactly built structure (brightfield) or invisible domain (darkfield, Ph3). Intermediate positions of the condenser (BF/Ph1, Ph1/Ph2) showed a structured roughly cylindrical zone I. The transition band also varied from invisibility (brightfield) to a well-defined domain comprising interwoven filamentous elements (phase contrasts, darkfield).

Conclusions

Imaging of entire tear microdesiccates by transmitted-light microscopy depends upon illumination. A more comprehensive description of tear microdesiccates can be achieved by combining illumination methods.

Extrahepatic manifestations in chronic hepatitis C virus carriers

Patients with chronic hepatitis C virus (HCV) infection frequently present with extrahepatic manifestations covering a large spectrum, involving different organ systems leading to the concept of systemic HCV infection. These manifestations include autoimmune phenomena and frank autoimmune and/or rheumatic diseases and may dominate the course of chronic HCV infection. Chronic HCV infection causes liver inflammation affecting the development of hepatic diseases. HCV is also a lymphotropic virus that triggers B cells and promotes favorable conditions for B lymphocyte proliferation, including mixed cryoglobulinemia (MC) and MC vasculitis, which is the most prominent extrahepatic manifestation of chronic HCV infection. HCV may also promote a low-grade chronic systemic inflammation that may affect the development of some extrahepatic manifestations, particularly cardiovascular and cerebral vascular diseases. Recognition of extrahepatic symptoms of HCV infection could facilitate early diagnosis and treatment. The development of direct-acting antiviral agents (DDAs) has revolutionized HCV treatment. DDAs, as well as new B-cell-depleting or B-cell-modulating monoclonal antibodies, will expand the panorama of treatment options for HCV-related extrahepatic manifestations including cryoglobulinemic vasculitis. In this context, a proactive, integrated approach to HCV therapy should maximize the benefits of HCV therapy, even when liver disease is mild.

IP3R deficit underlies loss of salivary fluid secretion in Sjögren's Syndrome

The autoimmune exocrinopathy, Sjögren’s syndrome (SS), is associated with secretory defects in patients, including individuals with mild lymphocytic infiltration and minimal glandular damage. The mechanism(s) underlying the secretory dysfunction is not known. We have used minor salivary gland biopsies from SS patients and healthy individuals to assess acinar cell function in morphologically intact glandular areas. We report that agonist-regulated intracellular Ca²⁺ release, critically required for Ca²⁺ entry and fluid secretion, is defective in acini from SS patients. Importantly, these acini displayed reduction in IP3R2 and IP3R3, but not AQP5 or STIM1. Similar decreases in IP3R and carbachol (CCh)-stimulated [Ca²⁺]_i elevation were detected in acinar cells from lymphotoxin-alpha (LTα) transgenic (TG) mice, a model for (SS). Treatment of salivary glands from healthy individuals with LT α, a cytokine linked to disease progression in SS and IL14α mice, reduced Ca²⁺ signaling. Together, our findings reveal novel IP3R deficits in acinar cells that underlie secretory dysfunction in SS patients.

Relationships among Tear Film Stability, Osmolarity, and Dryness Symptoms

PURPOSE

To examine the relationships among tear osmolarity, tear film stability, and several measures of dry eye (DE) symptoms in a multivariable analysis.

METHODS

A cross-sectional study was conducted with 137 subjects (68 non-contact lens [CL] wearers and 69 soft CL wearers) recruited from a university campus. Tear breakup time (TBUT) was measured noninvasively (NITBUT) and with fluorescein (FTBUT). Tear osmolarity was measured by an osmometer. Dry eye symptoms were assessed using the Dry Eye Flow Chart and several different questionnaires.

RESULTS

Subjects ranged in age from 18 to 67 years, with a mean of 28 years. Subjects had a mean (SD) osmolarity of 293 (10) mOsm/L, NITBUT of 14.1 (10.9) seconds, and FTBUT of 14.8 (12.6) seconds. Shorter NITBUT and FTBUT were significantly associated with female sex (p = 0.001 and p = 0.027, respectively) and Asian ethnicity (p = 0.030 and p = 0.004, respectively). There were no clinically significant relationships between tear osmolarity and FTBUT, NITBUT, or DE symptoms. Higher Dry Eye Flow Chart score (i.e., worse symptoms) was associated with older age (p < 0.001), female sex (p = 0.014), CL wear (p < 0.001), shorter NITBUT (p < 0.001), and shorter FTBUT (p = 0.028). The sensitivities and specificities for using clinical measurements to diagnose moderate to severe DE were as follows: osmolarity, 0.67 and 0.46, respectively; NITBUT, 0.72 and 0.52, respectively; and FTBUT, 0.68 and 0.57, respectively.

CONCLUSIONS

In a population of asymptomatic, mild and moderate DE patients, increased tear osmolarity was not significantly associated with reported symptom severity and frequency. Tear osmolarity, NITBUT, and FTBUT exhibited similar sensitivities and specificities when used to diagnose moderate to severe DE.

Distribution pattern of Sjögren's syndrome: a sialographical study

BACKGROUND/OBJECTIVES

The present controlled sialographical study was conducted to learn more from the horizontal and vertical symmetry of the ductal lesions of the major salivary glands in primary (pSS) and secondary (sSS) forms of the disease.

MATERIALS AND METHODS

A total of 98 patients (38 pSS patients, 38 sSS patients, 22 control subjects) were included in the study. Contrast radiography of both parotid and submandibular glands was performed within the same session. A 6-point scoring system allowed summary indexes for each of the glands to be calculated.

RESULTS

Pansialography was accomplished within 30 min each. The sparsity of the branching pattern of the ducts was the most frequent pathological finding. In pSS, horizontal symmetry was more pronounced in the parotid glands, whereas in sSS it was more pronounced in the submandibular glands. The most discriminating features were the width of the peripheral ducts in the parotid and the number of acinar dilatations in the submandibular glands. The most advanced lesions were found in the left parotid gland.

CONCLUSION

The peripheral ducts are more affected by SS than the main excretory duct. There is a tendency for asymmetric involvement of the parotid glands in pSS and of the submandibular glands in sSS. Parotid glands are globally more involved than submandibular glands. Differential diagnosis between pSS and sSS cannot be accomplished by means of pansialography alone. Left parotid sialography is recommended for routine use.

Reliability of a new modified tear breakup time method: dry tear breakup time

BACKGROUND

Tear breakup time (TBUT) is a useful technique for diagnosing dry eye disease (DED). The conventional method of measuring TBUT using fluorescein strips adds supplemental normal saline (NS) to the tear film (wet tear breakup time, WBUT) but does not represent the actual state of the tear film. We introduced a new TBUT method-dry tear breakup time (DBUT)-and investigated its reliability.

METHODS

We included DED patients with mild symptoms and a Schirmer test of 6 mm or more. Patients using tear substitutes and/or suffering from Sjogren's syndrome were excluded. For measuring DBUT, 1 μl of 5 % fluorescein solution was instilled on the end of an applicator using a micropipette. Once the fluorescein solution was dry, the applicator was sterilized using ethylene oxide gas, and the dried fluorescein was applied to the lower palpebral conjunctiva without supplemental NS. Agreement between the two tests and their sensitivity and specificity were analyzed.

RESULTS

The average age of the patients was 32.1 ± 9.7 years (n = 124). The DBUT was lower than the WBUT, with a mean difference of -0.63 s. Both tests had a low statistically significant correlation with the Ocular Surface Disease Index. When the basis of definite diagnosis for DED was over grade 1 on the Oxford schema of staining, the cutoff value for the WBUT was 4.48 s and the sensitivity and specificity were 0.790 and 0.548 respectively. The area under the receiver operating characteristic (AUROC) curve was 0.609 (95 % confidence interval (CI): 0.517-0.695). When the cutoff value was 3.5 s for the DBUT, the sensitivity and specificity were 0.726 and 0.694 respectively, and the AUROC curve was 0.724 (95 % CI: 0.637-0.801).

CONCLUSIONS

DBUT had a higher correlation with symptoms than the conventional WBUT. When DED was diagnosed with corneal or conjunctival staining based on the Oxford schema of staining, DBUT had a better accuracy than the conventional WBUT. DBUT may replace WBUT after confirming studies, especially when surface damage is to be detected as opposed to tear flow or symptoms.

Tear break-up time for tear film evaluation: Are moistening solutions interchangeable?

PURPOSE

It was the main purpose of this study to investigate the influence of the moistening solution on TBUT measurements in an asymptomatic population.

METHODS

An online survey was employed to determine the compliance of Spanish eye care practitioners with the recommended normalized procedure to administer TBUT. For the purpose of examining the clinical relevance of discrepancies from the recommended procedure, a randomized, double-masked, bilateral study was designed in which a micropipette was used to moisten fluorescein strips with a controlled volume of six different solutions, commonly available in the contact lens office, and TBUT was measured in 58 non-dry eye (OSDI<15) subjects (age from 19 to 32 years).

RESULTS

Results from the online survey revealed that 64% of Spanish practitioners frequently use (or have used) different solutions to moisten fluorescein strips during TBUT assessment. Statistically significant differences in TBUT values were found between the various solutions as a whole (χ(2)=198.384, p<0.001), as well as between all solutions when explored pair-wise (all p<0.001), except for the two saline solutions.

CONCLUSIONS

The present findings support the relevance of selecting the appropriate solution when conducting TBUT for the evaluation of the tear film. Deviations from the recommended procedure may result in misdiagnosis of dry eye and unnecessary patient referral.

Goblet cell density association with tear function and ocular surface physiology

PURPOSE

To determine the relationship of goblet cell density (GCD) with tear function and ocular surface physiology.

METHODS

This was a cross-sectional study conducted in 35 asymptomatic subjects with mean age 23.8±3.6 years. Tear film assessment, conjunctiva and cornea examination were done in each subject. Conjunctival impression cytology was performed by applying Nitrocellulose Millipore MF™-Membrane filter over the superior bulbar conjunctiva. The filter paper was than fixed with 96% ethanol and stained with Periodic Acid Schiff, Hematoxylin and Eosin. GCD was determined by optical microscopy. Relation between GCD and Schirmer score, tear break-up time (TBUT), bulbar redness, limbal redness and corneal staining was determined.

RESULTS

The mean GCD was 151±122 cells/mm(2). GCD was found higher in eyes with higher Schirmer score but it was not significant (p=0.75). There was a significant relationship of GCD with TBUT (p=0.042). GCD was not correlated with bulbar redness (p=0.126), and limbal redness (p=0.054) as well as corneal staining (p=0.079). No relationship of GCD with age and gender of the subjects (p>0.05) was observed.

CONCLUSION

GCD was found correlated with TBUT but no significant correlation was found with the aqueous portion of the tear, limbal as well as bulbar redness and corneal staining.

Prevalence of hyposalivation in patients with systemic lupus erythematosus in a brazilian subpopulation

Background. Systemic lupus erythematosus (SLE) is a chronic inflammatory, multisystem, and autoimmune disease. Objective. The aim of this study was to describe the prevalence of hyposalivation in SLE patients and evaluate factors associated. Methods. This is a cross-sectional study developed at the Cuiaba University General Hospital (UNIC-HGU), Mato Grosso, Brazil. The study population consisted of female SLE patients treated at this hospital from 06/2010 to 12/2012. Unstimulated salivary flow rates (SFRs) were measured. Descriptive and inferential analyses were performed in all cases using a significance level P < 0.05. Results. The results showed that 79% of patients with systemic lupus erythematosus suffered from hyposalivation and that the disease activity and age in years were the factors that resulted in statistically significant differences. Conclusion. The activity of the disease, age >27 years, and the drugs used were factors associated with hyposalivation, resulting in a statistically significant decrease in saliva production.

Primary Sjögren's Syndrome Associated Neuropathy

Primary Sjögren's syndrome (PSS) mainly affects exocrine glands and is clinically characterized by keratoconjunctivitis sicca and xerostomia. Among several possible extraglandular manifestations, involvement of the peripheral nervous system may occur with reported frequencies from 10% to 60%. Peripheral nerve manifestations constitute sensory neuropathy, including sensory ganglioneuronopathy, sensorimotor, including polyradiculoneuropathy and demyelinating neuropathy, motor neuropathy, multiple mononeuropathy, trigeminal and other cranial neuropathies, autonomic neuropathy, and mixed patterns of neuropathy. Knowledge of the neurological manifestations of PSS is hampered by evolving classification criteria of PSS over the years, and by use of highly selected patient populations on the basis of a primary neurological diagnosis. Sural nerve biopsy may show vascular or perivascular inflammation of small epineurial vessels (both arterioles and venules) and in some cases necrotizing vasculitis. Loss of myelinated nerve fibers is common and loss of small diameter nerve fibers occurs. Pathology in cases of sensory ganglioneuronopathy consists of loss of neuronal cell bodies and infiltration of T cells. Peripheral neuropathy in PSS often is refractory to treatment although newer biological agents may provide more effective treatment options. Current treatment strategies used in autoimmune neuropathies may be tried depending upon characteristics of the neuropathy and results obtained by a thorough clinical and laboratory investigation.

Change in tear film characteristics in visual display terminal users

PURPOSE

To evaluate changes in symptoms and tear film characteristics in young computer users.

METHODS

Fifty-one computer users and 26 controls were evaluated at the beginning and the end of the working day. Subjects with ocular or systemic disease, history of ocular surgery, use of contact lenses or glasses with antireflective surfaces, and use of topical or systemic medications were excluded from the study. Computer use duration, Ocular Surface Disease Index (OSDI) questionnaire, tear osmolarity, Schirmer test, tear break-up time (TBUT), and ocular surface vital dye staining were performed prevocationally and postvocationally.

RESULTS

The mean age was 31.2 ± 6.3 years in computer users and 33.7 ± 5.8 in controls. The mean reported computer use was 6.9 ± 2.7 hours/day in computer users and 0.4 ± 0.5 hours/day in controls. The mean prevocational and postvocational values in computer users for OSDI, osmolarity, TBUT, and Schirmer test were 23.2 ± 16.6 and 27.0 ± 17.6, 306.6 ± 14.9 and 311.0 ± 12.5 mOsm/L, 13.9 ± 4.0 and 13.2 ± 3.8 seconds, 22.7 ± 11.8 and 20.6 ± 12.5 mm, respectively. The vocational change was significant for all parameters in the computer user group but not in the control group. The osmolarity-based dry eye diagnosis was 27.4% in the computer users while it was 15.4% in the control group. Oxford score was only grade 1 in 5.9% of visual display terminal users and did not change at the end of the day.

CONCLUSIONS

Both symptoms and signs of dry eye increased significantly with computer use. Approximately 1 of every 3-4 computer users was found to have dry eye with higher tear osmolarity values.

Dynamics of tear fluid desiccation on a glass surface: a contribution to tear quality assessment

BACKGROUND

Fern-like crystalloids form when a microvolume of tear is allowed to dry out at ambient conditions on a glass surface. Presence of crystalloids in tear "microdesiccates" is used to evaluate patients with Dry-Eye disease. This study aims to examine morphologically the desiccation process of normal tear fluid and to identify changes associated with accelerated tear evaporation. Tear microdesiccates from healthy (Non-Dry Eye) and Dry Eye subjects were produced at ambient conditions. Microdesiccate formation was monitored continuously by dark-field video microscopy. Additionally, accelerated desiccation of tear samples from healthy subjects was conducted under controlled experimental conditions. Particular morphological domains of tear microdesiccates and their progressive appearance during desiccation were compared.

RESULTS

In normal tear microdesiccates, four distinctive morphological domains (zones I, II, III and transition band) were recognized. Stepwise formation of those domains is now described. Experimentally accelerated desiccation resulted in marked changes in some of those zones, particularly involving either disappearance or size reduction of fern-like crystalloids of zones II and III. Tear microdesiccates from Dry Eye subjects may also display those differences and be the expression of a more synchronous formation of microdesiccate domains.

CONCLUSION

Morphological characteristics of tear microdesiccates can provide insights into the relative rate of tear evaporation.

Level of agreement between 2002 American-European Consensus Group and 2012 American College of Rheumatology classification criteria for Sjögren's syndrome and reasons for discrepancies

INTRODUCTION

The aims of this study were to assess agreement between the currently used 2002 American-European Consensus Group (AECG) classification criteria and the new 2012 American College of Rheumatology (ACR) criteria for Sjögren's syndrome (SS) and to identify potential sources of disagreement.

METHODS

We studied 105 patients between 2006 and 2013 from the Brittany cohort of patients with suspected SS. AECG criteria were applied using only Schimer's test and unstimulated whole salivary flow (UWSF) to assess objective ocular and oral involvement, since these are the tests most physicians use in clinical practice. Agreement between the two sets of criteria was assessed using Cohen's κ coefficient.

RESULTS

Of those studied, 42 patients fulfilled AECG and 35 ACR criteria. Agreement between the two sets was moderate (κ = 0.53). Patients fulfilling ACR but not AECG criteria (n = 8) were significantly younger and had shorter symptom durations, but only three of them had SS in the opinion of the evaluating physician. Xerostomia and xerophthalmia (AECG set only) did not discriminate between patients with and without SS. The use of UWSF in the AECG but not the ACR criteria explained part of the disagreement. The serological item in the ACR set (positive rheumatoid factor and antinuclear antibody ≥1:320 or anti-SSA/SSB positivity) did not result in classification differences compared to anti-SSA/SSB antibody alone (AECG set). Agreement between ocular staining score ≥3 (ACR set) and Schirmer's test ≤5 mm/5 min (AECG set) was very low (κ = 0.14).

CONCLUSIONS

Agreement was only moderate between ACR and AECG criteria, suggesting these two sets would not select comparable patient populations. An international consensus about which classification criteria should be used in clinical studies is needed.

Noninvasive Keratograph assessment of tear film break-up time and location in patients with age-related cataracts and dry eye syndrome

OBJECTIVE

To investigate tear-film break-up time and spatial distribution via noninvasive Keratograph 4 in patients with cataracts and dry eye syndrome (DES).

METHODS

Noninvasive first break-up time (NIKf-BUT) and average break-up time (NIKav-BUT) were evaluated via Keratograph 4 in patients with age-related cataracts and DES. The location and size of tear break regions were recorded and the distribution of first break-up areas was summarized. Patients also underwent conventional break-up time assessments (TBUT test and Schirmer's test).

RESULTS

A total of 43 left and 43 right eyes were examined. There was no significant difference between TBUT and NIKav-BUT. NIKf-BUT was significantly shorter than TBUT. Both NIKf-BUT and NIKav-BUT correlated positively with TBUT. In both the left and right eye, the most common first break-up areas were the peripheral domain of the inferior precorneal surface and the central domain of the superior portion.

CONCLUSIONS

The Keratograph 4 appears to provide an effective noninvasive method for assessing tear film, enabling effective preoperative evaluation of tear film break-up regularity, informing the location of the incision and reducing the probability of postoperative DES.

Comparison of the American-European Consensus Group Sjogren's syndrome classification criteria to newly proposed American College of Rheumatology criteria in a large, carefully characterised sicca cohort

OBJECTIVE

To compare the performance of the American-European Consensus Group (AECG) and the newly proposed American College of Rheumatology (ACR) classification criteria for Sjögren's Syndrome (SS) in a well-characterised sicca cohort, given ongoing efforts to resolve discrepancies and weaknesses in the systems.

METHODS

In a multidisciplinary clinic for the evaluation of sicca, we assessed features of salivary and lacrimal gland dysfunction and autoimmunity as defined by tests of both AECG and ACR criteria in 646 participants. Global gene expression profiles were compared in a subset of 180 participants.

RESULTS

Application of the AECG and ACR criteria resulted in classification of 279 and 268 participants with SS, respectively. Both criteria were met by 244 participants (81%). In 26 of the 35 AECG+/ACR participants, the minor salivary gland biopsy focal score was ≥1 (74%), while nine had positive anti-Ro/La (26%). There were 24 AECG-/ACR+ who met ACR criteria mainly due to differences in the scoring of corneal staining. All patients with SS, regardless of classification, had similar gene expression profiles, which were distinct from the healthy controls.

CONCLUSIONS

The two sets of classification criteria yield concordant results in the majority of cases and gene expression profiling suggests that patients meeting either set of criteria are more similar to other SS participants than to healthy controls. Thus, there is no clear evidence for increased value of the new ACR criteria over the old AECG criteria from the clinical or biological perspective. It is our contention, supported by this report, that improvements in diagnostic acumen will require a more fundamental understanding of the pathogenic mechanisms than is at present available.

Clinical study of therapeutic ocular surface medium for persistent epithelial defect

PURPOSE

To investigate therapeutic ocular surface medium (TOSM), a potential physiological tear replacement therapy, for persistent epithelial defect (PED).

METHODS

11 eyes of 10 patients with PED for ≥ 2 weeks without improvement despite conventional treatment were enrolled in a prospective pilot study of TOSM over 1 month.

RESULTS

Healing of the PED occurred in 3 out of the 11 eyes at 1, 2 and 4 weeks, respectively. At week 4, 2 eyes were almost healed (PED area ≤ 0.5 mm(2)). In 4 of the remaining 6 eyes, the PED area was reduced. Failure occurred in 1 case with end-stage ocular cicatricial pemphigoid and severe dry eye, and 1 patient withdrew due to a mild allergic reaction. There were no serious or irreversible side effects with TOSM.

CONCLUSIONS

TOSM is a potential novel physiological therapy for PED that, unlike autologous serum, has the potential to be easily manufactured and widely available.

Maternal Vitamin A Deficiency during Pregnancy and Its Relation with Maternal and Neonatal Hemoglobin Concentrations among Poor Egyptian Families

Background. Vitamin A deficiency (VAD) during pregnancy represents a major public health problem in developing countries. Anemia is a common consequence of VAD. We aimed to measure serum retinol concentrations of a sample of poor Egyptian mothers and correlate it with their Hb% and cord Hb%. Methods. This cross-sectional study included 200 healthy mothers and their healthy full term newborns. Maternal and cord blood samples were collected for CBC and measurement of serum retinol concentrations. Results. Forty-seven mothers (23.5%) had VAD and 50% were anemic. Mothers with VAD had a significantly lower mean Hb% and a significantly higher frequency of anemia (95.7%) compared to mothers without VAD (35.9%). The relative risk for anemia among mothers with VAD was 2.7 (CI = 2.12–3.3). Newborns of mothers with VAD had a significantly lower mean cord Hb% compared to newborns of mothers without VAD. Maternal serum retinol concentrations were positively correlated with maternal Hb% and cord Hb%. Conclusion. Maternal VAD during pregnancy among poor mothers is associated with maternal anemia and lower Hb% of newborns at birth. Vitamin A supplementation is highly recommended for this vulnerable group.

Statistical approaches to assessing single and multiple outcome measures in dry eye therapy and diagnosis

Dry eye is a multifactorial disease which would require a broad spectrum of test measures in the monitoring of its treatment and diagnosis. However, studies have typically reported improvements in individual measures with treatment. Alternative approaches involve multiple, combined outcomes being assessed by different statistical analyses. In order to assess the effect of various statistical approaches to the use of single and combined test measures in dry eye, this review reanalyzed measures from two previous studies (osmolarity, evaporation, tear turnover rate, and lipid film quality). These analyses assessed the measures as single variables within groups, pre- and post-intervention with a lubricant supplement, by creating combinations of these variables and by validating these combinations with the combined sample of data from all groups of dry eye subjects. The effectiveness of single measures and combinations in diagnosis of dry eye was also considered.

Oral manifestations of systemic autoimmune and inflammatory diseases: diagnosis and clinical management

CONTEXT

Systemic autoimmune and inflammatory diseases often manifest oral lesions in their earliest stages, and early diagnosis, which may be spurred by a dental examination, is key for improved outcomes. After systemic diagnosis, oral lesions benefit from specialized care by dentists in collaboration with the medical team. This review aims to educate dental clinicians about the most relevant systemic autoimmune and inflammatory conditions with accompanying oral lesions, their implications for health, and management strategies supported by the biomedical literature and clinical experience. Ulcerative conditions including Behcet and Crohn diseases are discussed, along with rheumatic conditions including Sjögren syndrome, lupus erythematosus, and rheumatoid arthritis.

EVIDENCE ACQUISITION

Evidence was accumulated through PubMed searches using pertinent keywords for each subsection. References were reviewed and original publications examined to verify the accuracy of the information. We focused on evidence included in current reviews and randomized trials. Recommendations were supported by multiple studies and consensus expert opinion.

EVIDENCE SYNTHESIS

Disease phenotypes described and clinical recommendations were synthesized from best-quality evidence available for each disease. Efforts were made to describe evidence selection within each disease section.

CONCLUSIONS

Dentists play an important role in the early detection and multidisciplinary medical management of complex autoimmune diseases. It is important to recognize prevalent medical and dental issues and special needs of patients with autoimmune conditions. The management of many inflammatory conditions is similar, and often begins with the use of topical steroids, analgesics, and antimicrobial treatments, in addition to careful attention to oral hygiene and appropriate fluoride usage. In this brief review, we aim to discuss the presentation/prevalence, diagnosis, and treatment of oral manifestations encountered in autoimmune, autoinflammatory and systemic chronic inflammatory diseases. Systemic autoimmune conditions are estimated to affect 5% to 8% of Americans.(1) Oral manifestations are encountered with high frequency, and are often the first clinical signs or symptoms of the general disease. Optimal management of complex autoimmune diseases requires a multidisciplinary medical team including dentists to care for lesions of the oral cavity. The dental practitioner may be asked to play a primary role in the diagnosis of such conditions and to participate with other health professionals working together to achieve effective clinical management. To aid in this process, we discuss in this article the current general knowledge of systemic autoimmune conditions that present with prevalent oral manifestations. The focus is on the diagnosis and management of the oral component of each disease. Importantly, whereas the etiology and pathogenesis and systemic clinical presentation may vary, presentation in the oral cavity is often similar and many conditions involve oral ulcerations. For this reason, we discuss the differential diagnosis and management of the most common oral ulcerations in a general section and subsequently address individual conditions that present with oral ulcerations. Similarly, treatment of various autoimmune/inflammatory oral conditions is often common and involves modulation or suppression of the immune response locally and/or systemically and will be therefore addressed in a common section as well as individually for each disease when unique treatment regimens are recommended. We present here our general treatment recommendations based on clinical experience and literature review; however, it is critical that good clinical judgment and specifics of an individual case should determine the appropriate dental/oral medicine intervention for a specific patient.

Comparison of low-abundance biomarker levels in capillary-collected nonstimulated tears and washout tears of aqueous-deficient and normal patients

PURPOSE

Low tear volume limits the use of nonstimulated (NS) microcapillary tear collection in aqueous-deficient (AD) patients. Adding a small amount of "washout" fluid to the eye prior to tear collection is a potentially viable alternative method for abundant proteins, but is relatively untested for low-abundance biomarkers. This study determined the feasibility of the washout (WO) method as an NS alternative for low-abundance biomarkers. NS and WO biomarker profiles were compared between AD patients and non-AD controls to determine if the two methods identify the same intergroup differences.

METHODS

Matching NS and WO tears were collected from 48 patients by micropipette, the WO sample after instillation of 10 μL saline. Tear cytokine levels were measured by 27-Plex Bio-Rad assay. Bland-Altman analyses for each biomarker determined the agreement between tear sample types. Patients were grouped as AD or non-AD based on Schirmer score to determine if NS profile between-group differences were preserved in WO tears.

RESULTS

Bland-Altman plots showed good biomarker level agreement between NS and WO tears for most cytokines. Five biomarkers, among those most often cited as differing in AD dry eye, differed significantly between non-AD and AD groups in both tear types. Additional biomarker differences were seen in NS tears only.

CONCLUSIONS

The WO tear collection method is a viable alternative to NS tears for many low-abundance biomarkers and is able to replicate major NS tear differences between dry eye groups. More subtle intergroup differences are lost in WO samples because of reduced statistical power.

Dry Eye Disease: Impact on Quality of Life and Vision

Dry eye disease (DED) is a growing public health concern causing ocular discomfort, fatigue and visual disturbance that interferes with quality of life (QoL), including aspects of physical, social, psychological functioning, daily activities and workplace productivity. This paper assesses the current understanding of the impact of DED on QoL and vision. The full impact of DED on a patient's QoL is not easily quantifiable, but several methods and techniques have been evaluated to measure the decreased quality of vision from DED, and a number of questionnaires have been developed to quantify the impact of DED on various aspects of patient QoL. We summarize available evidence on the impact of DED based on a review of published literature.

Clinimetric methods in Sjögren's syndrome

OBJECTIVE

Clinimetric tools are useful in both clinical practice and research of Sjögren's syndrome. These instruments assist in the establishment of diagnosis and in the evaluation of disease status. We reviewed the available methods used to monitor sicca signs and symptoms, fatigue, quality of life as well as activity/chronicity in SS.

METHODS

PubMed and MEDLINE database were searched for the keywords "keratoconjunctivitis sicca diagnosis," "dry eye and dry mouth assessment," "sialometry," "sialochemistry," "Sjögren's syndrome outcomes," "Sjögren's syndrome activity," "Sjögren's syndrome damage," "fatigue scales in Sjögren's syndrome," and "Sjögren's syndrome quality of life." All relevant articles and pertinent secondary references were reviewed.

RESULTS

As there is a moderate correlation between sicca symptoms and signs, the assessment of both is crucial. Most of the tests focus on oral and ocular dryness (vital dye staining, tear quantification, tear composition, sialometry, sialochemistry, etc.) and may not be disease specific. Symptoms such as dryness and fatigue have been evaluated with different instruments, being the PROFAD and ESSPRI disease-specific tools. Standardized measures for activity (SSDAI, SCAI, and ESSDAI) and chronicity (SSDDI and SSDI) indexes are currently used, however these methods still present limitations such as low external validity and cross-validation.

CONCLUSION

The heterogeneous nature of the disease and its slow progression, challenge the evaluation of these patients. The use of composite measures might increase our ability to diagnose and evaluate disease activity and cumulative irreversible organ injury in this disease. However the distinction among oral and ocular activity vs. damage is still a matter of research.

Urban legends series: Sjögren's syndrome

Sjögren's syndrome (SjS) is one of the most common autoimmune rheumatic diseases, clinically characterized by xerostomia and keratoconjunctivitis sicca. We investigated the following controversial topics: (i) Do we have reliable ways of assessing saliva production? (ii) How important are the quantity and quality of saliva? (iii) Are only anti-SSA/Ro and anti-SSB/La relevant for the diagnosis of SjS? (iv) Are the American-European Consensus criteria (AECC) the best way to diagnose SjS? Results from literature searches suggested the following: (i) Despite the fact that numerous tests are available to assess salivation rates, direct comparisons among them are scarce with little evidence to suggest one best test. (ii) Recent developments highlight the importance of investigating the composition of saliva. However, more research is needed to standardize the methods of analysis and collection and refine the quality of the accumulating data. (iii) In addition to anti-Ro/La autoantibodies, anti α-fodrin IgA and anti-MR3 autoantibodies seem to be promising diagnostic markers of SjS, but more studies are warranted to test their sensitivity and specificity. (iv) AECC are classification, not diagnostic criteria. Moreover, recent innovations have not been incorporated into these criteria. Consequently, treatment directed to patients diagnosed using the AECC might exclude a significant proportion of patients with SjS.

Evaluation of tear osmolarity in non-Sjögren and Sjögren syndrome dry eye patients with the TearLab system

PURPOSE

To evaluate tear osmolarity with the recently introduced TearLab system (TearLab Corporation, San Diego, CA) in patients with non-Sjögren syndrome dry eye (NSSDE) and Sjögren syndrome dry eye (SSDE), and in healthy subjects, and to compare the results with those from classical dry eye tests.

METHODS

Thirty-nine eyes of 21 patients with NSSDE, 39 eyes of 20 patients with SSDE, and 44 eyes of 22 healthy individuals were included in the study. Tear osmolarity was measured with the TearLab system, lid-parallel conjunctival folds score was examined with the slit lamp, and then the classical diagnostic tests such as Schirmer I test, tear film break-up time, and corneal staining were carried out, followed by the examination of meibomian glands and corneal transparency.

RESULTS

Mean tear osmolarity was 296.77 ± 16.48 mOsm/L in NSSDE (15% abnormal), 303.36 ± 17.22 mOsm/L in SSDE (23% abnormal), and 303.52 ± 12.92 mOsm/L in the control group (16% abnormal; P = 0.018, Kruskal-Wallis). Schirmer test, corneal staining, tear film break-up time, and meibomian gland status were significantly different in the 2 patient groups when compared with those in the control group (P < 0.0001). In the control and SSDE groups, no significant correlation was disclosed between tear osmolarity and any of the dry eye tests performed.

CONCLUSIONS

Tear hyperosmolarity is considered a key factor that leads to dry eye symptoms and to the progression of clinical signs. Osmolarity measurements with the TearLab system disclosed no ability to distinguish between healthy individuals and patients with dry eye. This suggests that the TearLab device should not be used alone but in combination with classical dry eye tests.

Semi-quantitative evaluation of salivary gland function in Sjögren's syndrome using salivary gland scintigraphy

This retrospective study is designed to evaluate the diagnostic value of semi-quantitative parameters of salivary gland scintigraphy (SGS) in Sjögren's syndrome (SS) and explore the relationship between SGS parameters and salivary gland histopathologic manifestations. SGS and labial salivary gland biopsy were performed on 95 SS patients and 36 healthy age-matched and sex-matched volunteers. Uptake ratios at 15 min (UR(15)) and stimulated excretion fraction (EF) of each parotid and submandibular gland were calculated automatically from SGS; histopathologic grades were classified based on focal lymphocytic infiltration, and biopsy focus scores were calculated simultaneously. As a result, the UR(15) and EF of each salivary gland in SS patients were significantly lower than that in controls. Multivariate logistic regression equation was: logit p = 6.965 - 1.680 × UR(15) of left submandibular gland - 0.040 × EF of left parotid gland - 0.050 × EF of right submandibular gland. The receiver operating characteristic (ROC) curve validated high efficiency of this model with the area under curve of 0.911. And logistic regression analysis on combined original and validation cohorts confirmed its diagnostic value. Moreover, the EF of right parotid gland and both submandibular glands was correlated with histopathologic changes. Consequently, the semi-quantitative parameters of SGS may be helpful for diagnosing SS; UR(15) of left submandibular gland, EF of left parotid gland, and EF of right submandibular gland are more powerful predictor of SS. Besides, SGS parameters reflect the degree of salivary gland involvement, severe patients with low parameters would have high histopathologic grades and biopsy focus scores.

Comparison of the Schirmer I test with and without topical anesthesia for diagnosing dry eye

AIM

To determine the value of Schirmer I test (S I t) without anesthesia and with topical anesthesia for diagnosing dry eye (DE).

METHODS

Totally 220 eyes in 110 patients, male (44) and female (66), (39.56±12.67) years old diagnosed with DE were examined. S I t without anesthesia was performed firstly, and 15 minutes later, it was applied again in the same person after topical anesthesia with 0.5% proparacaine hydrochloride eye drops. The wetting strips counted <10mm per 5 minutes were defined positive, while ≤5mm per 5 minutes were defined strong positive.

RESULTS

The wetting length in S I t after topical anesthesia was significantly lower than that in S I t without anesthesia (P<0.001). The positive rate and strong positive rate of S I t after topical anesthesia were significantly higher than that of S I t without anesthesia (P<0.001). The positive rate and strong positive rate of S I t without anesthesia and the strong positive rate of S I t after topical anesthesia in patients with aqueous-deficiency dry eye (ADDE) were significantly higher than those in total patients whereas those in patients with evaporative dry eye (EDE) were significantly lower than those in total patients (P<0.001).

CONCLUSION

S I t after topical anesthesia with 0.5% proparacaine hydrochloride eye drops is more objective and reliable than that without anesthesia in reflecting the status of DE, and its diagnostic value in patients with ADDE was even higher, making itself a meaningful evidence for the diagnosis and treatment of DE.

A systematic review of methods to diagnose oral dryness and salivary gland function

Background

The most advocated clinical method for diagnosing salivary dysfunction is to quantitate unstimulated and stimulated whole saliva (sialometry). Since there is an expected and wide variation in salivary flow rates among individuals, the assessment of dysfunction can be difficult. The aim of this systematic review is to evaluate the quality of the evidence for the efficacy of diagnostic methods used to identify oral dryness.

Methods

A literature search, with specific indexing terms and a hand search, was conducted for publications that described a method to diagnose oral dryness. The electronic databases of PubMed, Cochrane Library, and Web of Science were used as data sources. Four reviewers selected publications on the basis of predetermined inclusion and exclusion criteria. Data were extracted from the selected publications using a protocol. Original studies were interpreted with the aid of Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool.

Results

The database searches resulted in 224 titles and abstracts. Of these abstracts, 80 publications were judged to meet the inclusion criteria and read in full. A total of 18 original studies were judged relevant and interpreted for this review. In all studies, the results of the test method were compared to those of a reference method.

Based on the interpretation (with the aid of the QUADAS tool) it can be reported that the patient selection criteria were not clearly described and the test or reference methods were not described in sufficient detail for it to be reproduced. None of the included studies reported information on uninterpretable/intermediate results nor data on observer or instrument variation. Seven of the studies presented their results as a percentage of correct diagnoses.

Conclusions

The evidence for the efficacy of clinical methods to assess oral dryness is sparse and it can be stated that improved standards for the reporting of diagnostic accuracy are needed in order to assure the methodological quality of studies. There is need for effective diagnostic criteria and functional tests in order to detect those individuals with oral dryness who may require oral treatment, such as alleviation of discomfort and/or prevention of diseases.

Diagnostic Approaches to Sjögren's syndrome: a Literature Review and Own Clinical Experience

OBJECTIVES

The purpose of present paper is to critically address the recent advances on diagnostic procedures of Sjögren's syndrome, taking into account the attained local and systemic features of the disease.

MATERIAL AND METHODS

A comprehensive review of the available literature regarding to the diagnostic approaches to Sjögren's syndrome was conducted. Eligible studies were identified by searching the electronic literature PubMed, Medline, Embase, and ScienceDirect databases for relevant reports (last search update January 2012) combining the MESH heading term "Sjögren's syndrome", with the words "diagnosis, diagnostic procedures, salivary gland function, ocular tests, histopathology, salivary gland imaging, serology". The authors checked the references of the selected articles to identify additional eligible publications and contacted the authors, if necessary.

RESULTS

Presented article addresses the established diagnostic criteria for Sjögren's syndrome and critically evaluates the most commonly used diagnostic procedures, presenting data from author's own clinical experience. Diagnostic criteria for Sjögren's syndrome are required both by healthcare professionals and patients, namely in order to provide a rational basis for the assessment of the symptoms, establish an individual disease prognosis, and orientate the therapeutic intervention.

CONCLUSIONS

Sjögren's syndrome is quite a common autoimmune disease of which the diagnosis and treatment are not easily established. Due to its systemic involvement, it can exhibit a wide range of clinical manifestations that contribute to confusion and delay in diagnosis. The use of proper diagnostic modalities will help to reduce the time to diagnosis and preserve the health and quality of life of patients with Sjögren's syndrome.

Ultrasonography of major salivary glands could be an alternative tool to sialoscintigraphy in the American-European classification criteria for primary Sjogren's syndrome

OBJECTIVE

To test the diagnostic accuracy of modified American-European classification criteria (AEC) for primary SS (pSS) by replacing sialoscintigraphy (sSC) with ultrasonography of the major salivary glands.

METHODS

One hundred and ninety subjects were evaluated for the diagnosis of pSS, including US of the salivary glands. We tested the diagnostic accuracy of the three different sets of five diagnostic criteria for pSS. Each set combined these four criteria (ocular symptoms, oral symptoms, Schirmer-I test and auto-SS-A antibody) and one of the following: US (US set), sSC (sSC set) or biopsy (Biopsy set). The area under the receiver operating characteristics curve (AUC-ROC) was used to evaluate the diagnostic accuracy of each set of criteria.

RESULTS

Out of 190 subjects examined, 140 subjects fulfilled the AEC for the diagnosis of pSS, whereas 50 subjects were classified as non-pSS subjects. US score was positive in 129 (92%), sSC in 123 (88%) and biopsy in 93 (66%) of 140 pSS patients. Among 140 patients with pSS, 88 (63%) patients fulfilled the criteria of the US set, 85 (61%) patients of the sSC set and 71 (51%) patients of the Biopsy set. None of the subjects from the non-pSS group fulfilled any of the sets of criteria. Diagnostic accuracy of each of the three sets of criteria was high and similar [AUC-ROC (s.e.) for the US set was 0.99 (0.00), followed by the sSC set at 0.98 (0.00) and the Biopsy set at 0.97 (0.00)].

CONCLUSION

US finding of major salivary gland involvement could replace sSC in AEC for the diagnosis of pSS.

Diagnosing dry eye with dynamic-area high-speed videokeratoscopy

Dry eye syndrome is one of the most commonly reported eye health conditions. Dynamic-area high-speed videokeratoscopy (DA-HSV) represents a promising alternative to the most invasive clinical methods for the assessment of the tear film surface quality (TFSQ), particularly as Placido-disk videokeratoscopy is both relatively inexpensive and widely used for corneal topography assessment. Hence, improving this technique to diagnose dry eye is of clinical significance and the aim of this work. First, a novel ray-tracing model is proposed that simulates the formation of a Placido image. This model shows the relationship between tear film topography changes and the obtained Placido image and serves as a benchmark for the assessment of indicators of the ring's regularity. Further, a novel block-feature TFSQ indicator is proposed for detecting dry eye from a series of DA-HSV measurements. The results of the new indicator evaluated on data from a retrospective clinical study, which contains 22 normal and 12 dry eyes, have shown a substantial improvement of the proposed technique to discriminate dry eye from normal tear film subjects. The best discrimination was obtained under suppressed blinking conditions. In conclusion, this work highlights the potential of the DA-HSV as a clinical tool to diagnose dry eye syndrome.