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

[Lymphoma's manifestations in Sjögren's syndrome: is there a relation?]

Sjögren's Syndrome (SS) is considered a multisystemic chronic disorder, which is characterized by a lymphocytic infiltration of exocrine glands and autoantibodies production.

AIM

Several studies have demonstrated increased incidence of Lymphoma in SS patients. Our study tries to determine this relation.

STUDY DESIGN

Transversal cohort.

MATERIAL AND METHOD

Patients with Sicca's Syndrome from the Stomathology service, Santa Casa de Misericórdia Hospital, in Sao Paulo, ENT Department, from July 1999 to April 2002.

RESULTS

Out of 39 patients, 24 were diagnose as SS. Ages ranged from 19 to 83 years old, with predominance of women (69.7%). Time between the first symptoms and SS diagnosis were variable, ranging within 3.77 years. None of the analyzed patients developed lymphoma.

CONCLUSION

Both SS early diagnosis and the increased risk of lymphoma's development in those patients are important, reason why long-term follow-up is essential. We observed that our findings were different from those in the literature. We did not detect any cases of lymphoma in our patients.

Validity of stimulated whole saliva collection as a sialometric evaluation for diagnosing Sjögren's syndrome

OBJECTIVE

The purposes were to compare the practice effect of stimulated whole saliva collection (SWSC) with unstimulated whole saliva collection (UWSC), and to investigate the validity of the tests as a criterion in the diagnosis of Sjogren's syndrome (SS), allowing for the practice effect.

STUDY DESIGN

SWSC (n = 34) or UWSC (n = 27) was performed 3 times on healthy volunteers to investigate practice effects; then the differences among the 3 measurements were analyzed. For evaluating the validity of the tests, UWSC and SWSC were performed alternately on 28 SS patients and 34 control subjects, all of whom had had a practice SWSC before the actual test; then the sensitivity and specificity of both tests as a criterion in the diagnosis of SS were calculated.

RESULTS

A practice effect was observed for SWSC, but not for UWSC. When an orientation measurement was performed before the actual SWSC, there was no statistically significant difference between the accuracy of SWSC and UWSC as a criterion in the diagnosis of SS.

CONCLUSION

If an orientation measurement is performed before the actual measurement, SWSC can be as valid a test for sialometric evaluation in the diagnosis of SS as UWSC.

Ultrasonographic changes of major salivary glands in primary Sjögren's syndrome. Diagnostic value of a novel scoring system

OBJECTIVES

To reveal typical ultrasonographic (US) changes in major salivary glands associated with Sjogren's syndrome (SS) and to determine the diagnostic value of a novel US scoring system.

METHODS

In 218 consecutive patients with suspected SS, US of both parotid and submandibular salivary glands was performed besides the regular diagnostic procedure following the American-European Consensus Group criteria of 2002. Five US parameters were assessed: echogenicity, inhomogeneity, number of hypoechogenic areas, the hyperechogenic reflections and clearness of the borders of the salivary gland. The grades of these five parameters for all four salivary glands were summed. The final US score ranged from 0 to 48.

RESULTS

SS was established in 68 patients. The remaining 150 subjects, in whom SS was not confirmed, constituted our control group. All five US parameters were significantly associated with SS. The patients with SS had significantly higher US scores than those not diagnosed with SS (P<0.01). Setting the cut-off US score at 17 resulted in the best ratio of specificity (98.7%) to sensitivity (58.8%).

CONCLUSIONS

Well-defined US changes in the major salivary glands summarized in our novel scoring system were typical of SS patients. Advanced structural changes found on US imaging almost invariably represent SS salivary gland involvement.

Multilevel examination of minor salivary gland biopsy for Sjogren's syndrome significantly improves diagnostic performance of AECG classification criteria

The recently observed low reproducibility of focus score (FS) assessment at different section depths in a series of single minor salivary gland biopsies highlighted the need for a standardized protocol of extensive histopathological examination of such biopsies in Sjögren's syndrome. For this purpose, a cumulative focus score (cFS) was evaluated on three slides cut at 200-μm intervals from each of a series of 120 salivary biopsies. The cFS was substituted for the baseline FS in the American–European Consensus Group (AECG) criteria set for Sjögren's syndrome classification, and then test specificity and sensitivity were assessed against clinical patient re-evaluation. Test performances of the AECG classification with the original FS and the score obtained after multilevel examination were statistically compared using receiver operating characteristic (ROC) curve analysis. The diagnostic performance of AECG classification significantly improved when the cFS was entered in the AECG classification; the improvement was mostly due to increased specificity in biopsies with a baseline FS ≥ 1 but <2. The assessment of a cFS obtained at three different section levels on minor salivary gland biopsies can be useful especially in biopsies with baseline FSs between 1 and 2.

The Lack of Association Between Signs and Symptoms in Patients With Dry Eye Disease

BACKGROUND

The purpose of this report was to examine the relation between clinical tests and dry eye symptoms in patients with dry eye disease.

METHODS

Seventy-five patients with dry eye disease (ICD-9 code 375.15) were included in these analyses. There was no specific entry criterion for enrollment in addition to a previous dry eye diagnosis in this clinic-based sample. Patients represented varying types and severity of dry eye disease and were previously diagnosed by clinic attending doctors in this university clinic setting. The study examination included a symptom interview that assessed dryness, grittiness, soreness, redness, and ocular fatigue. The interview was followed by a clinical dry eye examination conducted in the following sequence: meibomian gland assessment, tear meniscus height, tear breakup time test, fluorescein staining, the phenol red thread test, Schirmer test, and rose bengal staining. Partial Spearman correlation coefficients, the Wilcoxon rank sum test, chi 2 test, and multivariate logistic regression were used to evaluate the relationship between dry eye tests and symptoms.

RESULTS

Symptoms were generally not associated with clinical signs in patients with dry eye disease. There were no significant correlations between signs and symptoms after adjustment for age and artificial tear use. The rank of each clinical test result did not statistically differ when stratified by the presence of patient symptoms in Wilcoxon rank sum analyses. Likewise, the frequency of patient symptoms did not differ statistically when stratified by a positive clinical test result in chi 2 analyses. In multivariate logistic regression analyses, no clinical test significantly predicted frequently reported symptoms after adjustment for age and artificial tear use.

CONCLUSIONS

These results suggest a poor relation between dry eye tests and symptoms, which represents a quandary in dry eye clinical research and practice.

Prevalence of Sjogren's syndrome in ambulatory patients according to the American-European Consensus Group criteria

OBJECTIVE

To estimate the prevalence of Sjögren's syndrome (SS) in ambulatory patients attending a tertiary care centre, according to the American-European Consensus Group criteria, using a structured approach.

METHODS

Three hundred patients from rheumatology and internal medicine clinics were randomly chosen. During the screening phase, a face-to-face interview, a screening questionnaire, a Schirmer-I test and a wafer test were carried out in all patients. During the second phase, patients with positive screening had confirmatory tests including fluorescein staining test, non-stimulated whole salivary flow and autoantibody testing. Confirmatory tests were also done in 13 patients with negative screening. In the last phase, lip biopsy was proposed to those patients who met pre-established criteria.

RESULTS

Females constituted 79% of the study population. The mean age of the subjects was 42.8+/-15.7 yr. Two hundred and twenty patients (73%) had positive screening. Fifty-five (27%) out of 204 patients evaluated showed keratoconjunctivitis sicca and 28 (13%) out of 215 patients xerostomia. One hundred and sixty-eight patients met criteria for lip biopsy and it was performed in 80 subjects who accepted the procedure. Focal sialoadenitis was demonstrated in 39 patients (49%), but only 28 of them met criteria for SS. In total, 40 patients were classified as SS. The minimum prevalence of SS in the population studied was 13.3% (95% CI 9.5-17.1%). The structured approach used in this study allowed 24 (60%) undiagnosed cases of SS to be identified.

CONCLUSION

SS is common among ambulatory patients attending a tertiary care centre and in most of them it is undiagnosed.

Increased expression of the B-cell-regulatory molecule CD72 in primary Sjögren's syndrome

To determine whether there is an intrinsic abnormality of B-cell signaling in primary Sjögren's syndrome (pSS), the expression of B-cell coreceptors was determined in patients with primary Sjögren's syndrome and healthy and disease controls. Peripheral blood mononuclear cells were labeled with monoclonal antibodies to CD21, CD22, or CD72, and then the pan B-cell marker CD19. The expression of these coreceptors on the total CD19(+) population was determined. There was a significant increased expression of CD72 on the B cells of pSS patients (MFI, 215 +/- 6) compared to normal controls (MFI, 141 +/- 6). The increased CD72 expression was disease specific for pSS, as it was not observed in systemic lupus erythematosus or rheumatoid arthritis. The effect of B-cell stimulation on coreceptor expression was determined by culturing cells with B-lymphocyte-activating factor (BAFF) and/or pokeweed mitogen (PWM) or without either. Following culture, CD72 expression was decreased in both pSS and normal controls, regardless of the presence of BAFF or PWM. The upregulation of CD72 in pSS might be a compensatory response to increased B-cell receptor stimulation or a primary abnormality leading to uncontrolled B-cell activation.

Comparison of the NEI-VFQ and OSDI questionnaires in patients with Sjögren's syndrome-related dry eye

Background

To examine the associations between vision-targeted health-related quality of life (VT-HRQ) and ocular surface parameters in patients with Sjögren's syndrome, a systemic autoimmune disease characterized by dry eye and dry mouth.

Methods

Forty-two patients fulfilling European / American diagnostic criteria for Sjögren's syndrome underwent Schirmer testing without anesthesia, ocular surface vital dye staining; and measurement of tear film breakup time (TBUT). Subjects were administered the Ocular Surface Disease Index (OSDI) and the 25-item National Eye Institute Vision Functioning Questionnaire (NEI-VFQ). Main outcome measures included ocular surface parameters, OSDI subscales describing ocular discomfort (OSDI-symptoms), vision-related function (OSDI-function), and environmental triggers, and NEI-VFQ subscales.

Results

Participants (aged 31–81 y; 95% female) all had moderate to severe dry eye. Associations of OSDI subscales with the ocular parameters were modest (Spearman r (ρ) < 0.22) and not statistically significant. Associations of NEI-VFQ subscales with the ocular parameters reached borderline significance for the near vision subscale with TBUT (ρ = 0.32, p = .05) and for the distance vision subscale with van Bijsterveld score (ρ = 0.33, p = .04). The strongest associations of the two questionnaires were for: ocular pain and mental function with OSDI-symptoms (ρ = 0.60 and 0.45, respectively); and general vision, ocular pain, mental function, role function, and driving with OSDI-function (ρ = 0.60, 0.50, 0.61, 0.64, 0.57, and 0.67, respectively).

Conclusions

Associations between conventional objective measures of dry eye and VT-HRQ were modest. The generic NEI-VFQ was similar to the disease-specific OSDI in its ability to measure the impact of Sjögren's syndrome-related dry eye on VT-HRQ.

Eye trigeminal sensitivity, tear film stability and conjunctival epithelium damage in 182 non-allergic, non-smoking Danes

The population distributions of CO(2)-induced irritation sensitivity in the eyes (COI), tear film stability (break-up time, BUT), and epithelium damage (ED) and the relation of these to basic potential confounders were assessed in an age- and gender-stratified random sample of citizens in Aarhus County, Denmark. One hundred eighty-two non-allergic, non-smoking persons participated. A general health questionnaire and an indoor air questionnaire was filled out before the measurements. The BUT was non-normally distributed, as was COI at 16% CO(2) and single ED-scores. However, COI average for all levels was normally distributed and the total score for ED was only marginally deviating. BUT decreased, the threshold to CO(2) increased, and irritation intensity at CO(2) eye exposure decreased with increasing age. ED was increased among women. There were no internal relations between the three measures, but reduced BUT was seen among subjects rating high levels of exposure to dust, electrostatic fields, and dry air. ED decreased by perceived unpleasant odors and increased with experiences of high temperatures. CO(2) sensitivity increased by perceived draught, dry air, and noise exposure prior to measurements. Selection bias cannot be excluded and the results may therefore not be truly representative of the general population. However, the results may be used as reference data for future use of measurements of break-up time, epithelium defects, and CO(2) sensitivity of the eyes in the indoor air.

PRACTICAL IMPLICATIONS

The most direct implication is that results can be used as reference level for measurements in problem buildings and for individual measurements. The reference can also be used in research and the other results as basis for future hypotheses and for support of existing hypotheses.

New Insights into the Diagnosis and Treatment of Dry Eye

Over the past decade, numerous advances have been made in relation to dry eye diagnostic markers, technologies, and treatment options. The mainstay of treatment of dry eye is the use of artificial tear solutions and punctum plugs. A goal is the development of agents that provide symptomatic treatment and, at the same time, improve ocular surface keratinization. It is the authors' opinion that the functional visual acuity tester and the new tear stability analysis system will be widely used to improve diagnosis and evaluate treatment outcomes in KCS. Advances in treatment will utilize anti-inflammatory agents, immune suppressants such as Cyclosporin A and FK-506, growth hormones, androgens, topical mucins and ocular surface stimulating drugs, like INS365. Although aqueous-deficient dry eye is most commonly not associated with Sjogren syndrome (SS), aqueous-deficient dry eye is often most severe in patients with SS; thus, this article focuses mainly on SS-associated dry eye.

Quantitative ultrasonography and magnetic resonance imaging of the parotid gland: can they replace the histopathologic studies in patients with Sjogren’s syndrome?

OBJECTIVE

To assess the diagnostic value of parotid gland quantitative assessment using ultrasound (US) as well as magnetic resonance imaging (MRI) in patients with Sjogren's syndrome (SS) and to evaluate the possibility of using such modalities as a predictor of the histopathologic score of salivary gland biopsy in this group of patients.

METHODS

Sonographic and MRI studies were performed on the parotid glands of 47 patients diagnosed to have primary SS, 20 healthy control subjects of matched sex and age, and 20 subjects with sicca symptoms but without any evidence of SS. The patients and the control subjects were scored according to the structural changes seen in both radiologic modalities. In addition, sialography and labial gland biopsy were done for all patients as well as the control subjects and scored according to the degree of affection.

RESULTS

Parenchymal inhomogenity (PIH) was seen in 93.6% of the patients studied by US, while nodular pattern was seen in 97.8% in the MRI study. The US and MRI results correlated significantly with the histopathologic score of the minor salivary glands (r = 0.82, 0.84, respectively) as well as sialography score (r = 0.69, 0.60, respectively). There was good agreement between US and MRI findings (r = 0.87) in both SS cases and control subjects.

CONCLUSION

US and MRI are equally sensitive tools for the diagnosis of salivary involvement in patients with SS. Quantitative assessment of US and MRI images seem to represent an advance in the diagnosis of SS as they offer a good prediction of the pathology score of the salivary gland. MRI seems unnecessary as a routine diagnostic tool and should be considered as the second option in case of normal US.

The Effect of Artificial Tears on Visual Performance in Normal Subjects Wearing Contact Lenses

PURPOSE

Disruption of the anterior refracting surface of the eye reduces visual performance. In the case of a contact lens wearer, this surface is the prelens tear film. This study determined whether artificial tears stabilize the tear film in contact lens wearers and maintained optimal visual performance for a prolonged period.

METHODS

Five normal subjects all in good general and ocular health and adapted to contact lens wear were fitted with Acuvue lenses. A temporal, two-alternative, forced-choice paradigm was used to measure contrast sensitivity. The stimuli were vertically oriented sine-wave gratings (between 0.5 and 14 cpd) presented for 16.67 ms. The stimuli were presented at two different times after blink detection: 2 s after blink detection (i.e., before tear layer break-up) or 4 s after tear film break-up. Three conditions were investigated at 4 s after tear layer break-up: (1) without artificial tears added, (2) with Clerz2 (Ciba Vision) instilled, and (3) with Sensitive Eyes (Bausch & Lomb) applied. The artificial tears were instilled at 10-min intervals during the experimental run.

RESULTS

High spatial frequency contrast sensitivity was found to be reduced after tear film break-up and was not enhanced by either tear solution.

CONCLUSIONS

This study indicates that there is no effect of Clerz2 or Sensitive Eyes in maintaining or improving visual performance beyond the normal prelens tear film break-up time in normal subjects wearing Acuvue lenses.

The relation between tear film tests in patients with dry eye disease

PURPOSE

The purpose of this report was to investigate the relation between dry eye diagnostic tests.

METHODS

Dry eye patients were enrolled to complete a clinical examination, including the following dry eye tests: a meibomian gland evaluation, tear meniscus height, fluorescein tear breakup time, fluorescein staining of the cornea, the Schirmer 1 test, the phenol red thread test, and rose bengal staining of the conjunctiva. Statistical analyses, including correlation coefficients, the Wilcoxon sign rank test, chi-square test, and logistic regression were used to address the relation between these clinical tests of dry eye.

RESULTS

There was a strong relation between the Schirmer test and fluorescein staining in all four statistical analyses. Similarly, there was also a strong relation between the phenol red thread test and both fluorescein and rose bengal staining. Finally, the results of the Schirmer test were associated with the tear breakup time test in three of four analyses.

CONCLUSIONS

The results indicate that tests of aqueous deficiency (volume or production) are associated with ocular surface desiccation. This important relation should be recognized when choosing dry eye tests as outcomes in clinical trials and epidemiological studies.

Salivary gland scintigraphy in Sjögren's syndrome: are quantitative indices the answer?

We evaluated the role of quantitative indices derived from dynamic 99mTc-pertechnetate salivary scintigraphy in the differentiation between a group of patients with Sjögren's syndrome (SS), a group of patients without xerostomia, but with underlying autoimmune disorders, and a group of controls. Seventeen patients with SS (group A), 18 patients with autoimmune disorders (group B) and 15 controls (group C) underwent dynamic salivary gland scintigraphy. Functional indices for the parotid and submandibular glands were calculated and comparisons were made between the groups. There were no significant differences between the three groups in terms of the maximum accumulation (MA), maximum secretion (MS) and pre-stimulatory oral index (PRI). The uptake ratios (URs) for both the right and left parotid glands and the left submandibular gland in group A were significantly lower than those in group C, but no different from those in group B. The URs for the parotid glands in group B were significantly less than those in group C. The percentage uptake by the right parotid gland at 4 min (U4) was significantly lower in group A than in groups B or C, and lower than the percentage uptake by the left parotid gland at 4 min in group A. The rest of the U4 values and all of the uptakes at 14 min (U14) were not significantly different between the three groups. The time taken for the right parotid gland to reach peak activity (Tmax) was significantly less in group A than in the other groups, but other glands showed no significant differences. It can be concluded that MA, MS and PRI cannot be used to differentiate between the three groups. The URs in groups A and B were no different, but were significantly lower than those in group C. However, the extensive overlap between xerostomic patients and normal controls for all the quantitative indices calculated imposes a severe limitation on their discriminatory power.

Salivary and serum beta2-microglobulin and gamma-glutamyl-transferase in patients with primary Sjögren syndrome and Sjögren syndrome secondary to systemic lupus erythematosus

BACKGROUND

Sialochemistry has been proposed as a simple and useful tool for the diagnosis of Sjögren syndrome (SS). Although many changes have been detected in several constituents of saliva from patients with SS, none are individually sensitive or specific enough for diagnosing SS. The aim of this study was to assess the value of the combined determination of beta2-microglobulin (beta2m) and gamma-glutamyl-transferase (GGT) activity in serum and saliva as a diagnostic instrument for differentiating primary and secondary [to systemic lupus erythematosus (SLE)] SS patients from normal subjects.

METHODS

Nineteen primary SS (pSS) patients, 15 patients with SS secondary to SLE, and 25 SLE patients without SS were studied. Thirty healthy subjects were included in the study as control group.

RESULTS

By means of a mathematical model, (a) 84.1%, (b) 85.7%, and (c) 87.0% of patients were correctly classified as SS or normal when (a) salivary beta2m and GGT values, (b) serum beta2m and salivary GGT values, and (c) salivary beta2m and GGT along with serum beta2m values, respectively, were considered. To differentiate between pSS and sSS by means of the mathematical model, the combination of serum beta2m and salivary GGT values achieved that 81.8% of the patients were correctly classified.

CONCLUSION

Since sialochemistry is an easy, safe and reliable test, the combined determination of beta2m and GGT in saliva and serum was useful for differentiating SS patients from normal subjects, but not excessively good for differentiating pSS from sSS patients.

Use of retroillumination to visualize optical aberrations caused by tear film break-up

PURPOSE

The aim of the current study was to develop quantitative methods to assess optical aberrations caused by tear film disruption.

METHODS

We used standard fluorescein imaging (FL) and a novel retroillumination (RI) method to image tear film disruption in 12 eyes. Using a clinical slit lamp biomicroscope, we alternated between widefield blue and narrow-beam white light to obtain an interleaved series of FL and RI images of the time course and pattern of tear film break-up. We developed an optical analysis that indicates that the RI image should be proportional to the spatial derivative of the FL image. Intensity fluctuations in the RI images are due to thickness changes in the tear film, whereas intensity fluctuations in FL images are directly determined by tear film thickness.

RESULTS

As predicted by optical analysis of RI, the spatial distribution of gaps in the tear film seen with fluorescein appeared as pairs of light and dark contours in the RI images, and a precise correspondence between the spatial derivative of the FL image (slope) and the RI image was found. Both methods showed a gradual spreading of the tear disruption during blink suppression that varied tremendously among eyes in both time and spatial pattern. Resumption of normal blinking did not produce an immediate reconstitution of the normal tear film, and areas of tear break-up created during blink suppression remained abnormal for up to several minutes of normal blinking.

CONCLUSIONS

Our analysis indicates that both FL and RI have the potential to quantify optical changes occurring during tear break-up. These results support an interpretation of RI as an intensity-based method for mapping the highly irregular optical aberrations of the eye produced by tear film disruption.

Pathogenesis of Sjögren's syndrome

The pathogenesis of Sjögren's syndrome is poorly understood. Genetic and environmental factors appear to contribute to the development of this syndrome. Viral infection is one of the most likely environmental factors. The primary lesion of Sjögren's syndrome is in the exocrine glands. A majority of the infiltrating cells in the lesion are CD(4+) CD45RO(+) memory T cells. Although antigen-presentation to T cells seems to occur in the exocrine tissues, these T cells are not fully activated. On the other hand, B cells comprise approximately 20% of the infiltrating cells, and several features of this syndrome are attributed to stimulated B cells. The presence of autoantibodies, such as anti-SS-A/Ro and SS-B/La antibodies, is one of the characteristic features and is associated with severe disorders. Some antibodies appear to play a direct pathogenic role, for example, in cases of congenital heart block and sicca symptoms. Chronic inflammation with possible T cell-dependent antigen stimulation appears to induce neoplastic transformation of lymphocytes.

Photoprovocation test and immunohistochemical analysis of inducible nitric oxide synthase expression in patients with Sjögren's syndrome associated with photosensitivity

BACKGROUND

Annular erythema (AE) in Sjögren's syndrome (SS) usually develops on areas of sun-exposed skin and is exacerbated during summer.

OBJECTIVES

To evaluate photosensitivity in SS and to investigate the involvement of ultraviolet (UV) radiation in the development of AE in SS.

METHODS

Phototesting with UVA and UVB was performed on 14 SS patients, including 10 with primary SS. Clinical and histological features as well as expression of inducible nitric oxide synthase (iNOS) in the evoked skin lesions were compared with those of lupus erythematosus (LE). Eleven SS patients had a history of photosensitive AE (n = 4), papules (n = 3) or other types (n = 4) of lesions on their sun-exposed skin that were induced or aggravated by sunlight exposure.

RESULTS

Phototesting induced a prolonged erythematous response (n = 8), infiltrated erythema (IE) (n = 4) and/or papules (n = 3) in 11 of 14 SS patients, including one with primary SS without a history of photosensitivity. Histologically, the induced IE and papules showed coat-sleeve-like or sparse perivascular infiltration of lymphocytes similar to that in primary skin lesions of AE in SS. No epidermal changes characteristic for LE were found except for partial and mild liquefaction degeneration in three cases. In contrast, two cases were indistinguishable from the papular type of polymorphic light eruption in several aspects, including their primary skin lesions and early response to a photoprovocation test. Immunohistochemistry revealed diffuse expression of iNOS throughout the epidermis, which is characteristic for LE, in the three SS patients with minimal liquefaction degeneration, while the remaining seven SS patients examined exhibited no iNOS staining or a normal expression pattern.

CONCLUSIONS

Our results indicate that photosensitivity exists in certain primary SS patients, and that UV is critical to the development of AE in SS, probably through a pathological mechanism distinct from that in LE.

[Diagnosis of the Mikulicz-Sjogren syndrome using biopsy of the minor salivary glands]

BACKGROUND

Sjögren's syndrome (SS) represents autoimmune disease characterized by chronic inflammation, destruction and insufficiency of exocrine glands, particularly salivary and lacrimal glands, accompanied by dryness of mouths and eyes. Diagnostic work-up involves clinical laboratory tests, radiography, scintigraphy and bioptic histopathological examination. Examination of small salivary glands in the biopsy of the lower lip represents a "golden standard" of diagnosis of SS, concerning the fact that the growth and the disfunction of salivary and lacrimal glands occurs in different pathologic states.

METHODS

Resected specimens of the lower lip were obtained from 47 patients with clinical diagnosis of SS. After standard histopathological treatment, slices were hematoxylin and eosin stained. Immunohistochemistry against smooth muscle actin was performed using LSAB+ method (AHSMA-M7558, DAKO 1:50). On the basis of generally accepted histopathological diagnostic criteria the results were categorized as: findings suspicious for SS; findings compatible with the diagnosis of SS (mild, moderate and high degree of inflammation); nonspecific inflammatory reaction and nonrepresentative biopsy samples.

RESULTS

Diagnosis of SS was confirmed in 32% of cases. In 2% of cases findings were suspected for SS, in 36% of cases findings were compatible with the diagnosis of nonspecific inflammation, and in 30% of cases material was not representative.

CONCLUSIONS

By the biopsy of salivary glands of the lower lip the diagnosis of SS was confirmed in 50-60% of cases. Upon the precise diagnostic criteria it was also possible to determine the intensity of inflammation and tissue destruction in SS and identify other pathological conditions, which justified the biopsy. Surgical technique had to be adequate in order to obtain representative number of small salivary glands. In the presented material 30% of specimens were nonrepresentative which was very high percentage compared with literature data. This was most probably the reason why the diagnosis of SS was confirmed in only 32% of cases, i.e., in every third patient.

Use of the dry eye questionnaire to measure symptoms of ocular irritation in patients with aqueous tear deficient dry eye

PURPOSE

To demonstrate the ability of the Dry Eye Questionnaire (DEQ) to characterize the frequency of ocular surface symptoms and their diurnal intensity in patients with Sjögren's syndrome (SS), keratoconjunctivitis sicca (KCS), and age-matched controls.

METHODS

One hundred patients with tear-deficient dry eye from Toronto Western Hospital were mailed the DEQ and the McMonnies' questionnaire (MQ). Age- and gender-matched controls were selected from an historical data set. The DEQ measured the habitual frequency, intensity, and impact of common ocular surface symptoms and asked questions about computer use, medications, and allergies.

RESULTS

Sixty-two dry eye subjects responded; 30 with SS and 32 with KCS. Compared with controls, SS subjects consistently reported the highest frequency and intensity of symptoms, followed by non-KCS subjects. The intensity of symptoms was significantly greater in the evening than in the morning among SS subjects for all symptoms except dryness and light sensitivity (p < 0.05). Sixty percent of SS subjects reported the need to stop daily activities and close their eyes due to dryness, burning, and light sensitivity.

CONCLUSIONS

Symptoms of ocular irritation were frequent and intense among SS and KCS subjects. These symptoms often increased in intensity over the day, suggesting that open-eye conditions affect the progression of symptoms. Measurement of symptom frequency and diurnal intensity by the DEQ provides a sensitive tool that may be useful in clinical treatment trials for dry eye.

Parotid sialography for diagnosing Sjögren syndrome

OBJECTIVE

Despite the availability of many new imaging procedures, sialography has, after decades of use, maintained its status as the imaging procedure of choice for evaluating the oral component of Sjögren syndrome (SS). In this study, the clinical value of sialography as a diagnostic tool in SS was explored by assessing its diagnostic accuracy, observer bias, and staging potential.

METHODS

One hundred parotid sialograms were interpreted independently in a blinded fashion by 2 trained and 2 expert observers. Sialograms were derived from a group of consecutive patients referred for diagnostics of SS. Patients were categorized as SS and non-SS by the revised European classification criteria.

RESULTS

Trained observers reached a sensitivity of 95 and a specificity of 33% for SS by sialogram, whereas expert observers reached a sensitivity of 87 and a specificity of 84%. There was only "fair" interobserver agreement between trained and expert observers, whereas both expert observers showed "good" agreement with one another, according to Cohen's kappa. Intraobserver agreement was "good" to "very good" for all observers. The 4 different gradations of sialectasia, ie, punctate, globular, cavitary, and destructive, showed a weak but significant correlation with the duration of oral symptoms.

CONCLUSIONS

This study markedly shows that the diagnostic value of parotid sialography for diagnosing SS greatly depends on the skills of the observer, implying that sialography lacks general applicability as a diagnostic tool in SS and requires specific expertise. Nevertheless, given its potentially high sensitivity and specificity in diagnosing SS as well as its useful staging potential, sialography still has its use in the evaluation of the oral component of SS.

Contact lens drying and visual performance: the vision cycle with contact lenses

BACKGROUND AND PURPOSE

The purpose of this study was to measure the effect of precontact lens tear film break-up on visual performance.

METHODS

Four asymptomatic soft contact lens wearers had contrast sensitivity measured by a temporal, two-alternative, force choice paradigm combined with a self-paced methods of limits. Stimuli were vertically orientated sine wave gratings (0.5 to 14 cycles per degree [cpd] presented for 16.67 ms. Contrast sensitivity was measured before precontact lens tear break-up by a stimuli presented 2 s after the blink. A post-tear layer break-up measurement taken with the stimuli presented after break-up had been observed by the use of a video camera attached to a Tearscope.

RESULTS

Contrast sensitivity was found to be reduced following precontact lens tear film break-up for stimuli of 4, 6, and 10 cpd; the data approached significance at 14 cpd. Further reductions in contrast sensitivity were observed for one subject when measurements were continued for 4 s following break-up.

CONCLUSIONS

Contrast sensitivity is significantly reduced for middle to high spatial frequencies when the precontact lens tear film dries and breaks up. The combination of observations of visual performance immediately following the blink (from earlier experiments) and measurements following tear film break-up in this experiment allows description of a "vision cycle" for contact lens wearers in the interval between blinks. It is suggested that break-up of the precontact lens tear film could account for the complaints of intermittent blurred vision in some contact lens wearers and may provide a stimulus to blinking in these individuals.

TAP, HLA-DQB1, and HLA-DRB1 polymorphism in Colombian patients with primary Sjögren's syndrome

OBJECTIVE

Although primary Sjögren's syndrome (pSS) has a worldwide distribution, little data is available on pSS immunogenetics in non-white populations. Thus, we investigated the influence of transporters associated with antigen processing (TAP), human leukocyte antigen (HLA)-DQB1, and HLA-DRB1 gene polymorphism in mestizo Colombian patients with pSS.

METHODS

In this cross-sectional and controlled study, all patients met the European criteria for classification of pSS. TAP and HLA typing was performed by polymerase chain reaction techniques. Genetic data analysis was performed to detect deviations from the expected Hardy-Weinberg (H-W) proportions and to determine the presence of population stratification or subdivision and the existence of linkage disequilibrium between pairs of loci.

RESULTS

Seventy-three Colombian patients with pSS (95% women) and 76 healthy controls were studied. Although significant associations were not observed between TAP or HLA polymorphism and disease, strong linkage disequilibrium among the loci TAP2 and DQB1 was found in patients. Deviations from the H-W expected value were found in the DQB1 locus of patients (P =.02). HLA-DRB1*0301-DQB1*0201 haplotype was associated with more severe histopathologic disease (odds ratio [OR], 15.5; 95% confidence interval [CI], 1.9-129; P =.001) and the presence of anti-Ro (OR, 3.8; 95% CI, 1-15; P =.04) and anti-La antibodies (OR, 4.3; 95% CI, 1.3-14; P =.01).

CONCLUSION

The data show genetic evidence suggesting that, in Colombians, a region immersed or in the vicinity in the HLA class II system is strongly associated with a predisposition to acquire pSS, which is probably located between the TAP2 and HLA-DQB1 locus. Our results confirm that the HLA-DRB1*0301-DQB1*0201 haplotype participates in the pathogenesis of pSS.

Current issues in Sjögren's syndrome

Sjögren's syndrome is a chronic autoimmune and rheumatic disorder with prominent sicca complaints from the mucous membranes because of lack of proper exocrine secretions. There is no straightforward and simple diagnostic test for Sjögren's syndrome, although several classification criteria have been designed including several oral diagnostic tests. A new set of classification criteria in a joint effort by research groups in Europe and USA has recently been presented. A large number of autoantibodies have been reported in Sjögren's syndrome where, in some cases, the antibodies are correlated with the extent and severity of disease. The finding of serum autoantibodies directed against the muscarinic M3 receptor is an important advance in understanding the pathogenesis of not only the impaired glandular function but also associated features of autonomic dysfunction in some patients. The treatment of primary Sjögren's syndrome is still mainly symptomatic.

Decreased thyroid uptake of Tc-99m pertechnetate in patients with advanced-stage Sjögren syndrome: evaluation using salivary gland scintigraphy

PURPOSE

The authors assessed the uptake of Tc-99m pertechnetate in the thyroid using salivary gland scintigraphy in patients with Sjögren syndrome and in healthy controls.

MATERIALS AND METHODS

Salivary gland scintigraphy and a labial biopsy were performed in 73 patients with Sjögren syndrome. Based on the labial biopsy findings, 32 patients with a histopathologic grade of 1 or 2 were regarded as having early-stage Sjögren syndrome and 41 patients with a grade of 3 or 4 were regarded as having an advanced stage. After the administration of 370 MBq (10 mCi) Tc-99m pertechnetate, dynamic salivary gland scintigraphy was performed for 50 minutes. Lemon juice was used to stimulate the salivary glands, and the thyroid gland was included in the imaging area. Scintigraphy was also performed in an age- and sex-matched control group of 25 healthy persons. The thyroid uptake ratio was calculated for the scintigraphic images and compared among the three groups: healthy controls, patients with early-stage Sjögren syndrome, and those with advanced-stage Sjögren syndrome.

RESULTS

When compared with the control group, the thyroid uptake ratio of the early-stage Sjögren syndrome group was not significantly different, whereas that of the advanced-stage group was significantly lower.

CONCLUSIONS

Thyroid uptake of Tc-99m pertechnetate was less in patients with advanced-stage Sjögren syndrome than in patients with early-stage Sjögren syndrome or in healthy controls. Measuring the thyroid uptake of Tc-99m pertechnetate using salivary gland scintigraphy is an easy and useful method for assessing thyroid disorders in Sjögren syndrome and thus should be performed routinely.

The oral side of Sjögren syndrome. Diagnosis and treatment. A review

Sjögren syndrome (SS) is an inflammatory disease of the exocrine glands. Although not always present, signs and symptoms of dry eyes and xerostomia are characteristic features of SS. Oral dryness is one of the most important data of patients with SS. Several sets of criteria have been published; however, there is no definitive agreement concerning which is the most useful. In addition to its various clinical manifestations, lack of understanding of the causes of SS delays prompt diagnosis. Histologically, the salivary gland shows a characteristic lymphocytic infiltrate, which is implicated in the destruction of gland cells. Saliva performs an important role in maintaining and protecting oral health. Deficient quality and quantity of saliva have a detrimental consequence for dental and oral health. In some patients, appropriate information regarding dry mouth care is not offered because most professionals either neglect or ignore adequate attention to oral health. Therefore, lack of treatment is frequent. Medical and dental studies that focus on the oral aspects of diagnosis, consequences, and treatment of SS are commented on. Diagnostic methods used for the oral component are also reviewed. The role of the oral tests developed to diagnose SS is assessed, especially tests used by the majority of criteria. Impairment of salivary secretion increases the risk of developing oral diseases; the therapeutic modalities designed to ameliorate these damages by increasing salivary output or by substitution of saliva are reviewed. We discuss published prevention techniques to diminish dental, periodontal, and soft tissue infections.

Sicca symptoms and secondary Sjögren's syndrome in systemic lupus erythematosus: comparison with rheumatoid arthritis and correlation with disease variables

OBJECTIVE

Firstly, to study the prevalence of ocular and oral sicca symptoms, reduced tear and saliva production, and the minimum frequency of secondary Sjögren's syndrome (sSS) in systemic lupus erythematosus (SLE). Secondly, to compare sicca symptoms and findings with those of matched patients with rheumatoid arthritis (RA), and sicca symptoms with those in healthy controls. Finally, to study possible associations of clinical variables with sicca symptoms and sSS in SLE.

METHODS

Self reported sicca symptoms were recorded in 81 patients with SLE aged < or =70, 81 matched patients with RA, and 81 matched healthy controls. Other study variables included Schirmer-I test (S1T), unstimulated whole saliva, health status measures (in SLE and RA), disease activity, accumulated organ damage, and serological markers (in SLE).

RESULTS

A significantly higher proportion of patients with SLE reported sicca symptoms than healthy controls. Further, a significantly higher proportion reported ocular sicca symptoms (43 and 21%, respectively) and had pathologically reduced S1T compared with RA (46 and 21%, respectively). No difference was seen in oral sicca symptoms and saliva production. In SLE, sicca symptoms were associated with fatigue, and sSS with anti-SSB or anti-SSA antibodies, or both.

CONCLUSIONS

An increased prevalence of sicca symptoms was found in patients with SLE compared with controls, and a higher prevalence of ocular sicca symptoms and reduced tear production in SLE compared with RA. Sicca problems should be considered in the care of patients with SLE, especially those with anti-SSB and/or anti-SSA antibodies who have sicca symptoms and fatigue.

Sialometry and sialochemistry: diagnostic tools for Sjögren's syndrome

BACKGROUND

The common occurrence of xerostomia in Sjögren's syndrome (SS) as well as the easy accessibility of saliva supports the use of sialometry and sialochemistry in the diagnosis of SS. Collection and analysis of whole saliva (oral fluid) is currently the routine technique for sialometry, despite the fact that it is rather inaccurate and impure.

OBJECTIVE

To assess the value of glandular sialometry and sialochemistry as diagnostic instruments in SS.

METHODS

In a group of 100 consecutive patients referred for diagnosis of SS, glandular secretory flow rates and a spectrum of salivary components (sodium, potassium, chloride, calcium, phosphate, urea, amylase, total protein) were assessed. The patients were classified as positive or negative for SS according to the revised European classification criteria.

RESULTS

Patients with SS differed clearly from those who tested negative for SS, showing lower submandibular/sublingual (SM/SL) flow rates and an appreciably changed salivary composition of parotid and SM/SL saliva. Besides changes in salivary flow rate and composition, distinct sialometric profiles were observed, characteristic of either early or late salivary manifestation of SS, or of the xerogenic side effects of medication.

CONCLUSIONS

Glandular sialometry and sialochemistry are not only useful tools for differentiating SS from other salivary gland disease in clinical practice, but they also have great potential as diagnostic criteria for SS, showing distinct sialometric and sialochemical changes as well as profiles. Being simple, safe (non-invasive), and sensitive (early disease detection), they have three major advantages over other oral tests for SS.

Magnetic resonance imaging and magnetic resonance sialography of parotid glands in primary Sjogren's syndrome

OBJECTIVE

To look for structural parotid gland changes on magnetic resonance (MR) imaging and MR sialography of primary Sjögren's syndrome (SS) patients and healthy control subjects and to compare these methods with each other.

METHODS

MR imaging and MR sialography of both parotid glands were performed on 26 patients and 7 healthy controls. Bilateral surface coils were used to obtain high spatial resolution.

RESULTS

Twenty-two of the 26 patients had abnormalities on MR imaging. Twenty-one had a nodular or dendritic parenchymal pattern, 5 had cavities, and 6 had duct dilatations. On MR sialography, 25 of the 26 patients had abnormalities of the ducts, and 16 of them also had cavities. One patient and all 7 controls had normal results with both methods. The structural appearance of the parotid glands on MR images had marginal linear association with the duct system changes but no correlation with the cavitary changes seen on MR sialography. Furthermore, duct system abnormalities did not correlate with cavitary changes. Both parenchymal and sialographic abnormalities were associated with the presence of Ro/SSA antibodies but not with age of the patient, disease duration, salivary flow rate, or the presence of hypergammaglobulinemia or extraglandular manifestations.

CONCLUSION

MR imaging and MR sialography are noninvasive methods that provide definitive information of morphologic changes in parotid glands and can be used as diagnostic indicators of primary SS. Because these methods give information on different aspects of glandular pathology, both should be performed when evaluating parotid glands of SS patients. MR sialography is more sensitive, but conventional MR imaging gives complementary information on the progressive pathologic changes of glandular parenchyma.

Immunoglobulin Vlambda light chain gene usage in patients with Sjögren's syndrome

OBJECTIVE

To determine whether patients with Sjögren's syndrome (SS) have abnormalities in Ig Vlambda and Jlambda gene usage, differences in somatic hypermutation, defects in selection, or indications for perturbations of B cell maturation.

METHODS

Individual peripheral B cells from SS patients were analyzed for their Vlambda gene usage by single-cell polymerase chain reaction amplification of genomic DNA and compared with those from normal controls.

RESULTS

Molecular differences from controls in Vlambda-Jlambda recombination were identified that were reflected by findings in the nonproductive Vlambda repertoire of the patients, including enhanced rearrangement of Vlambda10A and Jlambda2/3 gene segments. In addition, a number of abnormalities in the productive repertoire were identified, indicating disordered selection. A greater usage of 4 Vlambda genes (2A2, 2B2, 2C, and 7A), representing 56% of all productive Vlambda rearrangements, was observed, suggesting positive selection of these genes. Overutilization of Jlambda2/3 and underutilization of Jlambda7 in both nonproductive and productive Vlambda rearrangements of SS patients compared with controls suggested decreased receptor editing in SS. The mutational frequency did not differ from that in controls, and positive selection of mutations into the productive V gene repertoire was found, similar to that in controls, although mutational targeting toward RGYW/WRCY motifs, typically found in controls, was not found in SS patients.

CONCLUSION

Disturbed regulation of B cell maturation with abnormal selection, defects in editing Ig receptors, and abnormal mutational targeting may contribute to the emergence of autoimmunity in SS.

Morbidity from parotid sialography

OBJECTIVE

Sialography is commonly used for the diagnosis of Sjögren's syndrome, although its invasive nature is often regarded as a serious drawback for routine usage. The aim of this study was to evaluate the morbidity and acceptability of parotid sialography using oil-based contrast fluid.

STUDY DESIGN

Twenty-four consecutive sialographic procedures were evaluated in terms of morbidity and the patient's acceptance of the procedure, assessed with a standardized questionnaire. Information was also obtained by recording relevant physical parameters during the procedure.

RESULTS

There was good acceptance of the sialographic procedure, and the morbidity was low. No signs of overfilling or false route were observed in any of the sialograms. On average, 0.74 mL of contrast fluid was infused with a velocity of 0.01 mL/s. The whole procedure was completed within 12 minutes.

CONCLUSIONS

Parotid sialography appears less invasive than is often thought. It had a low morbidity rate and was well accepted by the patients.

Ability of the American College of Rheumatology 1987 criteria to predict rheumatoid arthritis in patients with early arthritis and classification of these patients two years later

OBJECTIVE

To determine how well the American College of Rheumatology (ACR; formerly, the American Rheumatism Association) 1987 classification criteria for rheumatoid arthritis (RA), when used at study inclusion in a cohort of 270 patients with early (<1 year) arthritis, predicted a diagnosis of RA 2 years later and how well they classified these patients at the end of the 2 years.

METHODS

Patients were evaluated during 1995-1997 at 7 hospitals in the Brittany region of France. Patients were evaluated at 6-month intervals until November 1999. The diagnosis made by a panel of 5 rheumatologists (P5R) after the last visit was used as the "gold standard." The ACR 1987 criteria for RA were applied prospectively, without taking into account the initial diagnosis.

RESULTS

At the last visit (mean +/- SD followup 29.1 +/- 11.8 months; median 30 months), the P5R diagnosed RA in 98 patients. At the last visit, classification by the ACR criteria was satisfactory, and the combination of an office-based rheumatologist's (OBR's) diagnosis of RA and fulfillment of the ACR criteria was sensitive (87%; 85 of 98 RA patients had both) and highly specific (99%; 170 of 172 non-RA patients did not have both). Application of the criteria at the first visit was of limited value for predicting a diagnosis of RA 2 years later.

CONCLUSION

After a 2-year followup, the ACR 1987 classification criteria used in combination with an OBR's diagnosis were effective in distinguishing patients with and without RA. The criteria were not useful for predicting RA in patients with arthritis onset within the previous year. Some patients who met the criteria at baseline and after 2 years did not have RA, suggesting that incorporating exclusion criteria may improve the performance of the ACR criteria when used without taking into account the diagnosis by a rheumatologist, particularly in early arthritis.

Focal sialadenitis in patients with ankylosing spondylitis and spondyloarthropathy: a comparison with patients with rheumatoid arthritis or mixed connective tissue disease

OBJECTIVES

To investigate the occurrence of and risk factors for focal sialadenitis in patients with rheumatoid arthritis (RA), mixed connective tissue disease (MCTD), ankylosing spondylitis (AS), and spondyloarthropathy (SpA).

METHODS

A total of 85 patients (25 with RA, 19 with MCTD, 19 with AS, 22 with SpA) participated in the study. Each patient filled out a questionnaire for eye and oral symptoms and for the use of medication, and was interviewed; other tests included Schirmer's test, laboratory tests, collection of unstimulated and stimulated whole saliva, and minor salivary gland biopsy. A focus score of > or =1 was regarded as an indicator of focal sialadenitis.

RESULTS

Focal sialadenitis was observed in 68% (57/84) of all patients. It affected 80% (20/25) of the patients with RA, 94% (17/18) of those with MCTD, 58% (11/19) of those with AS, and 41% (9/22) of those with SpA (chi(2) test, p=0.0013). Salivary secretion correlated negatively with the focus scores-that is, severity of focal sialadenitis. Patients with focal sialadenitis had both decreased salivary secretion and decreased tear secretion significantly more often than did patients without (chi(2) test, p=0.0074 and p=0.048 respectively). Patients with positive rheumatoid factor (RF), antinuclear antibodies (ANA), or SSA or SSB antibodies had sialadenitis significantly more often than did patients with negative antibodies. In the subgroup of patients with AS or SpA, no associations were found between focal sialadenitis and the presence of these antibodies.

CONCLUSION

In addition to patients with RA or MCTD, focal sialadenitis also affects a very high proportion of patients with AS or SpA. Focus scores are significantly higher in patients with RA or MCTD than in those with AS or SpA. A significant association exists between focal sialadenitis and RF, ANA, SSA and SSB. However, in the subgroup of patients with AS or SpA, no associations were found between focal sialadenitis and serological markers or clinical symptoms.

Characterization of ocular surface symptoms from optometric practices in North America

PURPOSE

This study characterized ocular symptoms typical of dry eye in an unselected optometric clinical population in the United States and Canada.

METHODS

Self-administered dry eye questionnaires, one for non-contact lens wearers (dry eye questionnaire) and one for contact lens wearers (contact lens dry eye questionnaire), were completed at six clinical sites in North America. Both questionnaires included categoric scales to measure the prevalence, frequency, diurnal severity, and intrusiveness of nine ocular surface symptoms. The questionnaires also asked how much these ocular symptoms affected daily activities and contained questions about computer use, medications, and allergies. The examining doctors, who were masked to questionnaire responses, recorded a nondirected dry eye diagnosis for each patient, based on their own diagnostic criteria.

RESULTS

The dry eye questionnaires were completed by 1,054 patients. The most common ocular symptom was discomfort, with 64% of non--contact lens wearers and 79% of contact lens wearers reporting the symptom at least infrequently. There was a diurnal increase in the intensity of many symptoms, with symptoms such as discomfort, dryness, and visual changes reported to be more intense in the evening. The 22% percent of non-contact lens wearers and 15% of contact lens wearers diagnosed with dry eye (most in the mild to moderate categories) reported symptoms at a greater frequency than those not diagnosed with dry eye.

CONCLUSIONS

Our results show that symptoms of ocular irritation and visual disturbances were relatively common in this unselected clinical population. The intensity of many ocular symptoms increased late in the day, which suggested that environmental factors played a role in the etiology of the symptoms.

Dry eye disease: the scale of the problem

Dry eye disease, or keratoconjunctivitis sicca, is among the most frequently established diagnoses in ophthalmology; in Germany, one in four patients consulting an ophthalmologist complains of the symptoms of dry eye. Although epidemiological studies investigating the prevalence of dry eye disease are rare, published studies indicate that up to 20% of adults aged 45 years or more experience dry eye symptoms. Recent studies have shown that immunologic changes play a role in the pathogenesis of dry eye, not only in Sjögren's syndrome, but also in postinfectious and age-related conditions. Despite increasing understanding of the pathogenic factors involved in dry eye disease, there has been a lack of consensus on diagnostic criteria, classification of disease states, and the aims and interpretation of specific diagnostic tests. There is a need, therefore, for standardization of disease terminology and diagnostic tests in order to improve the usefulness of epidemiological and clinical investigation of this important ocular disorder.

Immunoglobulin Vkappa light chain gene analysis in patients with Sjögren's syndrome

OBJECTIVE

Patients with Sjögren's syndrome (SS) have characteristic lymphocytic infiltration of the salivary glands with a previously reported predominance of Vkappa-bearing B cells and produce a variety of autoantibodies, indicating that there is a humoral autoimmune component in this syndrome. This study was undertaken to determine whether there are primary deviations of immunoglobulin V gene usage, differences in somatic hypermutation, defects of selection, or indications for perturbances of B cell maturation in SS.

METHODS

Individual peripheral B cells from patients with SS were analyzed for their Ig V gene usage, and the findings were compared with results in normal controls.

RESULTS

Molecular differences, as reflected by findings in the nonproductive Vkappa repertoire of the patients, were identified by an enhanced usage of Jkappa2 gene segments and a lack of mutational targeting toward RGYW/WRCY sequences compared with controls. A greater usage of Vkappa1 family members and a reduced frequency of Vkappa3 gene segments in the productive repertoire suggested differences in selection, possibly driven by antigen. Overall positive selection for mutations, especially for replacements in the complementarity-determining region and for mutations in RGYW/WRCY, similar to that found in controls, was detected.

CONCLUSION

Disturbances of strictly regulated B cell maturation, during early B cell development as indicated by prominent Jkappa2 gene usage and during germinal center reactions as indicated by a lack of targeting of the hypermutation mechanism, might contribute to the emergence of autoimmunity in SS.

Disproportion of helper T cell subsets in peripheral blood of patients with primary Sjögren's syndrome

We studied the proportions of Th1 and Th2 cells in peripheral blood of 15 patients with primary Sjögren's syndrome (p-SS), by using a procedure to enumerate the cells synthesizing cytokines such as INF-gamma or IL-4 in cytoplasm of CD4+ lymphocytes. The frequency of Th1 (INF-gamma containing) cells in p-SS patients was significantly reduced as compared to normal control (20.57+/-7.48% vs 28.78+/-11.56%, p < 0.05), while that of Th2 (IL-4 containing) cells was not different from normal control (3.33+/-0.98% vs 2.85+/-1.88%). The ratio of Th1 to Th2 cells in p-SS patients was significantly decreased as compared to normal control (6.60+/-3.15 vs 11.55+/-6.72, p < 0.05). There was no difference in frequency of Th1 or of Th2 cells between 8 patients given small amounts of prednisolone (PSL) and 7 patients not given PSL (21.44+/-9.39% vs 19.57+/-5.05%, 3.12+/-0.80% vs 3.56+/-1.17%). The percentage of Th1 cells was not different between 7 patients with glandular symptoms (G) and 8 patients with extraglandular symptoms (EG) (18.61+/-9.63% vs 22.27+/-5.02%). Although the frequency of Th2 cells was higher in EG-patients than that in G-patients (3.84+/-0.78% vs 2.74+/-0.86%) with tendency of elevated IgG level in sera, the ratio of Th1 to Th2 cells was not different among them (6.26+/-2.84 vs 6.99+/-3.64). These results suggest that the reduced ratio of Th1 to Th2 cells is essential and is related to the dysfunction of cellular immunity in p-SS.

Sjogren's syndrome

Sjogren's syndrome is a chronic progressive autoimmune disorder manifested predominately by xerostomia (dry mouth) and keratoconjunctivitis sicca (dry eyes). It can also affect many body systems. Up to 5% of people over the age of 60 years have primary Sjogren's syndrome, and approximately one third of patients present with extraglandular (systemic) manifestations. This disease is seen mostly in middle-aged women, with a small but significant proportion of these women developing lymphoid neoplasia. The exact etiology is still unknown. This autoimmune disorder is characterized by B-cell activation, the production of numerous auto-antibodies, and the loss of immune tolerance. Salivary gland biopsy remains the most helpful diagnostic test. Treatment is aimed at moisture replacement, which alleviates the discomfort and slows the destructive process. Because of its prevalence in older women, the obstetrician-gynecologist must be aware of the diagnostic and therapeutic approach to Sjogren's syndrome.

Dry eye: an update on clinical diagnosis, management and promising new treatments

Dry eye conditions are prevalent with one in four to five patients presenting to eye care practitioners having dry eye signs and/or symptoms. An intimate relationship exists between the ocular surface and the tear film. The cycle of tear film instability and ocular surface damage characteristic of dry eye conditions suggests that dry eye represents a dysfunction of an integrated ocular surface-lacrimal gland unit. Therefore, dry eye is a multifactorial condition and an approach based on clinical subtypes is required for diagnosis and management. There is increasing evidence that inflammation is a contributing and exacerbating factor in dry eye conditions and anti-inflammatory or immunomodulatory therapy for chronic dry eye conditions may facilitate ocular surface healing. Other promising new treatments for dry eye include new generation artificial tear polymers and preservative systems, secretagogues, topical androgen supplements and surgical techniques for ocular surface reconstruction.

An investigation of interactions between the immune system and stimulus-secretion coupling in mouse submandibular acinar cells. A possible mechanism to account for reduced salivary flow rates associated with the onset of Sjögren's syndrome

OBJECTIVES

To determine whether chronic exposure to lymphocyte-derived cytokines could inhibit the fluid secretory mechanism in salivary gland acinar cells and so account for the loss of gland function seen in the early stages of Sjögren's syndrome.

METHODS

Mouse submandibular acinar cells maintained in primary culture were exposed to a profile of cytokines produced by concanavalin A-activated splenic lymphocytes in vitro for periods up to 72 h. Agonist-evoked changes in intracellular Ca(2+) were determined microfluorimetrically in both control and cytokine-treated cells.

RESULTS

Acinar cells maintained in primary culture in the presence of cytokines for up to 72 h were able to mobilize intracellular calcium in response to stimulus by acetylcholine in an identical fashion to those maintained in primary culture in the absence of cytokines. Acute application of the conditioned medium produced by the activated lymphocytes had an antisecretory effect on acetylcholine-evoked Ca(2+) mobilization, which was found to be mediated by cholinesterase rather than by cytokines.

CONCLUSION

Neither chronic nor acute exposure to the profile of cytokines released by concanavalin A-activated splenic lymphocytes interfered in any way with the second messenger cascade and fluid and electrolyte secretion in acinar cells. Our data suggest an alternative hypothesis, in which elevated levels of cholinesterase can metabolize acetylcholine released within the salivary glands and thus prevent fluid secretion.

Cytokine profile in minor salivary glands from patients with bronchial asthma

BACKGROUND

T lymphocytes are important components of the bronchial inflammatory cell infiltrate in asthma. Because lymphocytes activated in the respiratory tract recirculate to remote glandular and mucosal sites, we previously studied the histologic features of minor salivary glands (MSGs) in bronchial asthma and found an airway-like inflammation with T-lymphocyte infiltration, the presence of mast cells that were often degranulated, and basement membrane thickening but no eosinophil infiltration.

OBJECTIVE

We sought to investigate the cellular infiltration and cytokine profile in MSGs from untreated asthmatic subjects, steroid-treated asthmatic subjects, and control subjects and to compare these values with those found in bronchial biopsy specimens.

METHODS

The cellular infiltration was studied by using immunohistochemistry. Cytokine messenger (m)RNA expression for IL-4, IL-5, and IFN-gamma was determined by using in situ hybridization and cytokine immunoreactivity with immunohistochemistry.

RESULTS

A significant increase in CD4 and IL-4 mRNA(+) cells was observed in MSGs from asthmatic patients (both untreated and steroid-treated subjects) when compared with control subjects, which correlated with the clinical severity of asthma (FEV(1) and Aas score). In contrast to the bronchi, no IL-5 mRNA expression was observed in MSGs, and no difference was observed for MSG IFN-gamma mRNA between the groups. At the level of MSG protein expression, the 3 cytokines were seen, with a significant increase in IL-4 protein expression in steroid-treated asthmatic subjects compared with untreated asthmatic subjects and control subjects, but there were no differences between the groups in IL-5 and IFN-gamma protein expression.

CONCLUSION

The cytokine mRNA expression pattern observed in the MSGs of asthmatic subjects was different from that found in the bronchi, suggesting a different local immune regulation.

Prevalence of dry eye subtypes in clinical optometry practice

BACKGROUND

Dry eye conditions are now recognized as having multiple causes. A subtype-based dry eye diagnostic protocol was developed to determine the prevalence of dry eye and dry eye subtypes, and the effects of age and gender, in subjects presenting to clinical optometry practice.

METHODS

Dry eye diagnostic criteria were: presence of one or more McMonnies dry eye survey primary symptoms, fluorescein tear break time < 10 s and rose bengal ocular surface staining. Dry eye subtype differential diagnosis was made predominantly on the basis of biomicroscopic signs. Subtype categories were: lipid anomaly dry eye (LADE), aqueous tear deficiency (ATD), primary mucin anomalies, allergic/toxic dry eye (ADE), primary epitheliopathies and lid surfacing/blinking anomalies (LSADE).

RESULTS

Dry eye prevalence was 10.8% for n = 1584 subjects. Dry eye was significantly more prevalent in subjects 40 years or older (18.1%) compared with those < 40 years (7.3%) (p = 0.001). LADE was the most prevalent subtype (4.0%), followed by ADE at 3.1%, LSADE at 1.8%, and ATD at 1.7%. ATD was the only subtype with a significant gender prevalence difference, being more prevalent in women (p = 0.0023). The prevalence of LADE and ATD were significantly greater in those 40 years or older (p = 0.001 and p = 0.0023 respectively).

CONCLUSIONS

The results of this study support a subtype-based approach to dry eye diagnosis and management in clinical practice.