American College of Rheumatology classification criteria for Sjögren's syndrome: A data-driven, expert consensus approach in the Sjögren's International Collaborative Clinical Alliance Cohort

Chronic stress resulting from stressful life events and its role in the onset of primary Sjögren's syndrome: a comparative analysis using the modified Holmes-Rahe stress scale

Recent years brought considerable attention to the connection between chronic stress and the development of autoimmune diseases. However, little is still known about the impact of prolonged stress reactions on the onset and course of primary Sjögren Syndrome (pSS). This study aimed to seek for associations between chronic stress, resulting from stressful life events, and pSS. In the study, 50 patients with diagnosed pSS, as well as 50 control patients with osteoarthritis underwent an assessment. Modified Holmes-Rahe (H-R) stress scale was used in order to evaluate the impact of stressful events within 12 months prior to the diagnosis. Patients with pSS had a significantly higher total score on H-R stress scale within one-year preceding the disease diagnosis (152 ± 66.3 vs 50 ± 54.6; p <  0.001). Additionally, the pSS patients more commonly than the controls reported a subjectively perceived correlation between stressful events and the occurrence of disease symptoms (50% vs 12%; p <  0.001). Moreover, the H-R score at the time of the assessment correlated with the disease activity. The results support the view that pSS belongs to the group of diseases which pathogenesis is closely related to stressful life events. The novelty of this work lies in focus on both the correlation of stress on the onset of autoimmune disease as well as the activity of previously diagnosed disorder. Our data contributes to finding evidence-based medicine (EBM) arguments to what has until recently been merely a thematic observation-the harmfulness of negative stress on individual's health status.

Predicting and validating the risk of interstitial lung disease in systemic lupus erythematosus

OBJECTIVE

Our study aimed toconstruct a web-based calculator to predict high risk patients of interstitial lung disease (ILD) in systemic lupus erythematosus (SLE).

METHODS

This retrospective study comprised training and test cohorts, including 581 and 86 patients, respectively. Univariate, least absolute shrinkage and selection operator (LASSO), random forest (RF), eXtreme Gradient Boosting (XGBoost), and logistic regression (LR) analyses were performed. A Venn diagram was used to investigate critical features. Receiver operating characteristic (ROC) analysis and decision curve analysis were used to evaluate the model's performance. Risk stratification was performed using the best ROC cut-off value. The web-based calculator was established using Streamlit software.

RESULTS

Characteristics such as Raynaud's phenomenon, pulmonary artery systolic pressure, serositis, anti-U1RNP antibodies, anti-Ro52 antibodies, C-reactive protein, age, and disease course were associated with SLE complicated by ILD (SLE-ILD). LR-Venn, RF-Venn, XGBoost-Venn, LASSO-logic, RF, and XGBoost models were constructed. In training cohort, the XGBoost model demonstrated the highest area under the ROC curve (AUC, 0.890; cut-off value, 0.197; sensitivity, 0.793; specificity, 0.836) and provideda netbenefitin decision curve analysis (odds ratio [OR] for SLE-ILD [high- vs. low-risk], 19.6). The model was validated in the test cohort (AUC, 0.866; sensitivity, 0.722; specificity, 0.897; OR, 22.7). Furthermore, an XGBoost model-based web calculator was developed.

CONCLUSION

Our web calculator (https://st-xgboost-app-kcv9qm.streamlit.app/) greatly improved risk prediction for SLE-ILD and was implemented effectively.

Concomitant Sjögren's disease in patients with NMOSD: impacts on neurologic disease severity and recurrence

BACKGROUND

We aimed to characterize the phenotype of neuromyelitis optica spectrum disorder (NMOSD) in the presence and absence of Sjogren's disease (SjD) and to develop a predictive nomogram to evaluate the risk of coexisting SjD within a single tertiary-center cohort of NMOSD patients.

METHODS

Paraclinical and clinical features of patients with SjD were compared between NMOSD patients with SjD and those without SjD. Zstats v1.0 was utilized to randomly allocate participants into a derivation group (108 patients) and a validation group (47 patients) at a ratio of 7:3. Logistic regression analysis was used to assess the effectiveness of our predictive model, and a nomogram was created to illustrate the findings.

RESULTS

A total of 155 NMOSD patients who were serologically positive for AQP4-IgG were cross-sectionally recruited (70 NMOSD patients with SjD [45.16%] and 85 NMOSD patients without SjD [54.84%]). Independent predictors of coexisting SjD were age upon recruitment (P = 0.002); Expanded Disability Status Scale (EDSS) score (P = 0.023); blood white blood cell (WBC) count (P = 0.049); and rheumatoid factor (RF) (P = 0.049), anti-SSA (Ro), and anti-SSB (La) antibody positivity (P < 0.001; P = 0.012). The nomogram had an area under the receiver operating characteristic (ROC) curve (AUC) (95% confidence interval [CI]) of 0.95 (0.89, 1.00) in the derivation cohort and 0.91 (0.79, 1.00) in the validation cohort. Survival curve analysis revealed that the EDSS score in the NMOSD patients with SjD was associated with clinical relapse, and these patients reached an EDSS score of 4.0 earlier than those without SjD.

CONCLUSION

NMOSD patients with SjD manifested more severe disease at attack and relapsed earlier than those without SjD. The nomogram established by combining age upon recruitment; EDSS score; blood WBC count; and RF, anti-SSA (Ro), and anti-SSB (La) antibody levels can significantly predict the risk of NMOSD combined with SjD.

Anti-SSA/SSB antibody double-negative Sjögren's disease patients: a comprehensive clinical study and immune profile

INTRODUCTION/OBJECTIVES

Anti-Sjögren's syndrome A (SSA/Ro60) and anti-Sjögren's syndrome B (SSB/La) antibodies are not present in up to 25% of patients with primary Sjögren's disease (SjD). Our observational study aims to provide a clinical perspective on the presentation, extra-glandular manifestations, as well as the immune profile of anti-SSA/SSB antibody double-negative SjD patients.

METHOD

A total of 615 SjD patients of age 53.21 (± 0.59) were enrolled without acute infection or ongoing treatment that could affect the immune system. Of our participants, 254 (41.3%) were seronegative for both SSA (Ro60) and SSB (La) autoantibodies (SSA/SSB double-negative). A 1:1 propensity score matching was performed to balance age at diagnosis, disease duration, and gender for extra-glandular involvement analyses and immune profiling. Peripheral blood mononuclear cells (PBMCs) were derived from all patients. Flow cytometry was performed to further define the immune cell subsets.

RESULTS

Our study revealed that anti-SSA/SSB seronegative patients had a delayed onset by an average of 7.43 years and exhibited a lower prevalence of parotid gland enlargement compared to the seropositive group (50.8% vs. 59%, p < 0.05). In terms of extra-glandular involvement, seronegative patients exhibited a lower prevalence of white blood cell (WBC), hemoglobin (HGB), and platelet (PLT) reduction (OR 0.406, 95% CI 0.314-0.523; OR 0.751, 95% CI 0.587-0.959; OR 0.56, 95% CI 0.383-0.818, respectively) compared to anti-SSA/SSB antibody-positive group. Additionally, the double-negative group tended to hold higher CD4 + T helper cells and lower CD8 + T cell proportions compared with the anti-SSA/SSB-positive group (40.52% vs. 37.38%, p < 0.001; 28.25% vs. 32.55%, p < 0.001 respectively). Higher proportions of NK cells (13.05% vs. 10.32%, p < 0.001) and CD161 + Treg cells (13.69% vs. 12.03%, p < 0.001) were found in the double-negative group.

CONCLUSION

The observed higher frequency of CD161 + Tregs and NK cells, as well as the lower frequency of CD8 + T cells and B cells, in anti-SSA/SSB antibody double-negative patients suggests a potential role of innate immunity in this subgroup of Sjögren's syndrome. Our findings hint at the importance of serological and immune profiles in tailoring personalized management strategies for these patients. Key Points • Our analyses suggested a potential role of innate immunity in anti-SSA/SSB antibody double-negative SjD patients in comparison to seropositive counterparts. • Higher frequencies of CD4 + T cells, CD161 + Tregs, and NK cells were observed in the peripheral blood of double-negative patients, alongside lower proportions of CD8 + T cells and B cell subsets. • Double-negative patients exhibited a lower prevalence of reductions in white blood cell counts, hemoglobin level, and platelet level.

Undifferentiated connective tissue disease: the diagnoses critically revised-experience of a single center

Although anti-nuclear antibodies (ANA) are considered the main entry criteria for a diagnosis of undifferentiated connective tissue disease (UCTD), many patients show different rate of ANA positivity and questionable diagnoses. Aim of the study was to revise the UCTD diagnoses and analyse the main predictors of evolution in a monocentric cohort. We retrospectively revised the diagnoses of 331 ANA positive patients, with at least one year of follow-up, classified as UCTD from 2009 and 2017. The diagnosis of UCTD was confirmed in 180 cases (54.4%). The evolution occurred in 18% of cases, after a follow-up of 6.9 (SD: 4.4) years. Raynaud's phenomenon (RP) (OR: 2.39), puffy hands (OR: 6.3), anti-ENA (OR: 2.34), anti-Topoisomerase I antibodies (OR: 4.93), rheumatoid factor (RF) (OR: 2.86) were associated with evolution. Evolution in Systemic Lupus Erythematosus (SLE) occurred in 5 patients (2.78%) and associated with the addition of new autoantibodies, compared with other evolutions (p: 0.034; OR: 12; 95CI: 1.4-103.4). Evolution in Systemic Sclerosis and pSS was found in 14 (7.8%) and 8 cases (4.4%), respectively. Puffy hands and RF positivity as the predictors of SSc and pSS evolution, respectively. A confirmed diagnosis of UCTD, according with the available criteria, was assessed in about a half patients. The occurrence of puffy hands since the onset defines a patient with a potential evolution into SSc, while the addition of new specific autoantibodies represents a typical "fingerprint" of patients developing SLE. Trial registration: Studio ANACTD np 1318.

ADAM17/PTGS2 Facilitates Pulmonary Fibrosis by Regulating Ferroptosis

Pulmonary fibrosis (PF) is a chronic and progressive interstitial lung disease characterised by excessive deposition of extracellular matrix (ECM), resulting in high mortality rates. In this study, we provide evidence that ADAM17/PTGS2 plays a crucial role in inducing ferroptosis in fibroblasts, promoting PF. Initially, an assessment was made of ADAM17 protein levels in patients diagnosed with connective tissue diseases-interstitial lung diseases (CTD-ILD), using ELISA assays. Confirmation of the relationship between ADAM17 and fibrosis was achieved by stimulating cells with PMA or TAPI-1 (the ADAM17 inhibitor), in conjunction with the fibrosis-inducing factor, TGFβ1. To further explore the major downstream proteins of ADAM17 contributing to altered PF, we employed mRNA transcriptomics. To further investigate the role of ADAM17/PTGS2 in promoting ferroptosis and fibrosis, we employed western blot assays, immunofluorescence and transmission electron microscopy (TEM). Furthermore, the effects of the ADAM17/PTGS2/ferroptosis pathway in PF were verified using Adeno-associated virus (AAV)-mediated ADAM17 gene knockdown in mice. In CTD-ILD patients, ADAM17 expression was significantly elevated. Upon PMA stimulation, lung fibroblasts exhibited increased fibrosis-related proteins, and the combined stimulation of PMA and TGFβ1 synergistically promoted cellular fibrosis. Conversely, TAPI-1 alleviated fibrotic stimulation induced by TGFβ1. Transcriptomic analysis of lung fibroblast specimens overexpressing ADAM17 revealed significantly elevated PTGS2 expression levels. Knockdown and ferroptosis inhibition assays demonstrated that ADAM17 regulates ferroptosis in lung fibroblasts via PTGS2, ultimately inducing fibrosis. Furthermore, the deficiency of ADAM17 alleviated bleomycin-induced PF and inflammation in mice. These findings first verified that ADAM17/PTGS2/ferroptosis is a novel mechanism for regulating PF; it provides a new theoretical basis for further exploring the treatment of PF.

Clinical and laboratory characteristics of Sjögren's syndrome-associated autoimmune liver disease: a real-world, 10-year retrospective study

OBJECTIVES

To investigate the clinical and laboratory features of Sjögren's syndrome-associated autoimmune liver disease (SS-ALD) patients and identify potential risk and prognostic factors.

METHODS

SS patients with or without ALD, who visited Tongji Hospital between the years 2011 and 2021 and met the 2012 American College of Rheumatology (ACR) classification criteria for Sjögren's syndrome, were retrospectively enrolled. The clinical and laboratory data of the enrolled patients, including autoimmune antibodies, were collected and analyzed with principal component analysis, correlation analysis, LASSO regression, and Cox regression.

RESULTS

A total of 117 SS-ALD patients were confirmed out of 568 SS patients. Compared to SS-non-ALD patients (n = 451), SS-ALD patients exhibited more severe involvement of the hepatic and hematologic systems, albeit with less pronounced typical SS symptoms. Disease activity was higher in SS-ALD patients, as indicated by elevated ESR, CRP, and IL-6 levels, particularly in the SS-overlap subgroup. Furthermore, SS-AIH patients without AIH-specific autoantibody testing or with negative testing results had higher AST and ALT levels than those who were autoantibody-positive. Our predictive model, incorporating IgG, IgM, AST, GGT, ALT, and C4, effectively identified ALD complications in SS patients, achieving an AUC of 0.924. Additionally, a grimmer prognosis was associated with higher baseline AST and ALT levels.

CONCLUSIONS

SS-ALD patients often manifest with an insidious onset and atypical SS symptoms, yet frequently exhibit severe systemic involvement, intense inflammatory and immune responses, and a poor prognosis. To improve the clinical outcomes in SS-ALD patients, regular monitoring, early identification, and active treatment should be applied. Key Points • The study provided a detailed profile of clinical and laboratory features of SS-ALD and SS-non-ALD patients, contributing to a predictive model of ALD complications in SS patients • SS-ALD patients manifested with an insidious onset but exhibited severe systemic involvement, robust inflammatory and immune responses, and poor prognosis • SS-AIH patients without available testing for AIH-specific autoantibodies or with negative results demonstrated worse liver function, thus routine screening for autoimmune liver antibodies is recommended in SS patients • More severe baseline liver function status was associated with poorer therapeutic responses to routine medications, so early detection and timely intervention are essential for SS patients.

Evaluation of lacrimal gland vascularization using superb microvascular imaging: A potential diagnostic tool in Sjögren's syndrome

OBJECTIVES

The aim of this study is to evaluate the superb microvascular imaging (SMI) findings of the lacrimal glands for the sonographic diagnosis of primary Sjögren's syndrome (pSS).

METHODS

Twenty-one patients with pSS and 20 healthy groups were evaluated. Dry eye symptoms and their effects on vision-related functions were evaluated with McMonnies and Ocular Surface Disease Index (OSDI) questionnaires. Lacrimal glands were evaluated by power Doppler ultrasonography (PDUS), colour Doppler ultrasonography (CDUS), and SMI.

RESULTS

Dry eye symptoms, as determined by McMonnies and OSDI, were significantly more severe in patients with pSS than in the control group (P = .001 and P = .021, respectively). Lacrimal gland vascular activity rates and hypoechoic areas were significantly higher in pSS patients compared to the control group (P < .05). The detection rates of the degree of vascularity in the lacrimal glands of patients with pSS were higher with SMI compared to CDUS and PDUS. In addition, SMI positively correlated with CDUS, PDUS, OSDI, and McMonnies.

CONCLUSIONS

Evaluation of the lacrimal gland by the SMI was found to be excellent in predicting the likelihood of individuals having pSS compared to CDUS and PDUS. This technique may serve as a reliable and noninvasive adjunctive tool for assessing the degree of lacrimal vascularity in pSS.

Recommendations on neurologic, cognitive, and psychiatric manifestations in patients with Sjögren's disease by the Brazilian Society of Rheumatology

BACKGROUND

Neurological and psychiatric manifestations occur in patients with primary Sjogren's disease (SjD) with a wide-ranging clinical presentation, affecting quality of life, social participation, and prognosis. Despite this, neither central nor peripheral neurological symptoms are systematically evaluated in the context of autoimmunity or identified as manifestations of SjD. The EULAR Sjogren's Syndrome Disease Activity Index (ESSDAI) covers only part of them in the neurological domain.

METHODS

We performed a systematic review of the diagnosis and prevalence of central, peripheral, and autonomic nervous system manifestations in primary SjD, following the recommendations proposed by the Cochrane Collaboration Handbook. Observational studies were included when their main issue was the diagnosis and the prevalence of the manifestations individually. We employed a generalized linear mixed model (GLMM) method with a random-effects model, and the results were computed using logit transformation, implemented through the 'meta' and 'metafor' packages in the R software (version 3.6.1). To present these recommendations, agreement among experts was investigated using the Delphi method in in-person meetings.

RESULTS

We propose ten recommendations regarding the investigation and management of neurological involvement in SjD that had 100% agreement among participants.

CONCLUSION

These recommendations add to the literature on the clinical care of patients with SjD.

Autoimmune Thyroid Disease and Sjögren Disease: Organ-Specific Disease Triggered by Systemic Autoimmunity?

Background and Objectives: Autoimmune thyroid diseases are more prevalent in patients diagnosed with Sjögren disease (SD) than in the general population. SD and autoimmune thyroid diseases are two distinct yet interrelated autoimmune disorders. The objective of this study was to determine the frequency of autoimmune thyroiditis (AT), autoantibody relationships, and clinical features in patients with SD. Materials and Methods: The study included 525 patients. A retrospective evaluation was conducted on the demographic data, biochemical and serological tests, and pathological data of the patients. An anti-nuclear antibody (ANA) test was performed using the indirect immunofluorescence (IIF) method using HEp-2 (HEp-2000) cells as substrate. The Schirmer test and minor salivary gland biopsy were conducted on all patients. Results: AT was detected in 167 (31.8%) of 525 patients who participated in the study. The anti-nuclear antibody (ANA) test and anti-SS-A positivity rate were higher in the AT group (p value < 0.001 and 0.002 respectively). We found that the likelihood of developing AT increased as ANA titres increased. ANA positivity titres were found to be significant at 2+, 3+, and 4+ values (odd ratios 2.41, 3.40, and 4.21, respectively). Additionally, histological examination of salivary gland biopsies revealed a significantly higher prevalence of diffuse lymphocytic infiltration in the AT group. Conclusions: AT was present in 31% of patients with SD. The presence of ANA positivity, anti-SS-A positivity, and diffuse lymphocytic infiltration appears to exert an influence on the association between these two diseases.

Advances in laboratory diagnosis of Sjogren's disease in children

Sjogren's disease (SjD) in children is a rare chronic autoimmune disease not fully recognized due to clinical manifestations different from adults. As such, new objective indicators are needed to supplement existing markers and assist in diagnosis. This review summarizes pathogenesis of SjD in children, current diagnostic criteria and research progress in laboratory diagnosis including serologic testing, saliva and tear analysis, histopathological examination as well as emerging markers of interest.

Decreased Serum and Salivary Levels of Aquaporin 5 in Oral Lichen Planus

OBJECTIVES

Oral lichen planus (OLP) is an autoimmune disease with unknown etiology. Many OLP patients complain of xerostomia, and studies are still ongoing to find the reason for this manifestation. Aquaporin 5 has been expressed in salivary glands, and its physiological significance in transferring water as transcellular is properly identified. In this study, for the first time, we have investigated the serum and salivary levels of aquaporin 5 (as a salivary gland biomarker) in oral lichen planus patients with xerostomia.

MATERIAL AND METHODS

Thirty patients with OLP and xerostomia and 30 healthy individuals were chosen. The flow of stimulatory and non-stimulatory saliva was calculated, and the serums, in addition to salivary levels of aquaporin 5, were determined.

RESULTS

The level of Aquaporin 5 in serum and its output in stimulatory, and non-stimulatory saliva were significantly decreased, the stimulatory and non-stimulatory saliva flow was reduced, and the degree of xerostomia was significantly higher in the OLP group.

CONCLUSIONS

Aquaporin 5 is implicated in OLP patients in several ways such as impaired salivary functioning, xerostomia or dry mouth, diminished repair ability of the mucosal lesion, increased apoptosis, and probable carcinogenesis in this premalignant lesion.

Mortality and Survival Analysis in Patients With Cancer Occurrence After Sjögren's Syndrome: A Long-Term Cohort Study in China

OBJECTIVE

This study aimed to investigate the mortality, survival rates, and prognostic indicators of cancer occurrence after Sjögren's syndrome (SS-CA).

METHODS

The medical records of patients with SS-CA at the Peking Union Medical College Hospital (PUMCH) between January 2010 and August 2022 were retrieved. Clinical data and survival outcomes were compared to controls. The standard mortality ratio (SMR) versus the general population was calculated, and the survival and predictive markers of prognosis were analyzed using Kaplan-Meier curves and Cox regression.

RESULTS

In total, 114 SS-CA patients were included, with a median follow-up time of 105.1 (57.3-168.0) months. Non-Hodgkin lymphoma (32, 28.1%) was the most common cancer in patients with SS-CA. The SMR of SS-CA patients was 2.61 (95% confidence interval [CI] 1.73-3.77). Patients with SS-CA exhibited significantly inferior outcomes compared to controls (p = 0.010), with 5- and 10-year overall survival rates of 91.2% and 83.2%, respectively. SS patients with a diagnostic interval between SS and cancer (SS-CA diagnostic interval) ≤ 3 years or with hematological malignancies had poorer survival compared to those with a diagnostic interval > 3 years (p < 0.001) or with solid tumors (p = 0.019). Multivariate Cox regression analysis identified the prognosis-associated factors of SS-CA as age at SS diagnosis > 50 years (HR 3.129, 95% CI 1.224-7.998; p = 0.017), SS-CA diagnostic interval ≤ 3 years (HR 7.754, 95% CI 1.953-30.781; p = 0.004), and hematological malignancies (HR 2.648, 95% CI 1.201-5.838; p = 0.016).

CONCLUSION

Malignant comorbidities constituted a poor prognosis in patients with SS, wherein the SS-CA diagnostic interval and the types of cancer were associated with survival.

A Review of a Breakdown in the Barrier: Tight Junction Dysfunction in Dental Diseases

The tight junction (TJ), a type of cell-cell junction, regulates the permeability of solutes across epithelial and endothelial cellular sheets and is believed to maintain cell polarity. However, recent studies have provided conflicting views on the roles of TJs in epithelial polarity. Membrane proteins, including occludin, claudin, and the junction adhesion molecule, have been identified as TJ components. TJs are predominantly found at the stratum granulosum and stratum corneum. Although it remains unclear whether the disruption of TJs is the cause or consequence of certain dental diseases, evidence suggests that TJ dysfunction may be a crucial factor in gingival epithelial barrier impairment and the progression of oral diseases. Bacterial infection is among the most specific factors we found that may contribute to the breakdown of the epithelial barrier formed by TJs in dental diseases. Bacteria and their products may weaken the epithelial barrier by directly destroying intercellular junctions or altering the expression of junctional proteins. Additionally, they may induce the production of inflammatory cytokines, which could lead to the downregulation of TJ proteins and, consequently, impair the epithelial barrier. This review introduces a novel perspective by exploring, for the first time, the role of TJs dysfunction in the breakdown of the oral epithelial barrier and its potential link to the progression of dental diseases such as gingivitis, periodontitis, Sjӧgren syndrome, and oral squamous cell carcinoma.

A non-invasive model for diagnosis of primary Sjogren's disease based on salivary biomarkers, serum autoantibodies, and Schirmer's test

BACKGROUND

Minor salivary gland (MSG) biopsy is a critical but invasive method for the classification of primary Sjögren's disease (pSjD). Here we aimed to identify salivary proteins as potential biomarkers and to establish a non-invasive prediction model for pSjD.

METHODS

Liquid chromatography-tandem mass spectrometry was conducted on whole saliva samples from patients with pSjD and non-Sjögren control subjects (non-pSjD). Proteins involved in immune processes were upregulated in the pSjD group, such as complement C3 (C3), complement factor B (CFB), clusterin (CLU), calreticulin (CALR), and neutrophil elastase (NE), which were further confirmed by ELISA. Multivariate logistic regression analyses were performed to identify markers that differentiated pSjD from non-pSjD; receiver operating characteristic (ROC) curves were constructed. A diagnostic model based on the combination of salivary biomarkers (CFB, CLU, and NE), serum autoantibodies (anti-SSA /Ro60 and anti-SSA/Ro52), and Schirmer's test was evaluated in 186 patients (derivation cohort) with replication in 72 patients (validation cohort).

RESULTS

In multivariate analyses, CFB, CLU, and NE were independent predictors of pSS. A model based on the combination of salivary biomarkers (CFB, CLU, and NE), serum autoantibodies (anti-SSA and anti-Ro52), and Schirmer's test achieved significant discrimination of pSS. In the derivation cohort, the area under curve (AUC) of the ROC was 0.930 (95% CI 0.877-0.965, P < 0.001), with a sensitivity and specificity of 84.85% and 92.45%, respectively. Notably, similar results were obtained in a validation cohort.

CONCLUSION

The 6-biomarker panel could provide a novel non-invasive tool for the classification of pSjD.

Lung cancer in patients with pulmonary fibrosis: characteristics features and prognosis

BACKGROUND AND AIM

Lung cancer is one of the significant comorbidities seen in patients with Idiopathic Pulmonary Fibrosis (IPF). However, there is limited data on non-IPF Pulmonary Fibrosis (PF) patients with lung cancer (LC). The present study aims to compare the characteristics and survival outcomes of patients diagnosed with LC in IPF and non-IPF PF.

METHODS

The multicenter data records of IPF and non-IPF PF patients diagnosed with lung cancer between 2010- 2022 were analyzed in this descriptive, cross-sectional, and retrospective study.

RESULTS

Of the 251 patients involved in this study [164 IPF-LC, 87 non-IPF PF-LC], 89.6% were male, the mean age was 69±7.9 years and the smoking rate was 85.7%. Honeycomb pattern was more frequently observed in IPF-LC patients [62.8%,37.9%p<0.001], whereas ground-glass opacity [33.5%,59.8%p<0.001] and emphysema [37.8%,59.8%p<0.001] were more frequently seen in non-IPF PF-LC patients. The most commonly seen histological type was squamous cell carcinoma [42.7%,33.9%], followed by adenocarcinoma [28.2%; 32.2%]. [46.4%;47.2%] and their 5-year mortality rates were high [64.6%, 63.2%]. The median survival for both groups was 2±0.22 years [median 95% CI (1.55-2.44)]. The shortest survival time was observed in non-IPF PF-LC subgroup with unclassified PF [1±0.253 years median 95% CI (0.50-1.49) (p=0.030)].

CONCLUSIONS

The majority of IPF and non-IPF PF LC patients were male, elderly, and had a high smoking rate. Squamous cell carcinoma was the most frequently seen histological type and they had short survival periods and high mortality rates. The survival period of unclassified non-IPF PF-LC patients was found to be the shortest.

The Development and Content Validation of the Sjögren's Related Quality of Life Instrument (SRQoL)

INTRODUCTION

Several clinical outcome assessment (COA) instruments assess Sjögren's disease (Sjögren's) symptoms, but do not provide comprehensive assessment of the health-related quality of life (HRQoL) impact of Sjögren's. This study aimed to develop a patient-reported outcome (PRO) instrument for the assessment of HRQoL, intended for use in clinical trials and clinical practice in the assessment of treatment benefit.

METHODS

Review of study sponsor proprietary data and qualitative interviews informed the development of a conceptual model, the Sjögren's Related Quality of Life (SRQoL) and patient global impression of severity (PGI-S) and change (PGI-C) items. Combined concept elicitation and cognitive debriefing interviews with patients with Sjögren's explored their HRQoL impact experience and content validity of the SRQoL and PGI items.

RESULTS

Twenty participants were interviewed about their Sjögren's experience. Following inductive analysis of interviews, concepts were categorized into eight domains: emotional well-being (e.g., worry and stress; n = 20/20; 100%), sleep (e.g., daytime sleepiness and waking up during the night; n = 20/20; 100%), activities of daily living (e.g., difficulty looking at screens and difficulty driving; n = 20/20; 100%), cognition (e.g., concentration difficulties and word finding difficulties; n = 19/20; 95.0%), physical functioning (e.g., difficulty walking and difficulty exercising; n = 19/20; 95.0%), social and family functioning (e.g., dependent on others and relationship difficulties; n = 17/20; 85.0%), work (n = 15/20; 75.0%), and sexual functioning (n = 12/20; 60.0%). SRQoL and PGI items, instructions, response options, and recall period were well understood and relevant to participants.

CONCLUSIONS

The SRQoL is a new PRO instrument to assess Sjögren's impact on HRQoL, developed in accordance with regulatory guidance. This study provides considerable insight into the patient experience of Sjögren's and evidence to support the content validity of the SRQoL. Future research should evaluate the psychometric properties of the SRQoL to support its use in clinical trials and clinical practice and further validate its use as an assessment of treatment benefit.

Bilateral Snapping Knee in a Patient with Rheumatoid Arthritis Accompanied by Sjögren's Syndrome - A Case Report

Introduction

We experienced a rare case in which a bilateral snapping knee was caused by rheumatoid arthritis accompanied by Sjögren's syndrome (SS), and the symptoms were resolved by arthroscopic surgery.

Case Report

A 43-year-old Asian male presented at another hospital with finger, shoulder, and knee pain and was diagnosed with rheumatoid arthritis accompanied by SS. Two months later, he developed the snapping phenomenon in both knees and presented at our hospital. The patient was positive for rheumatoid factor, anti-Smith antibody, and anti-SS-A antibody. Arthroscopy revealed a hard scar-like tissue in the lateral patellofemoral joint in both knees. The scar-like tissue was excised arthroscopically. Post-operatively, the snapping phenomenon and pain during flexion of the bilateral knee joints had been resolved.

Conclusion

In the present case, rheumatoid arthritis accompanied by SS caused inflammation of the knee joints and degeneration of the articular capsules, and snapping of the bilateral knees was caused by impingement of the scar tissue in the patellofemoral joints.

Efficacy of disease-modifying antirheumatic drugs in primary Sjögren's syndrome-related interstitial lung disease

OBJECTIVES

To evaluate the treatment modalities and their effects in primary Sjögren's syndrome (pSS) patients with interstitial lung disease (ILD).

METHODS

In this chart review study, patients diagnosed with pSS-related ILD (pSS-ILD) between January 2004 and August 2022 were screened. Glucocorticoid use and administered disease-modifying antirheumatic drugs (DMARDs) were determined. The difference between forced vital capacity (FVC) and diffusion capacity of the lungs for carbon monoxide (DLCO) before and after treatment was evaluated.

RESULTS

ILD was present in 44 of 609 patients (7.2%) diagnosed with pSS. In 27 patients included in the study, steroid usage was 81.5%. There was a statistically insignificant increase in FVC% (from 80.20±22.1 to 81.6±23.0) and a decrease in DLCO% (53.7±15.3-52.2±19.3) with DMARD treatment (p=0.434 and p=0.652, respectively). There was no significant difference between the treatment groups (azathioprine [AZA], mycophenolate mofetil [MMF], and rituximab [RTX]) in terms of the change in FVC% and DLCO% compared with baseline levels. The effect of treatment on FVC and DLCO was similar in UIP and NSIP patterns.

CONCLUSIONS

AZA, MMF, and RTX have similar effects on pulmonary functions in pSS-ILD and provide disease stabilization.

Ocular manifestations of juvenile Sjögren's disease

PURPOSE OF REVIEW

This review aims to enhance understanding of juvenile Sjögren's disease (jSjD) by exploring diagnostic criteria, ocular clinical features, ancillary ophthalmic testing, and management strategies specific to this rare pediatric condition.

RECENT FINDINGS

Unlike adults, children with jSjD often present with recurrent parotitis and extra-glandular symptoms before developing sicca symptoms. Adult SjD classification criteria do not consider pediatric-specific symptoms and physiological differences. Underutilization of diagnostic tests such as the ocular staining score (OSS) and Schirmer I may result in an incomplete understanding of the prevalence of keratoconjunctivitis sicca in jSjD.

SUMMARY

Timely referral to an ophthalmologist can address perceived feasibility issues with respect to ocular features in jSjD. Management of keratoconjunctivitis sicca in jSjD includes improving ocular surface lubrication and decreasing inflammation. Recognition of pediatric-specific clinical features and development of universally accepted jSjD classification criteria will allow for better identification of potential participants for future jSjD studies.

Relationship Between Perfluoroalkyl Acids in Human Serum and Sjogren's Syndrome: A Case-Control Study of Populations in Hangzhou, China

Exposure to perfluoroalkyl acids (PFAAs) has been found to elicit a range of detrimental effects on human health. However, limited research has investigated the impact of PFAAs on immunity and immune disorders such as Sjogren's syndrome, with existing studies yielding inconsistent results. This study was conducted in Hangzhou, China, with an initial cohort comprising 156 healthy individuals and 162 patients diagnosed with Sjogren's syndrome. We quantified serum levels of PFAAs and examined associations between PFAAs and both susceptibilities to the development of Sjogren's syndrome and immune marker concentrations. Nine PFAAs were frequently detected in the serum, with perfluorooctanoate (PFOA) exhibiting the highest concentration, followed by perfluorooctanesulfonate (PFOS). Exposure to PFOA and perfluorotridecanoate (PFTrDA) was inversely associated with the disease. Furthermore, a negative correlation between PFOA and C-reactive protein (CRP) was observed. These findings suggest that exposure to specific PFAAs may impact the immune system and potentially influence the development of Sjogren's syndrome.

[Diagnostic values of anti-salivary gland protein-1 antibody combined with anti-parotid secretory protein antibody for Sjögren's syndrome]

OBJECTIVE

To assess the diagnostic value of anti-salivary gland protein-1 (SP1) antibody combined with anti-parotid secretory protein (PSP) antibody for Sjögren's syndrome (SS).

METHODS

A total of 60 patients with primary SS (pSS) who were treated in the outpatient and inpatient department of Department of Rheumatology and Immunology of the Second Hospital of Hebei Medical University from January 2020 to December 2022 were collected. Thirty patients with other autoimmune diseases accompanied by dry mouth and/or dry eyes were collected as disease control group. Thirty healthy subjects from the physical examination center were collected for healthy control group, serum samples were obtained from all of them. Their general features and clinical information including clinical manifestations, laboratory examinations and other examinations were recorded. The 2016 American College of Rheumatology (ACR)/European League against Rheumatism (EULAR) classification criteria were adopted as the diagnostic standard of pSS. Immunoglobulin G (IgG) subtype of anti-SP1 antibody and anti-PSP antibody were detected by chemiluminescence immunoassay. The receiver operating characteristic (ROC) curve was used to evaluate the accuracy of anti-SP1 antibody and anti-PSP antibody in diagnosing pSS.The cli-nical characteristics of anti-SP1 antibody and anti-PSP antibody positive patients and negative patients in pSS group were further compared. Independent samples t test, Mann-Whitney U test, variance analysis, Kruskal-Wallis test, Chi-square test or Fisher's exact test and Spearman correlation analysis were used for statistical analysis.

RESULTS

There was no significant difference in age (F=1.406, P=0.495) and gender (χ2=2.105, P=0.349) among pSS group, disease control group and healthy control group. The expression levels of anti-SP1 antibody (H=16.73, P < 0.001) and anti-PSP antibody (H=26.09, P < 0.001) were statistically different among the three groups. An intergroup comparison of anti-SP1 antibody expression levels showed that there was a statistically significant difference between pSS and healthy control group (P < 0.001), but no statistically significant difference between the other groups. Comparison of anti-PSP antibody expression levels between the groups showed that there were statistically significant differences between pSS and healthy control group (P < 0.001), and between disease control group and healthy control group (P=0.009), while no statistically significant differences between the other groups. The positive rate of anti-SP1 antibody in pSS group was significantly higher than that in disease control group and healthy control group (58.33% vs. 40.00% vs. 13.33%, P < 0.001). The positive rate of anti-PSP antibody in pSS group was significantly higher than that in disease control group and healthy control group (75.00% vs. 56.17% vs. 16.67%, P < 0.001). The area under the curve for anti-SP1 antibody was 0.688 (P < 0.001). The sensitivity and specificity of anti-SP1 antibody were 58.33% (35/60) and 70.00% (42/60) respectively, the positive predictive value was 66.04% (35/53) and the negative predictive value was 54.55% (42/77) of anti-SP1 antibody.The area under the curve of anti-PSP antibody was 0.720 (P < 0.001), with a sensitivity was 75.00% (45/60), and specificity was 63.33% (38/60).The positive predictive value and negative predictive value of anti-PSP antibody were 67.16% (45/67) and 71.70% (38/53) respectively. All the 13 pSS patients were negative for anti-Sjögren's syndrome A (SSA, including SSA52 and SSA60) antibody and anti- Sjögren's syndrome B (SSB) antibody. Among them, 11 patients were positive for both anti-SP1 antibody and anti-PSP antibody, 1 patient was positive for anti-SP1 antibody and 1 patient was positive for anti-PSP antibody. The clinical features of anti-SP1 antibody and anti-PSP antibody positive and negative groups were compared in pSS patients. The duration of disease in anti-SP1 antibody positive group was shorter (Z=-2.277, P=0.023) when compared with the negative patients. The patients with positive anti-PSP antibody were younger than those in the negative group (t=2.598, P < 0.05), the positive rate of rheumatoid factor (P=0.002) and the serum level of IgG (t=3.806, P=0.003) in anti-PSP antibody positive group were higher than in the negative group. Analysis of the correlation between anti-SP1 antibody and anti-PSP antibody in the pSS patients showed that there was significant correlation between them (r=0.801, P < 0.001).

CONCLUSION

Both anti-SP1 antibody and anti-PSP antibody are valuable in the diagnosis of SS, and anti-SP1 antibody is helpful for the early diagnosis of pSS. The combined detection of anti-SP1 antibody and anti-PSP antibody is helpful for the early diagnosis of pSS patients with negative anti-SSA antibody and anti-SSB antibody.

Limited Biomarker Potential for IgG Autoantibodies Reactive to Linear Epitopes in Systemic Lupus Erythematosus or Spondyloarthropathy

BACKGROUND

Autoantibodies are commonly used as biomarkers in autoimmune diseases, but there are limitations. For example, autoantibody biomarkers have poor sensitivity or specificity in systemic lupus erythematosus and do not exist in the spondyloarthropathies, impairing diagnosis and treatment. While autoantibodies suitable for strong biomarkers may not exist in these conditions, another possibility is that technology has limited their discovery. The purpose of this study was to use a novel high-density peptide array that enables the evaluation of IgG binding to every possible linear antigen in the entire human peptidome, as well as a novel machine learning approach that incorporates ELISA validation predictability in order to discover autoantibodies that could be developed into sensitive and specific markers of lupus or spondyloarthropathy.

METHODS

We used a peptide array containing the human peptidome, several viral peptidomes, and key post-translational modifications (6 million peptides) to quantify IgG binding in lupus, spondyloarthropathy, rheumatoid arthritis, Sjögren's disease, and control sera. Using ELISA data for 70 peptides, we performed a random forest analysis that evaluated multiple array features to predict which peptides might be good biomarkers, as confirmed by ELISA. We validated the peptide prediction methodology in rheumatoid arthritis and COVID-19, conditions for which the antibody repertoire is well-understood, and then evaluated IgG binding by ELISA to peptides that we predicted would be highly bound specifically in lupus or spondyloarthropathy.

RESULTS

Our methodology performed well in validation studies, but peptides predicted to be highly and specifically bound in lupus or spondyloarthropathy could not be confirmed by ELISA.

CONCLUSIONS

In a comprehensive evaluation of the entire human peptidome, highly sensitive and specific IgG autoantibodies were not identified in lupus or spondyloarthropathy. Thus, the pathogenesis of lupus and spondyloarthropathy may not depend upon unique autoantigens, and other types of molecules should be sought as optimal biomarkers in these conditions.

Clinical stratification of 1318 Primary Sjögren's Syndrome patients

OBJECTIVE

Primary Sjögren's Syndrome (pSS) is a complex autoimmune disorder characterized by diverse clinical manifestations yet lacking effective therapeutic strategies currently. This study aims to gain a thorough understanding of the clinical landscape of pSS and further delineate its clinical subtypes, thereby enabling the efficient management for pSS.

METHODS

We conducted a cross-sectional observational study of 1318 pSS patients. The pSS patients were categorized and compared based on gender, anti-SSA antibodies, and labial salivary gland biopsies (LGSB). Unsupervised clustering analysis was employed to identify pSS subtypes using systemic involvement among patients. Furthermore, we assessed clinical and biological variances among these subtypes.

RESULTS

Through group comparisons, we observed more pronounced extraglandular manifestations among male patients, SSA-negative group, and those with positive LGSB results. Based on systemic involvement, pSS patients were categorized into four groups. C1 exhibited minimal systemic involvement, lacking hematologic or serologic manifestations, with the lowest ESSDAI scores. C2 presented with serologic changes in all patients, partial joint involvement, and no hematologic systemic manifestations. C3 lacked joint involvement but all members displayed hematologic systemic involvement, with higher rates of renal, cutaneous, and systemic manifestations. C4 encompassed patients with joint and hematologic involvement, displaying the highest ESSDAI scores. The positivity rates of antibodies, immunological parameters, and inflammatory markers exhibited significant differences among the groups. Furthermore, notable variances were observed in the expression of peripheral blood transcriptomic modules among these groups.

CONCLUSION

In this cohort study, we summarized the clinical characteristics of Chinese patients with pSS and identified four distinct subgroups of pSS based on systemic involvement, revealing clinical and molecular disparities that unveil distinct pathobiological endotypes. Our findings hold significant implications for clinical management.

Salivary gland biopsy as a prognostic tool in Sjögren's syndrome

INTRODUCTION

Primary Sjögren's syndrome (pSS) is an autoimmune disorder primarily affecting salivary and lacrimal glands, although about 40% of patients experience systemic complications. In this setting, the identification of patient phenotypes characterized by increased risk of extra-glandular involvement still represents an unmet need.

AREAS COVERED

The aim of this paper is to review the scientific evidence on the utility of salivary gland biopsies in pSS, emphasizing their role in defining prognosis. In latest years, research focused on disease-specific clinical, serological, or histological features able to categorize patient prognosis. Among histopathological features, focus score and ectopic germinal centers exhibit associations with glandular and extraglandular manifestations, including higher rates of lymphomagenesis.

EXPERT OPINION

Pathological characterization of salivary glands provides information that go beyond a mere diagnostic or classification utility, providing insights for a stratification of disease severity and for predicting systemic manifestations. Thus, a salivary gland biopsy should be offered to all patients and included in routine practice, even when not strictly required for diagnostic purposes. More advanced analysis techniques of the tissue, including immunohistochemistry and 'omics' should be further explored in longitudinal studies to boost the ability to further stratify and predict disease evolution.

Capability of the Inter-Eye Differences in Osmolarity, Break-Up Time and Corneal Staining on the Diagnostic of Dry Eye

PURPOSE

Inter-eye variability is a recognized characteristic of Dry Eye Disease (DED) and has been proposed as a diagnostic indicator in clinical practice. This study aimed to assess the diagnostic potential of the absolute difference between eyes in three key diagnostic tests recommended by the Tear Film and Ocular Surface Society Dry Eye Workshop II (TFOS DEWS II) Diagnostic Methodology report: tear film osmolarity, Fluorescein Break-Up Time (FBUT), and ocular surface staining.

METHODS

A total of 180 participants were included in a cross-sectional study. Before a dry eye examination, participants completed an online self-administered OSDI questionnaire. The TFOS DEWS II diagnostic criteria for DED assessment were used: along with OSDI, osmolarity, FBUT and ocular surface staining were measured in all participants in both eyes following standardized methodology. Based on signs and symptoms, participants were diagnosed as having No DED or DED. After diagnosis, the parameters were computed as the right and left eyes' absolute inter-eye difference (|OD-OS|).

RESULTS

Receiver Operating Characteristics analyses for computed parameters were used based on the previous diagnosis. ROC analyses showed that Osmolarity|OD-OS| have a diagnostic capability to differentiate between No DED and DED participants with a cut-off value of 9.5 mOsm/L (AUC = 0.745 ± 0.052, p < 0.003), whereas FBUT|OD-OS| and Corneal Stainning|OD-OS| have not (AUC, both p ≥ 0.160).

CONCLUSION

The present study found that the Osmolarity|OD-OS| parameter could be used as a diagnostic indicator for DED assessment, while the FBUT|OD-OS| and the Corneal Staining|OD-OS| parameters do not have this capability.

The effect of intense pulsed light combined with topical 0.05% Cyclosporin A eyedrops in the treatment of Sjögren's syndrome related dry eye

OBJECTIVES

This study aimed to assess the effectiveness and safety of intense pulsed light (IPL) therapy plus topical 0.05% cyclosporine A (CsA) eye drops to treat Sjögren's Syndrome-related dry eyes (SS-DE).

RESEARCH DESIGN AND METHODS

In this prospective, randomized trial included, 60 individuals with SS-DE symptoms were randomized to receive topical eye drops containing either 0.1% sodium hyaluronate (Group S) or 0.05% CsA (Group C) plus IPL therapy. Before the first treatment (baseline), and at 12, 16, and 20 weeks after treatment commencement, we assessed the best corrected visual acuity (BCVA), the Ocular Surface Disease Index (OSDI) score, the Schirmer I test (SIT), noninvasive tear breakup time (NBUT), corneal fluorescein staining (CFS), meibomian gland (MG) dropout, lid margin abnormality, MG expressibility, and meibum quality.

RESULTS

Both groups showed significant improvements in the OSDI, NBUT, CFS, MG expressibility, and meibum quality (all p < 0.05). Group C showed a greater increase in OSDI, NBUT, MG expressibility, and meibum quality (all p < 0.05). Moreover, SIT and lid margin abnormalities significantly improved in Group C (both p < 0.05), but not in Group S.

CONCLUSION

Treatment with 0.05% CsA eyedrops plus IPL therapy could significantly reduce the issues and physical discomfort of patients with SS-DE.

CLINICAL TRIAL

Registered on 20 July 2021, with the registration number ChiCTR2100049059.

Sjogren's Syndrome: A Series of Five Cases

Sjogren's syndrome is an autoimmune disorder that has a prominent involvement of exocrine glands. Systemic involvement of other organs can also happen. Peripheral nervous system involvement is common and may present as axonal sensory/sensorimotor or demyelinating polyneuropathy, mononeuritis multiplex, ganglionopathy, or cranial neuritis. It can also present with transverse myelitis, especially longitudinally extensive transverse myelitis in association with aquaporin-4 antibodies. It can also mimic central nervous system (CNS) demyelinating disorders such as multiple sclerosis. The present case series highlights some uncommon neurological presentations of Sjogren's syndrome. In this series, patients presented with Miller-Fischer syndrome, recurrent Guillain-Barre syndrome, multifocal dystonia, and demyelinating disorder of CNS. None of the cases had presenting complaints of dry mouth or eyes. Special investigations such as magnetic resonance imaging (MRI), nerve conduction studies, anti-ganglioside panel, and cerebrospinal fluid analysis, depending on the clinical presentation of the cases, were conducted. Schirmer's test, tear breakup time, antinuclear antibodies (ANA) by immunofluorescent assay, ANA blot demonstrating the presence of anti-SSA (Ro) and/or anti-SSB (La) antibodies, and lip biopsy were conducted in all cases, which confirmed the diagnosis of Sjogren's syndrome. After the diagnosis was confirmed, other tests such as C- reactive protein, serum cryoglobulin, and rheumatoid factor were conducted. Treatment was initiated with steroids, followed by long-term immunosuppression with injection rituximab. Sjogren's syndrome may present with various presentations of neurological involvement, sometimes rare, and hence a high degree of suspicion is required when other usual causes are excluded.

Predictors of Discordance Between Dry Eye Symptoms and Signs: Insights From the Sjögren's International Collaborative Clinical Alliance

Purpose

The diagnosis and management of dry eye disease (DED) could be complicated by the discordance between DED-related symptoms and signs. We performed a cross-sectional study to investigate the factors of and develop predictive models for the discrepancy in DED symptomatology.

Methods

We used data from 3455 participants, 21 to 89 years old, from the Sjögren's International Collaborative Clinical Alliance study. We performed a multivariable stepwise linear regression model with backward elimination and Bayesian information criteria to select predictors for the discordance in DES symptomatology, which was defined as the difference between the rank score of Ocular Surface Disease Index 6 (OSDI-6) and the rank score of ocular staining score (OSS).

Results

Ten predictors, such as "vitality," "immunomodulating drugs," sensory symptoms," and "ethnicity," remained in the final models, achieving an adjusted R2 (aR2) of 0.35 (95% confidence interval [CI], 0.32-0.39). Specifically, medication use explained 19% (95% CI, 0.17-0.22) of the variance in the outcome, followed by medical history (aR2 = 0.18; 95% CI, 0.15-0.21). Health-related quality of life contributed 16% to the variance in the outcome (95% CI, 0.13-0.19), and, last, demographics contributed 11% (95% CI, 0.09-0.13).

Conclusions

Our results suggest that individuals of Asian descent and those using immunomodulating medications often present with severe ocular signs that necessitate regular ophthalmological evaluations, even in the absence of proportionate ocular symptoms. Additionally, ocular symptoms, when accompanied by abnormal sensations in other parts of the body, could indicate systemic conditions that require further investigation and medical care.

Clinical characteristics of chronic sclerosing sialadenitis as a distinctive entity from primary Sjögren's syndrome

Objective

This study aimed to elucidate the clinical and laboratory differences between chronic sclerosing sialadenitis (CSS) and primary Sjögren's syndrome (pSS), highlighting CSS as a distinct pathological entity within the spectrum of salivary gland pathology.

Methods

This retrospective, single-center study was conducted at Seoul St. Mary's Hospital between January 2000 and December 2022. Patients diagnosed with CSS via salivary gland biopsy were included, and those with IgG4-related disease (IgG4-RD) or other confounding factors were excluded. Clinical and laboratory CSS profiles were compared with those of a control group of patients with typical pSS from the Korean Initiative of Primary Sjögren's Syndrome (KISS) prospective cohort study. Twenty-one with CSS and 501 patients with pSS from Seoul St. Mary's Hospital were retrospectively analyzed.

Results

Patients with CSS were older at diagnosis, had a lower prevalence of ocular symptoms, and exhibited distinct immunological markers compared to those with pSS. Logistic regression analysis revealed that anti-Ro antibody positivity, elevated erythrocyte sedimentation rate levels, low serum complement 3 levels, and accompanying dry eye symptoms were factors distinguishing pSS from CSS.

Conclusion

Even after excluding IgG4-RD, CSS was significantly different from pSS in terms of clinical and laboratory findings. Recognition of these differences is crucial for the accurate diagnosis and management of CSS, underscoring its status as a distinct pathological entity among salivary gland pathologies.

A comprehensive review of Sjögren's syndrome: Classification criteria, risk factors, and signaling pathways

Sjögren's syndrome (SS) is a chronic autoimmune disease that affects the exocrine glands and may lead to a range of systemic symptoms that impact various organs. Both innate and adaptive immune pathways might trigger the disease. Studying the signaling pathways underlying SS is crucial for enhancing diagnostic and therapeutic effectiveness. SS poses an ongoing challenge for medical professionals owing to the limited therapeutic options available. This review offers a comprehensive understanding of the intricate nature of SS, encompassing disease classification criteria, risk factors, and signaling pathways in immunity and inflammation. The advancements summarized herein have the potential to spark new avenues of research into SS.

Issues in autoantibody tests used in the classification criteria for autoimmune rheumatic diseases: the laboratory autoimmunologist's perspective

Classification criteria of autoimmune rheumatic diseases are an important means to define homogenous groups of patients that can be compared across studies for clinical trials and research purposes. The measurement of autoantibodies is a relevant aspect in the definition of classification criteria, with a significant weight in the scores necessary to classify patients with autoimmune rheumatic diseases. The impact of autoantibodies has gradually increased over the years, contributing to the evolution and improvement of the classification criteria. However, these criteria often do not take into consideration how autoantibodies are measured, i.e. differences in diagnostic accuracy of the methods. This is a critical point especially when obsolete analytical methods that are no longer used in many clinical laboratories are taken into consideration. In this review we have critically examined assays and methods for the determination of autoantibodies that are (or could be) included among the classification criteria of autoimmune rheumatic diseases in light of more recent evidence and technology evolution.

Diagnostic and therapeutic potentials of extracellular vesicles for primary Sjögren's Syndrome: A review

Primary Sjögren syndrome (pSS) is a chronic autoimmune disease mainly affecting salivary and lacrimal glands. The current pSS biomarkers, serum autoantibodies, are negative in many pSS patients diagnosed with histopathology changes, indicating the need of novel biomarkers. The current therapies of pSS are merely short-term symptomatic relief and can't provide effective long-term remedy. Extracellular vehicles (EVs) are nano-sized lipid bilayer-delimited particles spontaneously released by almost all types of cells and carrying various bioactive molecules to mediate inter-cellular communications. Recent studies found that EVs from salivary gland epithelial cells and immune cells play essential roles in pSS pathogenesis. Correspondingly, EVs and their cargos in plasma and saliva are promising candidate biomarkers for pSS diagnosis. Moreover, EVs from mesenchymal stem cells have shown promises to improve pSS treatment by modulating immune responses. This review summarizes recent findings in roles of EVs in pSS pathogenesis, diagnosis, and treatment of pSS, as well as related challenges and future research directions.

Elevated concentration of beta2-microglobulin among patients with carpal tunnel syndrome in the course of primary Sjögren syndrome - a prospective observational study on 50 patients

INTRODUCTION

Sjögren's syndrome (SS) is a chronic autoimmune disease characterized by lymphocytic infiltrates in the exocrine glands. Carpal tunnel syndrome (CTS) is suggested to be more frequent among SS patients than in the general population. The aim of this study was to seek associations between the CTS and the laboratory and clinical findings of SS patients.

METHODS

Fifty patients diagnosed with primary SS (pSS) were examined. Clinical evaluation by a rheumatologist and electrophysiological studies were conducted. Data on laboratory tests results was collected. Control group consisted of 50 sex and age-matched individuals with osteoarthritis (OA).

RESULTS

Out of 50 patients in the study group 27 (54%) were diagnosed with CTS. The prevalence of CTS among 50 individuals in the control group was 8%. Among pSS patients with CTS the joint involvement was not more common than in those from the non-CTS group [15 vs. 13 (p = 0.945)]. There was an expected difference in sleep disorders [18 vs. 9 (p = 0.012)] and paresthesia [23 vs. 13 (p = 0.024)]. The major finding was a significant difference in elevated beta2-microglobulin (B2MG) [23 vs. 13 (p = 0.024)]. Other studied factors, suggested in the literature as significant in the pSS-related neuropathy, were not statistically different between the groups.

CONCLUSION

Our study confirms that CTS is more prevalent among pSS patients than in the general population and suggests that a new approach is required towards the pathogenesis of this phenomenon. We hypothesize that CTS is more associated with an overall disease activity than joint involvement as such.

Identification and Validation of IFI44 as a Novel Biomarker for Primary Sjögren's Syndrome

Background

Primary Sjögren's syndrome (pSS) is an autoimmune condition marked by lymphocyte infiltration in the exocrine glands. Our study aimed to identify a novel biomarker for pSS to improve its diagnosis and treatment.

Methods

The gene expression profiles of pSS were obtained from the Gene Expression Omnibus (GEO) database. The specific differentially expressed genes (DEGs) were screened by the Least Absolute Shrinkage and Selection Operator (LASSO), Random Forest (RF), and Recursive Feature Elimination with Support Vector Machines (SVM-RFE). A biomarker was picked out based on correlation and diagnostic performance, the connection between the biomarker and clinical traits and immune infiltrating cells was explored, and the biomarker's protein expression level in the serum of pSS patients was detected by enzyme-linked immunosorbent assay (ELISA). The competitive endogenous RNA (ceRNA) network regulated by the biomarker was predicted to verify the reliability of the biomarker in diagnosing pSS.

Results

IFI44, XAF1, GBP1, EIF2AK2, IFI27, and IFI6 showed prominent diagnostic ability, with the high accuracy (AUC = 0.859) and significance (R ≥ 0.8) of IFI44 within the training dataset. IFI44 strongly exhibited a negative correlation with resting NK cells, macrophages M0, and eosinophils, and a positive correlation with activated dendritic cells, naive B cells, and activated CD4 memory T cells. Furthermore, IFI44 was significantly positively correlated with clinical traits such as IgG, SSA, SSB, ANA, and ESSDAI, with its protein expression level in the serum of pSS patients being notably elevated compared to controls (p < 0.001). Finally, the ceRNA regulatory network showed that hsa-miR-944, hsa-miR-9-5p, hsa-miR-126-5p, and hsa-miR-335-3p were significantly targeted IFI44, suggesting that IFI44 may serve as a dependable biomarker for pSS.

Conclusion

In this study, we dug out IFI44 as a biomarker for pSS, systematically studied the potential regulatory mechanism of IFI44, and verified its reliability as a biomarker for pSS.

Novel autoantibodies help diagnose anti-SSA antibody negative Sjögren disease and predict abnormal labial salivary gland pathology

OBJECTIVES

Sjögren disease (SjD) diagnosis often requires either positive anti-SSA antibodies or a labial salivary gland biopsy with a positive focus score (FS). One-third of patients with SjD lack anti-SSA antibodies (SSA-), requiring a positive FS for diagnosis. Our objective was to identify novel autoantibodies to diagnose 'seronegative' SjD.

METHODS

IgG binding to a high-density whole human peptidome array was quantified using sera from SSA- SjD cases and matched non-autoimmune controls. We identified the highest bound peptides using empirical Bayesian statistical filters, which we confirmed in an independent cohort comprising SSA- SjD (n=76), sicca-controls without autoimmunity (n=75) and autoimmune-feature controls (SjD features but not meeting SjD criteria; n=41). In this external validation, we used non-parametric methods for binding abundance and controlled false discovery rate in group comparisons. For predictive modelling, we used logistic regression, model selection methods and cross-validation to identify clinical and peptide variables that predict SSA- SjD and FS positivity.

RESULTS

IgG against a peptide from D-aminoacyl-tRNA deacylase (DTD2) bound more in SSA- SjD than sicca-controls (p=0.004) and combined controls (sicca-controls and autoimmune-feature controls combined; p=0.003). IgG against peptides from retroelement silencing factor-1 and DTD2 were bound more in FS-positive than FS-negative participants (p=0.010; p=0.012). A predictive model incorporating clinical variables showed good discrimination between SjD versus control (area under the curve (AUC) 74%) and between FS-positive versus FS-negative (AUC 72%).

CONCLUSION

We present novel autoantibodies in SSA- SjD that have good predictive value for SSA- SjD and FS positivity.

Salivary Gland Sonography in Patients with Primary Fibromyalgia-A Pilot Study

Primary Sjogren's syndrome (pSS) is often concomitant with fibromyalgia (FM). Salivary gland sonography aids in the diagnosis of pSS. We aimed to discover, in primary FM patients, the presence of pSS in undiagnosed patients through salivary gland sonography. We prospectively recruited 42 primary FM patients. FM symptoms were evaluated based on the revised Fibromyalgia Impact Questionnaire (FIQR). Salivary gland sonography was performed. Patients with positive findings underwent salivary gland biopsy. Comparisons were undertaken using the Mann-Whitney U tests and Chi-squared test. In primary FM patients, the prevalence of dry eye was 83%, and dry mouth was 90%. The salivary gland sonographic score did not differ between patients with and without dry eye/mouth. One patient with a positive finding at salivary gland sonography had a positive result of salivary gland biopsy. In the other four patients who received salivary gland biopsy, despite negative findings in salivary gland sonography, only one had a positive result of salivary gland biopsy. To be noted, scores evaluated by salivary gland sonography were negatively associated with levels of pain (rho = -0.360, p= 0.023) and levels of sleep quality (rho = -0.447, p = 0.004). Our pilot study demonstrated the potential of salivary gland biopsy in detecting undiagnosed pSS in primary FM patients.

Serum biomarker-based risk model construction for primary Sjögren's syndrome with interstitial lung disease

Background

Cytokine network disturbances in primary Sjögren's syndrome (pSS) have been reported in many studies. However, their functions in patients with primary Sjögren's syndrome and interstitial lung disease (pSS-ILD) is controversial. In this study, we aim to investigate the associations of immunological characteristics and cytokine profiles with pSS-ILD pathogenesis and explore their predictive values for pSS progression.

Methods

A total of 256 patients initially diagnosed with pSS at Henan Provincial People's Hospital were enrolled. After excluding the patients previously diagnosed with various serious acute and chronic respiratory system diseases and cases with other connective tissue diseases or congenital heart diseases, 94 pSS patients were included for further analysis, including 40 patients with ILD (pSS-ILD) and 54 patients without ILD (pSS-N-ILD). For comparison, 41 age- and sex-matched healthy individuals were included as normal controls. Their clinical symptoms and serological data including cyclic citrullinated peptide (CCP) antibody (anti-CCP), antinuclear antibody (ANA), anti-Ro52, anti-SSA, anti-SSB, C-reactive protein, IgG, IgM, IgA, C3, C4, and 10 cytokines and chemokines were obtained. Wilcoxon test, chi-square test, Spearman correlation analysis, and logistics regression analysis were performed.

Results

Higher positive rates of anti-SSB and higher incidence of dry cough, dyspnea, and arthrosis symptoms were shown in pSS-ILD patients than in the pSS-N-ILD cases. Anti-CCP antibodies and cytokines (IL-1β, TNFα, IL-6, IL-5, IL-12p70, and IL-17) were higher, while C3 was lower in pSS-ILD patients than in pSS-N-ILD cases. Significant negative correlations of IgG with C3 and C4 and positive correlations of IL-12p70 and IL-17 with IL-6 were only shown in pSS-ILD patients. The anti-CCP antibody was positively correlated with IL-5 in pSS-ILD patients, but not in pSS-N-ILD cases. Multi-variable logistics regression analysis revealed the combination of anti-CCP, IL-17, IL-12p70, and IL-5 was effective in predicting the status of pSS-ILD in the pSS cases.

Conclusion

There were significant differences in serum marker levels between pSS-ILD and pSS-N-ILD cases. The combination of anti-CCP, IL-17, IL-12p70, and IL-5 might be a potential risk predictor for pSS-ILD occurrence. The cytokines might be involved in the development and progression of pSS-ILD. These results would provide new therapeutic targets for pSS-ILD treatment.

A graph-learning based model for automatic diagnosis of Sjögren's syndrome on digital pathological images: a multicentre cohort study

BACKGROUND

Sjögren's Syndrome (SS) is a rare chronic autoimmune disorder primarily affecting adult females, characterized by chronic inflammation and salivary and lacrimal gland dysfunction. It is often associated with systemic lupus erythematosus, rheumatoid arthritis and kidney disease, which can lead to increased mortality. Early diagnosis is critical, but traditional methods for diagnosing SS, mainly through histopathological evaluation of salivary gland tissue, have limitations.

METHODS

The study used 100 labial gland biopsy, creating whole-slide images (WSIs) for analysis. The proposed model, named Cell-tissue-graph-based pathological image analysis model (CTG-PAM) and based on graph theory, characterizes single-cell feature, cell-cell feature, and cell-tissue feature. Building upon these features, CTG-PAM achieves cellular-level classification, enabling lymphocyte recognition. Furthermore, it leverages connected component analysis techniques in the cell graph structure to perform SS diagnosis based on lymphocyte counts.

FINDINGS

CTG-PAM outperforms traditional deep learning methods in diagnosing SS. Its area under the receiver operating characteristic curve (AUC) is 1.0 for the internal validation dataset and 0.8035 for the external test dataset. This indicates high accuracy. The sensitivity of CTG-PAM for the external dataset is 98.21%, while the accuracy is 93.75%. In comparison, the sensitivity and accuracy for traditional deep learning methods (ResNet-50) are lower. The study also shows that CTG-PAM's diagnostic accuracy is closer to skilled pathologists compared to beginners.

INTERPRETATION

Our findings indicate that CTG-PAM is a reliable method for diagnosing SS. Additionally, CTG-PAM shows promise in enhancing the prognosis of SS patients and holds significant potential for the differential diagnosis of both non-neoplastic and neoplastic diseases. The AI model potentially extends its application to diagnosing immune cells in tumor microenvironments.

The clinical value of KL-6 for predicting the occurrence and severity of connective tissue disease-associated interstitial lung disease is not affected by CTD type or treatment

Objective

The aim of this study was to explore the potential values of Krebs von den Lungen-6 (KL-6), neutrophil to lymphocyte ratio (NLR), systemic immune inflammation (SII), platelet to lymphocyte ratio (PLR), monocyte to lymphocyte ratio (MLR) and red blood cell distribution width (RDW) in the diagnosis and evaluation of the severity of connective tissue disease-associated interstitial lung disease (CTD-ILD).

Methods

A total of 140 connective tissue disease (CTD) patients and 85 CTD-ILD patients were recruited for this study at Shanxi Provincial People's Hospital from May 2022 to May 2023. Patients were divided into subgroups based on medication history and CTD subtypes to compare and analyze the clinical data and laboratory parameters of CTD-ILD patients and CTD patients. The receiver operating characteristic curve (ROC) was used to evaluate the diagnostic efficacy of KL-6, NLR, SII, PLR, MLR, and RDW in identifying CTD-ILD patients from CTD patients. A Spearman correlation analysis was conducted to elucidate the correlations between these markers and the lung function parameters of forced vital capacity (FVC, %), forced expired volume in one second (FEV1, %), and diffusing capacity of carbon monoxide (DLCO, %). Finally, binary logistic regression analysis was applied to discern the independent risk factors for CTD-ILD.

Results

NLR, SII, MLR, RDW, and KL-6 displayed significant statistical differences in the experimental groups. In both untreated and treated subgroups, KL-6 displayed higher values for CTD-ILD than CTD among all CTD subtypes. In untreated subgroups, there were significant differences in MLR levels between rheumatoid arthritis (RA) and RA-ILD patients and in NLR levels between Sjögren syndrome (SjS) and SjS-ILD patients. There were also significant differences in RDW-SD between the "other CTD" and "other CTD-ILD" groups. In treated subgroups, there were significant differences in both RDW-SD and RDW-CV between RA and RA-ILD patients and in NLR, SII, MLR, PLR, and RDW-SD between "other CTD" and "other CTD-ILD" groups. ROC revealed that KL-6 emerged as the most effective predictor for CTD-ILD in both treated and untreated groups. The multivariate logistic regression analysis results showed that both KL-6 and age were independent risk factors for CTD-ILD. NLR, SII, and PLR were negatively correlated with DLCO (%) in the untreated CTD-ILD group, and KL-6 was negatively correlated with various lung function parameters in both treated and untreated CTD-ILD groups.

Conclusion

KL-6 emerged as the most promising biomarker for diagnosing CTD-ILD and assessing its severity. The diagnostic value of KL-6 was unaffected by medication interference and surpassed the value of other parameters, such as NLR, SII, MLR, and RDW. The diagnostic value of RDW-SD was higher than that of RDW-CV in CTD-ILD patients. NLR, SII, MLR, and PLR have potential value in diagnosing the different types of CTD-ILD.

Association between geniquin therapy and the risk of developing periodontal disease in patients with primary Sjögren's syndrome: A population-based cohort study from Taiwan

Primary Sjögren's syndrome (pSS) is a chronic autoimmune disease that causes dysfunction of salivation and harmful oral conditions. The association between periodontal disease (PD) and pSS with or without geniquin therapy remains controversial. This study evaluated the association between geniquin therapy and the risk of subsequent development of PD in pSS patients. From Taiwan's National Health Insurance Research Database, we selected a control cohort of 106,818 pSS patients, followed up from 2000 to 2015, matched (1:4) by age and index year with 427,272 non-pSS patients. We also analyzed 15,149 pSS patients receiving geniquin therapy (cohort 1) and 91,669 pSS patients not receiving geniquin therapy (cohort 2). After adjusting for confounding factors, multivariate Cox proportional hazards regression analysis was used to compare the risk of PD over the 15-year follow-up. In the control cohort, 11,941 (11.2%) pSS patients developed PD compared to 39,797 (9.3%) non-pSS patients. In cohorts 1 and 2, 1,914 (12.6%) pSS patients receiving geniquin therapy and 10,027 (10.9%) pSS patients not receiving geniquin therapy developed PD. The adjusted hazard ratio (HR) for subsequent PD in pSS patients was 1.165 (95% confidence interval [CI] = 1.147-1.195, p < 0.001) and in pSS patients receiving geniquin therapy was 1.608 (95% CI = 1.526-1.702, p < 0.001). The adjusted HR for PD treatment was 1.843. Patients diagnosed with pSS showed an increased risk of developing subsequent PD and receiving PD treatment than patients without pSS, while pSS patients receiving geniquin therapy showed even higher risks.

Does stress response axis activation differ between patients with autoimmune disease and healthy people?

Many studies have shown that patients with autoimmune disease present a hypoactive hypothalamic-pituitary-adrenal (HPA) axis, but the results are controversial. Our objective was to study differences in stress response axis activity between patients with autoimmune disease and healthy people. The study sample consisted of 97 women divided into four groups: 37 healthy women (HW), 21 with systemic lupus erythematosus (SLE), 21 with Sjögren's syndrome (SS), and 18 with systemic sclerosis (SSc). After being exposed to a stress task, participants' skin conductance and salivary cortisol levels were measured in order to assess their response to psychological stress. Diurnal cortisol concentrations were assessed by measuring salivary cortisol in samples collected five times over one day. In addition, self-administered questionnaires were used to assess psychological variables. A time × group interaction effect was found (p = 0.003) in salivary cortisol secretion in response to stressful challenge. The healthy group presented normal activation, the SS and SLE groups showed no activation, and the SSc group presented a similar activation pattern to the HW group, except at the time of recovery. Total cortisol production (AUCg) was higher in the SSc group than in the HW group (p = 0.001). Differences were also observed in the cortisol AUCg collected over one day between healthy women and patients with SLE (p = 0.004) as well as with SSc (p = 0.001): women with SLE and SSc presented higher total hormone production than healthy women. Patients with autoimmune disease present a different HPA axis response, which may contribute to the harmful effects of stress in these diseases.

Malnutrition is associated with mortality in Sjögren's syndrome-associated interstitial lung disease

The role of nutritional status as a prognostic factor in patients with Sjögren's syndrome-associated interstitial lung disease (SjS-ILD) is currently unclear. This study aimed to predict the prognosis of patients with SjS-ILD through their nutritional status assessment. In this retrospective observational study, nutritional status was evaluated at the time of diagnosis using body mass index (BMI) and nutritional markers such as controlling nutritional status (CONUT), the Glasgow prognostic score (GPS), and prognostic nutrition index (PNI) for all participants. Receiver operating characteristic (ROC) analyses were performed using BMI and each nutritional marker data to compare the area under the ROC curve (AUC) and find the cutoff value using the maximum Youden index. Kaplan-Meier analysis and Cox proportional hazards regression analysis were performed to predict the prognosis of SjS-ILD patients. A total of 112 SjS-ILD patients were enrolled in the study, and 8.9% died during the follow-up period. The median time from diagnosis to follow-up period was 4.2 years. The AUC for PNI was the highest among nutritional markers and BMI, and PNI cutoff value was used to distinguish between the PNI < 47.7 and PNI ≥ 47.7 groups. A statistical difference was observed in the Kaplan-Meier analysis and log-rank test (p = 0.005). In multivariable analyses, PNI < 47.7 (hazard ratio 9.40, 95% confidence interval 1.54-57.21) is associated with increased mortality, suggesting the importance of early nutritional intervention for malnutrition in SjS-ILD patients.

Clinical Significance of Antibodies to DFS70 in Immunoinflammatory Rheumatic Diseases

The relevance of the problem of immunoinflammatory rheumatic diseases (IIRD) for modern medicine is determined by their high prevalence in the population, the difficulty of early diagnosis, the rapid development of disability and poor life prognosis. Recent data on the significance of anti-DFS70 have opened up new possibilities for optimizing the step-by-step diagnosis of IIRD. The detection of these antibodies can help in the interpretation of a positive result for antinuclear antibodies (ANA) by indirect immunofluorescence assay on HEp-2 cells (IIFA-HEp-2) in the absence of autoantibodies specific for IIRD. Detection of anti-DFS70 in antinuclear factor (ANF) seropositive patients without clinical and/or serological markers characteristic of a certain disease from the IIRD group can be considered as a potential marker that excludes this group of diseases.

Recommendations on cutaneous and hematological manifestations of Sjögren's disease by the Brazilian Society of Rheumatology

Sjogren's disease (SjD) is an autoimmune disease that is characterized not only by the sicca symptoms it causes but also by its systemic nature, which is capable of several and not yet fully understood extraglandular manifestations. To gain a clearer understanding of these manifestations as well as a better practical approach, a panel of experts from the Brazilian Society of Rheumatology conducted a systematic review and meta-analysis on the identification of epidemiologic and clinical features of the extraglandular manifestations present in ESSDAI (EULAR Sjogren´s syndrome disease activity index), followed by a voting panel with recommendations for clinical practice. This publication is complementary to others already published and covers cutaneous and hematological manifestations, with prevalence data generated by a meta-analysis of 13 clinical or laboratory manifestations and 6 clinical management recommendations.

Consensus statement on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: Localized scleroderma, systemic sclerosis and overlap syndromes

The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present consensus provides an update to the 2017 European Dermatology Forum Guidelines, focusing on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, updated strategies for the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this consensus provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes.

Does ultrasound elastography have a role as a diagnostic method for Sjögren's syndrome in the salivary glands? A systematic review

OBJECTIVE

This systematic review was performed to examine the usefulness of salivary gland ultrasound elastography (USE) as a diagnostic tool for Sjögren's syndrome (SjS).

METHODS

Electronic databases (MEDLINE, EMBASE, the Cochrane Library, and Web of Science: Science Citation Index) were searched to identify studies using USE to diagnose SjS from database inception to 15 July 2022. The primary outcome was improved diagnostic accuracy for SjS with the use of USE. Risk of bias and applicability concerns were assessed using the GRADE system, which is continuously developed by the GRADE Working Group.

RESULTS

Among 4550 screened studies, 24 full-text articles describing the applications of USE to diagnose SjS were reviewed. The overall risk of bias was determined to be low for 17 of the 24 articles, medium for 5, and high for 2. Articles comparing patients with SjS and healthy subjects reported high diagnostic accuracy of USE, with most results showed statistically significant differences (parotid glands: 15 of the 16 articles, submandibular glands: 11 of the 14 articles).

CONCLUSIONS

This systematic review suggests that the assessment of salivary glands using USE is a useful diagnostic tool for SjS.

Reconstruction of Sjögren's syndrome-like sialadenitis by a defined disease specific gut-reactive single TCR and an autoantibody

Lymphocytes such as CD4+ T cells and B cells mainly infiltrate the salivary glands; however, the precise roles and targets of autoreactive T cells and autoantibodies in the pathogenesis of Sjögren's Syndrome (SS) remain unclear. This study was designed to clarify the role of autoreactive T cells and autoantibodies at the single-cell level involved in the development of sialadenitis. Infiltrated CD4+ T and B cells in the salivary glands of a mouse model resembling SS were single-cell-sorted, and their T cell receptor (TCR) and B cell receptor (BCR) sequences were analyzed. The predominant TCR and BCR clonotypes were reconstituted in vitro, and their pathogenicity was evaluated by transferring reconstituted TCR-expressing CD4+ T cells into Rag2-/- mice and administering recombinant IgG in vivo. The reconstitution of Th17 cells expressing TCR (#G) in Rag2-/- mice resulted in the infiltration of T cells into the salivary glands and development of sialadenitis, while an autoantibody (IgGr22) was observed to promote the proliferation of pathogenic T cells. IgGr22 specifically recognizes double-stranded RNA (dsRNA) and induces the activation of dendritic cells, thereby enhancing the expression of IFN signature and inflammatory genes. TCR#G recognizes antigens related to the gut microbiota. Antibiotic treatment severely reduces the activation of TCR#G-expressing Th17 cells and suppresses sialadenitis development. These data suggest that the anti-dsRNA antibodies and, TCR recognizing the gut microbiota involved in the development of sialadenitis like SS. Thus, our model provides a novel strategy for defining the roles of autoreactive TCR and autoantibodies in the development and pathogenesis of SS.

Clinical features associated with the presence of anti-Ro52 and anti-Ro60 antibodies in Jo-1 antibody-positive anti-synthetase syndrome

Introduction

Anti-SSA antibodies target two unrelated proteins, Ro52 (E3 ligase) and Ro60 (RNA binding protein). Previous studies indicate that anti-Ro52 antibodies are frequently associated with various myositis-specific autoantibodies (MSAs)-including anti-tRNA synthetase antibodies-and that the coexistence of MSAs and anti-Ro52 antibodies may portend worse clinical outcomes. Although not well-described in the setting of myositis, work from our animal model of HRS (histidyl-tRNA synthetase)-induced myositis suggests that anti-Ro60 antibodies may also be linked to specific MSAs such as anti-HRS/Jo-1. We therefore aimed to demonstrate the prevalence and clinical characteristics of Ro52 and Ro60 antibody positivity in patients possessing Jo-1 antibodies.

Methods

To establish the immunological link between anti-synthetase, anti-Ro52, and anti-Ro60 antibodies, we evaluated the relative titers of these antibodies in blood and bronchoalveolar lavage fluid (BALF) of mice following immunization with HRS/Jo-1. In parallel, we used ELISA-based approaches to assess sera from 177 anti-Jo1 antibody-positive patients for the presence of anti-Ro52 and/or anti-Ro60 antibodies. We then determined statistical associations between co-existing anti-Jo-1, anti-Ro52, and/or anti-Ro60 antibodies and clinical manifestations associated with the anti-synthetase syndrome.

Results

Mice immunized with HRS had higher levels of anti-Ro52 and anti-Ro60 antibodies in serum and BALF than PBS-immunized mice. In 177 anti-Jo-1 antibody-positive patients, the prevalence of anti-Ro52 and anti-Ro60 antibodies was 36% and 15%, respectively. The frequency of dry eye/dry mouth, interstitial pneumonia, and pulmonary events over time differed between patients with various combinations of anti-Ro52 and anti-Ro60 antibodies. While anti-Ro52 antibodies generally correlated with statistically significant increases in each of these clinical manifestations, the presence of Ro60 antibodies alone was associated with decreased frequency of ILD.

Discussion

Anti-Ro52 and/or anti-Ro60 antibodies are often co-expressed with anti-Jo1 antibodies, defining clinical subsets with different disease course/outcomes.

CD4/CD8 Ratio: An Independent Predictor of Herpes Zoster in Patients With Autoimmune Inflammatory Rheumatic Diseases

BACKGROUND

A higher incidence of herpes zoster (HZ) was found in people with decreased cell-mediated immunity. However, the relationship between cellular immunity and HZ infection in patients with autoimmune inflammatory rheumatic diseases (AIRD) remains elusive.

OBJECTIVE

To investigate the role of CD4/CD8 ratio in patients with AIRD and HZ.

METHODS

This case-control study compared AIRD patients with and without HZ. We chose 70 AIRD patients with HZ as the experimental group and 140 AIRD patients without HZ as the control group. The clinical and laboratory findings were assessed in each trial participant.

RESULTS

The CD4/CD8 ratio (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.10-0.49) was independently associated with the occurrence of HZ after adjusting for various confounders. Nonlinear analysis has unveiled a more profound nonlinear relationship between the CD4/CD8 ratio and the occurrence of HZ in patients with AIRD. The OR of HZ increased with a decreasing CD4/CD8 ratio before the turning point of 2. The adjusted regression coefficient was 0.14 (95% CI, 0.05-0.37, p<0.0001) for CD4/CD8 ratio less than 2.

CONCLUSION

The CD4/CD8 ratio was expected to be a very promising quantitative biomarker for predicting the risk of developing HZ in patients with AIRD.