Increased risk of concurrent gastroesophageal reflux disease among patients with Sjögren's syndrome: A nationwide population-based study

Relationship between Sjogren's syndrome and gastroesophageal reflux: A bidirectional Mendelian randomization study

The clinical incidence of sjogren's syndrome combined with gastroesophageal reflux disease is high. Existing observational studies have shown inconsistent results in the association between gastroesophageal reflux disease (GERD) and Sjogren's syndrome (SS).We observed that the symptoms of SS patients also improved after receiving GERD-related treatment. Therefore, we aimed to investigate the relationship between GERD and SS through a bidirectional two-sample Mendelian randomization (MR) study. Independent SNPs associated with GERD and SS were selected from a genome-wide association study (GWAS) as instrumental variables to conduct a bidirectional two-sample Mendelian analysis of GERD and SS. Genetic data were obtained from two databases for the following two outcomes: Gastroesophageal reflux (IEU Open GWAS) [sample size = 602,604 (patients = 129,080; nonpatients = 473,524)] and SS (FinnGen) [sample size = 392,423 (patients = 2,495; nonpatients = 389,928)]. Statistical methods for the MR analysis included the inverse-variance weighting method, weighted median, simple mode and weighted mode, as well as heterogeneity and sensitivity analyses using the Cochran Q statistic, MR‒Egger regression, outlier detection methods (MR-PRESSO). In addition, Steiger Test was conducted to test the direction of causality. MR analysis showed a positive correlation between GERD and SS risk [odds ratio (OR) = 1.3279 (95% confidence interval 1.0312-1.7099, P = 0.0280)]. However, in contrast, no significant causal effect of SS on GERD was observed [OR = 1.0024 (95% CI 0.9651-1.0412; P = 0.8995)]. This bidirectional two-sample Mendelian randomization study confirmed a causal relationship between SS and GERD, and suggested that GERD is a risk factor for SS, while SS does not affect GERD.

The experience of dry mouth and screening for Sjogren's syndrome by the dentist: patient-reported experiences

BACKGROUND

One of the main clinical features of Sjögren's Syndrome is oral dryness, which is associated with an increased risk of oral diseases and a lower oral life quality. Dentists have a key role to play in the Sjögren's Syndrome diagnosis and specific management. In parallel, many patients rely on patient associations, which offer opportunities for members to seek information about their disease and share their experiences. We aimed to evaluate patients experience with dry mouth and the importance of dentists in Sjögren's Syndrome diagnosis and its management.

METHODS

We carried out a cross-sectional survey in 2020 based on a questionnaire drafted in collaboration with clinicians specializing in Sjögren's Syndrome and patient members of a patient association. The survey consisted of 27 questions divided into the six sections: the patient's profile, their experience with dry mouth and treatments used to manage, characteristics of experienced oral-health problems, effects of dry mouth and its consequences on the quality of life, evaluation of the dentist role in the screening of Sjögren's Syndrome, and its management by the dentist. Recruitment was carried out via the patient association's newsletter, website, and social networks. Sjögren's diagnosis was self-reported.

RESULTS

One thousand four hundred fifty-eight patients fully responded to the survey. Most respondents were women over 50 and were mainly concerned with primary Sjögren's Syndrome. Overall, 86.97% of respondents reported experiencing frequent or constant dry mouth and 69.01% declared having had oral problems (candidiasis, oral pain, loss or alteration of taste, bad breath, gastro-esophageal reflux). We found a positive correlation between the frequency of dry mouth and each of these disorders and between the frequency of dry mouth and alterations in life quality dimensions. Finally, 74.9% of patients did not report having dry mouth to their dentist prior to being diagnosed with Sjögren's Syndrome and 58% had not been informed about the oral risks associated with it by their dentist and sought information themselves or from their physician.

CONCLUSIONS

We confirm the significant consequences of dry mouth on oral quality of life, as well as its association with oral health problems. Sjögren's Syndrome screening by dentists should be increased, as well as prevention of the associated oral health risks.

Influence of Reduced Saliva Production on Phonation in Patients With Ectodermal Dysplasia

OBJECTIVE

Patients with ectodermal dysplasia (ED) suffer from an inherited disorder in the development of the ectodermal structures. Besides the main symptoms, i.e. significantly reduced formation/expression of teeth, hair and sweat glands, a decreased saliva production is objectively accounted. In addition to difficulties with chewing/swallowing, ED patients frequently report on the subjective impression of rough and hoarse voices. A correlation between the reduced production of saliva and an affliction of the voice has not yet been investigated objectively for this rare disease.

METHODS

Following an established measurement protocol, a study has been conducted on 31 patients with ED and 47 controls (no ED, healthy voice). Additionally, the vocal fold oscillations were recorded by high-speed videoendoscopy (HSV@4 kHz). The glottal area waveform was determined by segmentation and objective glottal dynamic parameters were calculated. The generated acoustic signal was evaluated by objective and subjective measures. The individual impairment was documented by a standardized questionnaire (VHI). Additionally, the amount of generated saliva was measured for a defined period of time.

RESULTS

ED patients displayed a significantly reduced saliva production compared to the control group. Furthermore, the auditory-perceptual evaluation yielded significantly higher ratings for breathiness and hoarseness in the voices of male ED patients compared to male controls. The majority of male ED patients (67%) indicated at least minor impairment in the self-evaluation. Objective acoustic measures like Jitter and Shimmer confirmed the decreased acoustic quality in male ED patients, whereas none of the investigated HSV parameters showed significant differences between the test groups. Statistical analysis did not confirm a statistically significant correlation between reduced voice quality and amount of saliva.

CONCLUSIONS

An objective impairment of the acoustic outcome was demonstrated for male ED patients. However, the vocal folds dynamics in HSV recordings seem unaffected.

Sex hormones, body mass index, and related comorbidities associated with developing Sjögren's disease: a nested case-control study

OBJECTIVE

Sjögren's disease (SjD), a highly female predominant systemic autoimmune disease, peaks in perimenopause. Prior studies lack details on timing or type of sex hormone exposure. We examined SjD risk using endogenous and exogenous hormone exposure and related comorbidities.

METHODS

We performed a retrospective case-control study of adult women, nested within a population cohort. Cases had SjD diagnosed by a rheumatology provider or two SjD diagnoses from a non-rheumatology provider with a positive anti-SSA antibody or salivary gland biopsy. Cases were age-matched to three SjD-free controls. We calculated modified composite estrogen scores (mCES) and collected demographics, comorbidities, and endogenous and exogenous hormone exposures. Risk ratios were adjusted for demographics.

RESULTS

Of 546 SjD cases and 1637 age-matched controls, mCES was not significantly associated with SjD in adjusted models. The top individual hormone exposures associated with SjD included estrogen replacement therapy (ERT; RR 1.78 [95% CI 1.47-2.14]), polycystic ovarian syndrome (1.65 [1.28-2.12]), and hysterectomy without bilateral oophorectomy (1.51 [1.13-2.03]). We identified comorbidities preceding SjD including fibromyalgia, pulmonary disease, diabetes, lymphoma, osteoporosis, peripheral vascular disease, and renal disease. Taking comorbidities into account, we developed a predictive model for SjD that included fibromyalgia (2.50 [1.93-3.25]), osteoporosis (1.84 [1.27-2.66]), hormone replacement therapy (HRT) (1.61 [1.22-2.12]), diabetes (0.27 [0.13-0.50]), and body mass index (BMI) (0.97 [0.95-0.99]).

CONCLUSIONS

We report a novel algorithm to improve identifying patients at risk for SjD and describe sex hormone association with SjD. Finally, we report new comorbidities associated with SjD decrease, BMI and diabetes, and increase, lymphoma and osteoporosis.. Key Points •Given female predominance and typical perimenopausal onset, sex hormones should be considered when studying comorbidities in Sjögren's disease. •The top exposures associated with developing Sjögren's disease included fibromyalgia, osteoporosis, and use of hormone replacement therapy. Possible protective factors included prior diabetes and higher body mass index. •We used our newly identified exposures to generate a predictive algorithm, which has potential to improve diagnosis and pathogenic insights into Sjögren's disease.

Higher Dementia Risk in People With Gastroesophageal Reflux Disease: A Real-World Evidence

Background

Whether or not patients with gastroesophageal reflux disease (GERD) have a higher risk of developing subsequent dementia remains unknown, and no observational evidence from population-based data is available. This study was to determine whether patients with GERD have a higher future risk of developing dementia.

Methods

For the period 2000–2012, datasets from the Longitudinal Health Insurance Database (LHID, subset of National Health Insurance Research Database in Taiwan) were analyzed. Definition of GERD was based on ICD-9-CM codes 530.11 and 530.81 and prescriptions for PPIs. After matching gender, age, index year, and comorbidities, each GERD patient was matched with four control patients without GERD. Future risk of dementia was evaluated, and sensitivity analysis of subgroups was conducted to clarify the potential association.

Results

In the present study, 13,570 patients were included in the GERD cohort and 54,280 patients were included in the control cohort. Patients with GERD showed higher risk developing dementia than control group, with an aHR of 1.34 (95% C.I., 1.07, 1.67). In GERD patients between above 70 years old, the risk of developing dementia was higher than that of the control groups (aHR = 1.34; 95% C.I., 1.01, 1.77).

Conclusion

Patients with GERD showed higher incidence of dementia, and elder patients had the highest risk of developing dementia. Clinicians should be concern of the association between GERD and dementia and should develop strategies to prevent dementia while managing patients with GERD.

Clinical characteristics and esophageal motility in Sjögren's syndrome: A single‐center study in Taiwan

Sjögren's syndrome is an autoimmune disease that may cause inflammation of exocrine glands, including the salivary glands. Some patients with Sjögren's syndrome also have gastrointestinal disease, such as gastroesophageal reflux disease. A few studies have shown that an association might exist between Sjögren's syndrome and esophageal motility disorder, but the results have been inconsistent. This study aimed to investigate the relationships between clinical symptoms and esophageal motility function in patients with Sjögren's syndrome. Fifty‐six patients with suspected esophageal reflux or motility disease who had undergone esophagogastroduodenoscopy and esophageal manometry were retrospectively enrolled. Thirteen patients were diagnosed as having Sjögren's syndrome according to the American‐European Consensus Criteria. Forty‐three patients without any rheumatic disease or esophageal motor disorder were designated as the control group. We compared the clinical symptoms and endoscopic and esophageal manometric findings between the Sjögren's syndrome and the control groups. Acid regurgitation was more prevalent in the Sjögren's syndrome group (53.8%) than in the control group (11.6%) (P = .003), but the endoscopic findings of reflux esophagitis were similar in both groups (Sjögren's: 38.5%; control: 39.5%; P = .945). Barrett's esophagus was more prevalent in the Sjögren's syndrome group than in the control group (15.4% vs 0%, respectively; P = .051). The upper esophageal sphincter was shorter in the Sjögren's syndrome group than in the control group (2.38 ± 0.65 cm vs 3.07 ± 0.74 cm, respectively; P = .003). More reflux symptoms and distinct motility patterns were found in the Sjögren's syndrome group as compared with the control subjects.

Cardiac involvement in primary Sjӧgren's syndrome

Primary Sjӧgren's syndrome (pSS) is an autoimmune-mediated, inflammatory, and systemic connective tissue disease (CTD), especially in middle-aged women, which often involves multiple systems and organs of the body. In fact, the heart is an important target organ in patients with pSS. In recent years, it has been confirmed that the morbidity of cardiac involvement has increased in patients with pSS, and cardiovascular disease (CVD) is one of the main causes of death. The increased risk of CVD in pSS patients is associated with a great variety of risk factors, such as age, gender, hypertension, diabetes mellitus, dyslipidemia, disease duration, extra-glandular manifestations, therapeutic drugs of pSS, and so on. Early recognition and effective treatment of CVD may play a crucial role in improving adverse cardiovascular prognosis. Whereas cardiac involvement is closely related to patient prognosis and survival, the cardiac involvement of patients with pSS remains poorly studied. Therefore, this article reviews the cardiovascular risk factors, clinical manifestations of cardiac involvement, cardiovascular biomarkers, and therapeutic strategies of pSS patients.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GERD) is a common disorder in adults and children. The global prevalence of GERD is high and increasing. Non-erosive reflux disease is the most common phenotype of GERD. Heartburn and regurgitation are considered classic symptoms but GERD may present with various atypical and extra-oesophageal manifestations. The pathophysiology of GERD is multifactorial and different mechanisms may result in GERD symptoms, including gastric composition and motility, anti-reflux barrier, refluxate characteristics, clearance mechanisms, mucosal integrity and symptom perception. In clinical practice, the diagnosis of GERD is commonly established on the basis of response to anti-reflux treatment; however, a more accurate diagnosis requires testing that includes upper gastrointestinal tract endoscopy and reflux monitoring. New techniques and new reflux testing parameters help to better phenotype the condition. In children, the diagnosis of GERD is primarily based on history and physical examination and treatment vary with age. Treatment in adults includes a combination of lifestyle modifications with pharmacological, endoscopic or surgical intervention. In refractory GERD, optimization of proton-pump inhibitor treatment should be attempted before a series of diagnostic tests to assess the patient's phenotype.

Comorbidities (excluding lymphoma) in Sjögren's syndrome

The information about comorbidities (excluding lymphoma) in primary Sjögren's syndrome (pSS) is relatively scarce. Cardiovascular disease, infections, musculoskeletal conditions or malignancy are likely the most relevant comorbid conditions in pSS. Different infections (particularly oral candidal infections) and fibromyalgia are extremely frequent in the daily clinical practice. On the other hand, the incidence of cardiovascular events and cancer in pSS is low, so information about them comes from large epidemiological studies or meta-analysis. For this reason, preclinical vascular disease is investigated by different techniques, demonstrating the presence of early atherosclerosis in pSS patients. Coronary events could be slightly more frequent in pSS than in the general population. The overall risk of malignancy in pSS patients seems to be slightly increased, likely due to excess occurrence of lymphoma. An association between pSS and thyroid cancer might exist, although it should be confirmed by further investigations.

Cardiovascular Morbidity and Mortality in Primary Sjögren's Syndrome: A Systematic Review and Meta-Analysis

OBJECTIVE

Patients with immune-mediated inflammatory diseases such as rheumatoid arthritis or systemic lupus erythematosus are at increased risk of cardiovascular disease. However, the cardiovascular risk of patients with primary Sjögren's syndrome (SS) remains poorly studied. We aimed to investigate the association between primary SS and cardiovascular morbidity and mortality.

METHODS

We performed a systematic review of articles in Medline and the Cochrane Library and recent abstracts from US and European meetings, searching for reports of randomized controlled studies of cardiovascular morbidity and cardiovascular mortality in primary SS. The relative risk (RR) values for cardiovascular morbidity and mortality associated with primary SS were collected and pooled in a meta-analysis with a random-effects model by using Review Manager (Cochrane collaboration).

RESULTS

The literature search revealed 484 articles and abstracts of interest; 14 studies (67,124 patients with primary SS) were included in the meta-analysis. With primary SS versus control populations, the risk was significantly increased for coronary morbidity (RR 1.34 [95% confidence interval (95% CI) 1.06-1.38]; P = 0.01), cerebrovascular morbidity (RR 1.46 [95% CI 1.43-1.49]; P < 0.00001), heart failure rate (odds ratio 2.54 [95% CI 1.30-4.97]; P < 0.007), and thromboembolic morbidity (RR 1.78 [95% CI 1.41-2.25]; P < 0.00001), with no statistically significant increased risk of cardiovascular mortality (RR 1.48 [95% CI 0.77-2.85]; P = 0.24).

CONCLUSION

This meta-analysis demonstrates that primary SS is associated with increased cardiovascular morbidity, which suggests that these patients should be screened for cardiovascular comorbidities and considered for preventive interventions, in a multidisciplinary approach with cardiologists.

Dietary Intake, Body Composition, and Oral Health Parameters among Female Patients with Primary Sjögren's Syndrome

There is limited knowledge about dietary intake and body composition among patients with primary Sjögren’s syndrome. We assessed dietary intakes with 24-h recalls and body composition with anthropometry and bioelectrical impedance in 20 female patients. Various scoring tools were used to assess oral health. The patients had a lower energy percentage (E%) from carbohydrates (p = 0.02) and a higher E% from fat (p = 0.01) compared to a reference group. The lower intake of carbohydrates was due to a lower bread intake (p = 0.04), while the higher intake of fat was due to a higher intake of butter, margarine, and oil (p = 0.01). The patients ate more than twice (p = 0.02) as much fish as the reference group. The compliance to recommended intakes of macro- and micronutrients was good. Forty-percent of the patients were overweight/obese. Increased intake of beverages was observed in patients with severe xerostomia and/or low oral health-related quality of life, whereas reduced fat intake was found in hyposmic patients. In conclusion, the dietary intake among the patients was not much different from the reference group and complied with recommendations. Most oral health parameters were not associated with nutrient intakes. Specific dietary guidelines are probably not needed to ensure adequate nutrition among such patients.

Dental and oropharyngeal lesions in rats with chronic acid reflux esophagitis

OBJECTIVE

In this study, we evaluated pathological changes in the tooth and pharynx of GERD rats to elucidate the association between gastric acid reflux and oral and pharyngeal diseases.

METHODS

An experimental rat model of chronic acid reflux esophagitis was surgically created. The oral cavities were observed histologically every 2 weeks until 20 weeks after surgery.

RESULTS

At 10 weeks after surgery, molar crown heights in GERD rats were shorter than that in control rats, and inflammatory cell infiltration by gastric acid reflux was found in the periodontal mucosa of GERD rats. Furthermore, dental erosion progressed in GERD rats at 20 weeks after surgery, and enamel erosion and dentin exposure were observed. During the same period, inflammatory cell infiltration was observed in the mucosa of the posterior part of the tongue. These findings suggest that gastric acid reflux may be one of the exacerbating factors of dental erosion, periodontitis and glossitis.

CONCLUSION

We investigated oral changes in an experimental rat model of GERD and observed development of dental erosion, periodontitis and glossitis. Our findings suggested chronic gastric acid reflux may be involved in the pathogenesis of oral disease.