Assessment of the European classification criteria for Sjögren's syndrome in a series of clinically defined cases: results of a prospective multicentre study. The European Study Group on Diagnostic Criteria for Sjögren's Syndrome

An explainable machine learning-based model to predict intensive care unit admission among patients with community-acquired pneumonia and connective tissue disease

BACKGROUND

There is no individualized prediction model for intensive care unit (ICU) admission on patients with community-acquired pneumonia (CAP) and connective tissue disease (CTD) so far. In this study, we aimed to establish a machine learning-based model for predicting the need for ICU admission among those patients.

METHODS

This was a retrospective study on patients admitted into a University Hospital in China between November 2008 and November 2021. Patients were included if they were diagnosed with CAP and CTD during admission and hospitalization. Data related to demographics, CTD types, comorbidities, vital signs and laboratory results during the first 24 h of hospitalization were collected. The baseline variables were screened to identify potential predictors via three methods, including univariate analysis, least absolute shrinkage and selection operator (Lasso) regression and Boruta algorithm. Nine supervised machine learning algorithms were used to build prediction models. We evaluated the performances of differentiation, calibration, and clinical utility of all models to determine the optimal model. The Shapley Additive Explanations (SHAP) and Local Interpretable Model-Agnostic Explanations (LIME) techniques were performed to interpret the optimal model.

RESULTS

The included patients were randomly divided into the training set (1070 patients) and the testing set (459 patients) at a ratio of 70:30. The intersection results of three feature selection approaches yielded 16 predictors. The eXtreme gradient boosting (XGBoost) model achieved the highest area under the receiver operating characteristic curve (AUC) (0.941) and accuracy (0.913) among various models. The calibration curve and decision curve analysis (DCA) both suggested that the XGBoost model outperformed other models. The SHAP summary plots illustrated the top 6 features with the greatest importance, including higher N-terminal pro-B-type natriuretic peptide (NT-proBNP) and C-reactive protein (CRP), lower level of CD4 + T cell, lymphocyte and serum sodium, and positive serum (1,3)-β-D-glucan test (G test).

CONCLUSION

We successfully developed, evaluated and explained a machine learning-based model for predicting ICU admission in patients with CAP and CTD. The XGBoost model could be clinical referenced after external validation and improvement.

Perception of aesthetic impairment in patients with systemic sclerosis determined using a semi-quantitative scale and its association with disease characteristics

Background

Systemic sclerosis is a fibrotic disease. Body image assessments could be key in optimizing care; however, data are scarce. The main objective was to assess the perception of aesthetic impairment using a visual aesthetic evaluation scale in patients with systemic sclerosis compared with healthy subjects. The secondary objectives were to assess associations between the perception of aesthetic impairment and scores on standardized questionnaires for aesthetic impairment as well as clinical, psychological/quality of life, and functional parameters of patients with systemic sclerosis.

Methods

This study evaluated and compared the perception of aesthetic impairment in two populations: patients with systemic sclerosis from a referral center at Lille Hospital, France, and healthy controls.

Results

This study included 88 patients (69 (78.4%) women) with a median age of 52 years and 88 controls (49 (55.7%) women) with a median age of 45 years. The perception of aesthetic impairment assessed using the aesthetic evaluation scale was poorer in systemic sclerosis patients than in controls (3.7 ± 0.3 vs 2.8 ± 0.3, p = 0.028) and was statistically correlated with assessments using the adapted satisfaction with appearance, a specific aesthetic impact assessment questionnaire for patients with systemic sclerosis. Patients with anxiety or depressive symptoms had significantly higher aesthetic evaluation scale scores. Systemic sclerosis patients with facial involvement and pitting scars had a worse perception of aesthetic impairment. Compared with healthy controls, systemic sclerosis patients had a worse perception of aesthetic impairment, especially systemic sclerosis patients with anxiety or depression and those with facial and hand involvement.

Conclusion

The aesthetic evaluation scale appears to be an easy-to-use tool to evaluate body image. Correlations of the aesthetic evaluation scale score with psychological and quality of life parameters reflect the importance of these parameters for body image evaluation and its complex assessment.

Trial registration

Clinical Trial NCT03271320 (Registered 9 January 2017, https://www.clinicaltrials.gov/ct2/show/NCT03271320?term=NCT03271320&cntry=FR&draw=2&rank=1).

Identification of outcome domains in primary Sjögren's disease: A scoping review by the OMERACT Sjögren disease working group

OBJECTIVES

Sjögren's disease (SjD) is a heterogenous disease with a wide range of manifestations, ranging from symptoms of dryness, fatigue, and pain, to systemic involvement. Considerable advances have been made to evaluate systemic activity or patient-reported outcomes, but most of the instruments were not able to assess all domains of this multifaceted disease. The aim of this scoping review was to generate domains that have been assessed in randomized controlled trials, as the first phase of the Outcome Measures in Rheumatology (OMERACT) process of core domain set development.

METHODS

We systematically searched Medline (Pubmed) and EMBASE between 2002 and March 2023 to identify all randomized controlled trials assessing relevant domains, using both a manual approach and an artificial intelligence software (BIBOT) that applies natural language processing to automatically identify relevant abstracts. Domains were mapped to core areas, as suggested by the OMERACT 2.1 Filter.

RESULTS

Among the 5,420 references, we included 60 randomized controlled trials, focusing either on overall disease manifestations (53%) or on a single organ/symptom: dry eyes (17%), xerostomia (15%), fatigue (12%), or pulmonary function (3%). The most frequently assessed domains were perceived dryness (52% for overall dryness), fatigue (57%), pain (52%), systemic disease activity (45%), lacrimal gland function (47%) and salivary function (55%), B-cell activation (60%), and health-related quality of life (40%).

CONCLUSION

Our scoping review highlighted the heterogeneity of SjD, in the study designs and domains. This will inform the OMERACT SjD working group to select the most appropriate core domains to be used in SjD clinical trials and to guide the future agenda for outcome measure research in SjD.

Epidemiology of Sjögren syndrome

Sjögren syndrome is a phenotypically varied autoimmune disorder that can occur alone in primary Sjögren syndrome or in association with other connective tissue diseases (CTDs), including rheumatoid arthritis, systemic lupus erythematosus (SLE) and systemic sclerosis (SSc). The estimation of the prevalence and incidence of Sjögren syndrome varies depending on diagnostic criteria and study design, making it difficult to estimate geographical and temporal trends. Nonetheless, disease phenotype is influenced by geographical origin, which is a risk factor for systemic activity. Whether mortality in primary Sjögren syndrome is increased compared with that of the general population is not yet known, but extra-glandular manifestations, in particular lymphomas, are clear risk factors for mortality. In CTDs associated with Sjögren syndrome, lymphoma risk seems higher than that of patients with CTD alone, and there is potentially lower disease activity in SLE with Sjögren syndrome and in SSc with Sjögren syndrome than in SLE or SSc alone.

Clinical characteristics and risk factors of Helicobacter pylori infection-associated Sjogren's syndrome

OBJECTIVE

Although infectious pathogens are predominant factors for inducing and maintaining immune system disorders, there exist few reports establishing the significant correlation between Helicobacter pylori (H. pylori) infection and Sjogren's syndrome. This study aims to demonstrate the correlation between Sjogren's syndrome and H. pylori infection in patients, highlighting various clinical characteristics and risk factors.

METHODS

A single-center retrospective observational study was conducted in patients (n = 224) admitted from January 1, 2012, to February 10, 2021, in the First Affiliated Hospital of Wenzhou Medical University (Wenzhou, China). All the recruited subjects with Sjogren's syndrome and H. pylori infection were only included by validating the available medical records online.

RESULTS

In this study, a total of 224 patients from January 1, 2012, to February 10, 2021, were diagnosed with Sjogren's syndrome. Among them, 94 patients (41.96%) with Sjogren's syndrome were infected with H. pylori. Accordingly, the clinical manifestations, serological and immunological characteristics, as well as gastroscopic biopsy outcomes of the recruited patients with primary Sjogren's syndrome (pSS) were reported. The multivariable analysis of the dry syndrome patients infected with H. pylori displayed hypergammaglobulinemia (odds ratio [OR], 0.354; 95% confidence interval [CI], 0.189-0.663), total cholesterol (OR, 1.158; 95% CI, 0.856-1.550), hypertension (OR, 0.227; 95% CI, 0.114-0.455), Female sex (OR, 5.778; 95% CI, 1.458-22.9), anti-SSA/Ro60 positive (OR, 2.384; 95% CI, 233-4.645), γ-GT (OR, 0.99; 95% CI, 0.99-1.00) and alkaline phosphatase (ALP, OR, 1.00; 95% CI, 0.99-1.00) levels.

CONCLUSION

Together, our findings demonstrated that hypergammaglobulinemia could be the independent risk factors of H. pylori infection in patients with Sjogren's syndrome, requiring the physician's advice in the future.

Association between ventilatory ratio and ICU mortality in interstitial lung disease patients on mechanical ventilation: A retrospective study

BACKGROUND

Ventilatory ratio (VR) is a simple bedside index of ventilatory efficiency. Interstitial lung disease (ILD) is a diverse group of diseases that causes fibrosis or inflammation of the pulmonary parenchyma, and the main clinical manifestation is hypoxemia. To date, no study has explored ventilation efficiency in patients with ILD.

OBJECTIVES

This study aimed to explore the features of VR in mechanically ventilated patients with ILD and their relationship with intensive care unit (ICU) mortality.

METHODS

In this retrospective analysis, we included mechanically ventilated patients with ILD in the ICU of West China Hospital, Sichuan University, from 2013 to 2021. Demographic data and mechanical ventilation (MV) parameters within 24 h of intubation were collected. The characteristics of VR and their relationships with ICU mortality were also analyzed.

RESULTS

224 patients were included in the final analysis. There were 146 males (53.9%), and the median age was 65 years (interquartile range [IQR]54∼74). The mean value of VR was 2.22, and VR was significantly higher in nonsurvivors than in survivors (1.79 vs 2.32, P < 0.001). A high VR value was an independent risk factor for ICU mortality (odds ratio=1.602, P = 0.038) after adjustment. A high value of VR was associated with a shorter survival time after admission to ICU (hazard ratio=1.485, P = 0.006) CONCLUSIONS: VR in patients with ILD on MV was increased, and the VR of nonsurvivors within 24 h of intubation was higher than that of survivors. The high VR value within 24 h of intubation was an independent risk factor for ICU mortality after adjusting for other factors.

Imaging characteristics of Sjögren's syndrome

The current workup of Sjögren's syndrome is based on diagnostic criteria involving a combination of histology, immunology, ophthalmology, and salivary flow. Several modern imaging techniques provide complementary and additional information to diagnosis, staging, and surveillance. In this review article, we discuss the characteristic salivary imaging findings seen with the most commonly utilized imaging modalities. We also discuss imaging findings of the central nervous system disorders associated with Sjögren's syndrome, including the neuromyelitis optica spectrum disorder, and provide a differential diagnosis of alternative etiologies that can mimic Sjögren's syndrome.

Biomarkers of connective tissue disease-associated interstitial lung disease in bronchoalveolar lavage fluid: A label-free mass spectrometry-based relative quantification study

BACKGROUND

The pathogenesis of connective tissue disease-associated interstitial lung disease (CTD-ILD) is unclear. This study aims to identify differentially expressed proteins (DEPs) in CTD-ILD to determine the potential role of these DEPs that may play in the pathogenesis of CTD-ILD and to offer potential therapeutic targets.

METHODS

Bronchoalveolar lavage fluid (BALF) samples were collected from four patients with CTD-ILD and four patients without CTD-ILD. Label-free mass spectrometry-based relative quantification was used to identify the DEPs. Bioinformatics were used to determine the potential biological processes and signaling pathways associated with these DEPs.

RESULTS

We found 65 upregulated DEPs including SFTPD, CADM1, ACSL4, TSTD1, CD163, LUM, SIGLEC1, CPB2, TGFBI and HGD, and 67 downregulated DEPs including SGSH, WIPF1, SIL1, RAB20, OAS3, GMPR2, PLBD1, DNAJC3, RNASET2 and OAS2. The results of GO functional annotation for the DEPs showed that the DEPS were mainly enriched in the binding, cellular anatomical entity, cellular processes, and biological regulation GO terms. The results of KEGG analyses showed that the pathways most annotated with the DEPs were complement and coagulation cascades, metabolic pathways, pathways in cancer, and PPAR signaling pathway. COG analyses further informed the functions associated with these DEPs, with most focused on signal transduction mechanisms; posttranslational modification, protein turnover, chaperones; intracellular trafficking, secretion, and vesicular transport; amino acid transport and metabolism; and lipid transport and metabolism.

CONCLUSIONS

DEPs identified between patients with vs. without CTD-ILD may play important roles in the development of CTD-ILD and are potential new biomarkers for early diagnosis of CTD-ILD.

Prediction of long-term mortality by using machine learning models in Chinese patients with connective tissue disease-associated interstitial lung disease

Background

The exact risk assessment is crucial for the management of connective tissue disease-associated interstitial lung disease (CTD-ILD) patients. In the present study, we develop a nomogram to predict 3‑ and 5-year mortality by using machine learning approach and test the ILD-GAP model in Chinese CTD-ILD patients.

Methods

CTD-ILD patients who were diagnosed and treated at the First Affiliated Hospital of Zhengzhou University were enrolled based on a prior well-designed criterion between February 2011 and July 2018. Cox regression with the least absolute shrinkage and selection operator (LASSO) was used to screen out the predictors and generate a nomogram. Internal validation was performed using bootstrap resampling. Then, the nomogram and ILD-GAP model were assessed via likelihood ratio testing, Harrell’s C index, integrated discrimination improvement (IDI), the net reclassification improvement (NRI) and decision curve analysis.

Results

A total of 675 consecutive CTD-ILD patients were enrolled in this study, during the median follow-up period of 50 (interquartile range, 38–65) months, 158 patients died (mortality rate 23.4%). After feature selection, 9 variables were identified: age, rheumatoid arthritis, lung diffusing capacity for carbon monoxide, right ventricular diameter, right atrial area, honeycombing, immunosuppressive agents, aspartate transaminase and albumin. A predictive nomogram was generated by integrating these variables, which provided better mortality estimates than ILD-GAP model based on the likelihood ratio testing, Harrell’s C index (0.767 and 0.652 respectively) and calibration plots. Application of the nomogram resulted in an improved IDI (3- and 5-year, 0.137 and 0.136 respectively) and NRI (3- and 5-year, 0.294 and 0.325 respectively) compared with ILD-GAP model. In addition, the nomogram was more clinically useful revealed by decision curve analysis.

Conclusions

The results from our study prove that the ILD-GAP model may exhibit an inapplicable role in predicting mortality risk in Chinese CTD-ILD patients. The nomogram we developed performed well in predicting 3‑ and 5-year mortality risk of Chinese CTD-ILD patients, but further studies and external validation will be required to determine the clinical usefulness of the nomogram.

Renal and Salivary Gland Functions after Three Cycles of PSMA-617 Therapy Every Four Weeks in Patients with Metastatic Castration-Resistant Prostate Cancer

BACKGROUND

[¹⁷⁷Lu]Lu-PSMA-617 radioligand therapy (PSMA-RLT) could affect kidney and salivary gland functions in metastatic castration-resistant prostate cancer (mCRPC) patients.

METHODS

We retrospectively analyzed clinical, renal, and salivary scintigraphy data and salivary [⁶⁸Ga]Ga-PSMA-11 ligand PET scan measures such as metabolic volume and SUVmax values of 27 mCRPC men (mean age 71 ± 7 years) before and 4 weeks after receiving three cycles of PSMA-RLT every 4 weeks. Twenty-two patients additionally obtained renal and salivary scintigraphy prior to each cycle. A one-way ANOVA, post-hoc Scheffé test and Cochran's Q test were applied to assess organ toxicity.

RESULTS

In total, 54 PSMA PET scans, 98 kidney, and 98 salivary scintigraphy results were evaluated. There were no significant differences for the ejection fraction, peak time, and residual activity after 5 min for both parotid and submandibular glands prior to each cycle and 4 weeks after the last cycle. Similarly, no significant differences in serum creatinine and renal scintigraphy parameters were observed prior to each cycle and 4 weeks after the last treatment. Despite there being no changes in the metabolic volume of both submandibular glands, SUVmax values dropped significantly (p < 0.05).

CONCLUSION

Results evidenced no alterations in renal function and only minimal impairment of salivary function of mCRPC patients who acquired an intense PSMA-RLT regimen every 4 weeks.

Sjögren's syndrome in children: about 15 cases in Guinea Conakry

Objectives

Sjögren’s syndrome is rare in children and most often secondary. It frequently affects girls and is characterized by dry eye syndrome, mouth and sometimes systemic involvement. Its diagnosis is difficult to establish in children. We report a series of 15 cases of Sjögren’s syndrome in order to clarify the peculiarities of this condition in children.

Patients and methods

This retrospective study was carried out over a 2-year period focused on children under 16 years of age who had been followed for Sjögren’s syndrome in the rheumatology and pediatric departments. Patient data were collected and then analyzed by STATA/SE version 11.2 software. Anonymity and respect for ethical rules were the norm. There was no connection between the patients and the researchers.

Description of cases

The mean age of the patients was 11 years with extremes of 5–15 years. History reveals that a dry mouth was found in more than half of the cases, or in 10 (66.7%) patients. Clinical examination found oral ulceration and periodontitis in equal proportions, 6 (40%). The immunological workup and the biopsy of the accessory salivary glands served as diagnostic evidence in the 15 patients according to the US–European criteria of 2002.

Conclusion

Sjögren’s syndrome is a rare entity in pediatrics. Its diagnosis is difficult to establish in pediatrics and its severity is linked to the occurrence of late visceral and lymphomatous sicca syndrome. Rapid diagnosis and initiation of a synthetic antimalarial (hydroxychloroquine) increases the hope of a cure.

[Renal involvement in Sjögren's syndrome]

Primary Sjögren syndrome is an autoimmune disorder characterized by lymphoplasmacytic infiltration of the exocrine (salivary and lachrymal) glands resulting in sicca symptoms (dryness). Systemic complications can occur in primary Sjögren syndrome, but renal involvement is rare, affecting<10% patients. The most frequent form of nephropathy in primary Sjögren syndrome is tubulointerstitial nephritis, where infiltration of the kidney by plasma cells is a key feature and shows similarity to the lymphoplasmacytic infiltration of the salivary glands. Electrolyte disturbances may occur in primary Sjögren syndrome, such as renal distal tubular acidosis, diabetes insipidus, Gitelman syndrome, or Fanconi syndrome. Glomerular involvement is less frequently detected in patients with primary Sjögren syndrome, but can take the form of membranoproliferative glomerulonephritis secondary to cryoglobulinaemia. The renal prognosis in patients with primary Sjögren syndrome and TIN or glomerular disease is usually good, but the risk of chronic kidney disease remains significant for some patients. Appropriate screening must be performed at least once a year in patients with systemic primary Sjögren syndrome in order to facilitate the early detection of renal complications. In this Review, we discuss the epidemiology, pathophysiology, differential diagnosis, and treatment of renal disease in primary Sjögren syndrome.

Mechanical ventilation for acute respiratory failure due to idiopathic pulmonary fibrosis versus connective tissue disease-associated interstitial lung disease: Effectiveness and risk factors for death

INTRODUCTION

Relatively little is known about the effects of mechanical ventilation (MV; including invasive MV [IMV] and noninvasive ventilation) on clinical outcomes of patients with idiopathic pulmonary fibrosis (IPF) and connective tissue disease-associated interstitial lung disease (CTD-ILD) in the intensive care unit (ICU) and risk factors for ICU death remain to be determined.

OBJECTIVES

Our objective was to determine and compare mortality rates between IPF and CTD-ILD patients receiving MV and to identify risk factors for ICU death in these patients.

METHODS

We conducted a retrospective cohort study in respiratory ICUs of three university hospitals in China during a 7-year period. We compared clinical data and outcomes between patients with IPF and those with CTD-ILD and performed logistic regression analyses to identify risk factors for ICU death.

RESULTS

Of the 94 patients in the analyses, 63 were diagnosed with IPF and 31 were diagnosed with CTD-ILD. ICU mortality was significantly higher in the IPF group than in the CTD-ILD group (86% vs 68%; P = 0.041) and was significantly lower in patients receiving noninvasive ventilation than in those receiving IMV (62% vs 88%; P = 0.004). Risk factors for ICU death were disease progression as the principal cause of acute respiratory failure and IMV.

CONCLUSION

Based on current clinical practice in three ICUs, the mortality rate in IPF patients receiving MV might reach 86% and is higher than in CTD-ILD patients. IMV might be initiated cautiously, especially in patients with disease progression as the principal cause of acute respiratory failure.

IPAF should receive early treatment for sharing similar clinical characteristics as CTD-ILD: a report from 273 Chinese patients

OBJECTIVES

The clinical characteristics of interstitial pneumonia with autoimmune features (IPAF) and connective tissue disease interstitial lung disease (CTD-ILD) have not been adequately compared. We compared the clinical characteristics of these two conditions and analyzed the changes in lung function before and after treatment of IPAF.

METHODS

A total of 412 patients were enrolled in the study, and their clinical characteristics were assessed. The treatment-related changes in 12 cases of IPAF were analyzed.

RESULTS

Complete clinical data were available for 126 patients with CTD-ILD and 147 with IPAF. All IPAF patients showed autoantibody positivity. The proportion of patients showing extrapulmonary symptoms in the CTD-ILD group was higher than that in the IPAF group (P < 0.05). Patients with IPAF demonstrated lower P(A-a)O₂ and higher PaO₂ and PaCO₂ than those with CTD-ILD (P < 0.05 for all comparisons). Forced vital capacity (FVC) and diffusing capacity of the lungs for carbon monoxide (D_LCO) in IPAF patients were higher than those in CTD-ILD patients (P = 0.023 for FVC; P = 0.011 for D_LCO). Among patients with IPAF, only the proportions of honeycombing and nodules were lower than those in CTD-ILD patients (P < 0.05). Both FVC and D_LCO values increased after treatment in patients with IPAF (P < 0.05).

CONCLUSION

IPAF showed autoantibody positivity and similar computed tomography (CT) findings as CTD-ILD, and lung function in patients with IPAF improved after immunosuppressive treatment, indicating that IPAF should receive attention and early immunosuppressive treatment like CTD-ILD, even though IPAF exhibits no extrapulmonary symptoms. Key Points • Clinical characteristics of IPAF.

The Role of Meibography in the Diagnosis of Meibomian Gland Dysfunction in Ocular Surface Diseases

Purpose

To evaluate dysfunction in various ocular surface diseases (OSDs) including primary meibomian gland disease (MGD), perennial allergic conjunctivitis, and primary and secondary Sjögren syndromes.

Methods

A retrospective analysis of 146 patients (111 women and 35 men) with symptomatic OSDs was performed. Patients were divided into two groups: the non-MGD group (55 patients) and the MGD group (91 patients). All patients had an evaluation of ocular surface symptoms and clinical tests, including tear film breakup time (BUT), the first and the mean noninvasive breakup time (NIKBUTf and NIKBUTavg, respectively). The meibomian gland loss of the lower eyelid was quantified using meibography and the meiboscale.

Results

There was no significant difference regarding age or sex ratio between the two groups. The meiboscale in the MGD group was significantly higher than that in the non-MGD group (P = 0.003). The non-MGD patients were more symptomatic than those in the MGD group (P = 0.043). There were no significant differences between MGD and non-MGD groups regarding a Schirmer test (P = 0.195), BUT (P = 0.719), NIKBUTf (P = 0.96), or NIKBUTavg (P = 0.70). In the whole population, there was a negative correlation between meiboscale and NIKBUT (r = -0.21, P = 0.02), but no other correlations were found.

Conclusions

Meibomian gland dysfunction was observed among different OSDs. Meibomian gland loss evaluated by meibography might help identify MGD in patients suffering from OSD.

Translation Relevance

Meibography provides a better understanding of MGD in several OSD. It may be useful to integrate this objective analysis to improve treatments of OSD associated to MGD.

Classification criteria for secondary Sjögren's syndrome. Current state of knowledge

Dryness of mucosa and eyes is the most recognizable symptom of Sjögren’s syndrome (SS). Secondary SS (sSS) is diagnosed when symptoms of SS coexist with other systemic connective tissue disease. The sSS is often identified based on the symptoms of dryness in the presence of other connective tissue disease, making the diagnosis of sSS very subjective. The goal of this work was to summarize previously used and current criteria for the diagnosis of sSS. Classification criteria for sSS, which are universally accepted standards, do not exist. The diagnosis of sSS still depends on the experience of the investigator. Histopathological examination of minor salivary glands appears to be crucial for characterization of patients with sSS due to a specific picture of the disease and repeatability of the test.

Comparison of clinical courses and mortality of connective tissue disease-associated interstitial pneumonias and chronic fibrosing idiopathic interstitial pneumonias

Interstitial lung disease (ILD) is a common pulmonary manifestation of connective tissue diseases (CTD). Prognostic effect of radiological usual interstitial pneumonia (UIP) pattern in CTD-associated interstitial lung disease (CTD-ILD) is unknown. This study aimed to investigate the disease progression and mortality of patients with CTD-ILD and idiopathic interstitial pneumonias (IIP) including idiopathic pulmonary fibrosis (IPF) and idiopathic nonspecific interstitial pneumonia and the prognostic impact of the radiological UIP pattern on both disease groups. The medical records of 91 patients (55 with CTD-ILD and 36 with IIP) diagnosed with ILD at pulmonary medicine department, Faculty of Medicine, Gazi University from 2004 to 2014 were retrospectively reviewed. Patients included whose baseline high-resolution computed tomography (HRCT) scans showed either a UIP or non-UIP pattern. While 67.3% (n = 37) of CTD-ILD patients possessed UIP pattern, 38.9% (n = 14) of IIP patients had UIP pattern in HRCT. Respiratory functions including the forced expiratory volume in the first second (FEV₁ ), functional vital capacity (FVC), and transfer coefficient for carbon monoxide (diffusing capacity of the lung for carbon monoxide [DLCO]) of IIP group at the time of diagnosis were significantly lower than CTD-ILD group (P = .007, P = .002, and P = .019, respectively). There was no significant survival difference between CTD-ILD and IIP by using the log-rank test (P = .76). Multivariate analysis revealed that UIP pattern in HRCT (Hazard ratio: 1.85; 95% Confidence interval = 1.14-3; P = .013), annual FVC (Hazard ratio: 0.521; 95% Confidence interval = 0.32-0.84; P = .007), and annual DLCO declines (Hazard ratio: 0.943; 95% Confidence interval = 0.897-0.991; P = .02) were independent risk factors for mortality in both CTD-ILD and IIP groups. We found that UIP pattern in HRCT and annual losses in respiratory functions were the main determinants of prognosis of ILDs either idiopathic or CTD-associated.

Value of Serum Carbohydrate Antigen 19-9 and Carcinoembryonic Antigen in Evaluating Severity and Prognosis of Connective Tissue Disease-Associated Interstitial Lung Disease

OBJECTIVES

This study aims to detect serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9) levels in connective tissue disease-associated interstitial lung disease (CTD-ILD) patients and to demonstrate their values in evaluating the severity and prognosis of CTD-ILD.

PATIENTS AND METHODS

The study included 82 CTD-ILD patients (54 males, 28 females; mean age 67.9 years; range 29 to 91 years) and 82 controls (54 males, 28 females; mean age 68.1 years; range 30 to 92 years). Patients were followed-up for 12 months. Correlations of serum CEA and CA 19-9 with disease severity parameters (pulmonary function, oxygenation index and involvement score on high resolution computed tomography) were analyzed. Survival analysis was used to evaluate significance of serum CEA and CA 19-9 as prognosis predictors.

RESULTS

Serum CEA and CA 19-9 levels were higher in CTD-ILD patients compared with controls (both p<0.05) and correlated with disease severity (p<0.05 for all R2). High levels of serum CEA and CA 19-9 were associated with poor survival (both p<0.05). Serum CEA level was indicated as a prognostic factor for cumulative survival (hazard ratio=1.685, 95% confidence interval: 1.405-2.021, p=0.001).

CONCLUSION

In CTD-ILD patients, serum CEA and CA 19-9 are elevated and can be indicators of disease severity. Moreover, serum CEA is a significant and independent predictor of survival.

Autoimmune Diseases and Their Manifestations on Oral Cavity: Diagnosis and Clinical Management

Oral signs are frequently the first manifestation of autoimmune diseases. For this reason, dentists play an important role in the detection of emerging autoimmune pathologies. Indeed, an early diagnosis can play a decisive role in improving the quality of treatment strategies as well as quality of life. This can be obtained thanks to specific knowledge of oral manifestations of autoimmune diseases. This review is aimed at describing oral presentations, diagnosis, and treatment strategies for systemic lupus erythematosus, Sjögren syndrome, pemphigus vulgaris, mucous membrane pemphigoid, and Behcet disease.

The Association of Conjunctival Snake-Like Chromatin with Keratoconjunctivitis Sicca

Purpose

This work describes the snake-like chromatin cells in the conjunctiva of patients with keratoconjunctivitis sicca (KCS), assessing the relationship between tear function parameters and the severity of the disease, and searching for any differential pattern that could lead to early and diagnosis help clarify the etiology of KCS.

Methods

The conjunctiva of 366 eyes from 187 patients with KCS, and 30 eyes from 15 controls, were classified according to the results of the Schirmer I test, break-up time, rose Bengal staining, osmolarity, ferning tests and electrophoresis; they were then studied by impression cytology and electron microscopy.

Results

Snake-like chromatin cells, other nuclear changes, and a decreased number of goblet cells were found by impression cytology in different areas of the KCS conjunctiva. The presence of snake-like chromatin was significantly correlated with the severity of the disease. No nuclear changes were found in the control group.

Conclusions

We assume these findings can be attributed to a natural regeneration of conjunctival cells and to resistance to a pathological reaction to KCS.

[Primary Sjögren syndrome in a child]

Sjögren syndrome is uncommon in children and occurs most often in association with autoimmune diseases (secondary Sjögren syndrome). We describe the clinical and biological features of a 7-year-old girl with primary Sjögren syndrome revealed by recurrent parotiditis.

CASE REPORT

A 7-year-old girl was referred for investigation of multiple episodes of parotid swelling since age 4 years, without systemic symptoms. The examination was unremarkable except for enlarged and painless parotid glands. Laboratory investigations and labial salivary gland biopsy revealed Sjögren syndrome without associated disease. Hydroxychloroquine was prescribed with clinical improvement.

CONCLUSION

Recurrent parotiditis in children is an uncommon condition. The onset of parotid swelling at 5 years or over deserves screening for disimmune disorders, sarcoidosis, or Sjögren syndrome. Diagnosis of Sjögren syndrome is based on diagnostic criteria.

Standardisation of labial salivary gland histopathology in clinical trials in primary Sjögren's syndrome

Labial salivary gland (LSG) biopsy is used in the classification of primary Sjögren's syndrome (PSS) and in patient stratification in clinical trials. It may also function as a biomarker. The acquisition of tissue and histological interpretation is variable and needs to be standardised for use in clinical trials. A modified European League Against Rheumatism consensus guideline development strategy was used. The steering committee of the ad hoc working group identified key outstanding points of variability in LSG acquisition and analysis. A 2-day workshop was held to develop consensus where possible and identify points where further discussion/data was needed. These points were reviewed by a subgroup of experts on PSS histopathology and then circulated via an online survey to 50 stakeholder experts consisting of rheumatologists, histopathologists and oral medicine specialists, to assess level of agreement (0-10 scale) and comments. Criteria for agreement were a mean score ≥6/10 and 75% of respondents scoring ≥6/10. Thirty-nine (78%) experts responded and 16 points met criteria for agreement. These points are focused on tissue requirements, identification of the characteristic focal lymphocytic sialadenitis, calculation of the focus score, identification of germinal centres, assessment of the area of leucocyte infiltration, reporting standards and use of prestudy samples for clinical trials. We provide standardised consensus guidance for the use of labial salivary gland histopathology in the classification of PSS and in clinical trials and identify areas where further research is required to achieve evidence-based consensus.

Incidence, mortality, and causes of death in physician-diagnosed primary Sjögren's syndrome in Korea: A nationwide, population-based study

OBJECTIVES

The objective of this study was to investigate the epidemiological features of primary Sjögren's syndrome (pSS) in Korea at a national level, including the incidence, mortality, and causes of death.

METHODS

We used a national, population-based registry database called the Rare Intractable Disease Registration Program from the Health Insurance Review and Assessment Service to obtain pSS patient data for the period between 2010 and 2014. pSS was diagnosed by a physician based on uniform criteria. We also used data from Statistics Korea to confirm the mortality and causes of death.

RESULTS

Between 2010 and 2014, the total number of patients newly diagnosed with pSS was 5891, resulting in an annual incidence of 2.34 per 100,000 individuals. The female-to-male ratio was 14.5:1. A total of 114 pSS patients died during the study period. The overall survival rate of pSS patients was 99.0%, and the 1-year, 2-year, and 5-year survival rates were 98.7%, 98.1%, and 97.1%, respectively, and the standardized mortality ratio (SMR) was 1.47 (2.14 for males and 1.35 for females). The most common causes of death were respiratory disease (n = 25; 21.9%) followed by circulatory diseases (n = 21; 18.4%), musculoskeletal connective tissue diseases (n = 21; 18.4%), and cancer (n=19; 16.7%).

CONCLUSIONS

The national incidence of pSS in Korea presented in this study was lower in comparison with reports from other countries. However, the mortality rate was significantly higher than the corresponding values in the age- and gender-matched general population. The higher mortality in pSS patients is attributable to respiratory diseases and lung cancer.

Prevalence of secondary Sjögren's syndrome in Indian patients with rheumatoid arthritis: a single-center study

AIM

To assess the prevalence of secondary Sjögren's syndrome (sSS) and its association with joint damage in patients with rheumatoid arthritis (RA) from northern India.

METHODS

Patients included had RA, fulfilling the 1987 American College of Rheumatology criteria, with disease duration of more than 1 year. They were administered a sicca questionnaire that included six questions from subjective criteria of American European Consensus Group (AECG) criteria. Those who answered affirmatively to at least one question underwent Schirmer I test (ocular function) and salivary scintigraphy (salivary gland involvement). Patients with involvement of both were classified as having sSS as per AECG criteria. A damaged joint count was done using Norfolk Arthritis Register Damaged Joint Count (NOAR-DJC).

RESULTS

This study included 199 patients with RA, with mean (SD) age and disease duration of 44 (9.9) and 6.8 (5.5) years, respectively. The prevalence of sicca symptoms and sSS was 14.6% and 5.5%, respectively. Those having sSS had a longer (mean ± SD) disease duration (9.2 ± 4.0, 6.8 ± 5.5 years, P = 0.07) and were significantly older in age (50.8 ± 6.8, 43.6 ± 9.9 years, P = 0.005) than those without sSS. There was no significant difference in the median (interquartile range) damaged joint count (0 (0-2), 0 (0-2), P = 0.75).

CONCLUSIONS

The prevalence of sSS in northern Indian RA patients was 5.5%, and it was significantly associated with older age but not damaged joint count.

Clinical characteristics of immune thrombocytopenia associated with autoimmune disease: A retrospective study

To clarify clinical characteristics of immune thrombocytopenia (ITP) subsets associated with autoimmune diseases (AIDs).Five thousand five hundred twenty patients were reviewed retrospectively. One hundred four ITP patients were included for analysis. Clinical manifestations at first thrombocytopenic episode were recorded.Systemic lupus erythematosus (SLE) and primary Sjogren syndrome (pSS) accounted for a large part in AIDs associated with secondary ITP. SLE-ITP, pSS-ITP, and primary ITP (pITP) patients were different in several aspects in clinical and immunological characteristics. A subgroup of patients in pITP patients with some obvious autoimmune features (defined as AIF-ITP) such as positive ANA but failing to meet the diagnosis criteria now used for a specific kind of connective tissue diseases were also different with other pITP patients in some immunological features, indicating the difference in the pathogenesis mechanism of those autoimmune featured ITP patients.ITP patients were heterogeneous in clinical characteristics. Further study about the different pathogenesis of ITP subsets especially those AIF-ITP patients who only presented with thrombocytopenia will help us have a better understanding of pathogenesis of ITP and a better management of ITP patients.

Evaluation of Swallowing Functions in Patients with Sjögren's Syndrome

Patients with Sjögren's syndrome (SS) manifest symptoms such as dry eyes, dry mouth, and dysphagia. This study aims to evaluate the swallowing functions of the patients with SS. 69 patients with SS (65 females, 4 males) and 40 healthy individuals (33 females, 7 males) were included as study and control groups, respectively. Mean ages were 52.86 and 48.25 years for study and control groups, respectively. Swallowing functions were evaluated by fiberoptic endoscopic evaluation of swallowing (FEES). All the patients underwent FEES and were given 3, 5, and 10 ml water, yogurt, and fish-shaped crackers twice, respectively. The presence of bolus control, residue, penetration, and aspiration were evaluated. Additionally, certain types of foods triggering the dysphagia, any difficulties in bolus control, need to clean the throat, sensation of having a lump in the throat, sensation of choking, and xerostomia were included in the questionnaire. The MD Anderson Dysphagia Inventory and the Beck Depression Inventory were administered to patients. Considering the presence of residue with yogurt and fish cracker, there was a significant difference between groups (P < 0.05). Penetration was present in two patients in the study group; however, the difference was not significant (P > 0.05). Regarding the MD Anderson Dysphagia Inventory, the average scores were 48.18 ± 13.21 and 87.6 ± 10.67 for study and control groups, respectively, and a statistically significant difference was detected (P < 0.05). Regarding the Beck Depression Inventory, the average scores were 11.83 ± 9.37 and 8.03 ± 6.84 for study and control groups, respectively (P < 0.05). SS affected the swallowing functions significantly. The presence of residue with yogurt and cracker was the most obvious finding, whereas penetration/aspiration was not clinically significant. Swallowing dysfunction reduced the quality of life in patients with SS.

Comorbid autoimmune diseases in patients with sarcoidosis: A nationwide case-control study in Taiwan

The association between sarcoidosis and autoimmune comorbidities has been reported, however, it has seldom been confirmed by a large nationwide study. Our study aimed to clarify the association between sarcoidosis and autoimmune comorbidities in the Taiwanese. A total of 1237 patients with sarcoidosis and 4948 age- and sex-matched control subjects were selected from the National Health Insurance Research Database of Taiwan from 1997 to 2010. Multiple logistic regressions were performed to calculate the odds of comorbidities between the two groups. The prevalence of sarcoidosis was 2.17/100 000 individuals in Taiwan. Sarcoidosis patients tended to run a higher risk of autoimmune comorbidities than the control group (17.6% vs 9.4%, P < 0.05). Autoimmune thyroid disease (adjusted odd ratio [aOR], 1.32; 95% confidence interval [CI], 1.05-1.64), Sjögren's syndrome (aOR, 11.6; 95% CI, 4.36-31.0) and ankylosing spondylitis (aOR, 3.80; 95% CI, 2.42-5.97) were significantly associated with sarcoidosis. The sex-stratified analyses were carried out to demonstrate a significant association of sarcoidosis with ankylosing spondylitis in both sexes, but with autoimmune thyroid disease in male patients and with Sjögren's syndrome female patients, respectively. Besides, the diagnosis of the autoimmune comorbidities strongly associated with sarcoidosis tended to be established after that of sarcoidosis. This study demonstrated that patients with sarcoidosis tended to have autoimmune thyroid disease, Sjögren's syndrome and ankylosing spondylitis, and the diagnosis of sarcoidosis usually preceded that of associated comorbidities. Clinicians should be alert to autoimmune comorbidities in patients with sarcoidosis.

Antiphospholipid antibodies in primary Sjögren’s syndrome: prevalence and clinical significance in a series of 74 patients

The aim of this study is to determine prevalence, clinical significance of antiphospholipidantibodies (aPL) including anticardiolipin antibodies (aCL), anti-b2GP1 and lupus anticoagulant (LA) in a cohort of 74 patients with primary Sjögren’s syndrome (pSS) according to revised European criteria. aPL were found in 25 (34%) patients; IgG in 23 (12 had low titres, six moderate titres and five high titres) and IgM in five (three and two had respectively moderate and high titres). Eight (11%) patients were found to have LA; anti-b2GP1 antibodies were detected only in three (4%) patients. Only two patients with LA, aPL and b2GP1 had recurrent venous thrombosis. One patient with moderate titres of aPL exhibited recurrent spontaneous foetal losses. Peripheral neuropathies without cryoglobulinemia were more frequent in the aPL group. Other systemic involvements of pSS were the same in both groups with or without aPL. Patients with aPL have more concurrentimmunological diseases such as thyroiditis and primary biliary cirrhosis and a higher prevalence of hypergammaglobulinemia (P < 0.05). Even if aPL prevalence reached 30% in pSS, titres were usually low, with a close correlation with hypergammaglobulinemia but not with antiphospholipid syndrome, which is related to positivity of both LA and aPL.

Evaluation of different diagnostic criteria of diseases manifesting the oral cavity - A review. Part-1

There are many disorders affecting the oral cavity, which can cause difficulty in diagnosis for an oral physician. A criterion is defined as 'a principle or standard by which something may be judged or decided'. Several criteria have been given by different authors or committee, which further aids in diagnosis of certain disease. This article encompasses a collection and analysis of all the criteria of diseases affecting the oral cavity, which will be beneficial for an oral physician in their routine clinics.

Clinical Characteristics of Connective Tissue Disease-Associated Interstitial Lung Disease in 1,044 Chinese Patients

BACKGROUND

Because the prevalence of connective tissue disease (CTD)-associated interstitial lung disease (ILD; CTD-ILD) in China is unknown, we wanted to analyze the clinical characteristics of this disease in Chinese patients.

METHODS

The medical records of patients who received a diagnosis of ILD and treated in Shanghai Pulmonary Hospital from January 1999 to January 2013 were reviewed. Based on the records, patients who also received a diagnosis of CTD were identified, and their records of follow-up examinations for a minimum of 12 months until the end of December 2013 were reviewed.

RESULTS

Of the 2,678 patients who received a diagnosis of ILD, 1,798 (67%) were identified as having CTD-ILD; 299 (11.2%) had idiopathic pulmonary fibrosis (IPF). Complete clinical data were available for 1,044 patients with CTD-ILD and 178 with IPF. We found that 332 of the 1,044 patients with CTD-ILD (32%) did not receive an accurate diagnosis at the initial hospital admission, 195 (18.7%) of the 1,044 patients showed persistent negative test results for autoantibodies, and 262 (25.1%) of the 1,044 patients had negative autoantibodies at the initial hospital admission and then became positive at follow-up examinations. Of the 288 patients who had confirmed CTD-ILD, 41 (14%) showed pulmonary symptoms as the initial clinical manifestation (PSIM) and 247 (86%) showed extrapulmonary symptoms as the initial clinical manifestation (EPSIM). For the 756 patients who had undifferentiated CTD-ILD, the proportion of PSIM and EPSIM was 44% and 56%, respectively. For patients who presented with PSIM, 23 who had confirmed CTD-ILD (56%) and 216 who had unconfirmed CTD-ILD (65%) did not receive an accurate diagnosis at the initial visit but were ultimately diagnosed at subsequent follow-up examinations.

CONCLUSIONS

Patients with CTD-ILD do not receive an accurate diagnosis at the initial hospital admission possibly because of negative serologic test results for autoantibodies and the absence of obvious extrapulmonary symptoms. Thus, patients with ILD should be examined for extrapulmonary symptoms and tested for autoantibodies at follow-up examinations.

Renal involvement in primary Sjögren syndrome

Primary Sjögren syndrome (pSS) is an autoimmune disorder characterized by lymphoplasmacytic infiltration of the exocrine (salivary and lachrymal) glands that results in sicca symptoms (dryness of the eyes and mouth). Systemic complications can occur in pSS, but renal involvement is rare, affecting <10% patients. The most frequent form of nephropathy in pSS is tubulointerstitial nephritis (TIN), in which infiltration of the kidney by plasma cells is a key feature and shows similarity to the lymphoplasmacytic infiltration of the salivary glands. Electrolyte disturbances may occur in pSS, such as renal distal tubular acidosis, diabetes insipidus, Gitelman syndrome or Fanconi syndrome. Glomerular involvement is less frequently detected in patients with pSS, but usually takes the form of membranoproliferative glomerulonephritis secondary to cryoglobulinaemia. The renal prognosis in patients with pSS and TIN or glomerular disease is usually favourable, but the risk of chronic kidney disease remains high in patients with TIN. Appropriate screening must be performed at least once a year in patients with systemic pSS in order to facilitate the early detection of renal complications. In this Review we discuss the epidemiology, pathophysiology, differential diagnosis and treatment of renal disease in pSS.

Hepatitis C virus infection and the risk of Sjögren or sicca syndrome: a meta-analysis

Previous studies have suggested an association between hepatitis C virus (HCV) infection and the development of Sjögren's syndrome (SS), also known as sicca syndrome. The main objective of this study was to summarize the existing evidence and quantitatively evaluate the association between hepatitis C virus infection and SS/sicca syndrome by performing a meta-analysis of observational studies. MEDLINE and PubMed (January 1980-August 2013) were searched to identify relevant studies in English. Outcomes were calculated and are reported as odds risk (OR) and 95% CIs based on a random-effects model. Heterogeneity was assessed with I(2) statistics. Quality assessment was performed with the Newcastle-Ottawa scale. Based on meta-analysis of five cross-sectional and five cohort studies, a significant positive relationship between HCV infection and development of SS/sicca syndrome was found, the pooled random effects OR being 3.31 (95% CI, 1.46-7.48; P < 0.001). In subset analyses, the studies that used European diagnostic criteria showed a higher summary OR than did studies that adopted other diagnostic criteria. When the data were stratified by source of controls, significant associations were also observed when healthy people (OR = 9.44; 95% CI = 2.67-33.40; P = 0.204) or subjects with hepatitis B virus infection (OR = 6.57; 95% CI = 1.21-35.57; P = 0.5) were used as controls, but not when the controls were hospital-based (OR = 0.99; 95% CI = 0.61-1.61; P = 0.169). In summary, the findings suggest that HCV infection is associated with SS/sicca syndrome. The observed increased risk in studies in which European diagnostic criteria and healthy controls were used and the decreased risk in studies with hospital-based controls may be attributable to selection bias or other unknown factors.

Serum Krebs von den Lungen-6 level as a diagnostic biomarker for interstitial lung disease in Chinese patients

OBJECTIVES

The purpose of this study was to determine the diagnostic and prognostic values of serum KL-6 levels in Chinese patients with interstitial lung disease (ILDs).

METHODS

A total of 1084 subjects including 373 cases of ILDs, 584 cases of non-ILD pulmonary diseases, and 127 healthy individuals were recruited from three clinical centers in China between January 2011 and December 2013. A total of 106 patients undergoing treatments for ILDs in Shanghai Pulmonary Hospital between January 2011 and December 2013 were enrolled. Baseline and posttreatment serum KL-6 levels were determined.

RESULTS

Serum KL-6 levels in patients with ILDs were significantly higher than those in patients with non-ILD pulmonary diseases or in healthy individuals (1492.09 ± 2230.08 U/mL vs 258.67 ± 268.73 U/mL or 178.73 ± 71.17 U/mL, all P < 0.05). At the cut-off value of 500 U/mL, the sensitivity and specificity of serum KL-6 as a diagnostic marker for ILDs was 77.75% and 94.51%, respectively. The Kappa value was 0.743 (P < 0.001). The area below the receiver operating characteristic curve was 0.922 with a 95% Confidence interval of 0.904-0.941 (P < 0.001). The posttreatment serum KL-6 levels significantly reduced in patients with improved ILDs, whereas markedly increased in patients with exacerbated ILDs (All P < 0.05).

CONCLUSIONS

Serum KL-6 levels might be a promising diagnostic biomarker for ILDs in Chinese patients. The prognostic value of serum KL-6 levels for ILDs remains to be verified by large-scaled studies.

A systematic review of non-pharmacological interventions for primary Sjögren's syndrome

Objective. To evaluate the effects of non-pharmacological interventions for primary SS (pSS) on outcomes falling within the World Health Organization International Classification of Functioning Disability and Health domains.

Methods. We searched the following databases from inception to September 2014: Cochrane Database of Systematic Reviews; Medline; Embase; PsychINFO; CINAHL; and clinical trials registers. We included randomized controlled trials of any non-pharmacological intervention. Two authors independently reviewed titles and abstracts against the inclusion/exclusion criteria and independently assessed trial quality and extracted data.

Results. A total of 1463 studies were identified, from which 17 full text articles were screened and 5 studies were included in the review; a total of 130 participants were randomized. The included studies investigated the effectiveness of an oral lubricating device for dry mouth, acupuncture for dry mouth, lacrimal punctum plugs for dry eyes and psychodynamic group therapy for coping with symptoms. Overall, the studies were of low quality and at high risk of bias. Although one study showed punctum plugs to improve dry eyes, the sample size was relatively small.

Conclusion. Further high-quality studies to evaluate non-pharmacological interventions for PSS are needed.

Diagnostic utility of Acoustic Radiation Force Impulse (ARFI) imaging in primary Sjoegren`s syndrome

OBJECTIVES

The purpose of the study was to assess the diagnostic utility of acoustic radiation force impulse (ARFI) imaging in primary Sjögren's syndrome (pSS).

METHODS

One hundred fifty-seven patients with sicca symptoms and/or salivary gland swelling were included. Sicca symptoms, Schirmer test, unstimulated whole saliva (UWS), SS-A/B antibodies, and histology were assessed according to American-European Consensus group (AECG) criteria. All patients underwent high-resolution ultrasound and ARFI imaging of the parotid (PG) and submandibular glands (SMG).

RESULTS

Seventy patients were classified as having pSS. The remaining 87 patients suffered from idiopathic sicca (n = 24), rheumatoid arthritis (n = 12), sarcoidosis (n = 9), cutaneous/systemic lupus erythematosus (n = 7), scleroderma (n = 2), dermatomyositis (n = 1), HBV/HCV (n = 2), and panarteritis nodosa (n = 1), and disorders in 29 patients were classified as not otherwise specified. ARFI values of the PG were significantly higher in the pSS versus non-pSS groups (2.86 ± 0.07 m/s vs. 2.15 ± 0.11 m/s, p < 0.0001). ARFI imaging demonstrated diagnostic sensitivity and specificity of 81 % and 67 %, respectively.

CONCLUSIONS

In addition to histology, ARFI imaging was the most important diagnostic tool for identifying early pSS.

KEY POINTS

• Early stages in Sjögren's syndrome become apparent with major salivary gland enlargements. • Schirmer and unstimulated whole saliva tests demonstrated insufficient sensitivity/specificity for early-stage diagnosis. • Acoustic radiation force impulse imaging is a reliable tool for diagnosing early disease stages.

Individualized Prediction of Heat Stress in Firefighters: A Data-Driven Approach Using Classification and Regression Trees

The purpose of this study was to explore data-driven models, based on decision trees, to develop practical and easy to use predictive models for early identification of firefighters who are likely to cross the threshold of hyperthermia during live-fire training. Predictive models were created for three consecutive live-fire training scenarios. The final predicted outcome was a categorical variable: will a firefighter cross the upper threshold of hyperthermia - Yes/No. Two tiers of models were built, one with and one without taking into account the outcome (whether a firefighter crossed hyperthermia or not) from the previous training scenario. First tier of models included age, baseline heart rate and core body temperature, body mass index, and duration of training scenario as predictors. The second tier of models included the outcome of the previous scenario in the prediction space, in addition to all the predictors from the first tier of models. Classification and regression trees were used independently for prediction. The response variable for the regression tree was the quantitative variable: core body temperature at the end of each scenario. The predicted quantitative variable from regression trees was compared to the upper threshold of hyperthermia (38°C) to predict whether a firefighter would enter hyperthermia. The performance of classification and regression tree models was satisfactory for the second (success rate = 79%) and third (success rate = 89%) training scenarios but not for the first (success rate = 43%). Data-driven models based on decision trees can be a useful tool for predicting physiological response without modeling the underlying physiological systems. Early prediction of heat stress coupled with proactive interventions, such as pre-cooling, can help reduce heat stress in firefighters.

Sjögren's syndrome: an update on epidemiology and current insights on pathophysiology

Primary Sjögren's syndrome (pSS) is an autoimmune chronic inflammatory disorder affecting 0.2% to 3.0% of the population, with a 9:1 female to male ratio. Features are oral and ocular dryness, local and systemic autoantibody production, and progressive focal mononuclear cell infiltration in the affected salivary and lacrimal glands. Lymphoma is the most severe complication of pSS, occurring in 4% to 5% of patients. Genetic studies identified an association with HLA and susceptibility genes in cytokine genes and genes involved in B-cell differentiation. Genetic variations may help explain why disease manifestations differ among patients and supports the hypothesis of certain distinct disease phenotypes.

Clinical characteristics and treatment outcomes of autoimmune-associated hemophagocytic syndrome in adults

Objective

To better define the clinical characteristics and treatment outcomes of autoimmune-associated hemophagocytic syndrome (AAHS) in adults.

Methods

Adults with AAHS (defined as pathologic evidence of hemophagocytosis without any obvious cause other than an autoimmune disease) were identified through a review of the literature.

Results

Among 116 patients identified, underlying diseases included systemic lupus erythematosus (SLE) in 52.3%, adult-onset Still's disease (AOSD) in 26.7%, and dermatomyositis in 6.9%. Fever, lymphadenopathy, hepatomegaly, and splenomegaly were found in 86.8%, 41.0%, 41.8%, and 45.5% of patients, respectively. Cytopenia, liver dysfunction, and hyperferritinemia developed frequently, and coagulopathy was seen in 50.6% of patients. Normal or low C-reactive protein levels were characteristic of patients with underlying SLE. The most commonly used therapy was corticosteroids, which were initially administered in 95.7% of patients, with 57.7% responding. Patients with corticosteroid-refractory disease were usually treated with cyclosporine, intravenous cyclophosphamide (IV CYC), or intravenous immunoglobulin (IVIG), with IV CYC being highly effective. Treatment with biologic agents resulted in favorable effects in the majority of patients. The mortality rate was 12.9%. Male sex (odds ratio [OR] 6.47, 95% confidence interval [95% CI] 2.06–30.39, P < 0.01), dermatomyositis (OR 5.57, 95% CI 1.08–28.65, P < 0.05), and anemia (hemoglobin <8 gm/dl; OR 3.74, 95% CI 1.02–13.8, P < 0.05) were identified as factors associated with mortality.

Conclusion

AAHS is potentially fatal. Corticosteroids are a mainstay of initial treatment. For corticosteroid-refractory disease, IV CYC may be beneficial as compared with cyclosporine or IVIG. Treatment that proceeds directly from corticosteroids to biologic agents is promising.

A convenient and less invasive technique of labial minor salivary gland biopsy using a minimal incision with a needle tip

Objectives

This study was to show the technique and to compare the usefulness and complications of biopsy using a minimal incision with a needle tip of the labial minor salivary glands with those of conventional incisional lip biopsy in the diagnosis of Sjögren's syndrome.

Methods

We retrospectively reviewed the medical records of the patients who had the labial minor salivary gland biopsy for the diagnosis of Sjögren's syndrome between January 2005 and December 2008. One hundred forty-three patients were enrolled in this study. The yields of diagnostic salivary tissues and complications of the biopsy using a minimal incision with a needle tip and the conventional incisional lip biopsy were compared.

Results

Out of 143 patients, 56 patients underwent the conventional incisional lip biopsy and 87 patients received the biopsy using a minimal incision with a needle tip. In the biopsy using a minimal incision with a needle tip group, adequate salivary gland tissues were obtained in 85 patients out of 87 patients (97.7%). In the conventional incisional lip biopsy group, adequate specimens were acquired in 44 patients out of 56 patients (78.6%). There was no complication after the biopsy using a minimal incision with a needle tip, whereas there was one patient complained transient numbness of the lip after the conventional incisional lip biopsy.

Conclusion

The less invasive labial minor salivary gland biopsy using a minimal incision with a needle tip was easy to perform and safe and showed the better result than the conventional incisional lip biopsy in terms of the adequate specimen in the diagnosis of Sjögren's syndrome. So it might be a good alternative to the conventional incisional lip biopsy.

Renal tubular acidosis in Sjögren's syndrome: a case series

BACKGROUND

The exact frequency of distal and proximal renal tubular acidosis (RTA) in Sjögren's syndrome is unknown. Other features of Sjögren's syndrome like polyuria, glomerular manifestations, familial occurrence and pregnancy are not widely reported. The aim was to prospectively study the clinical features and outcome of distal and proximal RTA in Sjögren's syndrome and also report on other renal manifestations of Sjögren's syndrome.

METHODS

The present study is a prospective consecutive case series of patients who presented with a history suggestive of RTA and Sjögren's syndrome. All patients were followed for 1 year. The diagnosis of RTA was by fractional excretion of bicarbonate. The diagnosis of Sjögren's syndrome was according to the American-European classification system [modified by Tzioufas and Voulgarelis: Best Pract Res Clin Rheumatol 2007;21:989-1010].

RESULTS

The total number of RTA patients diagnosed during this period was 149. Sjögren's syndrome accounted for 34.8% (52 of 149) of RTA patients. The important symptoms and laboratory parameters were oral and ocular symptoms in 23 (44.2%), dental caries in 12 (23%), body pains in 47 (90.3%), mean serum pH 7.202 ± 0.03, mean serum bicarbonate, 14.03 ± 1.66 mmol/l, and mean urine pH, 7.125 ± 0.54. There were 30 (57.6%) patients with distal RTA and 22 (42.3%) patients with proximal RTA.

CONCLUSIONS

The clinical implication of the present study is that RTA is a common feature of Sjögren's syndrome. It may be missed if the presentation is not due to oral and ocular symptoms. The present study is also the only one with a 1-year follow-up.

Mucin 5B promoter polymorphism is associated with susceptibility to interstitial lung diseases in Chinese males

The variation of G>T in the MUC5B promoter (rs35705950) has been associated with idiopathic pulmonary fibrosis (IPF) and familial interstitial pneumonia (FIP) in Caucasians, but no information is available regarding this variant in the Chinese population. We recruited 405 patients with interstitial lung diseases (ILD), including 165 IPF patients and 2043 healthy controls, for genotyping the MUC5B gene in the Chinese population. One hundred three patients with pneumonia and 360 patients with autoimmune diseases (ADs) were recruited as disease controls. Our results indicated that the prevalence of the minor allele (T) of the polymorphism rs35705950 in healthy Chinese subjects was approximately 0.66%, which was lower than that described in the Caucasian population. The frequencies of the T allele were 3.33% and 2.22% in IPF and ILD patients, respectively, and these values were significantly higher than those of healthy controls (P = 0.001, OR = 4.332 for IPF, and P = 0.002, OR = 2.855 for ILD). A stratified analysis showed that this variant in MUC5B associated with the risk for ILD mainly in older male Chinese subjects. No difference was observed between patients with pneumonia, AD patients, and healthy controls.

Epidemiology of primary Sjögren's syndrome: a systematic review and meta-analysis

OBJECTIVE

Epidemiological studies of primary Sjögren's syndrome (pSS) are crucial for describing the burden to society and the public medical system and for shedding light on aetiology. Previous reports of the epidemiology of pSS show variable outcomes. We conducted a systematic review of the epidemiology of pSS to assess the prevalence rates (PRs) and incidence rates (IRs), and to investigate possible geographic variations in pSS.

METHODS

A systematic literature search of PubMed and Embase (updated to 22 October 2013) was performed to identify all published reports on the epidemiology of pSS. The incidence and prevalence rates of pSS were summarised with IRs or PRs and 95% CIs.

RESULTS

The literature search yielded 1880 related citations. Only 21 fulfilled the inclusion criteria. According to a random-effects model, the pooled IR for pSS was 6.92 (95% CI 4.98 to 8.86) per 100 000 person-years. The overall PR was 60.82 (95% CI 43.69 to 77.94) cases per 100 000 inhabitants with a slightly lower estimate of Baodong Qin is BDQ, Jiaqi Wang is JQW, Zaixing Yang is ZXY, Renqian Zhong is RQZ. 43.03 (25.74 to 60.31) cases per 100 000 inhabitants when only considering population-based studies. The female/male ratio in incidence data was 9.15 (95% CI 3.35 to 13.18). The female/male ratio in prevalence data was 10.72 (95% CI 7.35 to 15.62). The overall age of pSS patients was 56.16 years (95% CI 52.54 to 59.78).

CONCLUSIONS

Incidence and prevalence rates of pSS vary widely around the world. The results help us better understand the global epidemiology of pSS. Large population-based studies combining meticulous case-finding and case-ascertainment strategies are needed.

Comparison of the performance of the different classification criteria for primary Sjögren's syndrome: a prospective cohort study

The objective of the study is to compare the longitudinal performance of different classification criteria for primary Sjögren's syndrome (SS) in a cohort of patients previously diagnosed with primary SS. In each patient, we repeated diagnostic tests as required by the Copenhagen, European, Californian, and American-European Consensus Group (AECG) or the new American College of Rheumatology (ACR) classification criteria. Sixty-three out of 90 eligible patients (70 %) consented to participate. During the follow-up (mean (standard deviation, SD) 7.6 years (0.5)), we observed evolution from primary SS to SS with another systemic autoimmune disease (SAD) in 9/63 (14 %) patients, on average after 4.0 years (SD 0.9). The evolution from primary SS to SS-SADs was significantly more common if the diagnosis of primary SS was initially made using AECG (17 %, p = 0.008) or ACR (16 %, p = 0.016) criteria. In the 34 patients who underwent a full diagnostic reassessment, the diagnosis retention rate was statistically significant for all the criteria, except the European criteria. At reassessment, 3/32 (9 %) patients initially diagnosed as having primary SS using the European criteria could not be classified as having primary SS by any of the criteria. The differences in classification when using the AECG and the new ACR criteria were not statistically significant. The longitudinal diagnosis retention rate was highest for the Californian and AECG criteria. Regardless of the classification criteria, some patients eventually develop another SAD.