The Sjögren's Syndrome Damage Index--a damage index for use in clinical trials and observational studies in primary Sjögren's syndrome

OBJECTIVE

To validate a tool for assessment of accumulated damage in patients with Primary SS (PSS).

METHODS

Of the total 114 patients fulfilling American-European Consensus Group (AECG) criteria for PSS 104 were included in the study and assessed by rheumatologists at T (time) = 0 months and T = 12 months. On each occasion, damage and activity data, and autoantibody status were collected. SF-36 and Profile of Fatigue and Discomfort-Sicca Symptoms Inventory (PROFAD-SSI) questionnaires were completed. Cross-sectional analysis of this data was subject to a process of expert validation by 11 ophthalmologists, 14 oral medicine specialists and 8 rheumatologists. Items were removed from the index if >or= 50% of respondents recommended exclusion. Statistical validation was performed on remaining items. Spearman's rank analysis was used to investigate associations between damage scores and other disease status measures and Wilcoxon matched-pair analysis to assess sensitivity to change in the damage score.

RESULTS

Based on the expert validation, a 29-item damage score was agreed incorporating ocular, oral and systemic domains. Total damage score correlated with disease duration at study entry (r = 0.436; P < 0.001), physical function as measured by SF-36 (r = 0.250, T = 0 months; r = 0.261 T = 12 months) and activity as measured by the Sjögren's Systemic Clinical Activity Index (r = 0.213, T = 0 months; r = 0.215, T =12 months). Ocular damage score correlated with the 'eye dry' domain of PROFAD-SSI (r = 0.228, T = 0 months; r = 0.365, T = 12 months). Other associations not present on both assessments were considered clinically insignificant. On Wilcoxon analysis, the index was sensitive to change over 12 months (z = -3.262; P < 0.01).

CONCLUSION

This study begins validation of a tool for collection of longitudinal damage data in PSS. We recommend further trial in both the experimental and clinical environment.

Reduction of fatigue in Sjögren syndrome with rituximab: results of a randomised, double-blind, placebo-controlled pilot study

OBJECTIVE

Primary Sjögren syndrome (pSS) causes significant systemic symptoms including fatigue as well as glandular dysfunction. There are currently no effective systemic therapies; however, open label series have suggested that rituximab may be beneficial for systemic and glandular manifestations. Therefore, we performed a double blind, placebo-controlled, randomised pilot study of the efficacy of rituximab in reducing fatigue in pSS.

METHODS

A total of 17 patients with pSS and a score on fatigue visual analogue scale (VAS) >50 were randomised to receive either 2 infusions of rituximab 1 g or placebo; patients also received oral and intravenous steroids. Outcome measures included: the proportion of patients with >20% reduction in fatigue VAS, changes in pSS related symptoms, health related quality of life and immunological parameters of pSS. These were measured 6 months after therapy.

RESULTS

There was significant improvement from baseline in fatigue VAS in the rituximab group (p<0.001) in contrast to the placebo group (p = 0.147). There was a significant difference between the groups at 6 months in the social functioning score of SF-36 (p = 0.01) and a trend to significant difference in the mental health domain score of SF-36 (p = 0.06). There was one episode of serum sickness in the rituximab treated group.

CONCLUSIONS

This is the first double blind study of rituximab in pSS to show benefit; further studies are justified.

Facilitators and barriers to improving the quality of referrals for potential oral cancer

The quality and content of referral letters are important for prioritisation of patients who may have oral cancer. Referrals letters to the Oral Medicine Clinic at Birmingham Dental Hospital were analysed and practitioners interviewed. Whilst acceptable for general purposes, most letters did not contain sufficient information to allow effective prioritisation. Interviews disclosed a misunderstanding amongst practitioners about the way in which referrals were handled. A number of barriers to increasing the information included in letters were identified. Referral guidelines and a standardised proforma might help improve the ability of the service to operate a fast-track system.

High prevalence of Toxoplasma gondii in a commercial flock of chickens in Israel, and public health implications of free-range farming

Little is known of the prevalence of Toxoplasma gondii in commercially raised chickens. In the present study, the prevalence of T. gondii in 96 free-range chickens (Gallus domesticus) from a commercial farm in Israel was assessed. Blood, heart, and brain from each chicken were examined for T. gondii infection. Antibodies to T. gondii, assayed with the modified agglutination test (MAT > or = 1:5), were found in 45 of the 96 chickens. Hearts and brains of seropositive (MAT > or = 1:5) chickens were bioassayed in mice. Additionally, hearts and brains of 51 seronegative (MAT < 1:5) chickens were bioassayed in two T. gondii-free cats. T. gondii was isolated from 19 of the 45 (42.2%) seropositive chickens by bioassay in mice. Both the cats fed tissues pooled from seronegative chickens shed T. gondii oocysts. Tachyzoites and tissue cysts of all 21 isolates of T. gondii from chickens were avirulent for mice. Seventeen of the 19 isolates genotyped were found to be type II, and 2 were type III. Understanding of the sources of infection on such farms could be the key to the development of better prevention strategies.

Description of a tandem repeated DNA sequence of Echinostoma caproni and methods for its detection in snail and plankton samples

Echinostome larval stages in the snail have a great potential as effective competitors for the control of schistosomes and adult worms can cause painful intestinal diseases in humans. Ecology and transmission of the larval stages of trematodes are poorly understood, especially because their identification in field-collected samples by microscopy is difficult. We cloned, sequenced and analysed a 192 bp tandem repreated DNA sequence of Echinostoma caproni (EcSau3A), an often discussed antagonist of Schistosoma mansoni in Biomphalaria snails. PCR primers against this sequence can detect less than 10 fg of E. caproni DNA, 2 miracidia in snails 1 day p.i., 1 metacercaria in 50 mg snail tissue and 1 cercaria in 50 mg plankton with high specificity. Methods described in this study can support the discovery of fundamental ecological principles on distribution, host specificity and epidemiology of E. caproni larvae under field conditions.

Salivary gland expression of transforming growth factor beta isoforms in Sjogren's syndrome and benign lymphoepithelial lesions

AIM

Transforming growth factor beta (TGF-beta) is involved in the control of autoimmune reactions, cell proliferation, and the accumulation of lymphocytes within organs. The aim of this study was to determine the expression of TGF-beta in salivary glands from patients with primary Sjogren's syndrome (SS) and benign lymphoepithelial lesions (BLEL) with emphasis on ductal epithelium.

METHODS

Immunoperoxidase staining for TGF-beta isoforms and Ki67 antigen was performed on formalin fixed sections of labial glands from patients with primary SS (n = 15) and controls (n = 5) and parotid glands reported as BLEL (n = 5) or normal (n = 5). Ductal expression of TGF-beta was quantified by absorbance measurements using image analysis. The specificity of staining was confirmed by peptide blocking studies.

RESULTS

All TGF-beta isoforms were detected within the cytoplasm of most lymphocytes, endothelial cells, and ducts in all specimens. Acinar expression was variable and weaker than that seen in ducts. Absorbance measurements revealed that the expression of all isoforms was greater in ducts within primary SS glands than in control glands. Ductal expression in control parotid glands was greater than that seen in BLEL glands, irrespective of the presence of adjacent lymphoid infiltrates. Comparisons between control specimens showed that ductal expression of all isoforms was highest in parotid glands, whereas no differences were detected between primary SS and BLEL glands. Ki67 positive lymphocytes and duct cells were mainly restricted to pathological specimens, with BLEL glands containing larger populations of positive cells than primary SS glands.

CONCLUSION

These results demonstrate complex and variable changes in ductal expression of TGF-beta in primary SS and BLEL, which may be important in the control of lymphoid infiltration and the proliferation of lymphocytes and ductal epithelium.

Polymerase chain reaction assay based on a highly repeated sequence of Schistosoma haematobium: a potential tool for monitoring schistosome-infested water

We have cloned from Schistosoma haematobium genome a repeated sequence, the DraI repeated sequence, which consists of tandemly arranged 121-bp-long units and which is highly abundant (approximately 15% of the S. haematobium genome). By these features, the DraI repeat is similar to the Sm1-7 sequence of Schistosoma mansoni previously described by us. However, their nucleotide sequences are profoundly different. Polymerase chain reaction (PCR) primers were designed on the basis of the DraI sequence information and were used in a PCR assay by which as little as 10 fg of schistosomal DNA as well as individual cercariae were detected. The DraI repeat cross-hybridized with DNA from Schistosoma bovis, Schistosoma magrebowiei, Schistosoma mattheei, Schistosoma curassoni, and Schistosoma intercalatum, but not with DNA from S. mansoni nor from Trichobilharzia ocellata and Echinostoma sp. A potential value of this PCR assay is suggested for monitoring free-living cercariae and infected snails only in bodies free of cross-hybridizing species.

Ectopic expression of the B cell-attracting chemokine BCA-1 (CXCL13) on endothelial cells and within lymphoid follicles contributes to the establishment of germinal center-like structures in Sjögren's syndrome

OBJECTIVE

To test the hypothesis that the formation of ectopic germinal center (GC)-like structures in Sjögren's syndrome (SS) is associated with the ectopic expression of the constitutive lymphoid tissue-homing chemokines B cell-attracting chemokine 1 (BCA-1; or, CXCL13) and stromal cell-derived factor 1 (SDF-1; or, CXCL12).

METHODS

Immunohistochemical and immunofluorescence analysis was used to determine the expression of the constitutive chemokines BCA-1 (CXCL13) and SDF-1 (CXCL12) in salivary glands from 5 SS patients and 3 non-SS patients. In addition, the expression of their respective receptors (CXCR5 and CXCR4) was examined on infiltrating lymphocytes. Human tonsil was used as a positive control for secondary lymphoid tissue.

RESULTS

BCA-1 (CXCL13) was expressed within lymphoid aggregates in SS, which shared many structural features with GCs in tonsil. BCA-1 (CXCL13) was completely absent in control biopsy samples from patients who did not have SS. High levels of BCA-1 (CXCL13) were also found on endothelial cells in salivary glands from SS patients. Diseased SS tissue was infiltrated by CXCR5-expressing B cells which organized into GC-like clusters. In complete contrast, SDF-1 (CXCL12), a constitutive chemokine involved in leukocyte retention within lymphoid tissue, was expressed by epithelial cells in both diseased and control samples. The chemokine receptor for SDF-1, CXCR4, was expressed on T cells that accumulated in a periductal distribution in diseased tissue.

CONCLUSION

The ectopic expression of BCA-1 (CXCL13) on endothelial cells and within GC-like structures, together with the strong expression of SDF-1 (CXCL12) on ductal epithelial cells, is a unique feature of inflamed glands in SS. By creating a local microenvironment supportive of focal B cell aggregation and differentiation, with structural features that are remarkably similar to GCs, BCA-1 (CXCL13) and SDF-1 (CXCL12) may contribute to the excessive production of high-affinity, class-switched autoantibodies and to the high incidence of B cell lymphomas classically associated with SS.

Sjögren's syndrome as seen by an oral physician

This article provides a brief overview of the various orofacial presentations of Sjögren's syndrome. The paper summarises the clinical features of patients with xerostomia, and alludes to differential diagnosis, investigative procedures and therapeutic modalities for the oral component of Sjögren's syndrome.

Oral mucosal lichen planus in children

Although lichen planus is a relatively common mucocutaneous disorder in adults, it has only rarely been described in children. Moreover, even less data has been published regarding mucosal lesions in children. Six case reports of childhood oral lichen planus are presented and the available literature reviewed. It is believed that this paper documents the largest series of cases of childhood oral mucosal lichen planus to be reported in the literature to date. Lichen planus should be considered in the differential diagnosis of oral mucosal white patches in children, particularly those of Asian origin.

Mast cells, extracellular matrix components, TGFbeta isoforms and TGFbeta receptor expression in labial salivary glands in systemic sclerosis

OBJECTIVE

To determine whether there was altered elaboration of non-collagenous extracellular matrix proteins or expression of TGFbeta isoforms and their receptors in salivary glands of patients with systemic sclerosis (SSc) and Raynaud's phenomenon (RP). Because of the possible role of mast cells in the early stages of SSc their presence was also investigated.

METHODS

Sections of normal labial salivary glands (n=10) and glands from patients with SSc (n = 13) and RP (n = 5) were stained immunohistochemically and using acid toluidine blue.

RESULTS

SSc glands contained more mast cells than control tissues (p<0.005) and similar numbers to those found in RP specimens. There were no differences in the pattern or amount of non-collagenous matrix proteins detected. Tenascin and elastin were predominantly found surrounding ducts whereas fibronectin had a more general distribution. TGFbeta isoforms and receptors were expressed by glandular epithelium, fibroblasts, vascular endothelium and inflammatory cells. Cell counts showed no differences in expression of TGFbeta1 or TGFbeta receptors between groups. However, the percentage of TGFbeta2 positive fibroblasts was significantly higher in SSc glands compared with controls (p<0.004). RP glands showed an intermediate level of expression. By contrast, a lower percentage of RP fibrolasts expressed TGFbeta3 compared with controls with SSc glands showing an intermediate level of expression.

CONCLUSIONS

These results show that (a) there are no changes in glandular expression of tenascin, elastin and fibronectin in SSc and RP and (b) both conditions are associated with an increased salivary gland mast cell population and changes in expression of TGFbeta2 and beta3 isoforms by glandular fibroblasts.

Behçet's syndrome: a multidisciplinary approach to clinical care

Behçet's syndrome is a multisystem disorder characterized by recurrent orogenital ulceration and an occlusive vasculitis. Histologically, there is a combination of a perivascular lymphocytic infiltration with endothelial cell damage coupled with a pro-thrombotic tendency. We present a multidisciplinary approach to the management of Behçet's syndrome, and compare our findings with other published studies. Over a nine-year period, 50 patients with Behçet's syndrome were followed in a multidisciplinary combined clinic. Patients were assessed by an ophthalmologist, a rheumatologist and a specialist in oral medicine. Data on disease activity and damage were collected using a standardized proforma for each specialty. Mean age of onset was 30 years; 56% were male. Recurrent oral ulceration was the commonest manifestation and the presenting feature in 76%. The commonest second systems involved were genital mucosae and eyes. We found a larger proportion of patients with ophthalmic (80%) and central nervous system (14%) manifestations compared with many other studies. There was an association between central nervous system and thrombotic events (p<0.001). Our multidisciplinary approach allowed us to keep each system involved in Behçet's syndrome under careful review. The development of recurrent sight-threatening eye disease was unpredictable and occurred despite aggressive immunosuppression.

Identification of two novel mutations in keratin 13 as the cause of white sponge naevus

BACKGROUND

White sponge naevus (WSN) is a rare autosomal dominant condition which is characterised by benign, white spongy plaques (oral leukokeratoses) affecting non-cornifying, wet mucosa. WSN shares several ultrastructural characteristics (eg, epithelial thickening, acanthosis, keratin filament aggregation) with a number of epithelial disorders caused by mutations in keratin genes and to-date two mutations, one in each of the mucosal specific keratins, K4 and K13, have been identified as the molecular basis of the disorder.

OBJECTIVES

To identify the molecular basis of WSN in two families with a history of the disease.

RESULTS

Two novel mutations were identified in helix initiation motif of K13. A T-to-C transition was found in the affected members of one family which is predicted to change leucine115 to proline. In the second family, a similar T-to-C transition was found in codon 108 which is predicted to change methionine to threonine in the protein sequence. These changes were not found in 50 unrelated, unaffected individuals.

CONCLUSIONS

The mutations in the helix initiation motif of K13 are the cause of WSN in these families. These cases confirm mutations in the mucosal specific keratins as a significant cause of the disorder.

Diagnosis of Wuchereria bancrofti infection by the polymerase chain reaction employing patients' sputum

A preliminary evaluation of the diagnostic potential of a polymerase chain reaction (PCR) assay using diurnally collected sputum from bancroftian filariasis patients is described. A new set of PCR primers amplifying a 254-bp-long sequence termed AccI, derived from a long dispersed repeated sequence and SspI primers previously employed for PCR-based diagnosis were employed in this study with similar results. Of the 34 sputum samples from patients, 32 (94%) were PCR positive. Of the 18 patients with low to high microfilaremia (21-1560 microfilariae/ml), 16 (88.8%) were PCR positive. Of the remaining 16 patients, 6 with very low microfilaremia (2-6 microfilariae/ml) and 10 without microfilaremia, all (100%) were PCR positive. Two PCR-positive cases among the 13 endemic normal individuals tested (15.4%) may represent cases of occult filariasis. PCR amplification was also demonstrated with one PCR-positive sputum aliquot when mixed with 14 sputum aliquots from uninfected (PCR-negative) individuals. The potential diagnostic merits of the sputum-PCR assay are discussed.

Long term outcome after coronary stent implantation: a 10 year single centre experience of 1000 patients

OBJECTIVE

To describe the long term clinical outcome (up to 11 years) after coronary stenting.

DESIGN

A single centre observational study encompassing 1000 consecutive patients with a first stent implantation (1560 stents) between 1986 and 1996, who were followed for at least one year with a median follow up of 29 months (range 12-132 months).

RESULTS

Up to July 1997 the cumulative incidence of the major adverse cardiac events (MACE) of death, non-fatal acute myocardial infarction, coronary artery bypass grafting, and repeat percutaneous transluminal coronary angioplasty was 8.2%, 12.8%, 13.1%, and 22.4%, respectively. Survival at one, three, and five years was 95%, 91%, and 86%, respectively. Comparison of MACE incidence during the "anticoagulant era" and the "ticlopidine era" revealed significantly improved event free survival with ticlopidine (27% v 13%; p < 0.005). Multivariable analyses showed that ejection fraction < 50% (relative risk (RR) 4. 1), multivessel disease (RR 3.0), diabetes (RR 2.9), implantation in saphenous vein graft (RR 2.1), indication for unstable angina (RR 1. 9), and female sex (RR 1.7) were independent predictors of increased mortality after stenting. Independent predictors of any MACE were multivessel stenting (RR 2.0), implantation in saphenous bypass graft (RR 1.6), diabetes (RR 1.5), anticoagulant treatment (versus ticlopidine and aspirin) (RR 1.5), bailout stenting (RR 1.5), multivessel disease (RR 1.4), and multiple stent implantation (RR 1. 5).

CONCLUSIONS

Long term survival and infarct free survival was good, particularly in non-diabetic men with single vessel disease and good ventricular function, who had a single stent implanted in a native coronary artery. A dramatic improvement was observed in event free survival, both early and late, with the replacement of anticoagulation by ticlopidine. This, of course, cannot be separated from improved stent implantation techniques between 1986 and 1995. Ultimately, almost 40% of the patients experienced an adverse cardiac event (mainly repeat intervention) in the long term. New advances in restenosis treatments and in secondary prevention must be directed at this aspect of patient management after stenting.

A polymerase chain reaction assay for detecting snails infected with bilharzia parasites (Schistosoma mansoni) from very early prepatency

In the present study, we adapted a polymerase chain reaction (PCR) assay, previously shown by us to be very sensitive for detecting cercariae in water, for the sensitive detection of Schistosoma mansoni DNA in infected snails from early prepatency. Polymerase chain reaction primers were designed based on the 121-basepair highly repeated sequence we previously identified in the genome of S. mansoni. The DNA was prepared from the snails by a simple alkaline extraction procedure, and the PCR assay enabled a clear differentiation between infected and normal snails. Infected snails were detected as early as one day after penetration of a single miracidium. The high sensitivity of the test enabled identification of a single infected snail even when its DNA was pooled with material from up to 99 uninfected snails, thus demonstrating the possibility of mass diagnosis in pools of snails. The assay has the potential for large-scale determination of prepatent infection prevalence in snails, thus offering new possibilities for the evaluation of schistosomiasis transmission and for schistosomiasis control, as discussed.

A severe reaction to carbamazepine: consequences for patient monitoring

Carbamazepine is a drug commonly prescribed by medical and dental practitioners for the treatment of trigeminal neuralgia. Although included in the Dental Practitioners' Formulary, general dental practitioners (GDPs) rarely prescribe this medication. Those GDPs who do prescribe carbamazepine may need to liaise with the patient's medical practitioner for haematological monitoring. However, a significant number of patients attending their GDP are taking carbamazepine prescribed by hospital colleagues or general medical practitioners. Thus a knowledge of potential side-effects and adverse reactions is useful for all practitioners.