New Treatment Guidelines for Sjögren's Disease

[Screening for sleep disorders in internal medicine as potential comorbidities of systemic autoimmune diseases and improving patients' quality of life]

Sleep medicine and internal medicine share a global and transdisciplinary vision of human physiology and illnesses, with an approach guided by the complaint and semiology. In France, approximately 13 to 18 million individuals suffer from a sleep disorder: these disorders therefore represent a public health problem. Their comorbidities with systemic autoimmune diseases are frequent. As such, this article suggests an approach to screening for sleep disorders in daily clinical practice of internal medicine leading, when appropriate, to request specialized diagnostic and/or therapeutic care in sleep medicine to substantially improve patients' quality of life.

Hydroxychloroquine dose-dependently reduces the risk of incident diabetes in primary Sjögren syndrome patients on glucocorticoids: a nationwide population-based cohort study

BACKGROUND

Hydroxychloroquine (HCQ) is commonly used to treat Sjögren syndrome (SS). Glucocorticoids, which are commonly applied for managing primary SS (pSS), can disrupt glucose metabolism and increase diabetes mellitus (DM) risk. HCQ reduces DM risk in systemic lupus erythematosus and rheumatoid arthritis.

OBJECTIVE

This study aimed to investigate the relationship between HCQ and glucocorticoids in the incidence of new-onset diabetes in pSS.

METHODS

This nationwide population-based cohort study identified patients diagnosed with pSS from the Taiwan's National Health Insurance Research Database from 2006 to 2015. Multivariate and stratified analyses, Kaplan-Meier method, and Cox proportional hazard regression were used to evaluate DM risk associated with the use of HCQ and glucocorticoid, both individually and in combination.

RESULTS

Among pSS patients (4,874 HCQ users and 2,437 HCQ nonusers), 497 patients developed DM over an average follow-up of 4.89 years. Multivariate analysis revealed significantly lower adjusted hazard ratios (aHRs) for DM in HCQ users in the 151-350 cumulative defined daily dose (cDDD) and ≥ 351 cDDD subgroups (0.600, 95% CI: 0.454-0.794 and 0.326, 95% CI: 0.246-0.433, respectively) compared with HCQ nonusers. High-dose glucocorticoids (≥ 151 cDDD) were linked to increased DM risk (aHR: 1.833, 95% CI: 1.410-2.383). However, high-dose HCQ (> 350 cDDD) mitigated this risk, even the risk caused by the use of high-dose glucocorticoids (≥ 151 cDDD) (aHR: 0.632, 95% CI: 0.421-0.948, P < 0.01).

CONCLUSIONS

Our study demonstrated that HCQ exposure significantly reduces the risk of developing diabetes in patients with pSS. While higher doses of glucocorticoids are associated with an increased diabetes risk, concurrent HCQ use mitigates this risk in a dose-dependent manner.

Application of stem cell-derived exosomes in anterior segment eye diseases: A comprehensive update review

Mesenchymal stem cell (MSC) therapy has emerged as a promising approach for addressing various eye-related conditions. Yet, its clinical application faces challenges due to issues such as limited biocompatibility and difficulties in effectively delivering treatment to specific ocular tissues. Recent studies have shifted attention towards MSC-derived exosomes, which share similar regenerative, reparative, and immunomodulatory capabilities with their origin cells. This review delves into the latest research on the use of MSC-derived exosomes for treating anterior segment diseases of the eye. It explores the exosomes' composition, biological functions, and the methods used for their isolation, as well as their roles in disease progression, diagnosis, and therapy. The review critically assesses the therapeutic advantages and mechanisms of action of MSC-derived exosomes in treating conditions like dry eye disease, Sjogren's syndrome, keratoconus, corneal lesions, and corneal allograft rejection. Additionally, it discusses the obstacles and future prospects of employing MSC-derived exosomes as innovative therapies for anterior segment eye diseases. This comprehensive overview underscores the significant potential of MSC-derived exosomes in transforming the treatment paradigm for anterior segment eye disorders, while also highlighting the necessity for further research to enhance their clinical application.

Emerging patterns in nanoparticle-based therapeutic approaches for rheumatoid arthritis: A comprehensive bibliometric and visual analysis spanning two decades

The aim of this study is to analyze scientific literature to investigate the current research status, focus areas, and developmental trends in nanoparticle systems for rheumatoid arthritis (RA) therapy. To do that, Research articles published from 2003 to 2023 were retrieved from the Web of Science database, and analysis included quantitative output, distribution by country/region, collaborative publishing data, influential authors, high-yield institutions, keywords, hotspots, and development trends. Visual knowledge maps were generated using VOSviewer and Citespace. Findings reveal a steady increase in publications related to nanoparticle systems for RA therapy, indicating growing global interest. China leads with 487 papers (37.433%), followed by the United States (233, 17.909%), India (179, 13.759%), South Korea (89, 6.841%), and Egypt (50, 3.843%). Active collaboration is observed, particularly between the United States and countries such as China, Germany, Saudi Arabia, India, England, and Pakistan. The Chinese Academy of Sciences ranks first in total articles published (55), with Liu Y from China being the most prolific author. The Journal of Controlled Release emerges as a primary outlet in this field. Primary keyword clusters include "Drug delivery systems," "Gold nanoparticles," "Transdermal delivery," "Angiogenesis," "Collagen-induced arthritis," "Rheumatoid arthritis," "Oxidant stress," "Dendritic cells," and "pH sensitive." Research hotspots with great development potential include "Immunopathological Mechanisms," "Novel drugs," and "Smart delivery system." In conclusion, research on nanoparticle systems for RA therapy has significantly expanded over the past two decades, with a focus on elucidating pathogenetic mechanisms and advancing novel drug delivery strategies anticipated to be prominent in the foreseeable future.

British Society for Rheumatology guideline on management of adult and juvenile onset Sjögren disease

Sjögren disease (SD) is a chronic, autoimmune disease of unknown aetiology with significant impact on quality of life. Although dryness (sicca) of the eyes and mouth are the classically described features, dryness of other mucosal surfaces and systemic manifestations are common. The key management aim should be to empower the individual to manage their condition-conserving, replacing and stimulating secretions; and preventing damage and suppressing systemic disease activity. This guideline builds on and widens the recommendations developed for the first guideline published in 2017. We have included advice on the management of children and adolescents where appropriate to provide a comprehensive guideline for UK-based rheumatology teams.

Endoplasmic reticulum stress in the salivary glands of patients with primary Sjögren's syndrome, associated Sjögren's syndrome, and non-Sjögren's sicca syndrome: a comparative analysis and the influence of chloroquine

BACKGROUND

Endoplasmic reticulum stress (ERS) and the unfolded protein response (UPR) are adaptive mechanisms for conditions of high protein demand, marked by an accumulation of misfolded proteins in the endoplasmic reticulum (ER). Rheumatic autoimmune diseases (RAD) are known to be associated with chronic inflammation and an ERS state. However, the activation of UPR signaling pathways is not completely understood in Sjögren's disease (SD). This study evaluated the expression of ERS-related genes in glandular tissue of patients with primary SD (pSD), associated SD (aSD) with other autoimmune diseases, and non-Sjögren sicca syndrome (NSS).

METHODS

In a cross-sectional study, minor salivary gland biopsies were obtained from 44 patients with suspected SD and 13 healthy controls (HC). Patients were classified as pSD, aSD, or NSS based on clinical, serological, and histological assessment. Histopathological analysis and mRNA expression analysis of genes associated with ERS and UPR (PERK, XBP1, ATF-6, ATF-4, CANX, CALR, CHOP, and BIP) were performed on the samples. Differences between groups (pSD, aSD, NSS, and HC) were assessed. The influence of chloroquine (CQ) on the ER was also investigated.

RESULTS

Twenty-eight SD patients showed increased expression of PERK (p = 0.0117) and XBP1 (p = 0.0346), and reduced expression of ATF-6 (p = 0.0003) and CHOP (p = 0.0003), compared to the HC group. Increased expression of BIP (p < 0.0001), PERK (p = 0.0003), CALR (p < 0.0001), and CANX (p = 0.0111) was also observed in the SD group compared to the NSS group (n = 16). Patients receiving CQ (n = 16) showed a significant increase in ATF-6 (p = 0.0317) compared to patients not taking the medication (n = 29).

CONCLUSIONS

Altogether, the results suggest a greater activation of the ERS and UPR genes in patients with SD, especially in the pSD group. Antimalarial drugs, like CQ, used to treat RAD, may affect the ER function in exocrine glands.

The choice of treatment and the motivations behind it impact clinical outcomes among patients with adequate control of their rheumatic disease: A real-life study

INTRODUCTION

Many factors influence how doctors make treatment decisions. The study compares the outcomes of patients with rheumatic diseases and adequate control (AC) whose treating rheumatologists prescribed their first choice of treatment (FCHO) versus the second choice (SCHO) and the motivations behind them. It also investigates the motivations associated with FCHO.

PATIENTS AND METHODS

The study was conducted at an outpatient clinic from February 2023 to February 2024. Patients with an RMD diagnosis were identified using systematic sampling (P-1). After their consultation, their rheumatologists detailed their treatment choice (FCHO vs. SCHO), the motivations behind it, and the outcomes. In a subsample of patients from P-1 and AC (SubP-1), treating rheumatologists repeated the assessment of outcomes at the next scheduled consultation. Descriptive statistics and multivariate regression analysis were used.

RESULTS

There were 703 patients enrolled (P-1), 543 (77.2%) had AC, and 292 (Subp-1) underwent a follow-up evaluation. In P-1 and subP-1, FCHO was prescribed to 644 (91.5%) and 269 (92.1%) patients. Motivations related to evidence-based medicine and personal experience were more frequently referred to in FCHO. Concerns related to current or future drug shortages and a history of adverse events/intolerance were more frequent in SCHO. In SubP-1, a higher proportion of patients remained in AC and experienced remission/ improved disease activity with FCHO. Patients who received FCHO experienced a greater risk for favorable outcomes. The following motivations were associated with FCHO: "It aligns with guidelines"; "solid scientific evidence supporting the treatment effectiveness"; "I am concerned that the shortage of the drug may hinder the continuation of the treatment" and "history of adverse events or intolerance".

CONCLUSIONS

Patients with AC of their underlying RMD, whose rheumatologists prescribed their FCHO, had better outcomes than those who were prescribed SCHO. Evidence-based motivations, rheumatologists´ concern of medication shortage, and patient-related motivations were associated with FCHO.

Obesity: Friend or Foe in Sjögren's Syndrome Patients?

BACKGROUND/OBJECTIVES

In Sjögren's syndrome, exocrine glands are destructed in an autoimmune-mediated process. Obesity is known to influence a wide range of diseases. This study aimed to examine whether obesity has an impact on the disease course of our patients with Sjögren's syndrome.

METHODS

Out of the regularly followed-up patients, 125 were grouped based on their body mass index (BMI). Below a BMI of 25, they were listed as "non-obese" (n = 45), whereas above a BMI of 25, they were categorized as "obese" (n = 80). Demographic, laboratory, and immunological parameters; Sjögren's syndrome disease activity index; certain extraglandular manifestations; and treatment modalities were compared using biostatistical methods.

RESULTS

Among the examined cardiovascular and cerebrovascular co-morbidities, type 2 diabetes and hypertension were significantly more frequent in the obese group. Considering the associated further autoimmune disorders and extraglandular manifestations, in our patients, there were no significant differences between the two groups. Among laboratory parameters, gamma glutamil transferase, alanine transaminase, hemoglobin, hematocrit, lymphocyte rate, triglyceride, and c3 and c4 complement levels were significantly higher in the obese group, while the proportion of rheumatoid factor positivity and the neutrophil granulocyte rate were significantly lower. Immunoglobulin G, A, and M levels did not differ significantly between the two subsets. Obese patients needed steroid therapy significantly less frequently; however, statin therapy was remarkably more frequent in that group. Furthermore, the European League Against Rheumatism (EULAR) Sjögren's syndrome disease activity index (ESSDAI) was significantly lower in the group of overweight patients.

CONCLUSIONS

Our results suggest that several immunological parameters of obese patients are more favorable compared to those with normal body weight. Behind that, we might suspect either the beneficial effect of statin therapy and/or the obesity paradox.

Usenamine A: a potential therapeutic agent for rheumatoid arthritis and ankylosing spondylitis through its anti-inflammatory activity

Background

Usenamine A (UA) is a natural compound isolated from the lichen Usnea diffracta, and its therapeutic effects on rheumatic diseases are not well understood. This study aimed to evaluate the potential anti-inflammatory effects of UA and its therapeutic effects on rheumatoid arthritis (RA) and ankylosing spondylitis (AS).

Materials and methods

Molecular docking was performed between the 3D structure of UA and the TNF-TNFR2 complex. Peripheral blood mononuclear cells (PBMCs) from RA and AS patients were treated with UA, and cell viability was measured using the MTS assay and flow cytometry. The in vitro effects of co-culture with UA were determined by measuring inflammatory cytokines, including IFN-γ, IL-17A, and GM-CSF, using flow cytometry and enzyme-linked immunosorbent assay (ELISA). The in vivo effects of UA were evaluated using an arthritis mouse model.

Results

The docking complex of UA bound to the TNF-TNFR2 complex exhibited docking scores of -5.251 kcal/mol and -6.274 kcal/mol, confirming their active sites. UA did not affect cell viability and suppressed the production of inflammatory cytokines in the PBMCs of RA (IFN-γ, IL-17A, and GM-CSF) and AS (GM-CSF) patients. The ELISA also confirmed reduced cytokine levels in the co-culture of UA and PBMCs from RA or AS patients. In the arthritis mouse model, significantly reduced clinical and histological scores were observed in the UA treatment group.

Conclusion

Our findings suggest that UA has potential as a binding target for TNF, suppresses inflammatory cytokines in PBMCs, and exhibits anti-inflammatory effects on arthritis in a mouse model.

G protein-coupled receptor kinase 2 as a novel therapeutic target for gland fibrosis of Sjögren's syndrome

Sjogren's syndrome (SS) is a chronic, progressive autoimmune disorder characterized by gland fibrosis. We previously found a close correlation between gland fibrosis and the expression of G protein-coupled receptor kinase 2 (GRK2). In this study we explored the pathological and therapeutic significance of GRK2 in SS. Submandibular gland (SMG) antigen-induced SS mouse model was established in WT and GRK2+/- mice. We showed that the expression levels of GRK2 were significantly up-regulated in glandular tissue and positively correlated with fibrotic morphology in SS patients and mice. Hemizygous knockout of GRK2 significantly inhibited the gland fibrosis. In mouse salivary gland epithelial cells (SGECs), we demonstrated that GRK2 interacted with Smad2/3 to positively regulate the activation of TGF-β-Smad signaling with a TGF-β-GRK2 positive feedback loop contributing to gland fibrosis. Hemizygous knockout of GRK2 attenuated TGF-β-induced collagen I production in SGECs in vitro and hindered gland fibrosis in murine SS though preventing Smad2/3 nuclear translocation. Around 28 days post immunization with SMG antigen, WT SS mice were treated with a specific GRK2 inhibitor paroxetine (Par, 5 mg·kg-1·d-1, i.g. for 19 days). We found that Par administration significantly attenuated gland fibrosis and alleviated the progression of SS in mice. We conclude that genetic knockdown or pharmacological inhibition of GRK2 significantly attenuates gland fibrosis and alleviates the progression of SS. GRK2 binds to Smad2/3 and positively regulates the activation of TGF-β-Smad signaling. A TGF-β-GRK2 positive feedback loop contributes to gland fibrosis. Our research points out that GRK2 could be a promising therapeutic target for treating SS.

Possible involvement of Toll-like receptor 8-positive monocytes/macrophages in the pathogenesis of Sjögren's disease

Background

Sjögren's disease (SjD) is an autoimmune disease marked by lymphocytic infiltration of salivary and lacrimal glands, leading to glandular dysfunction, where CD4-positive helper T (Th) cells and their cytokines are crucial in the pathogenesis. Recent studies have demonstrated that Toll-like receptors (TLRs), particularly those recognizing immune complexes containing DNA and RNA, contribute to Th cell activation in various autoimmune diseases. This study explores the expression and function of these TLRs in SjD.

Methods

DNA microarray analysis of salivary gland tissue from six SjD patients and real-time PCR (n = 32) was used to identify overexpressed TLRs. Single-cell RNA sequencing (scRNA-seq) was performed using tissue lesions and integrated with published scRNA-seq data from tissues and peripheral blood mononuclear cells to examine gene expression in macrophages and monocytes. Finally, multi-color immunofluorescence staining was conducted to confirm TLR8 expression and function in SjD lesions (n = 19).

Results

DNA microarray analysis revealed the up-regulation of TLR8, along with other TLRs and innate immune response genes in SjD. Real-time PCR showed significant up-regulation of TLR7 and TLR8. TLR8 up-regulated in both analyses. In scRNA-seq analysis, the TLR8-expressing cluster comprised macrophages and monocytes, which also produced T cell activation genes like CD86. TLR8-positive macrophages infiltrated inflammatory sites and frequently expressed CD86 in quantitative imaging approaches.

Conclusions

These results suggest that infiltrating monocytes and macrophages may produce cytokines and chemokines through TLR8 stimulation, potentially enhancing B7 molecule expression, promoting the adaptive immune response, and contributing to SjD pathogenesis.

Uncovering the Therapeutic Target and Molecular Mechanism of Upadacitinib on Sjogren's Syndrome

Objective

Upadacitinib, a selective Janus associated kinase 1 (JAK-1) inhibitor, can be prescribed particularly for the clinical treatment with Crohn's disease or rheumatoid arthritis. It is clinically observed that upadacitinib has been found with potential therapeutic effectiveness on Sjogren's syndrome (SS). However, the anti-SS targets and mechanisms involved in upadacitinib treatment remain uninvestigated.

Materials and methods

Thus, this study was designed to identify therapeutic targets and mechanisms of upadacitinib for treating SS through conducting network pharmacology and molecular docking analyses.

Results

In total, we identified 298 upadacitinib-related target genes, 1339 SS-related targets before collecting 56 overlapped target genes and 12 hub target genes. Upadacitinib largely exerted the critical biological processes including regulation of microenvironment homeostasis, inflammatory response, and cell apoptosis, and largely acted on pivotal molecular mechanisms including hypoxia-inducible factor 1 (HIF-1) signaling pathway, apoptosis pathway, phosphatidylinositol 3-kinase/protein kinase B (PI3K/Akt) signaling pathway, or Th17 cell differentiation pathway. Molecular docking data suggested that upadacitinib exhibited the high affinities with signal transducer and activator of transcription 3 (STAT3), HIF1A, poly(ADP-ribose) polymerase 1 (PARP1) target proteins, in which the structural interactions between upadacitinib and STAT3, HIF1A, PARP1 showed potential therapeutic activities against SS.

Conclusion

In conclusion, upadacitinib possesses the bright anti-inflammatory and anti-apoptotic activities on SS, and this study can provide a theoretical basis for clinical therapy of SS using upadacitinib.

Laboratory features and pharmacological management of early and late-onset primary Sjögren's syndrome

BACKGROUND

Primary Sjögren's Syndrome (pSS) is a systemic chronic autoimmune disorder that contributes to dry mouth (xerostomia) and eyes (xerophthalmia). It mainly affects females between 40 and 60 years old. So far, there is no treatment to cure SS; however, there is a list of medications that can ameliorate the symptoms. In addition, there has been no single test until now to detect pSS, but clinical and immunological investigations are applied as diagnostic tools. Therefore, this study aimed to explore the characteristics of pSS in Saudi patients based on the onset of the disease through laboratory findings and pharmaceutical management.

METHODOLOGY

This retrospective study examined diagnosed patients with pSS between 2018 and 2023 from the National Guard Hospital, Saudi Arabia. Data of pSS patients was categorized into two groups: early (under 40 years old) and late-onset (40 years old and above). Data on demographic information, mortality rate, and blood tests such as complete blood count (CBC), creatinine, erythrocyte sedimentation rate (ESR), and vitamin levels, in addition to prescribed medications, were collected from the patient's medical record. Chi-square and t-tests were mainly used, and statistical significance was determined at a P-value less than 0.05.

RESULTS

A total of 453 patients were included in the study, where the early-onset group comprised 136 and the late-onset group comprised 317 patients. The mean age of the early and late onset was 34.2 and 60.4, respectively. ESR was significantly higher in the early (46.3 mm/hr) and late-onset (49.8 mm/hr). The most common medication used by all pSS patients was hydroxychloroquine. However, artificial tears were mainly observed in the late-onset group. Other medications, such as pilocarpine, methotrexate, and azathioprine, were prescribed to pSS patients to a lesser extent.

CONCLUSION

This study suggests that the onset of pSS could occur even before the age of 40 among Saudi citizens. Notably, elevated ESR levels appeared to be a feature of pSS, which was consistent with other previous findings. The variability of some medications between early-onset and late-onset pSS may indicate disease progression. However, further investigations are required to confirm this observation.

Emerging biologic frontiers for Sjogren's syndrome: Unveiling novel approaches with emphasis on extra glandular pathology

Primary Sjögren's Syndrome (pSS) is a complex autoimmune disorder characterized by exocrine gland dysfunction, leading to dry eyes and mouth. Despite growing interest in biologic therapies for pSS, FDA approval has proven challenging due to trial complications. This review addresses the absence of a molecular-target-based approach to biologic therapy development and highlights novel research on drug targets and clinical trials. A literature search identified potential pSS treatment targets and recent advances in molecular understanding. Overlooking extraglandular symptoms like fatigue and depression is a notable gap in trials. Emerging biologic agents targeting cytokines, signal pathways, and immune responses have proven efficacy. These novel therapies could complement existing methods for symptom alleviation. Improved grading systems accounting for extraglandular symptoms are needed. The future of pSS treatment may involve gene, stem-cell, and tissue-engineering therapies. This narrative review offers insights into advancing pSS management through innovative biologic interventions.

Exploring the Psychiatric Manifestations of Primary Sjögren's Syndrome: A Narrative Review

Background

Primary Sjögren's syndrome (pSS) is recognized for its autoimmune origin. Its hallmark symptoms, dry eyes and mouth, result from glandular inflammation. Prior literature indicates that pSS not only affects the peripheral system but also involves the central nervous system (CNS), giving rise to various neuropsychiatric symptoms. However, there is limited published research on the psychiatric comorbidities in individuals with pSS.

Methods

A comprehensive search was conducted on PubMed and Google Scholar for this narrative review. The search spanned from inception until August 2023. Its aim was to locate studies focusing on the psychiatric manifestations of pSS and the potential underlying mechanisms.

Results

The most commonly reported psychiatric complications among these individuals are depression and cognitive dysfunction. Other psychiatric manifestations that have been reported in pSS individuals include anxiety, sleep disorders, psychosis, catatonia, bipolar disorder, and obsessive-compulsive disorder.

Conclusion

In conclusion, patients with pSS often display multiple psychiatric symptoms. These symptoms can significantly impair functioning and reduce quality of life. Hence, prompt diagnosis and management are crucial.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Translation, Validation and Cultural Adaptation of Questionnaires Assessing the Quality of Life and Fatigue among Patients with Sjogren's Syndrome for the Romanian Context

About 70% of patients with Sjogren's syndrome suffer from fatigue, and for a large proportion of patients, it is one of the most noticeable manifestations leading to disability. To date, no study has been conducted in Romania to determine the quality of life of patients and the impact of fatigue in patients with Sjogren's syndrome. The present work proposes the translation, cultural adaptation, and validation of two questionnaires for the Romanian context, namely the 'Profile of Fatigue and Discomfort-Sicca Symptoms Inventory' (PROFAD-SSI-SF) and 'Primary Sjogren's Syndrome-Quality of Life' (PSS-QoL), whose purpose is to assess quality of life and fatigue in patients with Sjogren's syndrome. These two questionnaires were administered to 52 patients with Sjogren's syndrome diagnosed according to the 2016 ACR-EULAR criteria. Subsequently, the conceptual, semantic, and operational analyses of the data were performed with the aim of cultural adaptation. The data obtained were statistically analyzed using indices of measurement accuracy such as internal consistency. Based on statistical analyses, this pilot study shows that the Romanian versions of the PROFAD-SSI and PSS-QoL questionnaires are as reliable as their English counterparts.

Combined use of total glucosides of paeony and hydroxychloroquine in primary Sjögren's syndrome: A systematic review

OBJECTIVE

To assess the effectiveness and safety of the total glucosides of paeony (TGP) combined with hydroxychloroquine (HCQ) on the treatment of primary Sjögren's syndrome (pSS) by conducting a meta-analysis.

METHODS

Eight databases were searched for randomized controlled trials (RCTs) reporting the use of TGP combined with HCQ for pSS, which are before May 10, 2022. Meta-analyses were performed on disappeared clinical symptoms (dry mouth and dry eyes), Schirmer's test, saliva flow test, erythrocyte sedimentation rate (ESR), index of immunoglobulin G (IgG), immunoglobulin M (IgM), immunoglobulin A (IgA), and adverse events (AEs). The Revman 5.4 software was used for this meta-analysis.

RESULTS

Seven RCTs which included 632 participants were identified. The pooled results showed significant differences in clinical symptoms disappear (dry mouth and dry eyes) (p = .0004), IgM (p < .00001), IgA (p < .00001), salivary flow rate (p < .00001) and Schirmer's test (p = .02) in the comparison of TGP combined with HCQ and HCQ alone. For the IgG and ESR, both pooled and subgroup analyses showed that TGP + HCQ was superior to HCQ alone. For the safety analysis, no significant differences in AEs (p = .39) was revealed. The more frequently seen adverse reactions were diarrhea, vomit and there was no severe adverse events were reported in TGP + HCQ group.

CONCLUSION

Therefore, TGP + HCQ can be considered to be a potentially valid and safe combination for the treatment of pSS in the clinic.

Selective Action of Antimalarial Hydroxychloroquine on the Packing of Phospholipids and Interfacial Water Associated with Lysosomal Model Membranes: A Vibrational Sum Frequency Generation Study

Understanding the structural change of lysosomal membranes induced by hydroxychloroquine (HCQ) drug is essential as it has been considered as one of the probable mechanisms of its antimalarial action. In this context, vibrational sum frequency generation (VSFG) spectra of the O-H region of water and C-H of the hydrocarbon chain of negatively charged and zwitterionic phospholipids associated with the lysosomal membrane in the absence and presence of different concentrations of HCQ have been measured at the air/water interface. The interfacial water at the negatively charged and zwitterionic lipids gets restructured in the presence of HCQ; however, the mechanism of restructuring is different due to the charge of the head groups of lipids. Interestingly, the presence of HCQ leads to a disorder in the negatively charged lipids, irrespective of their chemical nature, mainly by creating the gauche defect in the hydrocarbon chain of the lipid. In contrast, the ordering of the zwitterionic lipid does not show any appreciable change with the addition of HCQ. The finding on the selectivity of HCQ in affecting the ordering of the lipid depending on its head group charge and restructuring of interfacial water may be useful in understanding the molecular level mechanism of the antimalarial action of HCQ.

Gastrointestinal microbiome and primary Sjögren's syndrome: a review of the literature and conclusions

The recognition of the profound impact of the human gastrointestinal microbiome (GM) on human autoimmune diseases has gradually increased thanks to deeper research efforts. As a systemic autoimmune disease, primary Sjögren's syndrome (pSS) cannot be completely cured. Human studies have revealed that GM species and diversity are altered in patients with pSS compared with healthy individuals. Animal studies have provided possible mechanisms for the association between pSS and GM. The potential role of GM in pSS is exerted through several mechanisms. GM dysbiosis leads to increased intestinal permeability, which increases the risk of GM antigen exposure and activates specific autoreactive T lymphocytes via "molecular mimicry". In addition, GM antigen exposure and intestinal immune tolerance loss caused by GM dysbiosis together induce chronic local gut mucosal inflammation, which deteriorates to systemic chronic non-specific inflammation with the circulation of pro-inflammatory lymphocytes and cytokines. These factors eventually activate autoreactive B lymphocytes and lead to pSS. If GM plays a key role in the pathogenesis of pSS, clarifying the underlying mechanisms will be helpful for the development of new therapies targeting GM for dry eye associated with pSS. This review summarizes the latest knowledge about the relationship between GM and pSS, with the aim of contributing to future research and to the development of new clinical applications.

The Future of Targeted Treatment of Primary Sjögren's Syndrome: A Focus on Extra-Glandular Pathology

Primary Sjögren's syndrome (pSS) is a chronic, systemic autoimmune disease defined by exocrine gland hypofunction resulting in dry eyes and dry mouth. Despite increasing interest in biological therapies for pSS, achieving FDA-approval has been challenging due to numerous complications in the trials. The current literature lacks insight into a molecular-target-based approach to the development of biological therapies. This review focuses on novel research in newly defined drug targets and the latest clinical trials for pSS treatment. A literature search was conducted on ClinicalTrials.gov using the search term "Primary Sjögren's syndrome". Articles published in English between 2000 and 2021 were included. Our findings revealed potential targets for pSS treatment in clinical trials and the most recent advances in understanding the molecular mechanisms underlying the pathogenesis of pSS. A prominent gap in current trials is in overlooking the treatment of extraglandular symptoms such as fatigue, depression, and anxiety, which are present in most patients with pSS. Based on dryness and these symptom-directed therapies, emerging biological agents targeting inflammatory cytokines, signal pathways, and immune reaction have been studied and their efficacy and safety have been proven. Novel therapies may complement existing non-pharmacological methods of alleviating symptoms of pSS. Better grading systems that add extraglandular symptoms to gauge disease activity and severity should be created. The future of pSS therapies may lie in gene, stem-cell, and tissue-engineering therapies.

Ophthalmological Approach for the Diagnosis of Dry Eye Disease in Patients with Sjögren's Syndrome

Dry eye has two basic subdivisions: aqueous deficient dry eye (ADDE), with SS a major cause; and evaporative dry eye (EDE), due to either intrinsic or extrinsic factors. SS is a chronic inflammatory disorder defined by dysfunction of the exocrine glands leading to dry eye and dry mouth. The objective of this article was to carry out a systematic and critical review of several scientific publications on dry eye disease, with the aim of providing general recommendations to distinguish dry eye and its different variants in patients with SS, during the period 1979 to 2020, using search engines for articles indexed in Scopus, Latindex, Scielo, Clinical Trials, Medline, Embase, and Cochrane, allowing the analysis of 132 articles published in indexed journals on the subject of dry eye disease and SS, evidencing its conceptualization, prevalence, risk factors, etiopathogenesis, clinical manifestations, diagnosis, and treatment.

Cytotoxic CD8+ T cells may be drivers of tissue destruction in Sjögren's syndrome

Sjögren's syndrome is a chronic autoimmune disorder whose pathogenesis is poorly understood and that lacks effective therapies. Detailed quantitative and spatial analyses of tissues affected by Sjögren's syndrome were undertaken, including the quantitation of the frequency of selected cell-cell interactions in the disease milieu. Quantitative analyses of CD4⁺ T cell subsets and of CD8⁺ T cells in the labial salivary glands from untreated patients with primary Sjögren's syndrome revealed that activated CD8⁺ cytotoxic T cells (CD8⁺CTLs) were the most prominent T cells in these infiltrates. An accumulation of apoptotic glandular epithelial cells, mainly ductal and acinar cells, was observed, consistent with the impaired salivary secretion often observed in patients with this disease. FasL expressing activated CD8⁺ T cells were seen to accumulate around Fas expressing apoptotic epithelial cells. Quantitative analyses of apoptotic cell types and of conjugates between cytotoxic T cells and epithelial cells undergoing apoptosis suggest that Sjögren's syndrome is primarily driven by CD8⁺CTL mediated execution of epithelial cells mainly represented by ductal and acinar cells.

Updates in diagnostics, treatments, and correlations between oral and ocular manifestations of Sjogren's syndrome

Sjogren's syndrome (SS) is characterized as an autoimmune disorder targeting secretory glands, including the lacrimal and salivary glands, causing dry eye and dry mouth predominantly in women over the age of 40. In this review, we summarize recent advancements in SS diagnostics, treatments, and our understanding of correlations between oral and ocular manifestations of SS. Google Scholar and PubMed databases were utilized to search peer-reviewed papers since 2016 on SS diagnosis, treatment, and correlations between oral and ocular manifestations. For diagnostics, we discuss the updated SS classification criteria by the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR), new biomarkers, and compare studies of current diagnostic methods with alternative technologies. For treatments, we discuss topical, systemic, and surgical treatment developments in the management of oral and ocular symptoms of SS as there is still no cure for the disorder. Finally, we report studies that directly suggest correlations between the ocular surface disease and oral disease in SS, as well as shared abnormalities in the microbiome and cytokine expression that may be correlated. We conclude by stating limitations to our review as well as paths moving forward. Elucidating correlations between oral and ocular manifestations may be the key to furthering our understanding of SS pathogenesis as well as defining new standards for diagnosis and treatment.

Direct and indirect antiparasitic effects of chloroquine against the virulent RH strain of Toxoplasma gondii: An experimental study

BACKGROUND

Toxoplasmosis is a deleterious parasitic disease with harmful impact on both humans and animals. The present study was carried out to evaluate the antiparasitic effect of chloroquine (CQ), spiramycin (SP), and combination of both against the highly virulent RH HXGPRT (-) strain of Toxoplasma gondii (T. gondii) and to explore the mechanisms underlying such effect.

METHODS

We counted the tachyzoites in the peritoneal fluid and liver smears of mice and performed scanning and transmission electron microscopy and immunofluorescence staining of tachyzoites. Moreover, relative caspase 3 gene expression was measured by real time polymerase chain reaction of liver tissues and immunoassay of anti-apoptotic markers [B cell lymphoma-2 (Bcl-2) and X-chromosome linked inhibitor of apoptosis (XIAP)] and interferon gamma (IFN-γ) was done in liver tissues by ELISA. In addition, we estimated serum levels of aspartate transaminase (AST) and alanine transaminase (ALT) and performed histopathological examination of liver sections for scoring of inflammation.

RESULTS

We found that both CQ and CQ/SP combination significantly reduced parasitic load in the peritoneal fluid and liver smears, induced apical disruption of tachyzoites, triggered host cell apoptosis through elevation of relative caspase 3 gene expression and suppression of both Bcl-2 and XIAP. Also, they upregulated IFN-γ level, reduced serum AST and ALT, and ameliorated liver inflammation.

CONCLUSIONS

Either of CQ and CQ/SP combination was more effective than SP alone against T. gondii with the CQ/SP combination being more efficient. Therefore, adding CQ to other anti-Toxoplasma therapeutic regimens may be considered in future research.

Impact of an Electronic Decision Support Tool to Improve Ophthalmic Safety in Hydroxychloroquine Prescribing Practices

BACKGROUND AND OBJECTIVE

The purpose of this study was to implement a clinical decision support tool (CDS) and assess its impact on adherence to 2016 American Academy of Ophthalmology (AAO) hydroxychloroquine dosing recommendations.

PATIENTS AND METHODS

This retrospective, interventional study implemented an automated alert to calculate maximum daily hydroxychloroquine dose based on 2016 AAO recommendations and flag noncompliant orders. Prevalence of excessive dosing after CDS implementation was assessed.

RESULTS

A total of 7,417 patients met inclusion criteria. After intervention, prevalence of excessive dosing decreased from 27.4% to 21.1% (P < .001) among all prescriptions and from 26.8% to 16.2% (P < .001) among new prescriptions. Daily doses exceeding 400 mg decreased from 0.8% to 0.02% (P < .001). Risk factors for excessive dosing included low weight (odds ratio, 75.6 [95% CI, 54.0 to 105.8]) and nonrheumatologist prescriber (odds ratio, 1.60 to 3.63; all P < .005).

CONCLUSIONS

This study highlights the efficacy of a CDS in reducing excessive hydroxychloroquine dosing and improving adherence to AAO ophthalmic safety guidelines. [Ophthalmic Surg Lasers Imaging 2022;53:310-316.].

Sjögren's syndrome: a systemic autoimmune disease

Sjögren's syndrome is a chronic autoimmune disease characterized by ocular and oral dryness resulting from lacrimal and salivary gland dysfunction. Besides, a variety of systemic manifestations may occur, involving virtually any organ system. As a result, the disease is characterized by pleomorphic clinical manifestations whose characteristics and severity may vary greatly from one patient to another. Sjögren's syndrome can be defined as primary or secondary, depending on whether it occurs alone or in association with other systemic autoimmune diseases, respectively. The pathogenesis of Sjögren's syndrome is still elusive, nevertheless, different, not mutually exclusive, models involving genetic and environmental factors have been proposed to explain its development. Anyhow, the emergence of aberrant autoreactive B-lymphocytes, conducting to autoantibody production and immune complex formation, seems to be crucial in the development of the disease. The diagnosis of Sjögren's syndrome is based on characteristic clinical signs and symptoms, as well as on specific tests including salivary gland histopathology and autoantibodies. Recently, new classification criteria and disease activity scores have been developed primarily for research purposes and they can also be useful tools in everyday clinical practice. Treatment of Sjögren's syndrome ranges from local and symptomatic therapies aimed to control dryness to systemic medications, including disease-modifying agents and biological drugs. The objective of this review paper is to summarize the recent literature on Sjögren's syndrome, starting from its pathogenesis to current therapeutic options.

Safety and efficacy of subcutaneous ianalumab (VAY736) in patients with primary Sjögren's syndrome: a randomised, double-blind, placebo-controlled, phase 2b dose-finding trial

BACKGROUND

Sjögren's syndrome is an autoimmune disease characterised by dry eyes and mouth, systemic features, and reduced quality of life. There are no disease-modifying treatments. A new biologic, ianalumab (VAY736), with two modes of suppressing B cells, has previously shown preliminary efficacy. This dose-finding trial aimed to assess the safety and efficacy of different subcutaneous doses of ianalumab in patients with moderate to severe primary Sjögren's syndrome.

METHODS

VAY736A2201 was a randomised, parallel, double-blind, placebo-controlled, phase 2b dose-finding study done in 56 centres in 19 countries. Patients aged 18-75 years with primary Sjögren's syndrome with moderate to severe disease activity (European Alliance of Associations for Rheumatology [EULAR] Sjögren's Syndrome Disease Activity Index [ESSDAI] score ≥6) and symptom severity (EULAR Sjögren's Syndrome Patient Reported Index score ≥5) were eligible. Participants were randomly assigned (1:1:1:1) to receive subcutaneous placebo or ianalumab (5 mg, 50 mg, or 300 mg) every 4 weeks for 24 weeks using a secure, online randomisation system. Randomisation was stratified by the ESSDAI score at baseline (≥10 or <10). Study personnel and patients were masked to treatment assignment. The primary outcome was the change in ESSDAI score from baseline to 24 weeks in all randomly assigned patients. Dose-related change in disease activity (ESSDAI) from baseline at week 24 was assessed by multiple comparison procedure with modelling analysis. Safety was measured in all patients who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, NCT02962895.

FINDINGS

Between June 27, 2017, and Dec 06, 2018, 293 patients were screened, 190 of whom were randomly assigned (placebo n=49, ianalumab 5 mg n=47, ianalumab 50 mg n=47, ianalumab 300 mg n=47). Statistically significant dose-responses were seen for overall disease activity (ESSDAI score) in four of the five dose-response models tested (p<0·025 in four models, p=0·060 in one model). The ESSDAI score decreased from baseline in all ianalumab groups, with the maximal ESSDAI score change from baseline observed in the ianalumab 300 mg group: placebo-adjusted least-squares mean change from baseline -1·92 points (95% CI -4·15 to 0·32; p=0·092). There were four serious adverse events in three patients considered treatment-related (pneumonia [n=1] and gastroenteritis [n=1] in the placebo group; appendicitis plus tubo-ovarian abscess in the same patient in the ianalumab 50 mg group).

INTERPRETATION

The study met its primary objective, showing a dose-related decrease in disease activity as measured by ESSDAI at week 24. Overall, ianalumab was well tolerated and safe, with no increase in infections. To our knowledge, this is the first large, randomised, controlled trial in primary Sjögren's syndrome that met its primary endpoint, and its results mean there is potential for more studies of this mechanism in the future.

FUNDING

Novartis.

Blocking IAg7 class II major histocompatibility complex by drug-like small molecules alleviated Sjögren's syndrome in NOD mice

BACKGROUND

Sjögren's syndrome (SjS) is an autoimmune disease with a strong genetic association. To date, no vaccine or therapeutic agent exists to cure SjS, and patients must rely on lifelong therapies to treat symptoms. Human leukocyte antigens (HLA) are primary susceptibility loci that form the genetic basis for many autoimmune diseases, including SjS. In this study, we sought to determine whether blocking MHC class II IAg7 antigen presentation in the NOD mouse would alleviate SjS by preventing the recognition of autoantigens by pathogenic T cells.

METHODS

Mapping of the antigenic epitopes of Ro60 autoantigen to IAg7 of the NOD mice was performed using structural modeling and in-vitro stimulation. Tetraazatricyclo-dodecane (TATD) and 8-Azaguanine (8-Aza) were previously identified as potential binders to IAg7 of the NOD mice using in silico drug screening. Mice were treated with 20mgs/kg via IP every day five days/week for 23 weeks. Disease profiling was conducted.

FINDINGS

Specific peptides of Ro60 autoantigen were identified to bind to IAg7 and stimulated splenocytes of the NOD mice. Treating NOD mice with TATD or 8-Azaguanine alleviated SjS symptoms by improving salivary and lacrimal gland secretory function, decreasing the levels of autoantibodies, and reducing the severity of lymphocytic infiltration in the salivary and lacrimal glands.

INTERPRETATION

This study presents a novel therapeutic approach for SjS by identifying small molecules capable of inhibiting T cell response via antigen-specific presentation.

FUNDING

CQN is supported financially in part by PHS grants AI130561, DE026450, and DE028544 from the National Institutes of Health.

Synthesis and pharmacological evaluation of choroquine derivatives bearing long aminated side chains as antivirus and anti-inflammatory agents

Starting from the antimalarial drugs chloroquine and hydroxychloroquine, we conducted a structural optimization on the side chain of chloroquine by introducing amino substituted longer chains thus leading to a series of novel aminochloroquine derivatives. Anti-infectious effects against SARS-Cov2 spike glycoprotein as well as immunosuppressive and anti-inflammatory activities of the new compounds were evaluated. Distinguished immunosuppressive activities on the responses of T cell, B cell and macrophages upon mitogen and pathogenic signaling were manifested. Compounds 9–11 displayed the most promising inhibitory effects both on cellular proliferation and on the production of multiple pro-inflammatory cytokines, including IL-17, IFN-γ, IL-6, IL-1β and TNF-α, which might be insightful in the pursuit of treatment for immune disorders and inflammatory diseases.

Systemic Immunosuppression in Cornea and Ocular Surface Disorders: A Ready Reckoner for Ophthalmologists

Purpose: Many diseases of the cornea and ocular surface are manifestations of an underlying autoimmune process and require systemic immunosuppression for their management. These cases often present to a general ophthalmologist before being referred to an ocular immunologist or rheumatologist. However, the patients do need to be followed by the ophthalmologist to assess disease progression or for management of ocular co-morbidities and for taking care of ocular complications of the disease. Undeniably, there is a certain hesitance to promptly initiate them on systemic therapy because the literature regarding the indications, dosages, and side effects of this group of drugs is vast and dispersed.The aim of this review is to provide a source of ready reference for the general ophthalmologist as well as trainees and residents, on systemic immunosuppression for corneal and ocular surface disease. Methods: This review included 153 studies which were published as randomized controlled trials, systematic reviews, or as nonrandomized comparative studies (cohort or case-control series) on the topic of systemic immunosuppression in cornea and ocular surface disorders.Results: This review provides a concise summary of both the types of drugs and the common indications where they would be indicated, along with treatment and monitoring algorithms for each specific disease condition. The most used group of drugs are corticosteroids, which have significant side effects, particularly when administered systemically or for longer periods of time. To overcome this, steroid-sparing immunosuppressants are recommended. The four main classes of immunosuppressants used today are antimetabolites, T-cell inhibitors, alkylating agents and biologic agents. This review details the use of these drugs in ocular surface inflammation, including the dosing schedule, side effects and monitoring in allergic conjunctivitis, mucous membrane pemphigoid, peripheral ulcerative keratitis, immunological rejection against corneal allografts, anterior scleritis and aqueous deficiency dry eyes. Conclusions: This review provides an uncluttered and wholesome understanding of systemic immunosuppression in cornea and ocular surface diseases, with the hope that this will serve as a ready reckoner and help bridge the gap between ophthalmology and rheumatology for the betterment of our patients.

Association between increased Bcl-2, Fas and FasL levels and inflammation extent in labial salivary glands during primary Sjögren's syndrome

BACKGROUND

Primary Sjögren syndrome (pSS) is a chronic autoimmune disease characterized by epithelial atrophy, mononuclear infiltration in exocrine glands resulting in defective function of these glands. In pSS, atrophy of the epithelium is caused by an increased amount of apoptosis.

OBJECTIVE

The main aim of this study is to investigate the role of the apoptosis-related factors by studying Bcl-2, Fas and FasL expression in relation to the extent of inflammation as well as the effect of therapy on the expression of these mediators.

METHODS

In pSS patients (n=62) documented for their serological and clinical features, Fas, FasL and Bcl-2 plasma levels were assessed using enzyme-linked immunosorbent assays. In the same context, we investigated their expression by immunohistochemistry analysis in the labial salivary glands samples in association with the extent of inflammation.

RESULTS

Interestingly, our results indicated that in pSS patients, the plasmatic Bcl-2, Fas and FasL levels, which appear to be associated with the severity of inflammation and were significantly elevated in comparison to the healthy controls. Moreover, a significant decrease in all these factors was observed in patients after combined corticosteroids-hydroxychloroquine therapy. Importantly, we report a strong positive correlation between Bcl-2 and NO levels. The immunohistochemical staining reveals a strong Bcl-2 expression in infiltrating mononuclear cells and a total absence in the acinar cells. The Bcl-2 level varies according to the severity of the pathology. However, the expression of Fas and FasL was less important and predominantly localized in infiltrating mononuclear cells.

CONCLUSION

Our current study highlights the involvement of Bcl-2, Fas and FasL in pSS glands injury. These factors may act as useful predictor markers of a clinical course in pSS suggesting a novel approach in the pSS patients monitoring.

Metformin as a Treatment Strategy for Sjögren's Syndrome

Sjögren's syndrome (SS), a chronic inflammatory disease involving the salivary and lacrimal glands, presents symptoms of sicca as well as systemic manifestations such as fatigue and musculoskeletal pain. Only a few treatments have been successful in management of SS; thus treatment of the disease is challenging. Metformin is the first-line agent for type 2 diabetes and has anti-inflammatory potential. Its immunomodulatory capacity is exerted via activation of 5' adenosine monophosphate-activated protein kinase (AMPK). Metformin inhibits mitochondrial respiratory chain complex I which leads to change in adenosine mono-phosphate (AMP) to adenosine tri-phosphate (ATP) ratio. This results in AMPK activation and causes inhibition of mammalian target of rapamycin (mTOR). mTOR plays an important role in T cell differentiation and mTOR deficient T cells differentiate into regulatory T cells. In this manner, metformin enhances immunoregulatory response in an individual. mTOR is responsible for B cell proliferation and germinal center (GC) differentiation. Thus, reduction of B cell differentiation into antibody-producing plasma cells occurs via downregulation of mTOR. Due to the lack of suggested treatment for SS, metformin has been considered as a treatment strategy and is expected to ameliorate salivary gland function.

Antimalarial drugs-are they beneficial in rheumatic and viral diseases?-considerations in COVID-19 pandemic

The majority of the medical fraternity is continuously involved in finding new therapeutic schemes, including antimalarial medications (AMDs), which can be useful in combating the 2019-nCoV: coronavirus disease (COVID-19). For many decades, AMDs have been widely used in the treatment of malaria and various other anti-inflammatory diseases, particularly to treat autoimmune disorders of the connective tissue. The review comprises in vitro and in vivo studies, original studies, clinical trials, and consensus reports for the analysis, which were available in medical databases (e.g., PubMed). This manuscript summarizes the current knowledge about chloroquine (CQ)/hydroxychloroquine (HCQ) and shows the difference between their use, activity, recommendation, doses, and adverse effects on two groups of patients: those with rheumatic and viral diseases (including COVID-19). In the case of connective tissue disorders, AMDs are prescribed for a prolonged duration in small doses, and their effect is observed after few weeks, whereas in the case of viral infections, they are prescribed in larger doses for a short duration to achieve a quick saturation effect. In rheumatic diseases, AMDs are well tolerated, and their side effects are rare. However, in some viral diseases, the effect of AMDs is questionable or not so noticeable as suggested during the initial prognosis. They are mainly used as an additive therapy to antiviral drugs, but recent studies have shown that AMDs can diminish the efficacy of some antiviral drugs and may cause respiratory, kidney, liver, and cardiac complications.

Primary Sjögren's Syndrome: A Retrospective Cohort Study of Burden of Illness in Sweden

INTRODUCTION

Primary Sjögren's syndrome (pSS) is an autoimmune disease that affects salivary and lachrymal glands and is associated with complex extraglandular manifestations. This study investigates the clinical and economic burden and disease course of pSS in Sweden.

METHODS

This retrospective cohort study utilizes data from Swedish national registries and consists of patients at least 18 years of age diagnosed in secondary care with pSS, and matched members of the Swedish general population. Healthcare resource utilization (HRU) and costs were compared. The clinical burden of pSS during follow-up was explored via year-on-year prevalence of and time-to-first extraglandular manifestation. Employment status and retirement rates were used to investigate the impact of pSS on productivity.

RESULTS

A total of 8884 patients with pSS and 88,233 general population comparators were included. Patients with pSS had significantly higher rates of HRU and higher healthcare costs than matched comparators, including twice as many outpatient visits. Costs were highest in year 1 post index before reducing in years 2 and 3 and stabilizing thereafter. Almost two-thirds of patients received their index diagnosis during an outpatient visit, and < 30% of diagnoses were from rheumatology departments. Overall, 41% of patients experienced a healthcare encounter that included a relevant extraglandular manifestation code during follow-up. Patients with pSS had significantly higher odds of early retirement than the general population at 5 years post index.

CONCLUSIONS

Patients with pSS experience a high clinical and economic disease burden in Sweden.

B cells as target for immunotherapy in rheumatic diseases - current status

This mini-review is a short overview of different therapeutical strategies targeting B cells in systemic autoimmune rheumatic diseases, mainly: rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and primary Sjogren Syndrome (pSS). Many strategies and their rationale are discussed in this review: B cells' depletion (anti-CD20, anti-CD22), long-lived plasma cells depletion (anti-CD19, anti-CD27, anti-CD38 and anti-CD138), changing activation of B cells (anti-BAFF) and inhibiting proteasomes in plasma cells (bortezomib). The past successful therapies and less successful are shown, and the possible reasons for failures are discussed.

The management of Sjögren's syndrome: British Society for Rheumatology guideline scope

The guideline will be developed using the methods and processes outlined in Creating Clinical Guidelines: Our Protocol [1]. This development process to produce guidance, advice and recommendations for practice has National Institute for Health and Care Excellence (NICE) accreditation.

A Review of the Efficacy of Influenza Vaccination in Autoimmune Disease Patients

Patients suffering from autoimmune diseases appear to be at greater risk for developing infections with the influenza virus compared to healthy controls due to their immunosuppressive treatment, suggesting the importance of vaccination. Within this literature review, we highlight the importance, efficacy, and safety of influenza vaccination in individuals with autoimmune diseases, including systemic lupus erythematosus (SLE), Sjogren syndrome (SS), rheumatoid arthritis (RA), and inflammatory bowel disease (IBD) in both vaccinated and unvaccinated individuals. Overall, vaccination is generally well tolerated by SLE patients and the literature recommends the inactivated influenza vaccine to SLE patients according to the recommendations and schedules for the general population and annually against seasonal influenza viruses. While the data are still unclear in patients with SS, there does seem to be a general consensus to vaccinate these individuals to prevent harmful risks of influenza disease. In patients with RA and IBD, vaccination efficacy with the inactivated influenza vaccine should be determined on a case-by-case basis, taking patient therapy into account. In light of the current pandemic and global coronavirus disease 2019 (COVID-19) crisis, it is crucial to emphasize the safety and immunogenicity of influenza vaccination in vulnerable individuals suffering from autoimmune diseases. Public health measures are recommended to protect these individuals with vaccinations, keeping in mind the possibility of the multiple COVID-19 vaccines that are currently available.

Musculoskeletal Manifestations in Sjogren's Syndrome: An Orthopedic Point of View

Sjogren's syndrome (SS) is a frequent entity with a broad symptomatology spectrum, mainly affecting the salivary and lachrymal glands. The disease also affects the musculoskeletal system targeting bones, specific joints, muscles, and the peripheral nerve system. Disease related clinical manifestations canhave an accumulative impact, as the syndrome is commonly associated with other rheumatic diseases. A literature review was performed with the aim to assess the in-depth association of Sjogren's syndrome and its treatment agents with the musculoskeletal system and further investigate its potential relevance with common orthopedic postoperative complications.

What's new in ocular and oral aspects of Sjögren's syndrome and do new treatments work?

Primary SS (pSS) is a systemic autoimmune disease characterized by lymphocytic infiltration of the exocrine glands leading to glandular dysfunction, resulting in dryness of the eyes, mouth and other mucosal surfaces. Systemic manifestations also occur in the majority of patients. There has been increasing interest in recent years, with a number of publications regarding the classification criteria, diagnostic tools, disease activity, damage, impact and potential treatments. This article reviews recent advances in the diagnosis and treatment of ocular and oral involvement in pSS. Recent stand-out developments include measurement of tear osmolarity as a marker in dry eye disease diagnosis, new devices measuring tear constituents and meibomian gland structure and treatment of its dysfunction. Lip biopsy is still valuable despite emerging evidence of non-invasive diagnostic techniques, notably salivary gland ultrasound.

Immune Monitoring upon Treatment with Biologics in Sjögren's Syndrome: The What, Where, When, and How

Over the years, a wide variety of therapeutic antibodies has been successfully introduced in the auto-immunology clinic, and many more are on the way. Many of these treatments address either a pathogenic circulating molecule or a cell-bound molecule. Whereas addressing the former target results in neutralization of the soluble factor and binding to the latter target either inhibits cellular function or induces selective cell death. If this targeted molecule or cell is part of the immune system, this therapy evokes a state of immunodeficiency with infections as a possible consequence. Therefore, immune monitoring is needed to prevent such adverse side effects of immunotherapy. In this paper, different immunotherapies used in Sjögren's syndrome, as well as different approaches to monitoring the immune system, are discussed.

Respiratory RNA Viruses: How to Be Prepared for an Encounter with New Pandemic Virus Strains

The characteristics of the biology of influenza viruses and coronavirus that determine the implementation of the infectious process are presented. With provision for pathogenesis of infection possible effects of serine proteinase inhibitors, heparin, and inhibitors of heparan sulfate receptors in the prevention of cell contamination by viruses are examined. It has been determined that chelators of metals of variable valency and antioxidants should be used for the reduction of replicative activity of viruses and anti-inflammatory therapy. The possibility of a pH-dependent impairment of glycosylation of cellular and viral proteins was traced for chloroquine and its derivatives. The use of low-toxicity drugs as part of adjunct therapy increases the effectiveness of synthetic antiviral drugs and interferons and ensures the safety of baseline therapy.

CP-25, a compound derived from paeoniflorin: research advance on its pharmacological actions and mechanisms in the treatment of inflammation and immune diseases

Total glycoside of paeony (TGP) has been widely used to treat inflammation and immune diseases in China. Paeoniflorin (Pae) is the major active component of TGP. Although TGP has few adverse drug reactions, the slow onset and low bioavailability of Pae limit its clinical use. Enhanced efficacy without increased toxicity is pursued in developing new agents for inflammation and immune diseases. As a result, paeoniflorin-6'-O-benzene sulfonate (CP-25) derived from Pae, is developed in our group, and exhibits superior bioavailability and efficacy than Pae. Here we describe the development process and research advance on CP-25. The pharmacokinetic parameters of CP-25 and Pae were compared in vivo and in vitro. CP-25 was also compared with the first-line drugs methotrexate, leflunomide, and hydroxychloroquine in their efficacy and adverse effects in arthritis animal models and experimental Sjögren's syndrome. We summarize the regulatory effects of CP-25 on inflammation and immune-related cells, elucidate the possible mechanisms, and analyze the therapeutic prospects of CP-25 in inflammation and immune diseases, as well as the diseases related to its potential target G-protein-coupled receptor kinases 2 (GRK2). This review suggests that CP-25 is a promising agent in the treatment of inflammation and immune diseases, which requires extensive investigation in the future. Meanwhile, this review provides new ideas about the development of anti-inflammatory immune drugs.

Quantum mechanical simulation of Chloroquine drug interaction with C60 fullerene for treatment of COVID-19

Chloroquine (CQ) has been reported as an effective drug in the control of COVID-19 infection. Since C60 fullerene has been considered as a drug delivery system, the interaction between pristine fullerene and chloroquine drug and also the interaction between B, Al, Si doped fullerene and chloroquine drug have been investigated based on the density functional theory calculations. The results of this study show that the doped fullerene, especially Al and Si doped fullerene could be the better drug delivery vehicles for chloroquine drug because of their relatively better energetic and electronic properties with chloroquine.

The past, present and future of RNA respiratory viruses: influenza and coronaviruses

Influenza virus and coronaviruses continue to cause pandemics across the globe. We now have a greater understanding of their functions. Unfortunately, the number of drugs in our armory to defend us against them is inadequate. This may require us to think about what mechanisms to address. Here, we review the biological properties of these viruses, their genetic evolution and antiviral therapies that can be used or have been attempted. We will describe several classes of drugs such as serine protease inhibitors, heparin, heparan sulfate receptor inhibitors, chelating agents, immunomodulators and many others. We also briefly describe some of the drug repurposing efforts that have taken place in an effort to rapidly identify molecules to treat patients with COVID-19. While we put a heavy emphasis on the past and present efforts, we also provide some thoughts about what we need to do to prepare for respiratory viral threats in the future.

Do Postoperative Oral Corticosteroids Improve Results After Sialendoscopy for Ductal Stenosis?

OBJECTIVES

This study aims to review the effects of short- and long-term oral administration of postoperative corticosteroids in patients undergoing sialendoscopy for the treatment of obstructive sialadenitis due to ductal stenosis.

STUDY DESIGN

Prospective comparative study.

METHODS

A prospective observational study was conducted at Manukau Surgical Center in Auckland, New Zealand, where patients undergoing sialendoscopic surgery for recurrent obstructive sialadenitis due to ductal stenoses were reviewed. Univariable and multivariable analysis, and also logistic regression were performed to identify variables correlated with the likelihood of the need for revision surgery for persistent or recurrent symptoms.

RESULTS

In this study, sialendoscopy was performed in 142 patients: 162 parotid glands (86.6%) and 25 submandibular glands (13.4%). Postoperative oral steroids were prescribed for 48 patients (34%); 19 (13%) were prescribed for less than 7 days and 29 (20%) for more than 7 days. In total, 33 patients (23.2%) required a revision sialendoscopy during follow-up due to recurrence of symptoms. Oral steroids prescribed for more than 7 days after a sialendoscopy reduced the likelihood of a revision procedure by 93% when compared with patients who did not receive this medication, and by 96% when compared with patients who received steroids for less than 7 days.

CONCLUSION

The results showed that in our population oral administration of corticosteroids for more than 7 days after sialendoscopy for the treatment of recurrent obstructive sialadenitis due to ductal stenosis markedly reduced the need for later revision surgery. Routine use of corticosteroids for more than 7 days is recommended after sialendoscopy in patients with ductal stenosis.

LEVEL OF EVIDENCE

II Laryngoscope, 131:E1503-E1509, 2021.

Sialoscintigraphy - Shopworn or Bestselling? A Traditional Procedure with New Prominent Role in Theranostics and Immuno-Oncology

Sialoscintigraphy has been used in nuclear imaging for almost sixty years. It allows functional assessment and quantification of all large salivary glands. Physiological function of the salivary glands is essential for the preservation of the oral mucosa, the sense of taste and dental health. Impaired salivary gland function may lead to reduced or even absent salivation resulting in various complaints such as loss of taste reducing quality of life. During the recent years clinical relevance of assessment of salivary gland function has been rising. As novel radiopharmaceuticals such as 225Ac-PSMA or 177Lu-PSMA may cause damage to the salivary glands in a subset of patients, reliable methods for quantification of salivary gland function are vital for therapy planning and follow-up. Standardized protocols for the implementation and interpretation of this procedure are necessary to achieve comparable results from individual theranostic centers and to facilitate multicenter trials. Sialocintigraphy is also of clinical relevance for immunooncology. Treatments with checkpoint inhibitors such as Ipilimumab or Nivulomab frequently cause autoimmune disorders affecting the salivary glands that may lead to reduced production of saliva and finally loss of taste. Therefore, standardized procedure protocols for sialoscintigraphy are also important for general oncology.Here we suggest a protocol for sialoscintigraphy that may be used as standard in centers for theranostics or immunooncology and discuss the potential future role of this traditional procedure.