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Emmi G, Bettiol A, Hatemi G, Prisco D. Behçet's syndrome. Lancet 2024; 403:1093-1108. [PMID: 38402885 DOI: 10.1016/s0140-6736(23)02629-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/13/2023] [Accepted: 11/21/2023] [Indexed: 02/27/2024]
Abstract
Behçet's syndrome is a rare, chronic multisystemic inflammatory disorder also known as the Silk Route disease due to its geographical distribution. Behçet's syndrome is a multifactorial disease and infectious, genetic, epigenetic, and immunological factors contribute to its pathogenesis. Its heterogeneous spectrum of clinical features include mucocutaneous, articular, ocular, vascular, neurological, and gastrointestinal manifestations that can present with a relapsing and remitting course. Differential diagnosis is often hampered by the non-specific clinical presentation and the absence of laboratory biomarkers or pathognomonic histological features. The therapeutic approach is tailored on the basis of patient-specific manifestations and relies on glucocorticoids, colchicine, and traditional and biological immunosuppressants. Despite progress in the knowledge and management of the disease, unmet needs in diagnostics, monitoring, prediction, and treatment personalisation challenge clinical practice, making Behçet's syndrome a complex disorder associated with an increased risk of morbidity.
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Affiliation(s)
- Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Melbourne, VIC, Australia.
| | - Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gülen Hatemi
- Istanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Türkiye
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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2
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Xiao X, Shi Z, Song Y, Li K, Liu S, Song Z. Oral microbiota in active and passive states of recurrent aphthous stomatitis: An analysis of case-control studies. Arch Oral Biol 2023; 153:105751. [PMID: 37379635 DOI: 10.1016/j.archoralbio.2023.105751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/21/2023] [Accepted: 06/15/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE This study was presented to reveal the most distinct microbial prevalence in recurrent aphthous stomatitis (RAS) lesions compared to healthy controls. DESIGN The case-control studies were selected in electronic databases until Nov 2022 with key search terms, and the eligible publications were screened and analyzed by independent authors. RESULTS A total of 14 studies were identified, which included 531 cases of active states of RAS (AS-RAS), 92 cases of passive states of RAS (PS-RAS) and 372 healthy controls. The most sample pattern was the mucosa swab performed in 8 of 14 studies, biopsies in 3 studies, followed by micro-brush, and saliva. A variety of bacteria in higher or lower abundance were observed in RAS lesions. CONCLUSIONS The etiopathogenesis of RAS may not be ascribed to a single pathogen. A possible explanation is that microbial interactions modify immune response or destroy the epithelial integrity, thus contributing to the development of the condition.
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Affiliation(s)
- Xuan Xiao
- Department of Oral Mucosa, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai, China; Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University, Shanghai, China
| | - Zhaocheng Shi
- Department of Oral Mucosa, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai, China; Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University, Shanghai, China
| | - Yuhan Song
- Department of Oral Mucosa, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai, China; Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University, Shanghai, China
| | - Kaiyi Li
- Department of Oral Mucosa, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai, China; Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University, Shanghai, China
| | - Shangfeng Liu
- Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University, Shanghai, China.
| | - Zhifeng Song
- Department of Oral Mucosa, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai, China; Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University, Shanghai, China.
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3
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Hatemi G, Yazıcı Y. Outcome measures in Behçet syndrome. Clin Immunol 2023; 251:109341. [PMID: 37100337 DOI: 10.1016/j.clim.2023.109341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/28/2023]
Abstract
Disease assessment has been challenging in Behçet syndrome due to the heterogeneous disease course and multiorgan involvement with variable treatment response. There have been several recent improvements regarding outcome measures including development of a Core Set of Domains for Behçet syndrome and novel instruments for assessing specific organs and overall damage. This review focuses on the current state of outcome measures in Behçet syndrome, unmet needs, and a research agenda towards the development of standardized and validated outcome measure instruments.
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Affiliation(s)
- Gülen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Istanbul University, Cerrahpaşa, Turkey.
| | - Yusuf Yazıcı
- Division of Rheumatology, New York University School of Medicine, New York, NY, USA.
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Fragoulis GE, Bertsias G, Bodaghi B, Gul A, van Laar J, Mumcu G, Saadoun D, Tugal-Tutkun I, Hatemi G, Sfikakis PP. Treat to target in Behcet's disease: Should we follow the paradigm of other systemic rheumatic diseases? Clin Immunol 2023; 246:109186. [PMID: 36410686 DOI: 10.1016/j.clim.2022.109186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/08/2022] [Indexed: 11/23/2022]
Abstract
During the last decades the efficacy of biologic agents, mainly of anti-TNFs, in controlling the activity of serious manifestations of Behcet's Disease (BD) has been established. On the other hand, the clinical heterogeneity of BD has precluded the validation of a widely-accepted composite index for disease assessment and for target disease-state definitions, such as low disease activity and remission, and the testing of their implementation in clinical practice. Therefore, in contrast to other systemic rheumatic diseases, a treat-to-target strategy has not yet been developed in BD. There are several challenges towards this approach, including standardization of outcome measures for assessing the disease activity in each-affected organ and construction of a composite disease activity index. The challenges for the development of a treat-to-target strategy and possible solutions are discussed in this position paper, which stemmed from a round table discussion that took place in the 19th International Conference on BD.
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Affiliation(s)
- George E Fragoulis
- Joint Rheumatology Program and First Department of Propaedeutic and Internal Medicine, National & Kapodistrian University of Athens Medical School, Athens, Greece
| | - George Bertsias
- Rheumatology and Clinical Immunology, University of Crete Medical School, Heraklion, Greece
| | - Bahram Bodaghi
- Dept of Ophthalmology, IHU FOReSIGHT, Sorbonne University, APHP, Paris, France
| | - Ahmet Gul
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Turkey
| | - Jan van Laar
- Departments of Internal Medicine and Immunology, Division Clinical Immunology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Gonca Mumcu
- Department of Health Management, Faculty of Health Sciences, Marmara University, Istanbul, Turkey
| | - David Saadoun
- Sorbonne Université, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, National reference center for autoinflammatory diseases and for rare systemic autoimmune diseases, F-75013 Paris, France
| | - Ilknur Tugal-Tutkun
- Istanbul University, Istanbul Faculty of Medicine, Department of Ophthalmology, Istanbul, Turkey; Eye Protection Foundation Bayrampasa Eye Hospital, Istanbul, Turkey
| | - Gulen Hatemi
- Department of Internal Medicine, Division of Rheumatology, Cerrahpaşa School of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey; Behçet's Disease Research Center, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Petros P Sfikakis
- Joint Rheumatology Program and First Department of Propaedeutic and Internal Medicine, National & Kapodistrian University of Athens Medical School, Athens, Greece.
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Kaur R, Behl AB, Punia RS, Nirav K, Singh KB, Kaur S. Assessment of Prevalence of Recurrent Aphthous Stomatitis in the North Indian Population: A Cross-Sectional Study. J Pharm Bioallied Sci 2021; 13:S363-S366. [PMID: 34447110 PMCID: PMC8375864 DOI: 10.4103/jpbs.jpbs_581_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 09/30/2020] [Accepted: 10/08/2020] [Indexed: 11/04/2022] Open
Abstract
Aim and Objective The present study was undertaken for assessing the prevalence of recurrent aphthous stomatitis (RAS) in the North Indian population. Materials and Methods Assessment of a total of 4255 patients was done over a period of 2 years, who came for a routine dental checkup. Recording of the complete demographic and clinical details of all the patients was done. The prevalence of RAS was assessed. Profile of patients with RAS was assessed separately. A pro forma was made and the type of treatment protocol followed by patients with RAS was also recorded. All the results were recorded in a Microsoft Excel sheet and were analyzed using SPSS software. Results Analysis of a total of 4255 patients was done. RAS was found to be present in 800 patients. The overall prevalence of RAS was found to be 18.93%. Significant results were obtained when analyzing age, gender, and occupation as risk factors for RAS. Labial/buccal mucosa involvement occurred in 51.875% of the cases. In 44% of the cases, the size of the RAS was between 1 cm and 3 cm. Home remedy was followed in 17.875% of the cases. Conclusion A significant proportion of patients in the North Indian population is affected by RAS. In comparison to males, females are more commonly affected.
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Affiliation(s)
- Ramneet Kaur
- Consulting Oral Medicine and Radiologist, Punjab, India
| | - Ashima Bali Behl
- Department of Oral Medicine and Radiology, BJS Dental College and Hospital, Ludhiana, Punjab, India
| | - Ramandeep Singh Punia
- Department of Oral Medicine and Radiology, Dasmesh Institute of Research and Dental Sciences, Faridkot, Punjab, India
| | - Kumar Nirav
- Department of Periodontal Surgery and Implant, Vananchal Dental College and Hospital, Garhwa, Jharkhand, India
| | | | - Sukhpreet Kaur
- Department of Orthodontics, Maharaja Ganga Singh Dental College And Research Centre, Sriganganagar, Rajasthan, India
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Karacayli U, Adesanya A, Aksoy A, Belem JMFM, Cardin NB, Sarı FB, Beyhan TE, Çelik Z, Karacayli C, Alibaz-Öner F, Inanç N, Ergun T, Yay M, Madanat W, Silva de Souza AW, Fortune F, Direskeneli H, Mumcu G. The Assessment of Presenteeism and Activity Impairment in Behcet's Syndrome and Recurrent Aphthous Stomatitis: A multicentre Study. Rheumatology (Oxford) 2021; 61:1538-1547. [PMID: 34289015 DOI: 10.1093/rheumatology/keab581] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/06/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To evaluate key factors for Presenteeism and Activity impairment in multinational patients with Behçet's syndrome (BS) and recurrent aphthous stomatitis (RAS). METHODS In this cross-sectional study, 364 BS patients from Jordan, Brazil, the United Kingdom and Turkey and 143 RAS patients from the United Kingdom and Turkey were included. Work Productivity Activity Impairment (WPAI) scale was used for Presenteeism and Activity impairment. Mediation analyses were performed to evaluate both direct and indirect causal effects. RESULTS Presenteeism score was higher in active patients with genital ulcers and eye involvement as well as patients with comorbidities and current smokers than the others in BS (p< 0.05). In RAS, Presenteeism score was elevated by oral ulcer activity in the direct path (p= 0.0073) and long disease duration as a mediator in the indirect path (p= 0.0191).Patients with active joint involvement had poor scores in Absenteeism, Presenteeism, Overall impairment and Activity impairment compared with those of inactive patients (p < 0.05). Using mediation analysis, the Activity impairment score was directly mediated by joint activity (p = 0.0001) and indirectly mediated through oral ulcer-related pain in BS (p = 0.0309). CONCLUSION In BS, Presenteeism was associated with disease activity, presence of comorbidities and being a current smoker, whereas in RAS, Presenteeism was associated with oral ulcer activity and increased length of the disease. Moreover, Activity impairment was adversely affected by joint activity and oral ulcer related pain in BS. Patients need to be empowered by using appropriate treatment strategies in their working environment and daily life.
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Affiliation(s)
- Umit Karacayli
- Department of Oral and Maxillofacial Surgery, Gulhane Faculty of Dentistry, University of Health Sciences, Ankara, Turkey
| | - Adebowale Adesanya
- Barts and The London School of Medicine and Dentistry, Centre Immunobiology and Regenerative Medicine, Queen Mary University of London, UK
| | - Aysun Aksoy
- Division of Rheumatology, Medical School, Marmara University, Istanbul, Turkey
| | - Joice M F M Belem
- Division of Rheumatology, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Fatma Busra Sarı
- Department of Health Management, Faculty of Health Sciences, Marmara University, Istanbul, Turkey
| | - Tuğba Emine Beyhan
- Department of Health Management, Faculty of Health Sciences, Marmara University, Istanbul, Turkey
| | - Zülal Çelik
- Department of Health Management, Faculty of Health Sciences, Marmara University, Istanbul, Turkey
| | - Ceren Karacayli
- Department of Audiology, Gulhane Faculty of Health Science, University of Health Sciences, Ankara, Turkey.,Department of Otorhinolaryngology, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Fatma Alibaz-Öner
- Division of Rheumatology, Medical School, Marmara University, Istanbul, Turkey
| | - Nevsun Inanç
- Division of Rheumatology, Medical School, Marmara University, Istanbul, Turkey
| | - Tülin Ergun
- Department of Dermatology, Medical School, Marmara University, Istanbul, Turkey
| | - Meral Yay
- Department of Statistics, Mimar Sinan Fine Art Faculty, Istanbul, Turkey
| | - Wafa Madanat
- Jordan's Friends of Behçet's Disease Patients Society, Medical Department, Amman, Jordan
| | | | - Farida Fortune
- Barts and The London School of Medicine and Dentistry, Centre Immunobiology and Regenerative Medicine, Queen Mary University of London, UK
| | - Haner Direskeneli
- Division of Rheumatology, Medical School, Marmara University, Istanbul, Turkey
| | - Gonca Mumcu
- Department of Health Management, Faculty of Health Sciences, Marmara University, Istanbul, Turkey
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Nagieb CS, Harhash TAE, Fayed HL, Ali S. Evaluation of diode laser versus topical corticosteroid in management of Behcet's disease-associated oral ulcers: a randomized clinical trial. Clin Oral Investig 2021; 26:697-704. [PMID: 34212234 DOI: 10.1007/s00784-021-04047-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 06/22/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The current trial was conducted to assess the effect of diode laser therapy compared to topical corticosteroid in management of oral ulcers of BD. MATERIALS AND METHODS Fifty patients were divided randomly into two parallel groups. The first group received 980 nm diode laser; the second group received topical corticosteroid (0.1% triamcinolone acetonide). The outcome measures included oral ulcer activity index (composite index), pain (VAS), number of oral ulcers, healing time, and oral health-related quality of life (OHIP-14). The collected data were analyzed for any statistical significance. RESULTS A statistically significant difference was detected between laser and corticosteroid groups favoring laser on comparing composite index and VAS scores on the first and third days and on comparing number of ulcers on the third and fifth days. A statistically significant difference was detected between laser and corticosteroid groups on comparing scores of the questions assessing discomfort with eating food, irritability with other people, taste worsening, unsatisfactory diet, and painful aching on the first and/or third days. No adverse effects were reported by participants of both groups. CONCLUSIONS Diode laser is efficient safe treatment modality for management of BD-associated oral ulcers. Diode laser was more efficient than triamcinolone acetonide in controlling pain and reducing oral ulcer activity. CLINICAL RELEVANCE Laser therapy is efficient safe modality that could spare BD patient from adding a new medication to their long list, being just one visit compared to other regular daily regimen medications. TRIAL REGISTRATION ClinicalTrials.gov registration number: NCT03771768.
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Affiliation(s)
- Clair Sobhy Nagieb
- Department of Oral Medicine and Periodontology, Faculty of Dentistry, Cairo University, 11 El-Saraya Street, Manial, Cairo, 11553, Egypt
| | - Tarek Abd-ElHamid Harhash
- Department of Laser Application in Dentistry, National Institute for Laser Enhanced Sciences, Cairo University, Cairo, Egypt
| | - Hala Lotfy Fayed
- Department of Rheumatology & Rehabilitation, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Shereen Ali
- Department of Oral Medicine and Periodontology, Faculty of Dentistry, Cairo University, 11 El-Saraya Street, Manial, Cairo, 11553, Egypt.
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Shaat RM, El Meadawy S, Rizk EM, Elgawad MSA, Elsaid TO. The significance of α-defensins 1-3 in Behcet’s disease: a case-control study among Egyptian patients. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2020. [DOI: 10.1186/s43166-020-00026-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Behcet’s disease (BD) is associated with uveitis, oral ulcers, genital ulcers and arthritis. Enhanced activity of innate immunity components, such as neutrophils, natural killer (NK) cells and endothelial cells, is a prominent feature of BD. The aim of this study was to clarify the significance of α-defensins 1-3 in BD and detect their correlation with disease activity, severity and oral ulcer activity.
Results
Significant differences were found between Behcet’s patients and controls as regards serum α-defensins 1-3 (median 10.1, IQR 4–45 μg/ml versus median 7.4, IQR 0.6–13.2 μg/ml, p = 0.001) and salivary α-defensins 1-3 (median 17.4, IQR 5.7–44 μg/ml versus median 8.6, IQR 3.3–11 μg/ml, p < 0.001). Receiver operating characteristic (ROC) showed a fair area under curve (AUC) (AUC = 0.743), with sensitivity of 40% and specificity 100% at cutoff value of 17.3 μg/ml for serum α-defensins 1-3, while salivary α-defensins 1-3 showed excellent AUC (AUC = 0.936), with sensitivity of 93.3% and specificity of 86.7% at cutoff value of 9.8 μg/ml. The levels of serum and salivary α-defensins 1-3 > cutoff value were significantly higher in active severe Behcet’s patients with active oral ulcers (p < 0.001).
Conclusion
α-Defensins 1-3 may be involved in the pathogenesis of BD and could be valuable markers in the determination of disease activity, severity and oral ulcer activity.
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Mumcu G, Yay M, Karaçaylı Ü, Aksoy A, Taş MN, Armağan B, Sarı A, Bozca BC, Tekgöz E, Temiz Karadağ D, Badak SÖ, Tecer D, Yıldırım A, Bes C, Şahin A, Erken E, Cefle A, Çınar M, Yılmaz S, Alpsoy E, Boyvat A, Şenel S, Bilge ŞY, Kaşifoğlu T, Karadağ Ö, Aksu K, Keser G, Alibaz-Öner F, İnanç N, Ergun T, Direskeneli H. Moderation analysis exploring associations between age and mucocutaneous activity in Behçet's syndrome: A multicenter study from Turkey. J Dermatol 2020; 47:1403-1410. [PMID: 32981075 DOI: 10.1111/1346-8138.15553] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/19/2020] [Indexed: 11/30/2022]
Abstract
The aim of the present study was to examine the effects of age on mucocutaneous activity by using moderation analysis in Behçet's syndrome (BS). In this cross-sectional study, 887 BS patients (female : male, 481:406; mean age, 38.4 ± 10.9 years) followed in 13 tertiary centers in Turkey were included. Mucocutaneous activity was evaluated by using the Mucocutaneous Index (MI) according to sex and disease course. Moderation analysis was performed to test the effect of age on mucocutaneous activity. A moderator variable is a third variable and affects the relationship between independent and outcome variables. Age was chosen as a potential moderator variable (interaction effect), MI score as the outcome variable and sex as an independent variable in the analysis. The moderation analysis tested the effects of age in three steps: whole BS patient group, patients without systemic involvement and those with systemic involvement. The moderation model was only significant in BS patients with systemic involvement (P = 0.0351), and a significant relationship was observed between female sex and MI score (P = 0.0156). In addition, the interaction plot showed that female patients had increased MI scores compared with male patients, especially in the 28-year-old age group (P = 0.0067). Moreover, major organ involvement was newly diagnosed in the majority of these young female BS patients. Our results suggest that the relationship between sex and mucocutaneous activity was moderated by age in the systemic involvement group. Also, increased mucocutaneous activity may be associated with new major organ involvement in young female BS patients with systemic involvement.
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Affiliation(s)
- Gonca Mumcu
- Faculty of Health Sciences, Marmara University, Istanbul, Turkey
| | - Meral Yay
- Department of Statistics, Mimar Sinan Fine Arts University, Istanbul, Turkey
| | - Ümit Karaçaylı
- Department of Oral and Maxillofacial Surgery, Gulhane Faculty of Dentistry, Ankara, Turkey
| | - Aysun Aksoy
- Division of Rheumatology, Medical School, Marmara University, Istanbul, Turkey
| | - Mehmet Nedim Taş
- Division of Rheumatology, Medical School, Ege University, Izmir, Turkey
| | - Berkan Armağan
- Division of Rheumatology, Medical School, Hacettepe University, Ankara, Turkey
| | - Alper Sarı
- Division of Rheumatology, Medical School, Hacettepe University, Ankara, Turkey
| | - Burçin Cansu Bozca
- Dermatology Department, Medical School, Akdeniz University, Antalya, Turkey
| | - Emre Tekgöz
- Division of Rheumatology, Gulhane Medical Faculty, Gulhane Education and Research Hospital, Ankara, Turkey
| | - Duygu Temiz Karadağ
- Division of Rheumatology, Medical School, Kocaeli University, Kocaeli, Turkey
| | - Suade Özlem Badak
- Division of Rheumatology, Medical School, Cukurova University, Adana, Turkey
| | - Duygu Tecer
- Şanlıurfa Mehmet Akif İnan Education and Research Hospital, Sanlıurfa, Turkey
| | - Alper Yıldırım
- Division of Rheumatology, Medical School, Erciyes University, Kayseri, Turkey
| | - Cemal Bes
- Istanbul Bakırköy Dr. Sadi Konuk Education and Research Hospital, Rheumatology Clinic, Istanbul, Turkey
| | - Ali Şahin
- Division of Rheumatology, Medical School, Cumhuriyet University, Sivas, Turkey
| | - Eren Erken
- Division of Rheumatology, Medical School, Cukurova University, Adana, Turkey
| | - Ayse Cefle
- Division of Rheumatology, Medical School, Kocaeli University, Kocaeli, Turkey
| | - Muhammet Çınar
- Division of Rheumatology, Gulhane Medical Faculty, Gulhane Education and Research Hospital, Ankara, Turkey
| | - Sedat Yılmaz
- Division of Rheumatology, Gulhane Medical Faculty, Gulhane Education and Research Hospital, Ankara, Turkey
| | - Erkan Alpsoy
- Dermatology Department, Medical School, Akdeniz University, Antalya, Turkey
| | - Ayşe Boyvat
- Department of Dermatology, Medical School, Ankara University, Ankara, Turkey
| | - Soner Şenel
- Division of Rheumatology, Medical School, Erciyes University, Kayseri, Turkey
| | - Şule Yaşar Bilge
- Division of Rheumatology, Medical School, Osmangazi University, Eskisehir, Turkey
| | - Timuçin Kaşifoğlu
- Division of Rheumatology, Medical School, Osmangazi University, Eskisehir, Turkey
| | - Ömer Karadağ
- Division of Rheumatology, Medical School, Hacettepe University, Ankara, Turkey
| | - Kenan Aksu
- Division of Rheumatology, Medical School, Ege University, Izmir, Turkey
| | - Gökhan Keser
- Division of Rheumatology, Medical School, Ege University, Izmir, Turkey
| | - Fatma Alibaz-Öner
- Division of Rheumatology, Medical School, Marmara University, Istanbul, Turkey
| | - Nevsun İnanç
- Division of Rheumatology, Medical School, Marmara University, Istanbul, Turkey
| | - Tülin Ergun
- Dermatology Department, Medical School, Marmara University, Istanbul, Turkey
| | - Haner Direskeneli
- Division of Rheumatology, Medical School, Marmara University, Istanbul, Turkey
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Mumcu G, Direskeneli H. Triggering agents and microbiome as environmental factors on Behçet's syndrome. Intern Emerg Med 2019; 14:653-660. [PMID: 30523495 DOI: 10.1007/s11739-018-2000-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 11/29/2018] [Indexed: 12/13/2022]
Abstract
Environmental and other triggering factors are suggested to cause the onset and the clinical relapses of Behçet's syndrome (BS), a multi-systemic inflammatory disorder. In this review, environmental factors are discussed according to their interactions with etiopathogenesis, immune response and disease activity. Stress is a common self-triggering factor for most BS patients. Stimuli such as some foods can activate oral ulcers, and may be linked to the histamine content of the food. Oral/skin trauma and menstruation associated with hormonal factors aggravate, whereas allergy/atopy seem to alleviate the symptoms of BS. Infections are associated with BS, and microbial stimuli can activate inflammation in mucosal surfaces with increased Th1/Th17 responses. Fecal and oral microbiome patterns change in diversity and composition in BS. Better oral hygiene applications and anti-microbial interventions might be helpful to suppress oral ulcers in BS.
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Affiliation(s)
- Gonca Mumcu
- Department of Health Management, Faculty of Health Sciences, Marmara University, Istanbul, Turkey
| | - Haner Direskeneli
- Department of Internal Medicine, Division of Rheumatology, School of Medicine, Marmara University, Istanbul, Turkey.
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A novel prognostic biomarker for recurrent aphthous stomatitis: calprotectin. The Journal of Laryngology & Otology 2019; 133:691-695. [PMID: 31284886 DOI: 10.1017/s0022215119001440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aims to investigate whether there is a correlation between serum calprotectin concentration and oral ulcer activity in patients with active recurrent aphthous stomatitis. METHOD This prospective, cross-sectional, historical cohort study included 52 patients (26 with active lesions and 26 with inactive lesions) with recurrent aphthous stomatitis and 27 healthy volunteers. The relationship between the groups was statistically evaluated in terms of serum calprotectin level and other inflammatory parameters. RESULTS The median calprotectin value of the active lesion group (80.5 ng/ml) was significantly higher than that of the control group (55.4 ng/ml, p = 0.002). Furthermore, the median calprotectin value of the active lesion group was significantly higher than that of the inactive lesion group (72.5 ng/ml, p = 0.017). CONCLUSION In patients with recurrent aphthous stomatitis and active ulcer lesions, the serum calprotectin value can be used as a reliable and robust prognostic marker for inflammation.
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Kumar KM, Nachiammai N, Madhushankari GS. Association of oral manifestations in ulcerative colitis: A pilot study. J Oral Maxillofac Pathol 2018; 22:199-203. [PMID: 30158772 PMCID: PMC6097373 DOI: 10.4103/jomfp.jomfp_223_16] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: Ulcerative colitis (UC) is a chronic tissue destructive inflammatory bowel disease (IBD) of autoimmune origin characterized by predominant bowel symptoms such as abdominal pain, diarrhea and relapsing and remitting rectal bleeding, leading to loss of weight. Extraintestinal manifestations, including involvement of the oral cavity, may also occur. Oral involvement during IBD includes aphthous ulcers, pyostomatitis vegetans (PV) and lichen planus (LP). Objectives: The purpose of this study was to document the oral manifestations in UC patients and also to evaluate whether oral manifestation can predict relapse and remission of UC. Materials and Methods: Fifteen patients (8 men and 7 women) diagnosed for UC, in clinics of gastroenterology (with disease duration 5–15 years), with equal age- and sex-matched healthy controls were included in the study. All study participants were subjected to intraoral examination to evaluate for oral manifestation. The same patients were also asked a series of questions in the form of questionnaire to evaluate possible association between occurrence of oral manifestations and relapse of UC episode. Results: PV, minor aphthous ulcer, LP, halitosis, dysgeusia, dry mouth, tongue coating, gingivitis and periodontitis were documented as oral manifestations in UC. PV, minor aphthous ulcer and LP exhibited relapse and remission with the severity of UC. Conclusion: Our study revealed numerous and varied intraoral manifestations among the patients with UC. The previous episodes of oral manifestations were also similar and reported exacerbation of oral manifestations during relapses. Thus, oral manifestations can be used as an indicator of relapse in UC.
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Affiliation(s)
- Kp Mohan Kumar
- Department of Oral Pathology and Microbiology, College of Dental Sciences, Davangere, Karnataka, India
| | - N Nachiammai
- Department of Oral and Maxillofacial Pathology, Chettinad Dental College and Research Institute, Tamil Nadu, India
| | - G S Madhushankari
- Department of Oral Pathology and Microbiology, College of Dental Sciences, Davangere, Karnataka, India
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Fabiani C, Vitale A, Orlando I, Sota J, Capozzoli M, Franceschini R, Galeazzi M, Tosi GM, Frediani B, Cantarini L. Quality of life impairment in Behçet's disease and relationship with disease activity: a prospective study. Intern Emerg Med 2017. [PMID: 28620840 DOI: 10.1007/s11739-017-1691-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Our aim was to prospectively investigate the impact of Behçet's disease (BD), disease activity, and clinical and demographic characteristics on different aspects of quality of life (QoL) measured by the short-form (SF)-36 QoL scale. We administered the SF-36 to 37 consecutive BD patients in different moments of disease activity, and to 23 healthy controls (HC). The eight subcategories of the SF-36 underwent statistical analysis for identifying differences and correlations. Compared to HC, BD patients showed significantly lower mean scores in all SF-36 QoL subscales except mental health and role-emotional. Females showed a poorer QoL compared to males. Disease activity evaluated by the BD Current Activity Form inversely correlated with physical functioning (ρ = -0.68, p < 0.0001), bodily pain (ρ = -0.68, p < 0.0001), role-physical (ρ = -0.64, p < 0.0001), vitality (ρ = -0.64, p < 0.0001), general health (ρ = -0.64, p < 0.0001), social functioning (ρ = -0.50, p = 0.0002), mental health (ρ = -0.48, p = 0.0004), and role-emotional (ρ = -0.40, p = 0.003). Mucosal, central nervous system (CNS), musculoskeletal and ocular manifestations were the main factors that negatively affected QoL in BD. For ocular disease, physical functioning was significantly impaired in patients with panuveitis compared to other ocular manifestations (p = 0.0002). Best-corrected visual acuity was inversely correlated with social functioning (ρ = -0.53, p < 0.0001), role-physical (ρ = -0.48, p < 0.0001), bodily pain (ρ = -0.46, p = 0.02), and mental health (ρ = -0.43, p < 0.0001). Patients with BD have a poorer QoL compared to HC, particularly for women, while the decline of QoL is closely related to the overall disease activity of BD. Single organ involvements may affect independently specific SF-36 subscales, especially mucosal, CNS, musculoskeletal, and ocular manifestations.
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Affiliation(s)
- Claudia Fabiani
- Department of Ophthalmology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Antonio Vitale
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Ida Orlando
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Jurgen Sota
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Marco Capozzoli
- Ophthalmology and Neurosurgery Department, University of Siena, Siena, Italy
| | | | - Mauro Galeazzi
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Gian Marco Tosi
- Ophthalmology and Neurosurgery Department, University of Siena, Siena, Italy
| | - Bruno Frediani
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy.
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Wiriyakijja P, Fedele S, Porter S, Mercadante V, Ni Riordain R. Patient-reported outcome measures in recurrent aphthous stomatitis: A critical assessment of quality properties. Oral Dis 2017; 23:1168-1179. [PMID: 28779517 DOI: 10.1111/odi.12726] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/17/2017] [Accepted: 07/30/2017] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To analyse the range of existing patient-reported outcome measures (PROMs) used in studies of recurrent aphthous stomatitis (RAS) and to evaluate their quality properties via the assessment of psychometric properties and interpretability. MATERIALS AND METHODS Electronic databases were searched to identify relevant publications related to PROMs used in RAS. Publications were selected based on predefined criteria. All identified PROMs were then classified by measuring concepts and assessed for instrument characteristics and evidence for quality properties for RAS patients. RESULTS Twenty-eight PROMs were used in studies of RAS patients. Instruments focused upon oral symptoms (n = 4), psychosocial status (n = 15) and quality of life (n = 9). Five PROMs (Oral Health-related Quality of Life-UK, Chronic Oral Mucosal Disease Questionnaire, Oral Health Impact Profile-14, Medical Outcome Study Short Form-36 and Mumcu's composite index) were found to have some evidence of psychometric performance. No PROMs showed evidence for interpretability of their scores in RAS patients. CONCLUSION There was a wide range of PROMs used in clinical studies of RAS. The majority of these PROMs lack evidence of measurement properties and interpretability for RAS patients. Further studies are required to confirm whether these instruments are suitable and useful for this patient group.
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Affiliation(s)
- P Wiriyakijja
- UCL Eastman Dental Institute, London, UK.,Department of Oral Medicine, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - S Fedele
- UCL Eastman Dental Institute, London, UK.,NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - S Porter
- UCL Eastman Dental Institute, London, UK
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15
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Abstract
Behçet's disease (BD) is a chronic relapsing and remitting vasculitis of unknown aetiology. It has the capacity to affect almost all organ systems because of its potential to involve both arteries and veins of all sizes, resulting in significant organ-threatening morbidity and mortality. Traditionally known as the 'silk road' disease, it has a worldwide occurrence. The aetiopathological mechanisms of disease development in BD remain poorly understood, but genome wide studies show human leukocyte antigen and non-human leukocyte antigen associations. Environmental influences and genetic factors may have a role in the aetiopathogenetic mechanisms that lead to development of the disease, indicating the autoimmune and auto-inflammatory nature of BD. The evidence base for treatment is limited but new knowledge is emerging and current treatment options range from symptomatic treatment, through to non-biological and biological immunosuppressive drugs, to cover the spectrum of clinical manifestations.
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Affiliation(s)
- Jagdish R Nair
- National Behcet's Syndrome Centre of Excellence, Aintree University Hospital, Liverpool, UK
| | - Robert J Moots
- University of Liverpool and director, National Behcet's Syndrome Centre of Excellence, Aintree University Hospital, Liverpool, UK
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16
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MUMCU G, LEHİMCİ F, FİDAN Ö, GÜK H, ALPAR U, ÜNAL AU, ERTÜRK Z, ALİBAZ ÖNER F, İNANÇ GN, ERGUN SAT, DİRESKENELİ RH. The assessment of work productivity and activity impairment in Behçet’s disease. Turk J Med Sci 2017; 47:535-541. [DOI: 10.3906/sag-1603-161] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 09/11/2016] [Indexed: 11/03/2022] Open
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17
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Nair JR, Moots RJ. Behçet's disease: Review of management. INDIAN JOURNAL OF RHEUMATOLOGY 2015. [DOI: 10.1016/j.injr.2015.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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18
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Ní Ríordáin R, Shirlaw P, Alajbeg I, Al Zamel GY, Fung PL, Yuan AD, McCreary C, Stoopler ET, De Rossi SS, Lodi G, Greenberg MS, Brennan MT. World Workshop on Oral Medicine VI: Patient-reported outcome measures and oral mucosal disease: current status and future direction. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 120:152-60.e11. [DOI: 10.1016/j.oooo.2015.01.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 12/26/2014] [Accepted: 01/14/2015] [Indexed: 02/08/2023]
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19
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Evaluation of the fungiform papillae number in Behçet’s disease. Clin Oral Investig 2014; 19:887-90. [DOI: 10.1007/s00784-014-1298-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 07/22/2014] [Indexed: 12/14/2022]
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20
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Unmet need in Behcet’s disease: most patients in routine follow-up continue to have oral ulcers. Clin Rheumatol 2014; 33:1773-6. [DOI: 10.1007/s10067-014-2585-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Revised: 03/03/2014] [Accepted: 03/17/2014] [Indexed: 01/26/2023]
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21
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Hatemi G, Merkel PA, Hamuryudan V, Boers M, Direskeneli H, Aydin SZ, Yazici H. Outcome measures used in clinical trials for Behçet syndrome: a systematic review. J Rheumatol 2014; 41:599-612. [PMID: 24488418 DOI: 10.3899/jrheum.131249] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Behçet syndrome (BS) is a multisystem vasculitis that is most active during young adulthood, causing serious disability and significant impairment in quality of life. Differences in the disease course, severity, and organ involvement between patients, depending on the age at presentation and sex, makes it impossible to determine a single management strategy. The diversity and variability in the outcome measures used in clinical trials in BS makes it difficult to compare the results or inform physicians about the best management strategy for individual patients. There is a large unmet need to determine or develop validated outcome measures for use in clinical trials in BS that are acceptable to researchers and regulatory agencies. We conducted a systematic review to describe the outcomes and outcome measures that have been used in clinical trials in BS. This review revealed the diversity and variability in the outcomes and outcome measures and the lack of standard definitions for most outcomes and rarity of validated outcome tools for disease assessment in BS. This systematic literature review will identify domains and candidate instruments for use in a Delphi exercise, the next step in the development of a core set of outcome measures that are properly validated and widely accepted by the collaboration of researchers from many different regions of the world and from different specialties, including rheumatology, ophthalmology, dermatology, gastroenterology, and neurology.
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Affiliation(s)
- Gulen Hatemi
- From the Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey; Division of Rheumatology and Department of Epidemiology, University of Pennsylvania, Philadelphia, PA, USA; Department of Clinical Epidemiology, VU University Medical Center, Amsterdam, The Netherlands; Department of Rheumatology, Marmara University School of Medicine, Istanbul; Department of Rheumatology, Istanbul Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey
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22
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Mumcu G, İnanç N, Özdemir FT, Tulunay A, Ekşioğlu-Demiralp E, Ergun T, Direskeneli H. Effects of azithromycin on intracellular cytokine responses and mucocutaneous manifestations in Behçet's disease. Int J Dermatol 2013; 52:1561-6. [DOI: 10.1111/ijd.12144] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Gonca Mumcu
- Department of Health Informatics and Technologies; Faculty of Health Sciences; Marmara University; Istanbul Turkey
| | - Nevsun İnanç
- Department of Rheumatology; Faculty of Medicine; Marmara University; Istanbul Turkey
| | | | - Aysın Tulunay
- Department of Immunology; Faculty of Medicine; Istanbul Turkey
| | | | - Tülin Ergun
- Department of Dermatology; Faculty of Medicine; Marmara University; Istanbul Turkey
| | - Haner Direskeneli
- Department of Rheumatology; Faculty of Medicine; Marmara University; Istanbul Turkey
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23
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Lee HJ, Kim YN, Jang HW, Jeon HH, Jung ES, Park SJ, Hong SP, Kim TI, Kim WH, Nam CM, Cheon JH. Correlations between endoscopic and clinical disease activity indices in intestinal Behcet's disease. World J Gastroenterol 2012; 18:5771-8. [PMID: 23155319 PMCID: PMC3484347 DOI: 10.3748/wjg.v18.i40.5771] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 07/04/2012] [Accepted: 07/18/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To develop a novel endoscopic severity model of intestinal Behcet's disease (BD) and to evaluate its feasibility by comparing it with the actual disease activity index for intestinal Behcet's disease (DAIBD).
METHODS: We reviewed the medical records of 167 intestinal BD patients between March 1986 and April 2011. We also investigated the endoscopic parameters including ulcer locations, distribution, number, depth, shape, size and margin to identify independent factors associated with DAIBD. An endoscopic severity model was developed using significant colonoscopic variables identified by multivariate regression analysis and its correlation with the DAIBD was evaluated. To determine factors related to the discrepancy between endoscopic severity and clinical activity, clinical characteristics and laboratory markers of the patients were analyzed.
RESULTS: A multivariate regression analysis revealed that the number of intestinal ulcers (≥ 2, P = 0.031) and volcanoshaped ulcers (P = 0.001) were predictive factors for the DAIBD. An endoscopic severity model (Y) was developed based on selected endoscopic variables as follows: Y = 47.44 + 9.04 × non-Ileocecal area + 11.85 ×≥ 2 of intestinal ulcers + 5.03 × shallow ulcers + 12.76 × deep ulcers + 4.47 × geographic-shaped ulcers + 26.93 × volcano-shaped ulcers + 8.65 ×≥ 20 mm of intestinal ulcers. However, endoscopic parameters used in the multivariate analysis explained only 18.9% of the DAIBD variance. Patients with severe DAIBD scores but with moderately predicted disease activity by the endoscopic severity model had more symptoms of irritable bowel syndrome (21.4% vs 4.9%, P = 0.026) and a lower rate of corticosteroid use (50.0% vs 75.6%, P = 0.016) than those with severe DAIBD scores and accurately predicted disease by the model.
CONCLUSION: Our study showed that the number of intestinal ulcers and volcano-shaped ulcers were predictive factors for severe DAIBD scores. However, the correlation between endoscopic severity and DAIBD (r = 0.434) was weak.
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Abstract
Recurrent aphthous ulcers are common painful mucosal conditions affecting the oral cavity. Despite their high prevalence, etiopathogenesis remains unclear. This review article summarizes the clinical presentation, diagnostic criteria, and recent trends in the management of recurrent apthous stomatitis.
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Affiliation(s)
- L Preeti
- Department of Oral Pathology, SRM Dental College, Ramapuram, India
| | - KT Magesh
- Department of Oral Pathology, SRM Dental College and Hospital, Kattankulathur, India
| | - K Rajkumar
- Department of Oral Pathology, SRM Dental College, Ramapuram, India
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25
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Wiwanitkit V. New scoring system for oral ulcer activity: a comment. J Oral Pathol Med 2010; 39:510; author reply 511. [DOI: 10.1111/j.1600-0714.2010.00884.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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