Weak association between subjective symptoms or and objective testing for dry eyes and dry mouth: results from a population based study

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Identification of distinct subgroups of Sjögren's disease by cluster analysis based on clinical and biological manifestations: data from the cross-sectional Paris-Saclay and the prospective ASSESS cohorts

BACKGROUND

Sjögren's disease is a heterogenous autoimmune disease with a wide range of symptoms-including dryness, fatigue, and pain-in addition to systemic manifestations and an increased risk of lymphoma. We aimed to identify distinct subgroups of the disease, using cluster analysis based on subjective symptoms and clinical and biological manifestations, and to compare the prognoses of patients in these subgroups.

METHODS

This study included patients with Sjögren's disease from two independent cohorts in France: the cross-sectional Paris-Saclay cohort and the prospective Assessment of Systemic Signs and Evolution of Sjögren's Syndrome (ASSESS) cohort. We first used an unsupervised multiple correspondence analysis to identify clusters within the Paris-Saclay cohort using 26 variables comprising patient-reported symptoms and clinical and biological manifestations. Next, we validated these clusters using patients from the ASSESS cohort. Changes in disease activity (measured by the European Alliance of Associations for Rheumatology [EULAR] Sjögren's Syndrome Disease Activity Index [ESSDAI]), patient-acceptable symptom state (measured by the EULAR Sjögren's Syndrome Patient Reported Index [ESSPRI]), and lymphoma incidence during follow-up were compared between clusters. Finally, we compared our clusters with the symptom-based subgroups previously described by Tarn and colleagues.

FINDINGS

534 patients from the Paris-Saclay cohort (502 [94%] women, 32 [6%] men, median age 54 years [IQR 43-64]), recruited between 1999 and 2022, and 395 patients from the ASSESS cohort (370 [94%] women, 25 [6%] men, median age 53 years [43-63]), recruited between 2006 and 2009, were included in this study. In both cohorts, hierarchical cluster analysis revealed three distinct subgroups of patients: those with B-cell active disease and low symptom burden (BALS), those with high systemic disease activity (HSA), and those with low systemic disease activity and high symptom burden (LSAHS). During follow-up in the ASSESS cohort, disease activity and symptom states worsened for patients in the BALS cluster (67 [36%] of 186 patients with ESSPRI score <5 at month 60 vs 92 [49%] of 186 at inclusion; p<0·0001). Lymphomas occurred in patients in the BALS cluster (five [3%] of 186 patients; diagnosed a median of 70 months [IQR 42-104] after inclusion) and the HSA cluster (six [4%] of 158 patients; diagnosed 23 months [13-83] after inclusion). All patients from the Paris-Saclay cohort with a history of lymphoma were in the BALS and HSA clusters. This unsupervised clustering classification based on symptoms and clinical and biological manifestations did not correlate with a previous classification based on symptoms only.

INTERPRETATION

On the basis of symptoms and clinical and biological manifestations, we identified three distinct subgroups of patients with Sjögren's disease with different prognoses. Our results suggest that these subgroups represent different heterogeneous pathophysiological disease mechanisms, stages of disease, or both. These findings could be of interest when stratifying patients in future therapeutic trials.

FUNDING

Fondation pour la Recherche Médicale, French Ministry of Health, French Society of Rheumatology, Innovative Medicines Initiative 2 Joint Undertaking, Medical Research Council UK, and Foundation for Research in Rheumatology.

Evaluation and management of dry mouth and its complications in rheumatology practice

INTRODUCTION

The symptom of dry mouth has multiple potential etiologies and can be a diagnostic clue to the presence of common systemic diseases encountered in rheumatology practice. The presence of decreased saliva flow (i.e. salivary hypofunction) defines a subset of dry mouth patients in whom there may be reversible drug effects, an iatrogenic insult such as head and neck irradiation, or a disease that directly involves the salivary glands (e.g. Sjögren's disease). The assessment of salivary hypofunction includes sialometry, salivary gland imaging, salivary gland biopsy, and an assessment for relevant systemic diseases. Optimal management of dry mouth requires accurate definition of its cause, followed by general measures that serve to alleviate its symptoms and prevent its complications.

AREAS COVERED

Through a literature search on xerostomia and salivary hypofunction, we provide an overview of the causes of dry mouth, highlight the potential impact of salivary hypofunction on oral and systemic health, detail routine evaluation methods and treatment strategies, and emphasize the importance of collaboration with oral health care providers.

EXPERT OPINION

Our Expert Opinion is provided on unmet needs in the management of dry mouth and relevant research progress in the field.

Development and content validity assessment of the Dry Eye Disease Questionnaire in patients with dry eye disease, meibomian gland dysfunction, and Sjögren's syndrome dry eye disease

BACKGROUND

Dry eye disease (DED), Meibomian gland dysfunction (MGD), and Sjögren's syndrome dry eye disease (SS-DED) are eye dryness conditions that show significant overlap in various symptoms of ocular discomfort. The aim of this study was to qualitatively explore the patient experience and evaluate content validity of the newly developed Dry Eye Disease Questionnaire (DED-Q).

METHODS

Semi-structured interviews were conducted with 61 US adults who reported experiencing ocular symptoms due to their physician-confirmed primary diagnosis of DED (n = 21), MGD (n = 20), or SS-DED (n = 20). The open-ended concept-elicitation phase was followed by cognitive debriefing (CD) of the DED-Q to evaluate participants' understanding and relevance of the instructions, items, response options, and recall periods. Interviews were also conducted with eight specialist healthcare professionals to assess clinical relevance of the concepts included. Verbatim interview transcripts were analyzed using thematic analysis in ATLAS.ti v8 software.

RESULTS

A total of 29 symptoms and 14 impacts on quality of life were reported across participant interviews. Primary ocular symptoms reported included eye dryness (n = 61/61; 100%), eye irritation (n = 55/61; 90%), eye itch (n = 54/61; 89%), burning sensation (n = 52/61; 85%), and foreign body sensation (n = 51/61; 84%). The most impacted aspects of daily life were using digital screens (n = 46/61; 75%), driving (n = 45/61; 74%), working (n = 39/61; 64%), and reading (n = 37/61; 61%). CD findings showed most participants had good understanding of DED-Q items and confirmed most concepts were relevant to the lived experience of their condition. Aside from few minor changes to the items and examples to facilitate more accurate interpretation, the proposed instruction wording was modified for various symptom and impact modules to encourage participants to focus only on dry eye vision problems.

CONCLUSIONS

This research identified multiple prevalent symptoms and impacts of DED, MGD, and SS-DED, most of which were similar across the conditions. The DED-Q was confirmed to be a content-valid PRO measure suitable for use in clinical studies to assess the patient experience of DED, MGD, and SS-DED. Future work will focus on evaluating the psychometric properties of the DED-Q for use as an efficacy endpoint in clinical trials.

Diagnosis of Photokeratitis by Tear Ferning Using a Novel Set of SK Grading Criteria in a UVB-Induced Mouse Model

Purpose

Current ocular surface diagnostic methods may not totally meet and implement the clinical demands for early and precise treatments. The tear ferning (TF) test has been known as a quick, simple, and inexpensive procedure. This study aimed to validate the TF test as an alternative method for early determination of photokeratitis status.

Methods

The tear sample was collected from the UVB-induced photokeratitis eyes and processed for TF formation. The TF patterns were graded by both the Masmali and a Sophie-Kevin (SK) grading criteria, a new set of criteria modified from the Masmali grading, for differential diagnoses. In addition, the TF test results were correlated with three clinical ocular surface indicators, including tear volume (TV), tear film break-up time (TBUT), and cornea staining, to evaluate the diagnostic capacity.

Results

Differential diagnosis between the normal and the photokeratitis status was achieved by the TF test. The SK grading reflected earlier photokeratitis status than the Masmali grading criteria. The TF results were strongly correlated with the three clinical ocular surface indicators, particularly for the TBUT and cornea staining.

Conclusions

The TF test was proven to have a capacity to distinguish photokeratitis from the normal status at an early stage by using the SK grading criteria. It is therefore potentially useful for photokeratitis diagnosis in the clinical settings.

Translational Relevance

The TF test may fulfill the demands of precise and early diagnosis to facilitate in time the intervention for photokeratitis.

Validation of the PROFAD-SSI-SF in Patients with Primary Sjögren's Syndrome with Organ Involvement: Results of Qualitative Interviews and Psychometric Analyses

INTRODUCTION

The Profile of Fatigue and Discomfort-Sicca Symptoms Inventory-Short Form (PROFAD-SSI-SF) is a 19-item patient-reported outcome (PRO) measure to assess pain, fatigue, and dryness in patients with primary Sjögren's syndrome (pSS). This analysis identified concepts important to measure, and evaluated the content validity and measurement properties of the PROFAD-SSI-SF, in patients with pSS.

METHODS

Qualitative analyses (GSK Study 208396) used transcripts from an online concept elicitation (CE) discussion forum with patients with pSS and interviews with key opinion leaders (KOLs) to finalize a disease model depicting important concepts for patients with pSS. Cognitive debriefing (CD) interviews with patients with pSS were conducted to further evaluate the content validity of the PROFAD-SSI-SF. Quantitative analyses (GSK Study 213253) used post hoc analyses of blinded data from a phase 2 trial to assess PROFAD-SSI-SF measurement properties.

RESULTS

The CE discussion forum (N = 46) revealed dryness (oral 87.0%, ocular 73.9%, cutaneous 37.0%, vaginal 23.9%, nasal 15.2%, otic 6.5%), pain (89.1%), and fatigue (87.0%) as the most reported symptoms. KOLs (N = 5) found the concepts identified in the disease model accurate and understandable, and confirmed that PROs used in pSS studies should focus on dryness, joint pain, and fatigue. In the CD interviews (N = 20), of the 19 participants asked, all found the PROFAD-SSI-SF easy to understand, and 14/19 items were considered relevant by ≥ 18/20 participants. The quantitative analyses found an acceptable fit of the PROFAD-SSI-SF factor structure, with adequate internal consistency, test-retest reliability, convergent validity with other PRO measures, known-groups validity with Patient Global Assessment, and ability to detect change in patients with pSS.

CONCLUSION

The final disease model confirmed that the PROFAD-SSI-SF assesses concepts that are relevant and important to patients with pSS. Our findings support the content validity and measurement properties of the PROFAD-SSI-SF as a fit-for-purpose PRO measure appropriate for use in clinical trials in patients with pSS. CLINICAL TRIAL REGISTRATION NUMBER FOR THE PHASE 2 TRIAL: Clinicaltrials.gov NCT02631538.

Analytical Study of Ocular Surface Changes in Patients of Chronic Kidney Disease undergoing Hemodialysis and Peritoneal Dialysis

Objectives The idiopathic group is a significant cause of chronic kidney disease (CKD) in developing countries. Literature available on ocular surface changes has predominantly been reported in patients undergoing hemodialysis. Little is known about the changes in patients undergoing peritoneal dialysis. The present study aimed to identify ocular surface changes in an idiopathic group of CKD undergoing dialysis.

Aim To compare tear film disorders and the severity of ocular surface changes (goblet cell density, squamous metaplasia, and corneoconjunctival calcification) in patients of idiopathic etiology with CKD undergoing hemodialysis and peritoneal dialysis. This is an analytical study.

Materials and Methods Asymptomatic adult patients of idiopathic CKD, on treatment with dialysis underwent comprehensive ophthalmic examination, including best-corrected visual acuity, slit-lamp examination, and a dilated fundus examination. Dry eye assessment was done by ocular surface staining score, Schirmer test, and tear breakup time (TBUT). Conjunctival impression cytology was studied to assess changes on ocular surface. Chest X-rays for aortic calcification were reviewed and data analyzed.

Results Both eyes of 76 patients of hemodialysis and 32 patients of peritoneal dialysis were studied. Ocular surface staining (OSS) scores were low. Impression cytology showed a drop in goblet cell density, presence of squamous metaplasia, and conjunctival keratinization significantly more in the hemodialysis group. No correlation was seen between the presence of conjunctival calcification and aortic calcification.

Conclusion The hemodialysis group had mild subclinical dry eye but keratinization of conjunctiva was seen. Similarly, advanced squamous metaplasia was seen in the peritoneal dialysis group. These changes were positively correlated to decrease in goblet cell density.

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.

Relationships among Clinical Factors and Patient-reported Outcome Measures in Adults with Convergence Insufficiency

SIGNIFICANCE

When exploring relationships among clinical measures and patient-reported outcome measures in adults with convergence insufficiency, worse symptoms (Convergence Insufficiency Symptom Survey [CISS] score) seemed to be correlated with worse reading function domain score (Adult Strabismus-20 quality-of-life questionnaire). After treatment, improved symptoms were associated with improved reading function quality of life.

PURPOSE

This study aimed to explore relationships between clinical measures and patient-reported outcome measures in adults undergoing treatment for symptomatic convergence insufficiency.

METHODS

In a prospective multicenter observational study, we evaluated adults with symptomatic convergence insufficiency (i.e., clinical measures of near exodeviation, receded near point of convergence, reduced near positive fusional vergence; CISS score ≥21). Fifty-seven participants treated with vision therapy/exercises (n = 35) or base-in prism (n = 22) were analyzed. Spearman correlation coefficients ( R ) were used to assess associations among the three clinical measures and patient-reported outcome measures (CISS, Diplopia Questionnaire, four Adult Strabismus-20 quality-of-life domains) before treatment (baseline) and after 10 weeks and 1 year. Associations were interpreted to be present when the lower limit of the 95% confidence interval (CI) was moderate to strong ( R ≥ 0.4).

RESULTS

Among multiple exploratory analyses, the only moderate to strong baseline correlation was between worse CISS and worse Adult Strabismus-20 reading function scores ( R = 0.62; 95% CI, 0.43 to 0.76). Regarding change in measures with treatment, the only moderate to strong correlations were between improved CISS and improved Adult Strabismus-20 reading function scores for prism at 10 weeks ( R = 0.78; 95% CI, 0.52 to 0.91) and 1 year ( R = 0.85; 95% CI, 0.65 to 0.94) and for vision therapy/exercises at 1 year ( R = 0.78; 95% CI, 0.57 to 0.89).

CONCLUSIONS

In exploratory analyses, we found positive correlations between CISS symptom scores and reading function quality-of-life scores. The absence of correlations between symptoms and individual clinical measures is consistent with clinical experience that, in convergence insufficiency, symptoms and clinical findings can be discordant.

Current and Future Perspectives on Microfluidic Tear Analytic Devices

Most current invasive analytic devices for disease diagnosis and monitoring require the collection of blood, which causes great discomfort for patients and may potentially cause infection. This explains the great need for noninvasive devices that utilize other bodily fluids like sweat, saliva, tears, or urine. Among them, eye tears are easily accessible, less complex in composition, and less susceptible to dilution. Tears also contain valuable clinical information for the diagnosis of ocular and systemic diseases as the tear analyte level shows great correlation with the blood analyte level. These unique advantages make tears a promising platform for use in clinical settings. As the volume of tear film and the rate of tear flow are only microliters in size, the use of microfluidic technology in analytic devices allows minimal sample consumption. Hence, more and more microfluidic tear analytic devices have been proposed, and their working mechanisms can be broadly categorized into four main types: (a) electrochemical, (b) photonic crystals, (c) fluorescence, and (d) colorimetry. These devices are being developed toward the application of point-of-care tests with rapid yet accurate results. This review aims to provide a general overview of the recent developmental trend of microfluidic devices for tear analysis. Moreover, the fundamental principle behind each type of device along with their strengths and weaknesses will be discussed, especially in terms of their abilities and potential in being used in point-of-care settings.

Turkish translation and validation of the Xerostomia Inventory

Objectives

The Xerostomia Inventory (XI) was developed to assess the severity of dryness in patients with xerostomia. It has a long and a short form with three- and five-point Guttman-type response options. In this study, we aimed to translate the XI into Turkish, to assess the validity and reliability of both response options in patients with head & neck cancer (HNC) or Sjögren syndrome (SS), and to select the optimal version for Turkish patients.

Patients and methods

Between January 2019 and June 2019, the XI was translated into Turkish (XI-T) and applied to patients aged ≥18 years with HNC and SS. All patients were applied two tests including both the three- and five-point options. The internal consistency was assessed by Cronbach alpha and test-retest reliability by intraclass correlation coefficients (ICCs). Content validity was based on expert opinion and patient reviews.

Results

A total of 186 patients (109 males, 77 females; median age: 54 years; range, 19 to 78 years) answered the XI-T. The number of patients with HNC and SS was 143 (77%) and 43 (23%), respectively. Median XI-T score was 17 for the three-point, and 24 for the five-point option, respectively. Overall internal consistency was satisfactory for both options (α=0.81 and α=0.89, respectively). Overall test-retest reliability was satisfactory and ICCs ranged between 0.71 and 0.92 for the three-point, and 0.36 and 0.94 for the five-point option, respectively. Assessments based on expert opinions and patient reviews also favored the content validity of the scale.

Conclusion

The XI-T with both three- and five-point options is a valid and reliable tool to evaluate the presence and severity of dryness in patients with HNC and SS who experience xerostomia. The three-point option is more comprehensible and can be preferred over the five-point option in the Turkish population.

Investigation of changes in the activity and function of dry eye-associated brain regions using the amplitude of low-frequency fluctuations method

Objective: The local characteristics of spontaneous brain activity in patients with dry eye (DE) and its relationship with clinical characteristics were evaluated using the amplitude of low-frequency fluctuations (ALFF) method.

Methods: A total of 27 patients with DE (10 males and 17 females) and 28 healthy controls (HCs) (10 males and 18 females) were recruited, matched according to sex, age, weight and height, classified into the DE and HC groups, and examined using functional magnetic resonance imaging (fMRI) scans. Spontaneous brain activity changes were recorded using ALFF technology. Data were recorded and plotted on the receiver operating characteristic (ROC) curve, reflecting changes in activity in different brain areas. Finally, Pearson correlation analysis was used to calculate the potential relationship between spontaneous brain activity abnormalities in multiple brain regions and clinical features in patients with DE. GraphPad Prism 8 (GraphPad Software, Inc.) was used to analyze the linear correlation between the Hospital Anxiety and Depression Scale and ALFF value.

Results: Compared with HCs, the ALFF values of patients with DE were decreased in the right middle frontal gyrus (MFG)/right inferior orbitofrontal cortex (OFC), left triangle inferior frontal gyrus, left MFG, and right superior frontal gyrus. In contrast, the ALFF value of patients with DE was increased in the left calcarine.

Conclusion: There are significant fluctuations in the ALFF value of specific brain regions in patients with DE versus HCs. This corroborates previous evidence showing that the symptoms of ocular surface damage in patients with DE are related to dysfunction in specific brain areas.

Optogenetic Inhibition of Nav1.8 Expressing Corneal Afferents Reduces Persistent Dry Eye Pain

Purpose

The aim of the present study was to investigate the contribution of Nav1.8 expressing corneal afferent neurons to the presence of ongoing pain in lacrimal gland excision (LGE)-induced dry eye.

Methods

The proton pump archaerhodopsin-3/eGFP (ArchT/eGFP) was conditionally expressed in corneal afferents using Nav1.8-cre mice. Dry eye was produced by unilateral LGE. Real time place preference was assessed using a three-chamber apparatus. A neutral, unlit center chamber was flanked by one illuminated with a control light and one illuminated with an ArchT activating light. For real-time preference, animals were placed in the neutral chamber and tracked over five 10-minute sessions, with the lights turned on during the second and fourth sessions. In other studies, movement was tracked over three 10-minute sessions (the lights turned on only during the second session), with animals tested once per day over the course of 4 days. A local anesthetic was used to examine the role of ongoing corneal afferent activity in producing place preference.

Results

The corneal afferent nerves and trigeminal ganglion cell bodies showed a robust eGFP signal in Nav1.8-cre;ArchT/eGFP mice. After LGE, Nav1.8-cre;ArchT/eGFP mice demonstrated a preference for the ArchT activating light paired chamber. Preference was prevented with pre-application to the cornea of a local anesthetic. Nav1.8-cre;ArchT/eGFP mice with sham surgery and LGE wild-type control mice did not develop preference.

Conclusions

Results indicate LGE-induced persistent, ongoing pain, driven by Nav1.8 expressing corneal afferents. Inhibition of these neurons represents a potential strategy for treating ongoing dry eye-induced pain.

Burden of illness among subgroups of patients with primary Sjögren's syndrome and systemic involvement

OBJECTIVES

To describe how patients with primary SS (pSS) and systemic organ involvement are classified and clustered in routine practice.

METHODS

This multinational, cross-sectional survey of real-world quantitative data was conducted across Europe and the US. Rheumatologists who treated seven or more adult patients per month with pSS and current/past systemic manifestations undertook a survey before completing a patient record form capturing demographic, clinical and treatment information for their next six eligible patients. Patients with a completed patient record form were invited to complete a patient self-completion questionnaire capturing insights into their disease and treatment. Subgroups were defined by physicians' assessment of disease severity; clusters were derived based on key clinical characteristics using latent class analysis.

RESULTS

Rheumatologists completed 316 physician surveys and 1879 patient record forms; 888 patients completed the patient self-completion questionnaire. pSS severity reflected organ involvement and symptomatology. Latent class analysis produced five clusters distinguished by the organ systems involved and the presence of pain and fatigue symptoms at the time of the survey. A minority of patients [n = 67 (4%)] were categorized with multiple organ involvement and the highest frequency of pain and fatigue. A total of 324 patients (17%) were categorized as 'low burden'. The remaining three clusters exhibited high frequencies of articular involvement but were distinguished by the extent of other organ system involvement.

CONCLUSION

Cluster analysis using a real-world cohort of patients with pSS and systemic organ involvement highlights the heterogeneous presentation of patients with pSS and confirms the importance of pain and fatigue as well as organ involvement when determining disease burden.

Xerostomia and hyposalivation among a 65-yr-old population living in Oslo, Norway

This study aimed to describe the prevalence and associated factors for xerostomia and hyposalivation in a young‐elderly population. A random sample of 460 65‐yr‐old people living in Oslo, Norway, answered a questionnaire and underwent a clinical examination (237 men and 223 women; response rate 58%). Ten percent of respondents reported xerostomia. The median Summated Xerostomia Index was 6 (interquartile range [IQR]: 5–7) and the median Clinical Oral Dryness Score was 2 (IQR: 1–3). The median unstimulated whole saliva (UWS) secretion rate was 0.34 (IQR: 0.20–0.53) mL min^–1 and the median stimulated whole saliva (SWS) secretion rate was 1.74 (IQR: 1.24–2.38) mL min^–1. In 8% of the study participants the UWS secretion rate was ≤0.1 mL min^–1 and in 4% the SWS secretion rate was ≤0.7 mL min^–1. Three percent of the study participants had both xerostomia and hyposalivation with respect to UWS. Xerostomia was significantly associated with medication use, having rheumatic disease, and having received radiation therapy to the head/neck region. Hyposalivation with respect to UWS and SWS was significantly associated with medication use and type II diabetes. Even though xerostomia and hyposalivation were not prevalent conditions in this population, clinicians should be especially aware of the salivary conditions in patients taking four or more medications, patients diagnosed with type II diabetes, and those who have undergone radiation therapy to the head/neck region.

Application of systane complete for the treatment of contact lens discomfort

PURPOSE

To understand the safety of treating contact lens (CL) discomfort with a new artificial tear when it is directly applied to a CL-wearing eye.

METHODS

This was a two-week, two-visit, double-masked study that randomized participants with CL discomfort to use Systane Complete (artificial tear), Sensitive Eyes (rewetting drop), or no treatment. Drops were applied before, twice during, and after CL use each day. Corneal staining served as the primary safety metric. Conjunctival staining, tear break-up time, Schirmer's test, CL comfort (Contact Lens Dry Eye Questionnaire-8 [CLDEQ-8]), and dry eye symptoms (Standardized Patient Evaluation of Eye Dryness [SPEED]) were also evaluated.

RESULTS

This study recruited 73 participants with a mean age of 30.3 ± 11.5 years; 18 % of the participants were male. There were no significant changes in ocular surface signs from baseline or between the artificial tear and rewetting drop groups after two weeks (p ≥ 0.05). Participants in the artificial tear and rewetting drop groups had significant improvements in CLDEQ-8 scores after two weeks of treatment compared with baseline (p < 0.0001), though scores for this test were not significantly different between these groups after two weeks (p = 0.94). CLDEQ-8 scores were significantly better in the artificial tear and rewetting drop groups compared with no treatment after two weeks (p < 0.0001).

CONCLUSIONS

Both drops were found to be safe for use with CLs while also significantly improving ocular symptoms compared to no treatment after two weeks of use.

Sicca Symptoms, Oral Health Conditions, Salivary Flow and Oral Candida in Sjögren's Syndrome Patients

This study aimed to investigate the relationships among sicca symptoms, oral health conditions, salivary profiles and oral Candida in Sjögren's syndrome (SS) patients. Eighty-five SS patients (mean age = 50.5) and 40 healthy non-SS individuals (mean age = 51.4) were recruited. They self-completed the Sicca Symptoms Inventory (SSI). Decayed, missing and filled surface (DMFS) scores, salivary flow rates, pH and oral Candida colonization were determined. Mean SSI summary scores of SS patients and non-SS individuals were 11.1 and 5.4 respectively (p < 0.001). The most prevalent sicca symptoms in SS patients were eye irritation (93%), dry throat or nose (88%) and need of fluid for mouth wetting (88%). SS patients had significantly lower whole salivary flow rates than the non-SS individuals. Candida strains were isolated from over 60% of SS patients but not in non-SS patients. C. albicans was the predominant species. SSI summary score was negatively correlated to salivary flow rates while SSI summary and domain scores were positively correlated to the number of filled surfaces (FS) and DMFS scores and oral Candida counts. In conclusion, SS patients had more severe sicca symptoms than non-SS individuals. SSI scores were negatively correlated to the salivary flow rates but positively correlated to caries experience and oral Candida colonization.

Reliability and validity of the Japanese version of the Ocular Surface Disease Index for dry eye disease

OBJECTIVES

The Ocular Surface Disease Index (OSDI) questionnaire is widely used to evaluate subjective symptoms of dry eye disease (DED) as a primary diagnostic criterion. This study aimed to develop a Japanese version of the OSDI (J-OSDI) and assess its reliability and validity.

DESIGN AND SETTING

Hospital-based cross-sectional observational study.

PARTICIPANTS

A total of 209 patients recruited from the Department of Ophthalmology at Juntendo University Hospital.

METHODS

We translated and culturally adapted the OSDI into Japanese. The J-OSDI was then assessed for internal consistency, reliability and validity. We also evaluated the optimal cut-off value to suspect DED using an area under the receiver operating characteristic curve (AUC) analysis.

PRIMARY OUTCOME MEASURES

Internal consistency, test-retest reliability and discriminant validity of the J-OSDI as well as the optimal cut-off value to suspect DED.

RESULTS

Of the participants, 152 had DED and 57 did not. The J-OSDI total score showed good internal consistency (Cronbach's alpha=0.884), test-retest reliability (interclass correlation coefficient=0.910) and discriminant validity by known-group comparisons (non-DED, 19.4±16.0; DED, 37.7±22.2; p<0.001). Factor validity was used to confirm three subscales within the J-OSDI according to the original version of the questionnaire. Concurrent validity was assessed by Pearson correlation analysis, and the J-OSDI total score showed a strong positive correlation with the Dry Eye-Related Quality-of-Life Score (γ=0.829). The optimal cut-off value of the J-OSDI total score was 36.3 (AUC=0.744).

CONCLUSIONS

The J-OSDI was developed and validated in terms of reliability and validity as an effective tool for DED assessment and monitoring in the Japanese population.

Value of lipid layer thickness and blinking pattern in approaching patients with dry eye symptoms

OBJECTIVE

To analyze the relationship between dry eye symptoms and modern dry eye tests, including the Schirmer I test, lipid layer thickness (LLT), and blinking pattern by LipiView interferometer.

DESIGN

Cross-sectional study.

PARTICIPANTS

115 dry eye outpatients.

METHODS

Dry eye symptoms were quantified by questionnaire scores, such as Ocular Surface Disease Index (OSDI) and Standard Patient Evaluation of Eye Dryness (SPEED). LLT, complete, and incomplete blinking rate were recorded by the LipiView interferometer.

RESULTS

115 patients (229 eyes, mean age = 60.5 ± 13.6 years) were enrolled in this study. The mean value of the SPEED and OSDI scores was 9.5 and 10.2, respectively. A total of 44.3% of all subjects had severe dry eye syndrome (SPEED, OSDI ≥ 10). LLT (mean = 71.2 nm) was inversely correlated with both the SPEED and OSDI (p = 0.003 and 0.004, respectively). The incomplete-to-complete ratio of blinking rate (i/c ratio) was correlated with both the SPEED and OSDI (p = 0.0048 and 0.0234, respectively). Patients with LLT less than 69 nm were more likely to have severe dry eye syndrome. There was no significant relationship between the Schirmer I test and the SPEED or OSDI. However, LLT was inversely related to the Schirmer I test (linear regression, p = 0.0002, r = -0.1857).

CONCLUSIONS

LLT and the i/c ratio were significantly correlated to dry eye symptoms. Eyes with thinner LLT are more likely to have better aqueous tear production. The role of the reciprocal influence between each tear component in the maintenance of tear function warrants further investigation.

How Common is Dry Mouth? Systematic Review and Meta-Regression Analysis of Prevalence Estimates

The aim of this paper is to systematically review the literature to estimate the overall prevalence of xerostomia/hyposalivation in epidemiological studies. An electronic search was carried out up to February 2018 with no language restrictions. A total of 5760 titles were screened and just twenty-nine papers were included in review and the meta-analysis after a two independently reviewers applied the selection criteria. Data were extracted from PubMed and Web of Science databases. Eligibility criteria included original investigations from observational population-based studies that reported the prevalence of xerostomia or data that allowed the calculation of prevalence of xerostomia and/or hyposalivation. Studies conducted in samples with specific health conditions, literature reviews, case reports and anthropological studies, as conferences or comments were excluded. Sample size, geographic location of the study, study design, age of the studied population, diagnosis methods, and evaluation criteria used to determine xerostomia e/or hyposalivation were extracted for meta-analysis and meta-regression. Multivariate meta-regression analysis was performed to explore heterogeneity among studies. The overall estimated prevalence of dry mouth was 22.0% (95%CI 17.0-26.0%). Higher prevalence of xerostomia was observed in studies conducted only with elderly people. Despite diverse approaches to the condition's measurement, just over one in four people suffer from xerostomia, with higher rates observed among older people. Moreover, the measurement methods used currently may over- or underestimate xerostomia. These findings highlight the need for further work on existing and new clinical measure and will be useful to determine which one is more reliable in clinical and epidemiological perspectives.

Neurological and Inflammatory Manifestations in Sjögren's Syndrome: The Role of the Kynurenine Metabolic Pathway

For decades, neurological, psychological, and cognitive alterations, as well as other glandular manifestations (EGM), have been described and are being considered to be part of Sjögren's syndrome (SS). Dry eye and dry mouth are major findings in SS. The lacrimal glands (LG), ocular surface (OS), and salivary glands (SG) are linked to the central nervous system (CNS) at the brainstem and hippocampus. Once compromised, these CNS sites may be responsible for autonomic and functional disturbances that are related to major and EGM in SS. Recent studies have confirmed that the kynurenine metabolic pathway (KP) can be stimulated by interferon-γ (IFN-γ) and other cytokines, activating indoleamine 2,3-dioxygenase (IDO) in SS. This pathway interferes with serotonergic and glutamatergic neurotransmission, mostly in the hippocampus and other structures of the CNS. Therefore, it is plausible that KP induces neurological manifestations and contributes to the discrepancy between symptoms and signs, including manifestations of hyperalgesia and depression in SS patients with weaker signs of sicca, for example. Observations from clinical studies in acquired immune deficiency syndrome (AIDS), graft-versus-host disease, and lupus, as well as from experimental studies, support this hypothesis. However, the obtained results for SS are controversial, as discussed in this study. Therapeutic strategies have been reexamined and new options designed and tested to regulate the KP. In the future, the confirmation and application of this concept may help to elucidate the mosaic of SS manifestations.

Update on Sjögren Syndrome and Other Causes of Sicca in Older Adults

Dry eye and dry mouth symptoms are each reported by up to 30% of persons more than 65 years of age, particularly in women. Medication side effects are the most common contributing factors. The evaluation of these symptoms requires measures of ocular and oral dryness. Sjögren syndrome is the prototypical disease associated with dryness of the eyes and mouth and predominantly affects women in their perimenopausal and postmenopausal years. In addition to topical treatment of the mucosal dryness, patients with Sjögren syndrome may require treatment with systemic immunomodulatory and immunosuppressive agents to manage a variety of extraglandular manifestations.

Dry eye symptoms and impact on vision-related function across International Task Force guidelines severity levels in the United States

BACKGROUND

International Task Force (ITF) guidelines established a grading scheme to support treatment of dry eye disease based on clinical signs and symptoms. The purpose of this study was to assess the impact of dry eye on vision-related function across ITF severity levels using the Ocular Surface Disease Index (OSDI) questionnaire.

METHODS

Non-interventional, cross-sectional study of prescription treatment-naïve dry eye patients seeking symptom relief at 10 ophthalmology and optometry practices. Clinicians assessed corneal and conjunctival staining, tear break-up time, Schirmer's test (type I with anesthesia), and best-corrected visual acuity. Patients completed the OSDI questionnaire and OSDI overall and domain (Symptoms, Visual Function, and Environmental Triggers) scores were compared across ITF guidelines severity levels (1-4).

RESULTS

Of 158 patients (mean age, 55 years) enrolled, 52 (33%) were ITF level 1, 54 (34%) ITF level 2, and 52 (33%) ITF levels 3/4 combined. No significant differences were observed in most baseline characteristics. Overall OSDI scores (mean [standard deviation]) were 26.5 [20.0] for ITF level 1, 33.8 [17.5] for ITF level 2, and 44.9 [26.1] for ITF level 3/4 cohorts (P < 0.0001). Component OSDI Symptoms, Visual Function, and Environmental Triggers domain scores all worsened with increasing ITF severity level (P ≤ 0.01).

CONCLUSIONS

Dry eye disease has significant deleterious impact on vision-related function across all ITF severity levels.

High Prevalence of Ocular Surface Disease Among Glaucoma Patients in Thailand

PURPOSE

To determine the prevalence of symptoms and signs of ocular surface disease (OSD) among Thai patients with glaucoma receiving topical intraocular pressure (IOP)-lowering therapy.

METHODS

Consecutive patients with glaucoma were recruited prospectively for this cross-sectional study from Siriraj Hospital. Subjective symptoms were evaluated using the Ocular Surface Disease Index (OSDI), and objective clinical signs were evaluated using the tear breakup time (TBUT), corneal fluorescein, rose bengal staining, and the Schirmer test.

RESULTS

One hundred nine patients (56% women; mean age, 64.0 ± 13.7 years) were included. The mean number of IOP-lowering eye drops instilled daily was 3.2 ± 2.4; the mean duration of treatment was 5.4 ± 3.9 years. Forty-two (38.5%) patients reported symptoms using the OSDI. The TBUT was normal in 1 patient, and the others (99.1%) had abnormal tear quality. Fluorescein and rose bengal staining showed positive results in 35 (32.1%) and 42 (38.6%) patients, respectively. The Schirmer test showed decreased tear production in 80 (73.4%) patients. A greater number of IOP-lowering eye drops daily was associated significantly with 3.8 and 4.4 times higher odds of abnormal corneal fluorescein and rose bengal staining, respectively (95% confidence interval [CI], 1.62-9.34, P = 0.002 and 95% CI, 1.91-10.32, P = 0.001, respectively). A significant (P = 0.03, 0.04) correlation was seen between OSDI and corneal dye staining tests.

CONCLUSIONS

A high prevalence of OSD was found among glaucoma patients in Thailand. OSD is more prevalent in Asians than in westerners. Awareness regarding prescribing multiple IOP-lowering eye drops in Asians should be heightened to avoid ocular surface toxicity.

Changes in Distribution of Dry Eye Disease by the New 2016 Diagnostic Criteria from the Asia Dry Eye Society

Dry eye disease (DED) is a disorder of the tear film. Here, we delineate the changes in distribution of DED after diagnostic criteria changes from the 2006 Japanese Diagnostic Criteria to the 2016 Asia Dry Eye Society criteria. We included 250 right eyes of 250 patients and all patients completed ophthalmic assessments for DED. The 2006 criteria classified patients into definite DED, probable DED, and non-DED based on subjective symptoms, tear function, and/or vital staining. The 2016 criteria eliminated probable DED and classified patients into definite DED or non-DED based on subjective symptoms and decreased tear break-up time. We examined how probable DED patients were reclassified by the 2016 criteria. By the 2006 criteria, 38.8% (97/250) of patients had definite DED, 35.6% (89/250) had probable DED, and 25.6% (64/250) had non-DED. By the 2016 criteria, 66.8% (167/250) had definite DED and 33.2% (83/250) had non-DED. Among patients with probable DED using the 2006 criteria, 79.8% (71/89) were reclassified as definite DED and 20.2% (18/89) were reclassified as non-DED using the 2016 criteria. Our data revealed that prevalence of definite DED increased because most probable DED patients were reclassified as definite DED after changes in the diagnostic criteria.

Sjögren Syndrome and Other Causes of Sicca in Older Adults

Dry eye and dry mouth symptoms are each reported by up to 30% of persons more than 65 years of age, particularly in women. Medication side effects are the most common contributing factors. The evaluation of these symptoms requires measures of ocular and oral dryness. Sjögren syndrome is the prototypic disease associated with dryness of the eyes and mouth and predominantly affects women in their perimenopausal and postmenopausal years. In addition to topical treatment of the mucosal dryness, patients with Sjögren syndrome may require treatment with systemic immunomodulatory and immunosuppressive agents to manage a variety of extraglandular manifestations.

Patient burden of Sjögren's: a comprehensive literature review revealing the range and heterogeneity of measures used in assessments of severity

CONTEXT

The severity of Sjögren's syndrome has been evaluated using a wide variety of clinical measures and patient-reported outcomes (PROs). This may contribute to the lack of clarity concerning the burden of Sjögren's from the patient perspective.

OBJECTIVE

To perform a comprehensive peer-reviewed literature analysis of the patient aspects of Sjögren's, focusing on PROs, to investigate the complexity underlying the evaluation of the syndrome and to elucidate the discordance between the different measures.

METHODS

We searched Embase for articles published between January 2005 and September 2015. Research articles, clinical and diagnostic reviews, and validation studies with a focus on patient aspects of Sjögren's were selected as the primary information source.

RESULTS

157 articles met the eligibility criteria. A wide variety of assessment measures used to evaluate glandular, extraglandular and functional domains were observed. Many different, non-validated Visual Analogue Scales, with a wide range of anchor words, were used in the quantification of Sjögren's disease burden, impeding comparisons between studies. Relatively few clinical trials of drug therapies used validated scales: European League Against Rheumatism Sjögren's Syndrome Patient Reported Index was used most often for symptom assessment and 36 Item Short Form Survey for quality of life (QoL).

CONCLUSION

A wide range and diversity of measures are used to evaluate the patient burden of Sjögren's; most are not validated for use in this disease. PRO endpoints, validated specifically in Sjögren's, that demonstrate improvement are needed. These measures should focus on QoL aspects important to patients and will most likely involve gauging change in function rather than patient-reported symptoms.

Patient burden of Sjögren's: a comprehensive literature review revealing the range and heterogeneity of measures used in assessments of severity

CONTEXT

The severity of Sjögren's syndrome has been evaluated using a wide variety of clinical measures and patient-reported outcomes (PROs). This may contribute to the lack of clarity concerning the burden of Sjögren's from the patient perspective.

OBJECTIVE

To perform a comprehensive peer-reviewed literature analysis of the patient aspects of Sjögren's, focusing on PROs, to investigate the complexity underlying the evaluation of the syndrome and to elucidate the discordance between the different measures.

METHODS

We searched Embase for articles published between January 2005 and September 2015. Research articles, clinical and diagnostic reviews, and validation studies with a focus on patient aspects of Sjögren's were selected as the primary information source.

RESULTS

157 articles met the eligibility criteria. A wide variety of assessment measures used to evaluate glandular, extraglandular and functional domains were observed. Many different, non-validated Visual Analogue Scales, with a wide range of anchor words, were used in the quantification of Sjögren's disease burden, impeding comparisons between studies. Relatively few clinical trials of drug therapies used validated scales: European League Against Rheumatism Sjögren's Syndrome Patient Reported Index was used most often for symptom assessment and 36 Item Short Form Survey for quality of life (QoL).

CONCLUSION

A wide range and diversity of measures are used to evaluate the patient burden of Sjögren's; most are not validated for use in this disease. PRO endpoints, validated specifically in Sjögren's, that demonstrate improvement are needed. These measures should focus on QoL aspects important to patients and will most likely involve gauging change in function rather than patient-reported symptoms.

Can the optimum artificial tear treatment for dry eye disease be predicted from presenting signs and symptoms?

PURPOSE

To assess dry eye treatment with four preservative-free dry eye artificial tear treatments to facilitate evidence-based prescribing.

METHODS

A randomised, single masked crossover trial of Clinitas Soothe, Hyabak, Tears Again and TheraTears artificial tears was conducted on 50 symptomatic dry eye patients, aged 60.8±14.2years. At baseline and after trialling each treatment for 4 weeks, signs and symptoms were assessed using the Ocular Surface Disease Index (OSDI), non-invasive tear break-up time, fluorescein tear break-up time, tear meniscus height (TMH), Phenol Red test, lid-parallel conjunctival folds (LIPCOF), ocular surface staining, and lipid layer grading and osmolarity (baseline visit only).

RESULTS

OSDI (p=0.002), LIPCOF (p=0.014) and conjunctival staining (p<0.001) significantly improved from baseline, however, the impact of each dry eye treatment on ocular symptoms and signs was similar. Clinitas Soothe and Hyabak were preferred by 34%/30% of participants, but only subjective comparison with the other drops influenced this choice. TheraTears was preferred (by 24%) by those with a lower baseline tear volume (p=0.01) and Tears Again (by 12%) by those with a thinner baseline lipid layer (p=0.04). The treatment that afforded the greatest improvement in clinical signs did not consistently match each individual's preferred treatment.

CONCLUSIONS

If prescribed to a general dry eye population, the artificial tears performed similarly, improving symptoms and conjunctival signs. However, osmolarity balanced artificial tears were the preferred treatment in individuals with low baseline tear volume and lipisomal spray for individuals with a baseline lipid layer deficiency.

Dry Eye Disease: Concordance Between the Diagnostic Tests in African Eyes

OBJECTIVE

To assess the concordance between the diagnostic tests for dry eye disease (DED) in a Nigerian hospital population.

METHODS

The study was a hospital-based cross-sectional survey of adults (≥18 years) presenting at the eye clinic of the University of Nigeria Teaching Hospital (UNTH), Enugu; September-December, 2011. Participants' socio-demographic data were collected. Each subject was assessed for DED using the "Ocular Surface Disease Index" (OSDI) questionnaire, tear-film breakup time (TBUT), and Schirmer test. The intertest concordance was assessed using kappa statistic, correlation, and regression coefficients.

RESULTS

The participants (n=402; men: 193) were aged 50.1±19.1 standard deviation years (range: 18-94 years). Dry eye disease was diagnosed in 203 by TBUT, 170 by Schirmer test, and 295 by OSDI; the concordance between the tests were OSDI versus TBUT (Kappa, κ=-0.194); OSDI versus Schirmer (κ=-0.276); and TBUT versus Schirmer (κ=0.082). Ocular Surface Disease Index was inversely correlated with Schirmer test (Spearman ρ=-0.231, P<0.001) and TBUT (ρ=-0.237, P<0.001). In the linear regression model, OSDI was poorly predicted by TBUT (β=-0.09; 95% confidence interval (CI): -0.26 to -0.03, P=0.14) and Schirmer test (β=-0.35, 95% CI: -0.53 to -0.18, P=0.18).

CONCLUSION

At UNTH, there is poor agreement, and almost equal correlation, between the subjective and objective tests for DED. Therefore, the selection of diagnostic test for DED should be informed by cost-effectiveness and diagnostic resource availability, not diagnostic efficiency or utility.

Predictors of Discordance between Symptoms and Signs in Dry Eye Disease

PURPOSE

To investigate predictors of discordance between symptoms and signs in dry eye disease (DED).

DESIGN

Cross-sectional association study.

PARTICIPANTS

A total of 648 patients with dry eye from the Groningen LOngitudinal Sicca StudY (GLOSSY), a tertiary dry eye clinic patient cohort from the Netherlands.

METHODS

Patient symptoms were assessed using the Ocular Surface Disease Index (OSDI) questionnaire. Dry eye signs were assessed by tear osmolarity, Schirmer test, tear breakup time, corneal and conjunctival staining, and meibomian gland dysfunction, all in both eyes, and a composite dry eye signs severity score was calculated from these 6 tests for each patient. Linear regression analysis was used to test the association of discordance between symptoms and signs with a wide range of independent variables (demographic and environmental variables, systemic diseases, ocular traits, and medications).

MAIN OUTCOME MEASURES

Predictors of discordance between symptoms and signs in DED, defined by the difference between the rank score of the OSDI and the rank score of the dry eye signs severity score.

RESULTS

Of the 648 subjects in this cohort, 536 (82.7%) were female and the mean age was 55.8 years (standard deviation, 15.6 years). Significant predictors of greater symptoms than signs were the presence of a chronic pain syndrome, atopic diseases, a known allergy, the use of antihistamines (all P < 0.001), depression (P = 0.003), osteoarthritis (P = 0.008), and the use of antidepressants (P = 0.02). Predictors of lesser symptoms than signs were increased age (P < 0.001) and the presence of Sjögren's disease (P < 0.001) (primary Sjögren's disease, P < 0.001) more than secondary Sjögren's disease (P = 0.08), and graft-versus-host disease (P = 0.04). Furthermore, greater symptoms compared with signs were highly associated with lower self-perceived health (P < 0.001).

CONCLUSIONS

This large clinical study has shown that discordance between symptoms and signs in DED is an indicator of self-perceived health. The study found important predictors of greater symptoms to signs but also predictors of lesser symptoms to signs. Awareness of these predictors is helpful in assessing patients with dry eye in clinical practice.

Development, Sensibility, and Validity of a Systemic Autoimmune Rheumatic Disease Case Ascertainment Tool

OBJECTIVE

Case ascertainment through self-report is a convenient but often inaccurate method to collect information. The purposes of this study were to develop, assess the sensibility, and validate a tool to identify cases of systemic autoimmune rheumatic diseases (SARD) in the outpatient setting.

METHODS

The SARD tool was administered to subjects sampled from specialty clinics. Determinants of sensibility - comprehensibility, feasibility, validity, and acceptability - were evaluated using a numeric rating scale from 1-7. Comprehensibility was evaluated using the Flesch Reading Ease and the Flesch-Kincaid Grade Level. Self-reported diagnoses were validated against medical records using Cohen's κ statistic.

RESULTS

There were 141 participants [systemic lupus erythematosus (SLE), systemic sclerosis (SSc), rheumatoid arthritis, Sjögren syndrome (SS), inflammatory myositis (polymyositis/dermatomyositis; PM/DM), and controls] who completed the questionnaire. The Flesch Reading Ease score was 77.1 and the Flesch-Kincaid Grade Level was 4.4. Respondents endorsed (mean ± SD) comprehensibility (6.12 ± 0.92), feasibility (5.94 ± 0.81), validity (5.35 ± 1.10), and acceptability (3.10 ± 2.03). The SARD tool had a sensitivity of 0.91 (95% CI 0.88-0.94) and a specificity of 0.99 (95% CI 0.96-1.00). The agreement between the SARD tool and medical record was κ = 0.82 (95% CI 0.77-0.88). Subgroup analysis by SARD found κ coefficients for SLE to be κ = 0.88 (95% CI 0.79-0.97), SSc κ = 1.0 (95% CI 1.0-1.0), PM/DM κ = 0.72 (95% CI 0.49-0.95), and SS κ = 0.85 (95% CI 0.71-0.99). The screening questions had sensitivity ranging from 0.96 to 1.0 and specificity ranging from 0.88 to 1.0.

CONCLUSION

This SARD case ascertainment tool has demonstrable sensibility and validity. The use of both screening and confirmatory questions confers added accuracy.

Analysis of the cell populations composing the mononuclear cell infiltrates in the labial minor salivary glands from patients with rheumatoid arthritis and sicca syndrome

OBJECTIVES

Sicca symptoms occur in around 30% of rheumatoid arthritis (RA) patients. Herein, we examined the characteristics of RA patients bearing sicca symptomatology (RA-sicca) with a special focus on the immunohistopathological features of their labial minor salivary gland (LMSG) biopsies.

METHODS

Our cohort included 100 consecutive RA patients which were interrogated using a sicca symptoms questionnaire. Positive responders were evaluated for ocular and oral dryness and underwent an LMSG biopsy. All samples were immunohistochemically evaluated for the presence and distribution of specific leukocyte subsets using appropriate markers and for the expression of certain immunoregulatory molecules by salivary gland epithelial cells. Positively stained and total mononuclear cells (MNC) were counted in the entire section. Counts were expressed as cell frequency (percentage of cell type number/total infiltrating MNC number).

RESULTS

In the majority (86.1%) of the 44 RA-sicca cases, periductal infiltrates were observed in LMSG biopsies. The frequencies of infiltrating cell subtypes and their correlation with lesion severity were different from that previously described in primary Sjögren's syndrome (pSS). Moreover, DCs and ΜΦs frequencies were increased in RA-sicca patients who had a biopsy focus score <1 and absence of anti-Ro/anti-La autoantibodies, in contrast to what was observed for B cells. In about half of the biopsies, salivary gland epithelial cells expressed CD80/B7.1 molecules, most commonly in patients with a positive biopsy or anti-Ro/anti-La autoantibodies.

CONCLUSION

LMSG infiltrates composition in RA-sicca patients is distinct from that described in pSS. These differences, further attest to diverse pathophysiologic processes operating in these two entities.

Oral health in patients taking psychotropic medications: Results from a pharmacy-based pilot study

OBJECTIVES

Individuals with mental illness face an increased risk of oral disease compared with those without mental illness. The goals of this study were to examine the self-reported oral health and dental access of individuals filling psychotropic medication prescriptions and to determine whether pharmacy patients would choose to speak with a pharmacist about their oral health if given the option to do so.

DESIGN

Pharmacists across 6 community pharmacies within a local chain identified and surveyed adult patients filling prescriptions for psychotropic medications. Surveys included questions about oral health, dry mouth, and dental care utilization.

SETTING

Six community pharmacy locations.

PARTICIPANTS

Adults (≥18 years of age) filling prescriptions for psychotropic medications.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Self-reported oral health, dental utilization, desire to discuss oral health with a pharmacist.

RESULTS

Participants (N = 178) filling prescriptions were mostly (65.9%) female with a mean age of 48.2 years (SD 14.3, range 19-82 years). One in 4 (24.9%) said their mouths "always" or "frequently" felt dry; these individuals were significantly more likely to have last seen a dentist for emergency (rather than routine) treatment (P <0.01) and rated their oral health as significantly worse (P <0.001) than participants whose mouths "never" or "occasionally" feel dry. A small percentage (5.7%) requested to speak with pharmacists about oral health; they reported poorer oral health than those who opted not to speak with a pharmacist (P <0.05).

CONCLUSION

One in 4 patients reported having dry mouth, and those with dry mouth reported significantly worse oral health than patients without dry mouth. Although dry mouth and poor oral health were common in this sample of individuals taking psychotropic medications, this did not consistently translate into seeking information regarding oral health. Future research will focus on pharmacist-initiated oral health interventions with high-risk patients.

Diagnostic Performance of McMonnies Questionnaire as a Screening Survey for Dry Eye: A Multicenter Analysis

Purpose. To evaluate the diagnostic performance of the McMonnies questionnaire as a screening survey for dry eye in Chinese outpatients. Methods. The questionnaire was self-administered by 27,999 patients with dry eye symptoms. A thorough ophthalmic examination including tear break-up time (TBUT), fluorescein staining, and Schirmer I test was completed to make a clinical diagnosis of dry eye. Reliability, validity, and accuracy of the McMonnies questionnaire were assessed. Results. The McMonnies questionnaire showed poor internal consistency (Cronbach α = 0.37), but excellent validity as the scores correlated with TBUT (Spearman test, r = −0.322, P < 0.001) and Schirmer I test (Spearman's test, r = −0.370, P < 0.001), and significantly differed between the dry eye and control groups (2-sample t-test, t = 69.51, P < 0.001). The area under the receiver-operating characteristics (ROC) curve (AUC) was 0.729, suggesting moderate accuracy in identifying dry eye and non-dry eye patients. However, the AUCs varied significantly in different gender and age subgroups (z test, P < 0.001), as the discriminating ability declined with age. Analysis of the ROC curves also revealed that different cut-off points should be employed for each subgroup to achieve the same level of accuracy. Conclusions. The McMonnies questionnaire demonstrates moderate diagnostic value, and different cut-off points should be selected for various study populations.

Translation and Validation of a Korean Version of the Xerostomia Inventory in Patients with Primary Sjögren's Syndrome

This study was conducted to generate and validate a cross-culturally adapted Korean version of the xerostomia inventory (XI), an 11-item questionnaire designed to measure the severity of xerostomia. The original English version of the XI was translated into Korean according to the guidelines for cross-cultural adaptation of health-related quality-of-life measures. Among a prospective cohort of primary Sjögren's syndrome (pSS) in Korea, 194 patients were analyzed. Internal consistency was evaluated by using Cronbach's alpha, and test-retest reliability was obtained by using an intraclass correlation coefficient (ICC) analysis. Construct validity was investigated by performing a correlation analysis between XI total score and salivary flow rate (SFR). Cronbach's alpha for internal consistency was 0.868, and the ICC for test-retest reliability ranged from 0.48 to 0.827, with a median value of 0.72. Moderate negative correlations between XI score and stimulated SFR, unstimulated SFR, and differential (stimulated minus unstimulated) SFR were observed (Spearman's rho, ρ = -0.515, -0.447, and -0.482, respectively; P < 0.001). The correlation analysis between the visual analogue scale (VAS) score of overall dryness and SFR indicated a smaller ρ value (-0.235 [P = 0.006], -0.243 [P = 0.002], and -0.252 [P = 0.003], respectively), which supports that XI more accurately reflects the degree of xerostomia in the pSS patients. In conclusion, the Korean version of the XI is a reliable tool to estimate the severity of xerostomia in patients with pSS.

Assessment of conjunctival goblet cell density using laser scanning confocal microscopy versus impression cytology

PURPOSE

To determine the association between conjunctival goblet cell density (GCD) assessed using in vivo laser scanning confocal microscopy and conjunctival impression cytology in a healthy population.

METHODS

Ninety (90) healthy participants undertook a validated 5-item dry eye questionnaire, non-invasive tear film break-up time measurement, ocular surface fluorescein staining and phenol red thread test. These tests where undertaken to diagnose and exclude participants with dry eye. The nasal bulbar conjunctiva was imaged using laser scanning confocal microscopy (LSCM). Conjunctival impression cytology (CIC) was performed in the same region a few minutes later. Conjunctival goblet cell density was calculated as cells/mm(2).

RESULTS

There was a strong positive correlation of conjunctival GCD between LSCM and CIC (ρ=0.66). Conjunctival goblet cell density was 475±41 cells/mm(2) and 466±51 cells/mm(2) measured by LSCM and CIC, respectively.

CONCLUSIONS

The strong association between in vivo and in vitro cellular analysis for measuring conjunctival GCD suggests that the more invasive CIC can be replaced by the less invasive LSCM in research and clinical practice.

Dry eyes and AIs: If you don't ask you won't find out

OBJECTIVES

Our objective was to investigate the hypothesis that women on adjuvant aromatase inhibitors (AIs) for treatment of breast cancer have a higher prevalence of dry eye syndrome (DES) compared with controls.

MATERIALS AND METHODS

Exposure and control groups were recruited. A cross sectional questionnaire-based study was performed. Demographic data and medical histories were collected. The presence of dry eye syndrome was determined by the ocular surface disease index (OSDI). The Functional Assessment of Cancer Treatment - Endocrine Subscale (FACT-ES) was performed to investigate correlations with other side effects of AIs.

RESULTS

93 exposure group and 100 control group questionnaires were included. The groups were similar in all demographic variables. The prevalence of dry eye syndrome was 35% (exposure) and 18% (control) (p < 0.01, OR 2.5). AIs were the only factor associated with dry eyes. The OSDI score was negatively correlated with the total FACT-ES score and positively correlated with duration of treatment.

CONCLUSION

Our study is the first to use a validated questionnaire to assess for DES in this population. DES is significantly more prevalent in women on AIs compared with controls. This is a newly emerging, and easily treated side effect of AIs. Self-reporting of dry eye symptoms underestimates the prevalence of DES with AIs. We recommend routine screening of patients on AIs with the OSDI with the aim of improving patient quality of life and possibly adherence.

Associations between signs and symptoms of dry eye disease: a systematic review

PURPOSE

The accurate diagnosis and classification of dry eye disease (DED) is challenging owing to wide variations in symptoms and lack of a single reliable clinical assessment. In addition, changes and severity of clinical signs often do not correspond to patient-reported symptoms. To better understand the inconsistencies observed between signs and symptoms, we conducted a systematic literature review to evaluate published studies reporting associations between patient-reported symptoms and clinical signs of DED.

METHODS

PubMed and Embase were searched for English-language articles on the association between clinical signs and symptoms of DED up to February 2014 (no lower limit was set).

RESULTS

Thirty-four articles were identified that assessed associations between signs and symptoms, among which 33 unique studies were reported. These included 175 individual sign-symptom association analyses. Statistical significance was reported for associations between sign and symptom measures in 21 of 33 (64%) studies, but for only 42 of 175 (24%) individual analyses. Of 175 individual analyses, 148 reported correlation coefficients, of which the majority (129/148; 87%) were between -0.4 and 0.4, indicating low-to-moderate correlation. Of all individual analyses that demonstrated a statistically significant association, one-half (56%) of reported correlation coefficients were in this range. No clear trends were observed in relation to the strength of associations relative to study size, statistical methods, or study region, although results from three studies did suggest that disease severity may be a factor.

CONCLUSION

Associations between DED signs and symptoms are low and inconsistent, which may have implications for monitoring the response to treatment, both in the clinic and in clinical trials. Further studies to increase understanding of the etiopathogenesis of DED and to identify the most reliable and relevant measures of disease are needed to enhance clinical assessment of DED and the measurement of response to therapeutic interventions.

Diadenosine polyphosphates in the tears of aniridia patients

PURPOSE

To quantify diadenosine polyphosphate levels in tears of congenital aniridia patients to estimate the ocular surface changes associated with congenital aniridia compared to normal individuals.

METHODS

Fifteen patients diagnosed with congenital aniridia and a control group of forty volunteers were studied. Tears were collected to quantify the levels of diadenosine polyphosphates Ap4 A and Ap5 A by high-performance liquid chromatography (H.P.L.C). Break-up time (BUT), corneal staining, McMonnies questionnaire and the Schirmer I test were applied to both groups.

RESULTS

Dinucleotides in congenital aniridia patients were higher than in control subjects. For the congenital aniridia group, under 15 years old, the values were 0.77 ± 0.01 μm and 0.17 ± 0.02 μm for Ap4 A and Ap5 A, respectively. The group aged from 15 to 40 years old provided concentrations of 4.37 ± 0.97 μm and 0.46 ± 0.05 μm for Ap4 A and Ap5 A, the group over 40 gave concentrations of 11.17 ± 5.53 μm and 0.68 ± 0.17 μm for Ap4 A and Ap5 A. Dinucleotide concentrations increased with age, being statistically significant different among the three age groups (p < 0.05). Congenital aniridia patients showed a normal tear secretion and no dry eye McMonnies scores, except for the group over 40 years old. BUT values decreased and corneal staining increased with age and correlated with the levels of diadenosine polyphosphates (p < 0.05).

CONCLUSIONS

The levels of dinucleotides in tears increase in aniridia patients compared with healthy subjects, and they seem to be related with the progression of corneal disorders in aniridia patients, both of which increase with ageing.

Real-time sonoelastography of salivary glands for diagnosis and functional assessment of primary Sjögren's syndrome

The purpose of this study was to investigate the value of real-time sonoelastography (RTS) of salivary glands for the diagnosis and assessment of glandular damage in primary Sjögren's syndrome (pSS). After institutional review board approval, 45 pSS patients, 24 sicca patients and 11 healthy controls were investigated prospectively. Questionnaires were completed and Saxon and Schirmer tests and routine blood tests carried out in all patients. All patients underwent B-mode ultrasonography and RTS of parotid and submandibular glands. Abnormal findings were graded from 0 to 48 and from 0 to 16, respectively. Sialoscintigraphy was done according to a routine protocol; scoring ranged from 0 to 12. Statistical analysis comprised receiver operating characteristic curve and multivariate regression analysis. Patients with pSS had higher B-mode (median score = 25 [range: 2-44] vs. 9 [1-20], p < 0.001) and RTS (6.5 [2-13] versus 4 [1-9], p < 0.001) scores than controls with sicca syndrome, yielding areas under the curve of 0.83 and 0.85 (p < 0.05 each), respectively for pSS diagnosis. In cases with an inconclusive B-mode ultrasonography result, RTS (cutoff score: ≥ 6) led to a sensitive (66.7%) and specific (85.7%) classification of patients and sicca controls. In multivariate regression analysis, RTS (regression coefficient = -0.48, p = 0.005), but not B-mode ultrasonography, reflected impaired salivary gland function according to the Saxon test, whereas none of the subjective measures of dryness or discomfort were related to ultrasonography results. B-mode and RTS results were both associated with sialoscintigraphy scores (regression coefficient = 0.66, p < 0.001, and regression coefficient = 0.55, p = 0.001, respectively). Reproducibility of B-mode ultrasonography and RTS was good, with intra-class correlation coefficients of 0.93 (95% confidence interval: 0.57-0.98) and 0.93 (95% confidence interval: 0.79-0.98), respectively. In summary, RTS might be a useful adjunct to B-mode ultrasonography for diagnosis and assessment of salivary gland impairment in primary Sjögren's syndrome.

Dry eye in the beaver dam offspring study: prevalence, risk factors, and health-related quality of life

PURPOSE

To estimate dry eye prevalence in the Beaver Dam Offspring Study (BOSS), including a young adult population, and investigate associated risk factors and impact on health-related quality of life.

DESIGN

Cohort study.

METHODS

The BOSS (2005-2008) is a study of aging in the adult offspring of the population-based Epidemiology of Hearing Loss Study cohort. Questionnaire data on health history, medication use, risk factors, and quality of life were available for 3275 participants. Dry eye was determined by self-report of frequency of symptoms and the intensity of those symptoms. Associations between dry eye and risk factors were analyzed using logistic regression.

RESULTS

The prevalence of dry eye in the BOSS was 14.5%: 17.9% of women and 10.5% of men. In a multivariate model, statistically significant associations were found with female sex (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.33-2.11), current contact lens use (OR, 2.01; 95% CI, 1.53-2.64), allergies (OR, 1.59; 95% CI, 1.22-2.08), arthritis (OR, 1.44; 95% CI, 1.12-1.85), thyroid disease (OR, 1.43; 95% CI, 1.02-1.99), antihistamine use (OR, 1.54; 95% CI, 1.18-2.02), and steroid use (OR, 1.54; 95% CI, 1.16-2.06). Dry eye was also associated with lower scores on the Medical Outcomes Study Short Form 36 (β = -3.9, P < .0001) as well as on the National Eye Institute 25-Item Visual Function Questionnaire (NEI VFQ-25) (β = -3.4, P < .0001) when controlling for age, sex, and comorbid conditions.

CONCLUSIONS

The prevalence of dry eye and its associated risk factors in the BOSS were similar to previous studies. In this study, dry eye was associated with lower quality of life on a health-related quality-of-life instrument and the vision-specific NEI VFQ-25.