Primary Sjögren's syndrome: Extraglandular manifestations and hydroxychloroquine therapy.

The use of hydroxychloroquine (HCQ) in Primary Sjögren's Syndrome (pSS) has been assessed in different studies over the last years, with conflicting results regarding its efficacy in sicca syndrome and extraglandular manifestations (EGM). The goal of this study was to compare the incidence rate of EGM in pSS patients with and without HCQ therapy.We performed a multicenter retrospective study, including patients with pSS (European classification criteria) with at least 1 year of follow-up. Subjects with concomitant fibromyalgia, autoimmune hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis were excluded. Demographics and pSS characteristics were recorded. The EGM were defined by EULAR-SS disease activity index (ESSDAI). Patients were divided into two groups according to their use or not of HCQ therapy. We evaluated the use of HCQ and its relationship to EGM. HCQ therapy was defined as the continuous use of the drug for at least 3 months. A descriptive analysis of demographics and pSS characteristics was performed. We compared the incidence of EGM between groups defined by HCQ therapy using chi2 test or Fisher's exact test. A total of 221 patients were included (97.3% women), mean age, 55.7 years (SD 14). Mean age at diagnosis, 48.8 years (SD 15); median disease duration, 60 months (IQR 35-84). One hundred and seventy patients (77%) received HCQ. About half of the patients had at least one EGM during the course of the disease, 20% of them developed an EGM before the onset of the sicca syndrome and 26% simultaneously with dryness symptom. Overall, EGM were less frequent in those on HCQ therapy (36.5% vs 63.5%, p < 0.001). Considering each EGM individually, the following manifestations were more frequent in the non-treated group: arthritis (p < 0.001), fatigue (p < 0.001), purpura (p = 0.01), Raynaud phenomenon (p = 0.003), and hypergammaglobulinemia (p = 0.006). Immunosuppressive treatment was indicated on 28 patients (12.7%), 13 of which were receiving also HCQ. The first reason for those treatments was the presence of arthritis in 12/28 patients (42.8%), and the drug used in all the cases was methotrexate. Only three patients required immunosuppressive therapy with cyclophosphamide, due to the presence of glomerulonephritis, vasculitis, and interstitial lung disease. None of the patients received biologic therapy. The lower incidence of EGM was observed in patients on HCQ therapy supports its efficacy in pSS. However, further large scale prospective studies are needed to confirm these findings.

The effect of various methods of eye immobilization on corneal topography.

BACKGROUND: Accurate, predictable, and safe refractive surgery requires immobilization of the eye. We measured the effects of current eye fixation techniques on human cadaver eyes. MATERIALS AND METHODS: Central to our study was a device specially designed to secure cadaver eyes and stabilize intraocular pressure. Topographical measurements were made with a modified Model 2 Corneal Analysis System (EyeSys Technologies, Houston, Tex) mounted vertically to allow analysis of a cadaver eye mounted in the artificial orbit. The effect on human cadaver eyes of six fixation instruments was assessed: forceps, U-shaped fixation forceps, a full Hofman-Thornton ring, a VISX vacuum fixation ring, a Meditec suction ring, and a new instrument, the Eye Fixation Speculum. RESULTS: The circular vacuum fixation rings caused minimal distortion, resulting in less than 1.00 diopter (D) of change. Forceps and U-shaped fixation forceps, which apply force at one or two points, caused significantly more distortion. Single-point fixation forceps distorted the cornea at the point of application a mean of +5.50 +/- 3.50 D, and, at 180 degrees from the point of instrument application, a mean of +2.00 +/- 1.90 D. U-shaped forceps apply force at two points, 90 degrees and 270 degrees, from the axis of instrument application. At these axes, the cornea was distorted a mean of +9.40 +/- 3.70 D and +8.30 +/- 3.10 D, respectively. CONCLUSIONS: Single- and multi-point fixation instruments, due to an asymmetric application of fixation force, significantly distort the cornea. Ring fixation instruments, which apply a more equally distributed force, cause less distortion.

Population-specific screening by mutation analysis for diseases frequent in Ashkenazi Jews.

We describe a partially automated DNA mutation assay for detecting the most frequent mutations in the alpha-subunit of beta-hexosaminidase A, the acid beta-glucosidase and the cystic fibrosis transmembrane conductance regulator genes for the Ashkenazi Jewish population. The assay detects carriers for Tay-Sachs disease, Gaucher disease, and cystic fibrosis with sensitivities of at least 92%, 96%, and 97%, respectively. Among 1,364 young adults of Ashkenazic ancestry in the Dor Yeshurim community who were tested, 52 were Tay-Sachs carriers, 110 were Gaucher carriers, and 62 were cystic fibrosis carriers. Ten individuals were carriers for two diseases, and three unsuspected cases were diagnosed with Gaucher disease based on mutation test results. In addition to Tay-Sachs mutation data, results for hexosaminidase A activity were also available. All of 1,254 samples normal by enzyme quantitation were also negative for the three alpha-subunit mutations tested, and all of 43 samples with 'inconclusive' enzyme results were negative by DNA. Only 52 of 67 samples positive by enzyme assay were also positive for one of the three mutations tested for Tay-Sachs disease. The data suggest a high degree of false positivity inherent in enzyme identification of carriers. There are no correlative methods to assess the sensitivity of Gaucher and CF carrier testing. The results show that population screening can be carried out efficiently by DNA analysis, with the accrual of carrier information for three separate diseases conducted as a single test. Furthermore, the DNA method for Tay-Sachs screening appears to exceed the specificity of hexosaminidase A enzyme testing.

193-nm excimer photorefractive keratectomy in high myopia.

PURPOSE: To evaluate the refractive results of 193-nm excimer laser photorefractive keratectomy (PRK) performed on 48 highly myopic eyes in a multicenter study. METHODS: A Visx 2015 or 2000 argon-fluoride excimer laser and a single-zone ablation technique were used. Postoperatively, eyes were treated with topical fluoromethalone for up to 5 months. Most eyes were treated with a 6.0- to 6.2-mm beam diameter after undercorrections and increased regression were noted with a 5.5-mm beam in earlier studies. Forty-eight eyes were treated for myopia, which was between -8.0 and -15.25 diopters (D) (spherical equivalent). The mean preoperative refraction was -11.2 D. Retreatment was performed after 6 to 16 months on 11 eyes for undercorrection. All eyes not retreated were followed for at least 12 months. RESULTS: At 6 months, follow-up was available on 47 eyes. Of these eyes, 40% and 64% achieved corrections within 1 and 2 D of attempted correction, respectively. At 1 year, 60% of eyes attained 20/40 visual acuity or better uncorrected. Eleven patients (23%) were retreated between 6 to 16 months for undercorrection and/or regression. After retreatment, 47% and 81% of eyes achieved corrections within 1 and 2 D of attempted correction, respectively. At 1 year, 15% of eyes lost two lines of best-corrected visual acuity, and no eyes lost more than two lines. There was slightly more corneal haze seen in this group compared with the haze seen in patients undergoing PRK for low and moderate myopia. CONCLUSIONS: These data show that excimer PRK can correct high amounts of myopia with reasonable stability after 6 months. Excimer PRK is an effective surgical treatment of severe myopia, but long-term follow-up is still needed to assess the stability of its effect.

Genetic analysis of Hispanic individuals with cystic fibrosis.

We have performed molecular genetic analyses of Hispanic individuals with cystic fibrosis (CF) in the southwestern United States. Of 129 CF chromosomes analyzed, only 46% (59/129) carry delta F508. The G542X mutation was found on 5% (7/129) of CF chromosomes. The 3849 + 10kbC-->T mutation, detected primarily in Ashkenazi Jews, was present on 2% (3/129). R1162X and R334W, mutations identified in Spain and Italy, each occurred on 1.6% (2/129) of CF chromosomes. W1282X and R553X were each detected once. G551D and N1303K were not found. Overall, screening for 22 or more mutations resulted in detection of only 58% of CF transmembrane conductance regulator gene mutations among Hispanic individuals. Analysis of KM19/XV2c haplotypes revealed an unusual distribution. Although the majority of delta F508 mutations are on chromosomes of B haplotypes, the other CF mutations are on A and C haplotypes at higher-than-expected frequencies. These genetic analyses demonstrate significant differences between Hispanic individuals with CF and those of the general North American population. Assessment of carrier/affected risk in Hispanic CF individuals cannot, therefore, be based on the mutation frequencies found through studies of the general population but must be adjusted to better reflect the genetic makeup of this ethnic group. Further studies are necessary to identify the causative mutation(s) in this population and to better delineate genotype/phenotype correlations. These will enable counselors to provide more accurate genetic counseling.

Difference in frequencies of the cystic fibrosis alleles, delta F508 and W1282X, between carriers and patients.

One major mutation, delta F508, causing cystic fibrosis (CF) is found in most populations around the world. Among CF patients of Jewish Ashkenazi origin two major mutations, W1282X and delta F508 were found. We compared the relative frequencies of the two major mutations found in this patient population to their relative frequencies in the healthy population. The studied patient population included the entire CF Jewish Ashkenazi patient population in Israel (238 chromosomes), and a small group of Jewish Ashkenazi patients in the USA (57 chromosomes). Among these, 79 (27%) chromosomes carried the delta F508 mutation, and 151 (51%) the W1282X mutation. In addition, we have analyzed the results of screening 1,946 unrelated healthy Jewish Ashkenazi individuals for the delta F508 and the W1282X mutations. Surprisingly, an almost equal number of carriers of the delta F508 (35) and W1282X (36) was found. The difference between the relative proportions of the mutations in the two groups is statistically significant (p = 0.025). A striking manifestation of this difference is revealed in the analysis of patients' genotypes. There were 36 patients homozygous for W1282X, while only 7 patients were homozygous for delta F508, although the number of delta F508 carriers in the general Jewish Ashkenazi population is almost equal to the number of W1282X carriers. This difference in allele frequencies found between healthy carriers and CF patients in the Jewish Ashkenazi population might not be unique to this ethnic group nor to the CF disease. The results indicate that the common practice of inferring general population epidemiologic parameters directly from patients information is liable to introduce biases.(ABSTRACT TRUNCATED AT 250 WORDS)

A robotics-assisted procedure for large scale cystic fibrosis mutation analysis.

We describe a convenient, efficient, semiautomated protocol for assaying large numbers of DNA samples for over 20 mutations causing cystic fibrosis. The protocol uses the following: (1) a programmable robotic workstation to perform rapid pipetting and dot-blotting operations, (2) an allele-specific oligonucleotide hybridization in a single water bath without correcting for G+C content of oligonucleotides, and (3) a combinatorial system that allows direct determination of the genotype for more frequent mutations. We have used this system routinely for 16 months for carrier detection and for diagnosis of cystic fibrosis. The method can be readily applied to any combination of allele-specific oligonucleotide assays whether for multiple alleles at one locus or for a few alleles at multiple loci.

Experience of an academic reference laboratory using automation for analysis of cystic fibrosis mutations.

OBJECTIVE: To examine the use of partial automation for molecular analysis of cystic fibrosis and to evaluate the diagnostic experience gained. DESIGN: Twenty-four cystic fibrosis mutations, with cumulative mutation detection of 89% in North American whites and of 97% in the Ashkenazim, were tested by multiplex amplification and allele-specific oligonucleotide hybridization. SETTING: A university-based DNA diagnostic laboratory. SUBJECTS: More than 700 serial specimens were analyzed for cystic fibrosis mutations over a 5-month period. The study included 377 individuals tested for carrier status, of which 288 had no family history for cystic fibrosis; prenatal diagnosis for 17 fetuses at a one in four risk and eight pregnancies at lower risk; fetal or parental samples for 33 pregnancies with fetal ultrasound abnormalities; 40 individuals diagnosed with cystic fibrosis; and 87 individuals with a possible diagnosis of the disease. RESULTS: Automation has permitted increasing numbers of mutations while decreasing personnel time and cost. Mutation testing identified 10 carriers with no family history for cystic fibrosis, four couples at a one in four risk, and five affected fetuses, one ascertained by abnormal fetal ultrasound. Mutation analysis also identified two mutant copies of the gene in 26 of 40 individuals with a clinical diagnosis of cystic fibrosis, and in two of 87 patients with possible cystic fibrosis. CONCLUSION: This partially automated, direct mutation analysis provides DNA diagnostic laboratories with the capacity to process a larger number of samples at lower cost with greater sensitivity for mutation detection. As pilot screening programs are reported, it is appropriate to reevaluate recommendations regarding population-based carrier screening for cystic fibrosis.

Topical diclofenac in the treatment of ocular pain after excimer photorefractive keratectomy.

BACKGROUND: Following excimer laser photorefractive keratectomy, patients experience significant ocular pain until corneal reepithelialization. Despite the use of cold compresses, bandage soft contact lenses, cycloplegics, narcotics, and topical corticosteroids, the pain has not been adequately controlled in many patients. METHODS: A randomized, double-masked, parallel-group study of diclofenac sodium 0.1% ophthalmic solution and its placebo vehicle was evaluated. Patients undergoing excimer myopic photorefractive keratectomy on their second eye were admitted overnight. Postoperative procedures included two drops of diclofenac or placebo immediately after surgery and then qid until reepithelialization, topical tobramycin (qid), 0.1% fluorometholone (q2h), cycloplegics, and a disposable soft contact lens. Thirty-two patients (diclofenac = 16, placebo = 16) were evaluated from +30 minutes to +96 hours by several types of questionnaires. RESULTS: Most patients who received placebo experienced pain, starting within 1 hour, peaking at 4 to 6 hours and lasting 36 to 48 hours. The diclofenac-treated patients rarely experienced the early peak in pain, had less pain overall until 72 hours postoperatively, and experienced significantly less photophobia and burning/stinging. Significantly fewer patients on diclofenac required oral narcotics. Three patients (diclofenac = 2, placebo = 1) developed corneal infiltrates, the etiology of which is not known. In a separate study we conducted, there was no difference in epithelial healing times between the diclofenac-treated eyes and those not receiving the drug. CONCLUSIONS: Diclofenac appears to significantly reduce the ocular pain following excimer photorefractive keratectomy.

Excimer laser photorefractive keratectomy in high myopia. A multicenter study.

Excimer photorefractive keratectomy was performed at three centers on 16 highly myopic eyes (8 diopters [D] or more) and followed up for 6 months. Ablation depths ranged from 137 to 230 microns. The preoperative spherical equivalent of myopia ranged from -8.62 D to -14.50 D (mean +/- SD, -11.57 +/- 1.62 D). Six months after surgery, the mean refraction (spherical equivalent) was -0.90 +/- 2.13 D. Eleven of 16 eyes achieved refractions within 2 D of that attempted. All eight patients at one site were treated with a maximum-beam diameter of 6.0 mm and were corrected to within 2 D of that attempted, and all were 20/40 or better uncorrected. Three of eight eyes at the other two sites were treated with a 5.5- or 5.6-mm maximum-beam diameter, which achieved corrections within 2 D of that attempted. The epithelium healed within 3 to 4 days, and there were no erosions. Mild subepithelial reticular haze, similar to that seen with excimer photorefractive keratectomy for lower myopia, was seen in all patients, with two patients experiencing more significant corneal haze. This peaked at 3 to 6 weeks and then gradually diminished. All but two patients had a return of their best corrected preoperative visual acuity to within one Snellen line at 6 months. This preliminary study shows excimer photorefractive keratectomy to be a promising surgical treatment for patients with higher myopia.

Analysis of an origin of DNA replication located at the L terminus of the genome of pseudorabies virus.

We have localized an origin of DNA replication at the L terminus of the pseudorabies virus genome. This origin differs in location as well as in general structure from the origins of replication of other herpesviruses that have been identified. The 600 leftmost nucleotides of the genome that were found to include origin function have been analyzed. This sequence is composed of an 82-bp palindrome whose center of symmetry is separated by 352 unique bp (UL2). Within the UL2, a sequence that fits the consensus sequence of the NF1 binding site, as well as one that has partial homology to the binding site of UL9 of herpes simplex virus, is present. Using truncated fragments of DNA, sequences essential for minimal origin function were delimited to within a fragment that includes the terminal 104 bp of the left end of the genome. Within these 104 bp, two elements essential to origin function have been identified. One of these elements is present within the terminal 64 bp of the L component (within one of the palindromic arms). The other is present within the 22 bp of the UL2 adjacent to this palindromic arm. Other auxiliary elements, although not essential for origin function, contribute to more efficient replication. The NF1 and UL9 binding site homologies were found to be nonessential to origin function.

Structural organization of the termini of the L and S components of the genome of pseudorabies virus.

The sequences of several hundred nucleotides around the junctions between the L and S components in concatemeric DNA and in mature virion DNA were ascertained. The two ends of the mature genome (which are joined in concatemeric DNA) show no sequence homology. Several directly repeated elements are present near both ends of the genome. Furthermore, the last 82 nucleotides at the left end of the L component (and of the genome) are repeated in inverted form (inverted repeat within the L component [IRL]) approximately 350 to 600 nucleotides downstream (depending on the virus isolate) bracketing the UL2 component. A comparison between the sequences at the right and left ends of the L component of the genome showed patchy homology, probably representing a vestigial inverted repeat bracketing the L component (IRL). Furthermore, less than 5% of the genomes have an L component that is in the orientation opposite to that of most of the viral genomes, indicating that the vestigial IRL that brackets the UL sequence may be sufficient to mediate inversion of the L component in some of the genomes. On the other hand, the UL2 component, which is bracketed by a perfect IRL, does not invert to a greater extent than does the L component (if it inverts at all). Analysis of the nucleotide sequence at the concatemeric junction of three different pseudorabies virus isolates showed almost complete sequence conservation. The sequence and organization of the repeated elements in the different isolates were almost identical, despite their different histories and origins. The high degree of conservation of these repeated elements implies that they may fulfill an essential function in the life cycle of the virus.

Nucleotide sequences at recombinational junctions present in pseudorabies virus variants with an invertible L component.

The genome of pseudorabies virus (PrV) consists of two components--a noninvertible long (L) and an invertible short (S) component. The S component is bracketed by inverted repeats. In some variant strains of PrV (which have a selective growth advantage in certain cell lines), a sequence normally present at the left end of the L component has been translocated to the right end of the L component next to the inverted repeat. Consequently, these strains have acquired a genome with an L component that is bracketed by inverted repeats and that also inverts. We have determined the restriction maps and have analyzed the nucleotide sequences of those parts of the genome of three strains with invertible L components that contain the translocated segment of DNA. The results were as follows. The translocated fragments were derived in all cases from the extreme left end of the L component only. The sizes of the translocated fragments were similar, ranging from 1.3 to 1.4 kilobase pairs. The junction between the L and S components in these strains was the same as that in standard viral concatemeric DNA. The translocation of sequences from the left end of the genome next to the inverted repeats was always accompanied by a deletion of sequences from the right end of the L component. The sizes of the deleted fragments varied considerably, ranging from 0.8 to 2.3 kilobase pairs. Sequence homology at the points of recombination, i.e., at the junction between the right end and the left end of the L component, existed sometimes but not always. A model depicting how a virus with a class 2 genome (such as PrV) may acquire a genome with characteristics of a class 3 genome (such as herpes simplex virus) is presented.

Sequence of the genome ends and of the junction between the ends in concatemeric DNA of pseudorabies virus.

The nucleotide sequences of the termini of the mature pseudorabies virus genome and of the junction between these termini in concatemeric DNA were compared. To ensure conservation of unmodified 5' and 3' termini, the end fragments obtained directly (uncloned) from mature viral DNA were sequenced. The sequence obtained from 5' and 3' end labeling revealed that whereas the L terminus was blunt ended, the S terminus had a 2-base (GG) 3' overhang. The sequences spanning the junction between the termini present in concatemeric DNA was also determined and compared with that expected when the two ends of the mature DNA were juxtaposed. This comparison showed that in concatemeric DNA the ends of the mature genome had become joined by blunt-end ligation of one of the strands and that the 2-nucleotide gap on the other strand had been repaired. A significant degree of homology between the sequences spanning the junction between the ends of the varicella-zoster virus and pseudorabies virus genomes was found.

Role of glycoproteins of pseudorabies virus in eliciting neutralizing antibodies.

The experiments described in this paper were designed to assess the role of the various virus glycoproteins of pseudorabies virus (PrV) in eliciting the production of neutralizing antibodies during the normal course of infection of swine. They also address the question of the degree of antigenic variation within each glycoprotein between different virus isolates. The results show the following: Antigenic variation between strains of PrV isolated from different geographic areas are readily detectable; antigenic differences between strains isolated from the same geographic area are less common. No antigenic drift in glycoprotein gII was observed. Glycoprotein gIII and, to some extent, also glycoprotein gI showed a high level of antigenic drift. The neutralizing activity of pooled convalescent sera of swine is not directed against glycoprotein gI. A large part of the neutralizing activity of pooled convalescent sera of swine is directed against glycoprotein gIII.

Proteins specified by the short unique region of the genome of pseudorabies virus play a role in the release of virions from certain cells.

Two pseudorabies virus vaccine strains (Bartha and Norden) that have a similar deletion in the short unique (Us) region of the genome have been identified previously (B. Lomniczi, M. L. Blankenship, and T. Ben-Porat, J. Virol. 49:970-979, 1984). These strains do not code for the glycoprotein gI, a glycoprotein that has been mapped on the wild type virus genome by T. C. Mettenleiter, N. Lukacs, and H. J. Rziha (J. Virol. 53:52-57, 1985) to the sequences deleted from the vaccine strain. Restoration of these deleted sequences to the Bartha strain genome restores to the virus the ability to specify the gI glycoprotein. The Bartha vaccine strain grows as well as wild-type virus in pig kidney and in rabbit kidney (RK) cells, but is not released efficiently from and forms small plaques in RK cells. The rescued Bartha 43/25a strain (which has an intact Us) is released considerably more efficiently than the Bartha vaccine strain, but less efficiently than wild-type virus from RK cells; it also forms larger plaques on RK cells than does the parental Bartha vaccine strain. The Norden vaccine strain, which has a deletion in the Us, is released better from RK cells than is the Bartha strain, but not as well as is wild-type virus. We conclude that whereas the sequences in the Us that are deleted from the Bartha and Norden strain genomes specify functions that play a role in the release of virions from some cell types, at least one other function (which is defective in the Bartha strain but not in the Norden strain) also affects release of virus from these cells. Since restoration to the Bartha strain of an intact Us restores to the virus both the ability to grow in chicken brains (B. Lomniczi, S. Watanabe, T. Ben-Porat, and A. S. Kaplan, J. Virol. 52:198-205, 1984) and to be released from RK cells, the possibility that the lack of virulence of the Bartha vaccine strain may be related to its limited release from some target cells is discussed.