Determination of Use of Alternative Medicine Methods in Patients With Ankylosing Spondylitis.

This study aimed to examine complementary and alternative medicine (CAM) use among patients with ankylosing spondylitis (AS) who had or who had not received treatment with biological agents; the study also aimed to determine the types of CAM methods used by these patients. This is a comparative and cross-sectional study. This research was conducted at a rheumatology outpatient clinic of a university hospital in Turkey. A total of 120 patients who had (n = 60) and had not (n = 60) received therapy with biological agents participated in this study. A patient identification form and a questionnaire prepared by the researchers were used to collate the study data. This study found that the most commonly used method among patients who did not receive biological therapy was thermal facilities, at a rate of 28.3%; and that the most commonly used method among patients who did receive biological therapy was the use of thermal facilities, at a rate of 25%. No significant difference was found between patients who had received and patients who had not received biological therapy in terms of age and disease duration. Information was provided by health professionals to the patients concerning frequently used CAM modalities.

Retrospective review of the clinical and laboratory data in silent lupus nephritis.

PURPOSE: To determine the ratio of renal disease necessitating immunosuppressive treatment in lupus patients who are clinically asymptomatic by means of renal disease. It was also examined whether silent lupus nephritis is associated with any of the non-renal clinical findings. METHODS: All kidney biopsies performed in lupus patients between 1990 and 2009 at the Rheumatology Department of Ege University Faculty of Medicine were retrospectively screened. Among the 258 kidney biopsies screened, 54 had no clinical renal findings but had active disease together with anti-dsDNA positivity and/or hypocomplementemia. Patients were classified into two groups who require and do not require immunosuppressive therapy according to their final pathological results at biopsy. The frequency of serious renal involvement in the sample was calculated. Then subgroups were compared with each other in terms of the clinical and laboratory features using Statistical Package for Social Sciences version 13 software. RESULTS: Thirteen of the 54 patients (24%) had severe renal involvement requiring immunosuppressant therapy. When the groups were compared to each other, it was found that serositis and hematologic involvement were significantly more frequent in patients who needed immunosuppressive treatment (42.9% versus 10.0%; p = 0.003 and 64.3% versus 37.5; p = 0.039). CONCLUSION: Even in the absence of clinical renal manifestations, active patients at high risk of renal disease such as hypocomplementemia, anti-ds DNA positivity may have severe renal disease requiring immunosuppressive treatment. Thus, renal biopsy indications in lupus patients should better be revaluated.

Saliva levels of caspase-1, TNF-α, and IFN-γ in primary Sjögren's syndrome: oral mucosal abnormalities revisited

Background/aim: Abnormalities in oral mucosal immunity contribute to complex pathogenesis of primary Sjögren's syndrome (pSjS). We aimed to measure saliva and serum levels of caspase-1, tumor necrosis factor-alpha (TNF-α) and interferon gamma (IFN-γ) in patients with pSjS. Materials and methods: We studied 43 pSjS patients fulfilling the AECG criteria and 30 age/sex-matched healthy controls, as well as 39 rheumatoid arthritis (RA) patients as a disease control group. ESSDAI scores were less than seven in all patients with pSjS, indicating low disease activity. Quantitative analyses were made in serum and whole saliva samples. The statistical analysis was performed using SPSS 19.0. Results: While no significant difference was found in serum measurements, saliva levels of TNF-α and caspase-1 were significantly higher in pSjS patients versus healthy controls when using the Mann-Whitney U test. On the other hand, in the pSjS group, saliva levels of TNF-α and caspase-1 were also significantly higher compared to the RA group using Student's t-test. In the pSjS group, those parameters did not show any correlation with disease duration, seropositivity, and smoking. Conclusion: Despite low disease activity, saliva TNF-α and caspase-1 levels were found to be significantly higher in the pSjS group, which may suggest a possible advantage of local anticytokine treatments in selected cases.

Clinical periodontal status and inflammatory cytokines in primary Sjögren syndrome and rheumatoid arthritis.

BACKGROUND: The aim of the present study is to compare the clinical periodontal findings as well as gingival crevicular fluid (GCF) and plasma levels of tumor necrosis factor-alpha (TNF-α), interleukin-1beta (IL-1ß), interferon gamma (IFN-γ) and caspase-1 in primary Sjögren syndrome (pSS) and rheumatoid arthritis (RA) subjects. METHODS: In the present case control study plasma and GCF samples were collected, full-mouth recordings comprising plaque index (PI), bleeding on probing (BOP) and probing depth (PD) were performed in 44 subjects with pSS, 39 subjects with RA and 30 systemically healthy subjects. Plasma and GCF TNF-α, IL-1ß, IFN-gamma and caspase-1 levels were determined by enzyme-linked immunosorbent assay. RESULTS: There were no differences in GCF and plasma levels of IFN-γ and TNF-α in all the study groups (p > 0.05). GCF levels of IL-1ß were higher in pSS group than healthy group (p = 0.035). Caspase-1 GCF levels were significantly higher in pSS group than RA group (p = 0.032). Highest plasma IL-1ß levels were detected in pSS compared to RA and healthy groups (p < 0.001). Healthy group has higher caspase-1 plasma levels than pSS and RA groups (p < 0.001). CONCLUSIONS: The results of the present study reveal that the periodontal status of patients with pSS does not differ from systemically healthy subjects. Further studies involving longitudinal assessments on larger populations with standardized patient inclusion criteria are needed to confirm the findings.

Criteria sets for primary Sjogren's syndrome are not adequate for those presenting with extraglandular organ involvements as their dominant clinical features.

Patients with primary Sjogren's syndrome (pSS) may go undiagnosed or be misclassified due to the insidious nature and wide spectrum of the disease. The available several classification criteria emphasize glandular findings. We aimed to analyze the efficiency of various classification criteria sets in patients diagnosed on the clinical basis by expert opinion and to compare those pSS patients who fulfilled these criteria with those who did not. This is a multicenter study in which 834 patients from 22 university-based rheumatology clinics are included. Diagnosis of pSS was made on the clinical basis by the expert opinion. In this study, we only interviewed patients once and collected available data from the medical records. The European criteria, American-European Consensus Group (AECG) and American College of Rheumatology (ACR) Sjogren's criteria were applied. Majority of the patients were women (F/M was 20/1). The median duration from the first pSS-related symptom to diagnosis was significantly shorter in men (2.5 ± 2.3 vs 4.3 ± 5.9 years) (p = 0 < 0.016). When the European, AECG and ACR Sjogren's criteria were applied, 666 patients (79.9%) satisfied at least one of them. In total, 539 patients (64.4%) satisfied the European, 439 (52.6%) satisfied the AECG, and 359 (43%) satisfied the ACR criteria. Among the entire group, 250 patients (29.9%) satisfied all and 168 (20.1%) met none of the criteria. The rates of extraglandular organ involvements were not different between patients who met at least one of the criteria sets and those who met none. There is an urgent need for the modification of the pSS criteria sets to prevent exclusion of patients with extraglandular involvements as the dominant clinical features.

Evaluation of Swallowing Functions in Patients with Sjögren's Syndrome.

Patients with Sjögren's syndrome (SS) manifest symptoms such as dry eyes, dry mouth, and dysphagia. This study aims to evaluate the swallowing functions of the patients with SS. 69 patients with SS (65 females, 4 males) and 40 healthy individuals (33 females, 7 males) were included as study and control groups, respectively. Mean ages were 52.86 and 48.25 years for study and control groups, respectively. Swallowing functions were evaluated by fiberoptic endoscopic evaluation of swallowing (FEES). All the patients underwent FEES and were given 3, 5, and 10 ml water, yogurt, and fish-shaped crackers twice, respectively. The presence of bolus control, residue, penetration, and aspiration were evaluated. Additionally, certain types of foods triggering the dysphagia, any difficulties in bolus control, need to clean the throat, sensation of having a lump in the throat, sensation of choking, and xerostomia were included in the questionnaire. The MD Anderson Dysphagia Inventory and the Beck Depression Inventory were administered to patients. Considering the presence of residue with yogurt and fish cracker, there was a significant difference between groups (P < 0.05). Penetration was present in two patients in the study group; however, the difference was not significant (P > 0.05). Regarding the MD Anderson Dysphagia Inventory, the average scores were 48.18 ± 13.21 and 87.6 ± 10.67 for study and control groups, respectively, and a statistically significant difference was detected (P < 0.05). Regarding the Beck Depression Inventory, the average scores were 11.83 ± 9.37 and 8.03 ± 6.84 for study and control groups, respectively (P < 0.05). SS affected the swallowing functions significantly. The presence of residue with yogurt and cracker was the most obvious finding, whereas penetration/aspiration was not clinically significant. Swallowing dysfunction reduced the quality of life in patients with SS.

Segmental arterial mediolysis mimics systemic vasculitis.

Segmental arterial mediolysis (SAM) is a rare, nonarteriosclerotic, noninflammatory vascular disease and mostly affects medium-to-large sized abdominal arteries as well as presents with hemorrhages in the abdominal cavity. We report the case of a patient with SAM of the celiac, right renal, jejunal branch of the superior mesenteric, left gastric, and splenic arteries who was diagnosed by excluding other causes and in whom transcatheter embolization was performed in two different sessions, but he died because of an undefined reason. SAM mimics systemic vasculitis and causes abdominal pain; it should be considered because abdominal hemorrhage or arterial infarction can result in death.

The Importance of Minor Salivary Gland Biopsy in Sjögren Syndrome Diagnosis and the Clinicopathological Correlation.

OBJECTIVE: Minor salivary gland biopsy is one of the objective tests used in the diagnosis of Sjögren syndrome. The aim of our study was to compare the clinical and laboratory data of primary and secondary Sjögren syndrome cases with a lymphocyte score 3 and 4 in the minor salivary gland biopsy. MATERIAL AND METHOD: Data from a total of 2346 consecutive minor salivary gland biopsies were retrospectively evaluated in this study. Clinical and autoantibody characteristics of 367 cases with lymphocyte score 3 or 4 and diagnosed with primary or secondary Sjögren syndrome were compared. RESULTS: There was no difference between lymphocyte score 3 and 4 primary Sjögren syndrome patients in terms of dry mouth, dry eye symptoms and Schirmer test results but Anti-Ro and Antinuclear Antibody positivity was statistically significantly higher in cases with lymphocyte score 4 (p= 0.025, p= 0.001). Anti-Ro test results were also found to be statistically significantly higher in secondary Sjögren syndrome patients with lymphocyte score 4 (p= 0.048). CONCLUSION: In this study, the high proportion of cases with negative autoantibody but positive lymphocyte score is significant in terms of showing the contribution of minor salivary gland biopsy to Sjögren syndrome diagnosis. Lymphocyte score 3 and 4 cases were found to have similar clinical findings but a difference regarding antibody positivity in primary Sjögren syndrome. We believe that cases with lymphocyte score 4 may be Sjögren syndrome cases whose clinical manifestations are relatively established and higher autoantibody levels are therefore found.

Is There an Increased Arterial Stiffness in Patients with Primary Sjögren's Syndrome?

OBJECTIVE: Primary Sjögren's syndrome (pSS) is a common chronic autoimmune disease that primarily affects the salivary and lacrimal glands. Arterial stiffness is one of the earliest detectable manifestations of adverse structural and functional changes within the vessel wall. The aim of this study was to evaluate the relationship between arterial stiffness and pSS. METHODS: In this study, 75 female patients with pSS who fulfilled the American European Consensus Criteria for Sjögren's syndrome, were included. A total of 68 age-, sex- and body mass index-matched subjects were recruited as the control population. Arterial stiffness was assessed by measurement of the carotid-femoral pulse wave velocity (PWV). RESULTS: The mean age of the patients was 54.0±9.3 years and the median duration of the disease was 10 years. Compared with the control subjects, patients with pSS had a higher mean PWV (8.2±1.5 m/s vs. 7.5±1.4 m/s; p=0.01). Correlation analysis showed that the PWV was positively correlated with age, body mass index, serum cholesterol, low-density lipoprotein (LDL) and C-reactive protein levels, blood pressure, mean arterial pressure (MAP), pulse pressure and left ventricular mass index. A multiple linear regression analysis revealed that arterial stiffness was associated with age, MAP and LDL levels in pSS patients. CONCLUSION: Although patients with pSS appear to have increased arterial stiffness, risk factors associated with arterial stiffness in these patients are similar to the general population. However, we cannot exclude the possibility that a higher PWV in pSS patients is caused, not by pSS itself, but by the use of steroids, hypertension and dyslipidemia.

Therapy resistant idiopathic scleredema: an underlying pathology not always present.

Scleredema is a rare connective tissue disorder of unknown pathogenesis. Three types of scleredema have been described, based on its association with postinfection, monoclonal gammopathy and diabetes mellitus. We report herein a case of scleredema which the diagnosis didn't get specified. The patient was followed regularly for 13 years and did not respond to various combinations of immunosuppressants and psoralen plus ultraviolet A therapy. Treatment of scleredema is quite difficult and of limited success. At present, there is no proved treatment for this disease.

Autoimmune thyroid disease in ankylosing spondylitis.

Although autoimmune thyroid disease is well known to be associated with primary Sjögren's syndrome (SjS) and with various autoimmune diseases, it is less clear whether a similar association also exists for ankylosing spondylitis (AS). Therefore, we investigated the frequency of autoimmune thyroid disease in patients with AS. In this cross sectional study, 80 patients with AS fulfilling the 1984 Modified New York Criteria and 80 healthy subjects, age and sex-matched with AS patients, were included. As the positive control group, 62 female patients with primary SjS were also studied. All cases underwent thyroid ultrasonography (USG) by a single endocrinologist. Thyroid function tests and thyroid autoantibodies were measured. The diagnosis of Hashimoto's thyroiditis (HT) was made if the patient had thyroid autoantibody positivity plus at least one of the following criteria: diffuse goiter with physical examination, abnormality in thyroid function tests, and parenchymal heterogeneity with USG. The chi-squared test and Fisher's exact test were used to compare cases and controls. The p values <0.05 were considered statistically significant. The frequencies of parenchymal heterogeneity with USG (30 vs 11.3 %, p = 0.045), thyroid autoantibody positivity (13.8 vs 2.5 %, p = 0.017), and concomitant diagnosis of HT (10 vs 1.3 %, p = 0.034) were significantly higher in AS group compared to healthy controls. Among AS patients having HT, subclinical hypothyroidism was detected only in a single patient. Frequency of autoimmune thyroid disease was significantly higher in AS group, compared to healthy controls. Prospective studies are needed to see the clinical relevance of these findings and outcome in the long term.

Interstitial cystitis: a rare manifestation of primary Sjögren's syndrome, successfully treated with low dose cyclosporine.

Chronic interstitial cystitis (IC), mostly affecting middle-aged women, is a very rare manifestation of primary Sjögren's syndrome (pSS). Hereby, we report a 42-year-old woman with pSS, presenting with dysuria, urinary frequency, and suprapubic pain. She was diagnosed to have chronic IC, based upon the cystoscopic biopsy finding of chronic inflammation in the bladder wall. Systemic corticosteroid and azathioprine treatments together with local intravesical therapies were not effective. Therefore, cyclosporine (CSA) therapy was initiated. Initial low dose of CSA (1.5 mg/kg/d) improved the symptoms of the patient, with no requirement for dose increment. After 4 months of therapy, control cystoscopic biopsy showed that bladder inflammation regressed and IC improved. This case suggests that even low doses of CSA may be beneficial for treating chronic IC associated with pSS syndrome.

Cigarette smoking in primary Sjögren's syndrome: positive association only with ANA positivity.

Smoking is well known to contribute to the pathogenesis and severity of some systemic autoimmune rheumatic diseases and especially to the production of certain autoantibodies. Primary Sjögren's syndrome (pSS) is an autoimmune disease, affecting primarily the exocrine glands. It may also cause extraglandular involvement in some cases. In this study, we aimed to determine the frequency of smoking habits in our cohort of pSS patients and to investigate whether the frequencies of autoantibody positivity and extraglandular involvement were significantly different between patients with and without smoking. In this cross-sectional study, 207 patients with pSS (F/M 203/4), fulfilling the United States-European Consensus Criteria, and 602 healthy controls (F/M 534/68) were included. Patients and controls were classified into five groups: never smokers, current smokers, former smokers; ever smokers, and passive smokers. The χ(2) and Kruskal-Wallis tests were used for statistical analysis; a p value of less than 0.05 was accepted as statistically significant. While the frequency of current smokers was significantly lower in the pSS group compared with the healthy controls (11.6 vs 22.3%), the frequencies of former smokers (30.4 vs 11.8%), ever smokers (42.0 vs 34.1%), and passive smokers (47.3 vs 37.5%) were significantly higher in the pSS group compared with the healthy controls. In pSS patients, only antinuclear antibody (ANA) positivity was significantly associated with smoking habits, while there was no significant association with other autoantibodies or with the presence of extraglandular involvement. We found that in pSS patients smoking was significantly associated only with ANA positivity. Unlike the deleterious effects of smoking upon disease severity and anti-cyclic citrullinated protein (CCP) antibody production in rheumatoid arthritis, we could not find any association of smoking with extraglandular involvement and/or anti-Ro/anti-La antibody positivity in pSS. These results are indeed in line with the limited number of previous studies reported in the literature. Further studies with higher numbers of pSS patients are required to confirm the seemingly negative association of smoking with pSS.

Clinical efficacy of the SmartPlug™ in the treatment of primary Sjogren's syndrome with keratoconjunctivitis sicca: one-year follow-up study.

To evaluate the efficacy of a thermo-sensitive punctum plug, (SmartPlug™) in Primary Sjogren's Syndrome (pSS) patients with dry eyes, whose symptoms persist despite preservative-free artificial tear treatment. In this study, 22 Primary Sjögren's Syndrome (pSS), as defined by American-European Consensus Group Classification Criteria. All patients being followed up by Ege University Departments of Rheumatology and Ophthalmology. The patients had positive Schirmer test results (<5 mm without anesthesia). SmartPlug™ (Medennium, Irvine, California, USA) was inserted into the inferior lacrimal canaliculi of both eyes. Visual acuity measurements, Schirmer I test measurements, lissamine green staining scores, and tear-film breakup times (BUT) were noted before plug insertion and at the 1st, 6th, and 12th months following the procedure. Minimum follow-up period was 6 months for 19 patients and 12 months for 16 patients. Significant improvements were seen in the Schirmer I test scores (before insertion: 1.98 ± 2.67; 1st month: 5.68 ± 6.69; 6th month: 5.35 ± 5.38; 12th month 6.43 ± 5.14 P = 0.006), tear-film BUT in seconds (before insertion: 4.64 ± 3.7; 1st month: 5.80 ± 2.36; 6th month: 7.53 ± 2.92; 12th month 7.50 ± 2.52, P < 0.0001), respectively. Thermodynamic punctum plug insertion only in inferior canaliculus is a simple, effective, and comfortable option for treatment of severe aqueous tear deficiency that cannot be controlled using preservative-free tears.

Effects of hydroxychloroquine on salivary flow rates and oral complaints of Sjögren patients: a prospective sample study.

OBJECTIVE: The objective of this study was to evaluate whether hydroxychloroquine (HCQ) therapy effects subjective and/or objective complaints and salivary flow rates of patients with primary Sjögren's syndrome (PSS). STUDY DESIGN: Thirty women recently diagnosed with PSS, scheduled for HCQ treatment (400 mg daily), participated and were clinically examined before initiation of 30 weeks of HCQ treatment. During baseline evaluation, both the objective and/or subjective oral findings were recorded. Unstimulated (uSFR) and stimulated salivary flow rates (sSFR) were determined. After initiation of HCQ treatment, study parameters were assessed at 6, 12, 18, 24, and 30 weeks. Each patient served as her own control; measurements of the baseline and control times were analyzed by ANOVA. RESULTS: uSFR values increased significantly with HCQ treatment, but sSFR values, objective and/or subjective complaints did not change considerably. CONCLUSION: A positive impact of 30 weeks of HCQ treatment only on uSFRs of SS patients was revealed.

Evaluation of quality of life in relation to anxiety and depression in primary Sjögren's syndrome.

The aim of this study was to evaluate health-related quality of life (HR-QOL) in patients with primary Sjögren's syndrome (pSS) using both Short-Form 36 (SF-36) and World Health Organization Quality of Life Assessment-BREF (WHOQOL-BREF) questionnaires and to determine the effects of anxiety and depression on HR-QOL using the Hospital Anxiety-Depression Scale (HADS). In this cross-sectional study, 107 female patients with pSS (mean age 54.10 ± 10.2 years), fulfilling US-European Consensus Criteria and 109 female controls (mean age 53.4 ± 10.9 years) were included. Student's t test, Mann-Whitney U test, and analysis of variance (ANOVA) were used for statistical analysis. P values > 0.05 were accepted as significant. All domains of the SF-36, with the exception of "Vitality", and all domains of the WHOQOL-BREF with the exception of "Environment", were significantly lower in pSS patients compared with healthy controls. In pSS patients having anxiety according to HADS, the scores of all domains of WHOQOL-BREF were significantly lower, and in patients having depression according to HADS, three of four domains of WHOQOL-BREF were significantly lower compared with the rest of the group. However, the scores of two domains of the SF-36, namely "Role-Physical" and "Role-Emotional" domains, were significantly higher in pSS patients having depression according to HADS. We confirmed the presence of impaired HR-QOL in pSS. Whereas the presence of anxiety and/or depression generally showed a negative affect on HR-QOL, interestingly, depression seemed to improve the scores of "Role-Physical" and "Role-Emotional" domains of the SF-36. This surprising finding might be related to adaptation to changing health. Social support based upon cultural traditions might also have contributed.