Systemic lupus erythematosus in children and adults: A retrospective study in Brazilian patients.

BACKGROUND: Systemic lupus erythematosus (SLE) may have a different serological and clinical profile according to age of disease onset. AIM: To compare clinical presentation and serological data from patients with SLE onset in childhood (cSLE) with disease onset in adulthood (aSLE) in a sample of Brazilian patients. METHODS: Retrospective study of 614 SLE patients from a single Rheumatology Unit from Brazil: 77 (12.5%) cSLE and 537 (87.4%) aSLE. Clinical and serological data were obtained from the charts. Comparisons of cSLE with aSLE in general and according to patient's gender were made. RESULTS: The comparison of whole sample showed that children had more malar rash (p = 0.04), seizures (p < 0.0001), psychosis (p = 0.02), glomerulonephritis (p = 0.001), anti-dsDNA (p = 0.008), anticardiolipin IgM (p = 0.04) but less discoid lesions (p = 0.01), anti-Ro (p < 0.0001) and anti-La antibodies (p = 0.007). When only the male sample was compared, no differences in glomerulonephritis and anti-dsDNA frequencies were found. CONCLUSION: Children had a higher frequency of severe manifestations (glomerulonephritis and central nervous system) than adults. The difference in glomerulonephritis occurrence disappeared when only males were compared.

Sleep Disturbance in Scleroderma.

INTRODUCTION: Sleep quality may be impaired in systemic scleroderma (SSc) patients and contribute to loss of life quality. AIM: The aims of this study were to study the prevalence of sleep disturbance in SSc patients and its possible association with epidemiological, clinical and laboratory data, treatment used, and depression, and to verify the association of sleep disturbance and quality of life in this group of patients. METHODS: This is a cross-sectional study including 60 SSc patients. Epidemiological, clinical, laboratory, and treatment data were extracted from the medical records. To evaluate sleep quality, the PSQI (Pittsburgh Sleep Quality Index) was used; to evaluate depression, the CES-D (Center for Epidemiological Scale-Depression) was used; and to evaluate quality of life, SF-12 (12-Item Short-Form Health Survey) was used. Disease severity was evaluated by the Medsger index and the degree of cutaneous involvement by the modified Rodnan index. RESULTS: The prevalence of patients with sleep disturbance was 73.3%. Sleep disturbance was associated with esophageal involvement (p = 0.03), Medsger index with higher disease severity (p = 0.01), and more depressive mood (p = 0.002). Patients with poor quality of sleep had worse quality of life by the SF-12 in mental (p = 0.001) and physical domains (p = 0.0008). No associations were found with epidemiological, serological, and treatment variables (all P's = nonsignificant). CONCLUSIONS: There is a high prevalence of sleep disturbance in patients with SSc that is associated with esophageal involvement, severity of disease, depression, and worse quality of life.

Dry eye and percentage of body fat: a cross-sectional prospective study.

BACKGROUND: Dry eyes are common in the general population. Some studies associate high prevalence of dry eyes with lipid metabolic changes and body fat composition. AIM: To study the association of dry eye with percentage of body fat. METHODS: One hundred and thirty five individuals (44 males and 91 females; median age of 42 years) were studied in a cross-sectional prospective study. Schirmer test and TBUT (tear breakup time) test were used to access dry eye. Body composition (percentage of lean and fat mass) were calculated using anthropometric measurements that included height, weight, abdominal, waist and neck circumference. RESULTS: About 44.4% of the sample had abnormal Schirmer test, and 70.3% had abnormal TBUT. Schirmer tests values were associated with age (p = 0.0006) female gender (p = 0.04) and percentage of body fat (p = 0.02). Abnormal TBUT test associated only with age (p = 0.0005). CONCLUSIONS: Percentage of body fat is associated with abnormal Schirmer but not TBUT test.

Rheumatoid arthritis and cognition dysfunction: lack of association with cumulative glucocorticoid use.

Aim: To study if cumulative glucocorticoid use could be related to cognitive impairment in rheumatoid arthritis (RA) patients.Methods: A sample of 60 RA patients and 64 controls were studied for the Mini Mental State Examination (MMSE) and depression scale (using CES-D or Center for Epidemiological Studies Depression scale). RA patients also filled a visual analogic scale (VAS) of pain and had disease activity evaluated by DAS-28 ESR (disease activity score using erythrocyte sedimentation rate). Clinical and treatment data, including cumulative dose of glucocorticoid, were collected from the charts.Results: Patients with RA had more cognitive impairment and depression than controls (p = .002 and .03, respectively). A weak and negative association of MMSE with VAS of pain was found (rho= -0.16; 95%CI = 0.49-0.004; p = .04) but not with depression and cumulative glucocorticoid doses (p = .22 and p = .52, respectively).Conclusion: Although RA patients have more cognitive impairment than controls, no correlation of this problem with cumulative glucocorticoid doses was found.

ASCA (Anti-Saccharomyces cerevisiae Antibody) in Patients With Scleroderma.

OBJECTIVES: The majority of scleroderma (SSc) patients present gastrointestinal involvement. Motility is usually compromised but few studies address permeability changes in the intestinal wall. ASCA (anti-Saccharomyces cerevisiae antibodies) positivity is associated with increased intestinal permeability. In this study we aimed to investigate ASCA positivity in SSc patients and its association with clinical, serological and epidemiological data. METHODS: Seventy-four SSc patients and 57 healthy controls were studied for ASCA (IgG and IgA) positivity by ELISA. ASCA positivity was associated with demographic, clinical severity index (by Medsger score) and serological data in SSc patients. RESULTS: ASCA-IgG was positive in 32/74 (43.2%) patients of the SSc group and 1/57 (1.7%) of controls (p < 0.0001); ASCA-IgA was positive in 12/74 (16.2%) of the SSc group and 3/57 (5.2%) of controls (p = 0.05). In univariate analysis, ASCA-IgG presence was associated positively with African ethnic background (p < 0.001) and negatively associated with anticentromere antibodies (p = 0.013); ASCA-IgA had a negative association with Medsger score (p = 0.05). In multivariate analysis ASCA-IgG associated independently only with African ethnic background. CONCLUSION: Positivity for ASCA-IgG and ASCA-IgA is higher among scleroderma patients than controls. African descendants have more positivity for ASCA-IgG. ASCA-IgA is less frequent in patients with a more severe disease.

Plasma levels of pentraxin 3 in patients with spondyloarthritis.

CONTEXT: Determining the disease's inflammatory activity in spondyloarthritis (SpA) is difficult although very important as it is this that drives treatment. OBJECTIVE: To investigate if plasma pentraxin-3 (PTX3) could act as an inflammatory marker in SpA. METHODS: Eighty one SpA patients (11 with psoriatic arthritis (PsoA) and 70 with ankylosing spondylitis (AS)) and 90 gender and age paired controls were studied for plasma PTX3 levels by ELISA. Patients had determinations of disease activity through C reactive protein (CRP), erythrocyte sedimentation rate (ESR), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score (ASDAS)-CRP. Epidemiological, clinical and treatment data were collected through chart review. RESULTS: SpA patients had lower concentrations of plasma PTX3 than controls (median of 0.95 ng/mL vs 1.64 ng/mL; p < 0.0001). Correlation of PTX3 levels and BASDAI, ASDAS-CPR, CRP levels and ESR could not be found. No differences in PTX3 levels were detected between PSoA and AS patients (p = 0.42). Uveitis, presence of HLA B27, tobacco exposure, age and disease duration did not influence PTX3 levels. CONCLUSIONS: PTX3 plasma levels do not reflect disease activity in SpA. However, it probably participates in the ethiopathogenetic process, as it is consumed in these patients.

Rheumatic Disease Autoantibodies in Patients with Autoimmune Thyroid Diseases.

BACKGROUND: Patients with autoimmune thyroid diseases (ATD) such as Graves' disease (GD) and Hashimoto thyroiditis (HT) may have non-organ specific autoantibodies such as antinuclear antibodies (ANA) and rheumatoid factor (RF). AIM: To study the prevalence of rheumatic autoantibodies in a group of ATD patients without known rheumatic diseases and to evaluate its association with the patients' epidemiological and treatment profiles. To follow positive non-organ specific autoantibody-positive ATD individuals to investigate whether they will develop a rheumatic disorder. METHODS: A sample of 154 ATD patients (70 HT and 84 GD; mean age 45.3 ± 14.2) had determination of ANA by immunofluorescence, using hep-2 cells as substrate, extractable nuclear antigen profile by ELISA kits and RF by latex agglutination. Epidemiological and treatment profiles were obtained through chart review. These patients were followed for the mean period of 5 years, between 2010 and 2015. RESULTS: Positive ANA was found in 17.5% (27/154) of the patients: anti-Ro/SS-A in 4/154 (2.5%); anti-RNP in 4/154 (2.5%), and anti-La/SS-B in 3/154 (1.9%). None had anti-Sm antibodies. RF was detected in 12/154 (7.7%) of ATD patients and was more common in older individuals (p = 0.007). There was a positive association between the presence of RF and ANA (p = 0.03; OR 3.89; 95% CI 1.1-13.3). None of the patients with positive autoantibodies developed clinical rheumatic diseases during the period of observation. CONCLUSION: We found rheumatic autoantibodies in 17.5% of ATD patients without rheumatic diseases. None of them were associated with the appearance of clinical rheumatic disorder during the period of 5 years.

Mannose-Binding Lectin Deficiency in Brazilian Patients with Spondyloarthritis.

BACKGROUND: Infections are usually involved in the pathogenesis of spondyloarthritis (SpA). Mannose-binding lectin (MBL) is a component of the innate immune system with an important role in microbial defense. OBJECTIVE: To study the prevalence of MBL deficiency in SpA patients as well as its influence in the clinical profile of these diseases. METHODS: We studied 89 SpA patients and 89 healthy individuals, paired for age and gender. MBL serum levels were measured by ELISA test. Individuals with levels ≤100 ng/mL were considered deficient. SpA patients had determination of Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score (ASDAS)-CRP, Bath Ankylosing Spondylitis Functional Index (BASFI), C reactive protein (CRP), erythrocyte sedimentation rate (ESR), and review of their clinical profile. RESULTS: SpA patients had MBL levels ranging from 100 to 4100 ng/mL (median = 375 ng/mL); controls levels ranged from 100 to 4703 ng/mL (median = 1204 ng/mL; p < 0.0001). The prevalence of MBL deficiency was 27/89 (30.3%) in SpA patients and 12/89 (13.5%) in controls, with p = 0.01; OR = 2.5 (95% IC = 1.2-5.3). No association/correlation was found between MBL levels with BASDAI, BASFI, age at disease onset, ASDAS-CRP, ESR, CRP, presence of uveitis, HLAB27, peripheral arthritis, or SpA subtype (all p = NS). CONCLUSION: MBL levels may be linked with the occurrence of SpA but do not influence its phenotype.

Rheumatic Disease Autoantibodies in Autoimmune Liver Diseases.

BACKGROUND: Autoimmune liver diseases (ALDs) are known to be associated with systemic autoimmune rheumatic diseases (SARDs) and their autoantibodies. We aimed to study the prevalence of SARDs and related autoantibodies, as well as their prognostic implications in a group of patients with ALDs. METHODS: This was a cross-sectional study. Sixty patients with ALDs (38.3% with autoimmune hepatitis; 11.7% with primary biliary cirrhosis; 25% with primary sclerosing cholangitis and 25% with overlap syndrome) were studied for the presence of SARDs and their autoantibodies. RESULTS: There was autoimmune rheumatic disease in 20% of the studied sample. Systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) were the commonest (11.6% and 5%, respectively). Antinuclear antibodies (ANAs) were present in 35% of the patients, followed by anti-Ro (20.0%); anti-nucleosome (18.3%); rheumatoid factor (10%) anti-CCP (8.3%); anti-RNP (8.3%); anti-ds-DNA (6.6%); anti-La (3.3%); anti-Sm (3.3%), anti-ribosomal P (3.3%). Anti-Ro (p = 0.0004), anti-La (p = 0.03), anti-RNP (p = 0.04) and anti-Sm (p = 0.03) were commonly found in patients with SARD, but not anti-DNA, anti-nucleosome and anti-ribosomal P. No differences were found in liver function tests regarding to the presence of autoantibodies. CONCLUSIONS: There was a high prevalence of SARD and their autoantibodies in ALD patients. Anti-Ro, anti-La, anti-RNP and anti-Sm positivity points to an association with systemic autoimmune rheumatic diseases. The presence of autoantibodies was not related to liver function tests.

Assessment of fatigue in a large series of 1492 Brazilian patients with Spondyloarthritis.

BACKGROUND: The aim of the present study was to analyze the score of fatigue in a large cohort of Brazilian patients with SpA, comparing different disease patterns and its association with demographic and disease-specific variables. METHODS: A common protocol of investigation was prospectively applied to 1492 Brazilian patients classified as SpA according to the European Spondyloarthropathies Study Group (ESSG) criteria, attended at 29 reference centers. Clinical and demographic variables were recorded. Fatigue was evaluated using the first item of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) questionnaire. RESULTS: The mean BASDAI fatigue score was 4.20 ± 2.99. There was no significant difference in the fatigue score between the different SpA. Fatigue was higher in female patients (p < 0.001), with mixed (axial + peripheral) involvement (p < 0.001) and in those who did not practice exercises (p < 0.001). Higher scores of fatigue were significantly associated with inflammatory low back pain (p = 0.013), alternating buttock pain (p = 0.001), cervical pain (p = 0.001), and hip involvement (p = 0.005). Fatigue presented a moderate positive statistical correlation with Bath Ankylosing Spondylitis Functional Index (BASFI) (0.469; p < 0.001) and Ankylosing Spondylitis Quality of Life (0.462; p < 0.001). CONCLUSION: In this large series of Brazilian SpA patients, higher fatigue scores were associated with female gender, sedentary, worse functionality, and quality of life.

Melatonin supplementation improves rheumatological disease activity: A systematic review.

BACKGROUND: Melatonin is a pineal hormone with a complex role. It is linked to sleep, inflammatory, oxidative, and immunological processes. AIM: To review the use of melatonin supplementation in rheumatological diseases. METHODS: A systematic search of PubMed, Embase, and Scielo databases was performed, looking for articles on Melatonin and rheumatic diseases published between 1966 and August 2022. RESULTS: Thirteen articles were identified: in fibromyalgia (n = 5 articles), rheumatoid arthritis (n = 2), systemic sclerosis (n = 1), systemic lupus erythematosus (n = 1) and osteoporosis/osteopenia (n = 3) and osteoarthritis (n = 1). There were positive results of melatonin administration in fibromyalgia, osteoarthritis, and osteoporosis/osteopenia but not in rheumatoid arthritis and lupus. The drug was well tolerated with mild side effects. CONCLUSION: This review shows the efficacy of Melatonin in some rheumatic diseases. However, new studies are needed to elucidate the real role of this treatment in rheumatology.

Dehydroepiandrosterone (DHEA) Supplementation in Rheumatic Diseases: A Systematic Review.

Background: Dehydroepiandrosterone (DHEA) is an adrenal hormone used to treat rheumatic conditions such as systemic lupus erythematosus (SLE), Sjogren's syndrome (SS), rheumatoid arthritis (RA) with controversial results. Aim: To review the results of DHEA use in rheumatic diseases. Methods: PubMed, Scielo, Scopus, and Embase databases were systematically searched for articles on the treatment of rheumatic diseases with DHEA between 1966 and April 2023. Results: Twenty-one studies were identified: 13 in SLE, 5 in SS, 2 in RA, and 1 in fibromyalgia. DHEA use in SLE has shown a mild to moderate effect on disease activity, a positive effect on bone mineral density (BMD), and improved fatigue. The studies on SS showed a decrease in symptoms of dry mouth, but its performance did not differ from placebo in disease activity. In RA, a questionable effect on disease activity was noted. The only study on fibromyalgia failed to show any improvement. The drug was well tolerated; mild androgenic effects were the most common complaints. Conclusion: DHEA seems to have a place in SLE treatment, where it improves BMD and disease activity. The use in RA, SS, and FM is questionable.

Fibromyalgia and menopause: an open study on postmenopausal hormone therapy.

BACKGROUND: Fibromyalgia women (FM) seems to get worse at menopause suggesting some influence of estrogens on its pathophysiology. We aimed to study the influence of postmenopausal hormone therapy (HT) in FM, the relationship with sleep and FM impact. METHODS: We analyzed prospectively 69 menopausal women, divided in two groups, FM group (FMG; N.=32) and comparison group (CG; N.=28) submitted to HT for twelve weeks (1.2 mg/g transdermal estradiol, 100 mg micronized natural progesterone oral/daily). Data on Utian Quality of Life Questionnaire (UQOL) and Pittsburgh Sleep Quality Index (PSQI) were obtained in both groups, at entrance and twelve weeks after HT. FM patients also completed the Fibromyalgia Impact Questionnaire - Revised (FIQ-R) and fibromyalgia severity (FS). RESULTS: FM patients improved significantly the FIQ-R (P=0.0001, median FIQ-R score 30% lower), mainly the severity of FM, assessed by FS (P<0.0001). Both groups had improved quality of life and sleep (UQOL: P=0.0001; P=0.001, PSQI: P<0.0001; P=0.007, respectively). Differences between first and second PSQI were greater for CG than for FMG (P=0.008). CONCLUSIONS: HT improving sleep and quality of life in both groups; it was a significant clinical improvement seen by FIQ and FS in FM patients. These changes characterize improvement of functional status and symptoms severity.

Anti-Saccharomyces cerevisiae (ASCA) and anti-endomysial antibodies in spondyloarthritis.

Spondyloarthritis (SpA) are diseases with increased gut inflammation. To search for (anti-Saccharomyces cerevisiae) ASCA IgA, ASCA IgG, and anti-endomysial antibodies (EmA-IgA) in a cohort of 70 patients with SpA, we found 18.6% (13/70) positive for IgA-ASCA in the SpA group and 3/57 (5.2%) in the control group (P = 0.031). ASCA IgG and EmA-IgA were found at the same frequency in SpA and controls. No relationship of ASCA IgA positivity could be established with disease activity (measured by ESR, C-reactive protein, and BASDAI), presence of uveitis, or peripheral arthritis neither with functional status measured by BASFI. SpA patients present an increase in the IgA-ASCA positivity without any relationship to disease activity, functional index, clinical profile or the presence of HLA-B27. There is no evidence of higher prevalence of EmA-IgA in SpA patients in the studied sample.

Lidocaine in fibromyalgia: A systematic review.

BACKGROUND: Fibromyalgia (FM) patients are treated with antidepressants, and in most cases, these drugs lose efficacy or present side effects. Intravenous lidocaine (IL) is an anesthetic drug used in some FM trials. AIM: To systematically review the safety and efficacy of IL in FM patients. METHODS: To systematically search PubMed for articles in English, Spanish, and Japanese with English Abstracts on FM and lidocaine between 1966 and February 2021. This study was registered at PROSPERO. RESULTS: We found only ten articles published in this field, with a total of 461 patients. Females predominated varying from 95% to 100% in the studies. Age varied from 40.9 to 55 years old. Disease duration varied from 1 mo to 6.4 years. Lidocaine dose varied from 2 to 7.5 mg/kg via intravenous infusion. Follow-up period varied from 65.7 to 90 days. Regarding outcomes, most studies used the visual analogue scale (VAS) for pain; before short-term lidocaine administration, VAS was between 6.1 and 8.1 and after treatment was between 1.7 and 4.5 mm. Concerning long term lidocaine, VAS varied from 30% to 35.4% after lidocaine infusion. Side effects were observed in 0% to 39.6% of cases, they were usually mild or moderate. CONCLUSION: This study demonstrates the short-term effectiveness and safety of intravenous lidocaine in FM patients. However, more studies, including long-term follow-up, are still needed.

Rheumatoid arthritis and nutritional profile: A study in Brazilian females.

BACKGROUND: Patients with rheumatoid arthritis (RA) may have nutritional impairment. In RA, muscle loss is associated with an increase in fat tissue, and the patients may not have body mass index (BMI) alterations. AIM: To study the nutritional status in a sample of patients with RA in Brazil through mini nutritional assessment (MNA) and electric bioimpedance and its relationship to BMI, functionality, disease activity, and treatment. METHODS: Seventy-one RA females were included. Chart review was used to obtain epidemiological, clinical, and treatment data. Patients answered the MNA and were submitted to electrical bioimpedance and anthropometric measurements. Disease activity was assessed through simple disease activity index (SDAI), clinical disease activity index (CDAI), and function, through health assessment questionnaire (HAQ). RESULTS: According to MNA, 23 (32.4%) patients were at risk for malnutrition and 1 (1.4%) was malnourished. MNA were associated with disease activity and function impairment (SDAI P = .02; CDAI P = .02, and HAQ P = .002) but not with used medications. According to BMI, 76% were overweight or obese. An increased percentage of body fat was found in 98.7% and a lower percentage of lean mass in 95.7%. Disease activity and function were not associated with the percentage of body fat of any used medications, with a lower percentage of body fat in those using abatacept (P = .01). CONCLUSION: Almost one-third of patients had nutritional impairment according to MNA which was associated with disease activity and loss of function. Almost the whole sample had an increased percentage of fat mass and a diminished percentage of muscle mass that could not be linked with disease activity, function or used medications.

Adverse childhood experiences in patients with psoriasis.

INTRODUCTION: Adverse childhood experiences (ACEs) have been linked to occurrence of autoimmune diseases in adults, including psoriasis. OBJECTIVES: To study the prevalence of ACEs in psoriasis patients, comparing them with a sample from the general population. METHODS: Three hundred and eighteen individuals were included (104 psoriasis patients and 214 controls). Patients and controls answered questions on an ACE study questionnaire about experiences of childhood abuse, negligence, domestic violence, and household dysfunction. Questionnaire scores range from zero (best result) to 8 (worst scenario). Psoriasis patients' charts were reviewed for epidemiological, clinical, and treatment data. A Psoriasis Area Severity Index (PASI) was calculated from measurements taken when the questionnaire was administered. RESULTS: Psoriasis patients reported a median of 4 ACEs (interquartile range [IQR] = 3-5) while controls had a median of 3 (IQR = 2-4) with p < 0.0001. The number of ACEs was not associated with PASI, age of disease onset, or presence of associated arthritis (all p > 0.5). Female psoriasis patients had more ACEs than males (p = 0.04). CONCLUSION: Patients with psoriasis have more ACEs than controls and ACEs were more common in female patients.

Seroconversion of rheumatoid arthritis patients after yellow fever vaccination.

Vaccination is a current strategy used to prevent infections in patients with immune-mediated rheumatic diseases. However, the use of live-attenuated vaccines prepared from living microorganisms in these patients should be avoided due to the risk of acquiring infections. The present study aimed to investigate the effect of the yellow fever (YF) vaccine (a live-attenuated vaccine) in 12 patients with rheumatoid arthritis (RA). The sample comprised 12 patients (9 females and 3 males; mean age 52.2 ± 6.5 years) with RA, who inadvertently received fractionated 17D yellow fever vaccination during an outbreak of this disease. In this cohort, 10 were administered leflunomide; 7 were administered methotrexate; 6 were administered prednisone (median dose of 5.0 mg/day); 6 took biologic drugs; and 1 took tofacitinib. All but one patient (used rituximab, prednisone, and methotrexate) seroconverted. None of them developed clinical signs of infection after the procedure. The fractionated dose of the YF vaccine is effective and safe in the observed sample. Key Points • Patients with autoimmune inflammatory rheumatic diseases (AIIRD) are at a high risk of acquiring infections • The fractionated dose of the YF vaccine is effective and safe in the observed sample • Vaccination against YF should be avoided in patients with AIIRD under immunosuppression owing to the risks of inducing YF infection.

Dry eyes in patients with diabetes mellitus.

Dry eyes may be caused by impairment in the tear production or excessive tear evaporation and are associated with photophobia, red eyes, vision impairment, local pain and pruritus. It has been described that patients with Diabetes Mellitus (DM) may have a higher prevalence of dry eyes than normal population. This is a case control study of 120 patients with Diabetes Mellitus (DM) and 120 paired controls aiming to compare their prevalence of dry eyes (by the Schirmer test) and its severity (measured by OSDI or Ocular Surface Disease Index) as well as their association with diseases' clinical variables. We found that 38.3% of DM patients had dry eyes, a prevalence that was higher than controls (p = 0.02). At univariate analysis, they were found to be more common in older individuals (p = 0.001) with type 2 diabetes (p = 0.001) and in those using metformin (p = 0.001). A multivariate linear regression showed that metformin use was the only independent variable associated with dry eyes. When patients with dry eyes with and without DM were compared, no differences in the symptom's intensity were found.