Mortality risk factors in primary Sjögren syndrome: a real-world, retrospective, cohort study.

Background: What baseline predictors would be involved in mortality in people with primary Sjögren syndrome (SjS) remains uncertain. This study aimed to investigate the baseline characteristics collected at the time of diagnosis of SjS associated with mortality and to identify mortality risk factors for all-cause death and deaths related to systemic SjS activity measured by the ESSDAI score. Methods: In this international, real-world, retrospective, cohort study, we retrospectively collected data from 27 countries on mortality and causes of death from the Big Data Sjögren Registry. Inclusion criteria consisted of fulfilling 2002/2016 SjS classification criteria, and exclusion criteria included chronic HCV/HIV infections and associated systemic autoimmune diseases. A statistical approach based on a directed acyclic graph was used, with all-cause and Sjögren-related mortality as primary endpoints. The key determinants that defined the disease phenotype at diagnosis (glandular, systemic, and immunological) were analysed as independent variables. Findings: Between January 1st, 2014 and December 31, 2023, data from 11,372 patients with primary SjS (93.5% women, 78.4% classified as White, mean age at diagnosis of 51.1 years) included in the Registry were analysed. 876 (7.7%) deaths were recorded after a mean follow-up of 8.6 years (SD 7.12). Univariate analysis of prognostic factors for all-cause death identified eight Sjögren-related variables (ocular and oral tests, salivary biopsy, ESSDAI, ANA, anti-Ro, anti-La, and cryoglobulins). The multivariate CPH model adjusted for these variables and the epidemiological features showed that DAS-ESSDAI (high vs no high: HR = 1.68; 95% CI, 1.27-2.22) and cryoglobulins (positive vs negative: HR = 1.72; 95% CI, 1.22-2.42) were independent predictors of all-cause death. Of the 640 deaths with available information detailing the specific cause of death, 14% were due to systemic SjS. Univariate analysis of prognostic factors for Sjögren-cause death identified five Sjögren-related variables (oral tests, clinESSDAI, DAS-ESSDAI, ANA, and cryoglobulins). The multivariate competing risks CPH model adjusted for these variables and the epidemiological features showed that oral tests (abnormal vs normal results: HR = 1.38; 95% CI, 1.01-1.87), DAS-ESSDAI (high vs no high: HR = 1.55; 95% CI, 1.22-1.96) and cryoglobulins (positive vs negative: HR = 1.52; 95% CI, 1.16-2) were independent predictors of SjS-related death. Interpretation: The key mortality risk factors at the time of SjS diagnosis were positive cryoglobulins and a high systemic activity scored using the ESSDAI, conferring a 2-times increased risk of all-cause and SjS-related death. ESSDAI measurement and cryoglobulin testing should be considered mandatory when an individual is diagnosed with SjS. Funding: Novartis.

Association of class II HLA alleles with susceptibility to develop immune-mediated diseases in Paraguayan patients.

Genetic and nongenetic factors are involved in the pathogenesis of immune-mediated inflammatory diseases (IMIDs). The best-known genetic factor for susceptibility to IMIDs is the human leukocyte antigen (HLA). The aim of the present study was to evaluate the association of HLA class II genes with the risk of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and systemic sclerosis (SSc) in the Paraguayan population. We included 254 patients with IMIDs (101 SLE, 103 RA, and 50 SSc) and 50 healthy controls. The haplotypes of five genes corresponding to HLA class II genes and their relationship to the IMIDs studied were determined. Note that 84.6% were women, with a mean age of 43.4 ± 14 years. Among the associated HLA alleles, we found the previously identified risk factors in other populations like HLA-DRB1*03:01 and HLA-DRB1*14:02 for RA, as well as new ones not previously identified, such as DPA1*02:01 for SLE and, DB1*02:01 for RA and SSc. In the genetic association analysis, already known associations have been replicated, and unpublished associations have been identified in Paraguayan patients with IMIDs. This is the first genetic association study in Paraguayan patients with IMIDs.

Association between vitamin D deficiency and disease activity in Paraguayan patients with systemic lupus erythematosus / Asociación entre la deficiencia de vitamina D y la actividad de la enfermedad en pacientes paraguayos con lupus eritematoso sistémico

ABSTRACT Objective: To identify the association between vitamin D (VD) concentrations and the activity of systemic lupus erythematosus (SLE) and determine a supplementation dose that allows patients to maintain adequate levels of VD. Methods: Longitudinal, observational study. Serum levels of 25-hydroxy-VD were measured in 100 Paraguayan SLE patients from the Hospital de Clínicas between 2016 and 2018. To analyze the response to different doses of VD supplementation, 50 patients received 1000IU/day and the other 50 patients received 2000IU. SLE disease activity measured by SELENA-SLEDAIwas scored before and after supplementation. Results: The mean age was 27.5 ±9.8 years, 88.9% of patients presented mild disease activ ity and 11.1% presented moderate to severe activity. The mean VD concentration was 30.8 ± 11.8 ng/mL. A total of 34% of patients presented VD insufficiency and 13% VD defi ciency. There was an inverse relationship between VD concentrations and SLE disease activity (p = 0.03). Increasing levels of serum VD are associated with supplementation of 2000 IU/day (p = 0.0224). Conclusion: SLE activity was associated with low levels of VD. In our cohort, SLE patients required a supplementation dose equal to or greater than 2000 IU/day to increase their serum VD.

R E S U M E N Objetivo: Identificar la asociación entre las concentraciones de vitamina D (VD) y la actividad del lupus eritematoso sistémico (LES), además de encontrar una dosis de suplementación que les permita a los pacientes mantener niveles adecuados de VD. Métodos: Estudio observacional longitudinal. Se midieron los niveles séricos de 25-hidroxi-VD en 100 pacientes paraguayos con LES, del Hospital de Clínicas, entre los años 2016 y 2018. Para analizar la respuesta a diferentes dosis de suplementación con VD, 50 pacientes recibieron 1.000 UI/día y los otros 50 pacientes recibieron 2.000 UI/día. La actividad de la enfermedad del LES medida por SELENA-SLEDAI se puntuó antes y después de la suplementación. Resultados: La media de edad fue de 27,5 ± 9,8 años, el 88,9% de los pacientes presentó actividad leve de la enfermedad y el 11,1% presentó actividad moderada a severa. La concentración media de VD fue de 30,8 ± 11,8 ng/ml. El 34% de los pacientes presentó insuficiencia de VD y el 13%, deficiencia de VD. Hubo una relación inversa entre las concentraciones de VD y la actividad de la enfermedad del LES (p = 0,03). Los niveles crecientes de VD en suero se asocian con una suplementación de 2.000 UI/día (p = 0,0224). Conclusión: La actividad del LES se asoció con niveles bajos de VD. En nuestra cohorte, los pacientes con LES requirieron una dosis de suplementación igual o superior a 2.000 UI/día para aumentar su VD sérica.

Parotid gland swelling in primary Sjögren's syndrome: activity and other sialadenosis causes.

OBJECTIVE: To assess the prevalence of parotid gland swelling (PGS) and its association with features of SS and other causes of sialadenosis in a Latin-American cohort of primary SS. METHODS: We included 668 patients from Argentina, Brazil, Mexico and Paraguay. We retrospectively registered demographics, disease duration, oral/ocular symptoms, serology and scored the basal ESSDAI. We defined PGS as a recurrent or persistent increase of volume of any parotid glands during adulthood (self-reported and/or physical examination). We registered the presence of diabetes mellitus, dyslipidaemia, body mass index and alcohol consumption. We used logistic regression analysis reporting odds ratio (OR) and 95% CI. RESULTS: PGS was present in 242 patients (36.2%): 78 previous to SS diagnosis, 86 concomitantly, 73 during follow-up and five unknown. At the multivariate analysis, PGS was associated with RF (OR 2.47, 95% CI: 1.1, 6.5, P = 0.0001), basal articular ESSDAI domain (OR 1.63, 95% CI: 1.01, 2.6, P = 0.04) and alcohol consumption (OR 2.42, 95% CI: 1.41, 4-15). Patients with PGS during the follow-up had a higher prevalence of alcohol consumption (45.3%) compared with the remaining PGS cases (26.8%; OR 2.41 95% CI: 1.2, 4.7), or patients without parotid gland swelling (15.6%; OR 3.8 95% CI: 1.7, 8.2) in all the adjusted models. CONCLUSION: PGS generally precedes or presents concomitantly with SS diagnosis, and is related to RF and articular activity. Alcohol consumption is an additional factor in PGS, especially during follow-up. The meaning of this last finding as well as its prognostic implications remains to be elucidated and deserves further evaluation in prospective studies.

Systemic phenotype related to primary Sjögren's syndrome in 279 patients carrying isolated anti-La/SSB antibodies.

OBJECTIVES: To evaluate the systemic phenotype associated with the presence of isolated anti-La/SSB antibodies in a large international registry of patients with primary Sjögren's syndrome (pSS) fulfilling the 2002 classification criteria. METHODS: The Big Data Sjögren Project Consortium is an international, multicentre registry created in 2014. Baseline clinical information from leading centres on clinical research in SS of the 5 continents was collected. Combination patterns of anti-Ro/SSA-La/SSB antibodies at the time of diagnosis defined the following four immunological phenotypes: double positive (combined Ro/SSA and La/SSB,) isolated anti-Ro/SSA, isolated anti-La/SSB, and immunonegative. RESULTS: The cohort included 12,084 patients (11,293 females, mean 52.4 years) with recorded ESSDAI scores available. Among them, 279 (2.3%) had isolated anti-La/SSB antibodies. The mean total ESSDAI score at diagnosis of patients with pSS carrying isolated anti-La/SSB was 6.0, and 80.4% of patients had systemic activity (global ESSDAI score ≥1) at diagnosis. The domains with the highest frequency of active patients were the biological (42.8%), glandular (36.8%) and articular (31.2%) domains. Patients with isolated anti-La/SSB showed a higher frequency of active patients in all ESSDAI domains but two (articular and peripheral nerve) in comparison with immune-negative patients, and even a higher absolute frequency in six clinical ESSDAI domains in comparison with patients with isolated anti-Ro/SSA. In addition, patients with isolated anti-La/SSB showed a higher frequency of active patients in two ESSDAI domains (pulmonary and glandular) with respect to the most active immunological subset (double-positive antibodies). Meanwhile, systemic activity detected in patients with isolated anti-La/SSB was overwhelmingly low. Even in ESSDAI domains where patients with isolated anti-La/SSB had the highest frequencies of systemic activity (lymphadenopathy and muscular), the percentage of patients with moderate or high activity was lower in comparison with the combined Ro/SSA and La/SSB group. CONCLUSIONS: Patients carrying isolated La/SSB antibodies represent a very small subset of patients with a systemic SS phenotype characterised by a significant frequency of active patients in most clinical ESSDAI domains but with a relative low frequency of the highest severe organ-specific involvements. Primary SS still remains the best clinical diagnosis for this subset of patients.

Prevalencia de valores inadecuados de vitamina D y factores de riesgo asociados en jóvenes universitarios de Asunción / Prevalence of inadequate vitamin D values and associated risk factors in university students of the city of Asunción

La vitamina D es una hormona cumple una función en la regulación de numerosos genes que participan en la proliferación y maduración celular. El objetivo de este trabajo fue determinar la prevalencia de valores inadecuados de esta vitamina en jóvenes sanos de Asunción e identificar los posibles factores de riesgo asociados. Estudio observacional descriptivo basado en datos clínico-epidemiológicos y en la determinación de la 25-hidroxivitamina D (25-OH vitamina D) por el método de quimioluminiscencia (CMIA). Se consideró valor adecuado ≥30 ng/dl, inadecuado por debajo de este rango y deficiente ≤20 ng/dl. El análisis estadístico se realizó con el programa R-proyect. Para establecer factores de riesgo para tener deficiencia de vitamina D se utilizó regresión logística bi y multivariante. Se incluyeron 817 jóvenes universitarios de edad promedio 21 años. La concentración de vitamina D tuvo una media de 25 ± 8 ng/dl, oscilando entre 64,3 y 2,4 ng/dl. El 75,5% de los participantes tenían valores inadecuados de vitamina D. La deficiencia de vitamina D fue significativamente (p = 0,006) más frecuente en mujeres, personas con sobrepeso (p = 0,03), con falta de exposición al sol (p = 0,001) y con sedentarismo (p = 0,0001). Este estudio confirma la elevada prevalencia de valores inadecuados de vitamina D en nuestro país y permite definir un perfil de muy alto riesgo para las jóvenes sedentarias y con sobrepeso, lo que justifica una atención especial de parte de los médicos y las instituciones responsables de la salud pública en nuestro país(AU)

Vitamin D is a hormone that plays a role in the regulation of numerous genes involved in cell proliferation and maturation. The objective of this work was to determine the prevalence of inadequate values of this vitamin in healthy young people of the city of Asunción and to identify the possible risk factors associated with it. Descriptive observational study based on clinical-epidemiological data and in the determination of 25-hydroxyvitamin D (25-OH vitamin D) by the chemiluminescence method (CMIA). It was considered appropriate values ≥30 ng/dl, inappropriate below this range and deficient <20 ng/dl. Statistical analyzes were carried out with the R-project program. To establish the association, bivariate and multivariate logistic regression was used. We included 817 university students with an average age of 21 years. The average value of the vitamin D concentration was 25 ± 8 ng/dl, ranging from 64.3 to 2.4 ng/dl. Inadequate vitamin D values were found in 75.5% of the participants. Vitamin D deficiency was significantly (p <0.006) more frequent in women, overweight people (p <0.03), lack of sun exposure (p = 0.001) and sedentary lifestyle (p = 0.0001). This study confirms the high prevalence of inadequate vitamin D values in our country and allows us to define a very high risk profile for sedentary and overweight young women, which justifies special attention from physicians and institutions responsible for public health in our country(AU)

Características clínico-epidemiológicas de los pacientes de la cohorte Lupus Paraguay (2013-2014) / Characteristics clinical-epidemiological of the patients of the Lupus Paraguay cohort (2013-2014)

El lupus eritematoso sistémico (LES) es una enfermedad autoinmune, de etiología desconocida que presenta manifestaciones clínicas de gravedad y curso impredecible. Se ha observado en varias cohortes que esta enfermedad tiene un comportamiento más agresivo en la población no caucásica debido a diferencias socioeconómicas, demográficas y genéticas. El objetivo del estudio es describir las características clínico-epidemiológicas de los pacientes con LES incluidos en la cohorte LUPUS-PY y la situación actual de las muestras custodiadas en el BIOBANCO IMID-PY. Estudio basado en la revisión de historias clínicas y en los cuestionarios clínico-epidemiológicos del día de la inclusión al registro LUPUS-PY. Se calcularon las frecuencias para las variables categóricas y las medias con su desvío estándar para las continuas. Se incluyeron de forma consecutiva, 83 pacientes con diagnóstico de LES (edad media: 34,4±10,0 años), el 86,7% era del sexo femenino, el 55% provenía de Asunción, el 49,1% tenía nivel educativo básico, el 45% percibía un ingreso mensual de un sueldo mínimo (aproximadamente 350 dólares americanos) o menos. El 46,8% no realizaba ningún tipo de actividad física. La media del tiempo trascurrido desde el inicio de los síntomas y el diagnóstico del LES fue de 9,3±13,7 años y el tiempo de evolución de la enfermedad hasta el ingreso al registro fue de 5,9±6,3. El 16% refirió antecedentes familiares de enfermedades autoinmunes. La primera manifestación de la enfermedad más descripta fue la articular (45%). Los pacientes con LES de nuestro centro tienen características tanto clínicas como epidemiológicas similares a las reportadas por otras cohortes(AU)

A 51-Year-Old Woman With Hypoacusia and Increased Respiratory Effort in the Supine Position and OSA.

A 51-year-old woman with a personal history of vitiligo, normal thyroid hormone studies, a simple hysterectomy for multiple uterine myomas at age 35 years, and childhood adenotonsillectomy was seen for progressive hearing loss. She reported mild asthenia, cold intolerance, mild dysphagia with frequent choking while eating and drinking, and a progressive increase in inspiratory effort, especially in the supine position. Her partner described a progressively worsening history of snoring and witnessed apneic episodes, mostly in the supine position. Mild to moderate daytime sleepiness was also present.

Características clínicas y de laboratorio en pacientes con cetoacidosis diabética

La cetoacidosis diabética (CAD) es una de las complicaciones agudas severas de la diabetes mellitus. La mayoría de los pacientes con CAD tienen diabetes autoinmune tipo 1, sin embargo, los pacientes con diabetes tipo 2 (DM2) también están en riesgo de padecerla durante el estrés catabólico de una enfermedad aguda como traumatismo, cirugía o infección. Se presenta una serie de 20 casos donde se diagnosticó CAD en sujetos con DM2, la edad media fue 62 años, todas eran mujeres, cuya principal causa precipitante fue la infección. La forma clínica moderada (85%) fue la predominante.

The diabetic ketoacidosis (DKA) is one of the severe acute complications of diabetes mellitus. Most patients with DKA have type 1 autoimmune diabetes but patients with type 2 diabetes are also at risk of suffering it during the catabolic stress of an acute disease like a traumatism, surgery or infection. We present a series of twenty cases with DM2 in whom DKA was diagnosed. All were women with a mean age of 62 years, being infection the main cause. The moderate clinical form was predominant (85%).

Reporte de paciente con síndrome de insensibilidad completa a los andrógenos

Se presenta caso de mujer con fenotipo femenino pero con cariotipo 46XY, que genera una insensibilidad completa a los andrógenos.

We report the case of a woman with a female phenotype, but with a 46, XY karyotype, that generates complete androgen insensitivity.

Pseudoaneurisma gigante de carótida extracraneal / Giant pseudoaneurysm of the extracranial carotid

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