Abstract Sjögren’s is a chronic autoimmune disease with diverse symptomatology, and varying patient satisfaction with management. Patients with chronic conditions are known to be higher users of complementary and alternative (CAM) practices, yet little information regarding extent of such use exists. This paper describes usage of CAM practices among people living with Sjögren’s, encompassing visits to healthcare providers, CAM practitioners, self-administered CAM and self-help practices. We explored both purposes and perceived helpfulness of the various modalities utilised. 296 respondents completed an online survey administered through Sjögren’s Research Ireland in 2023. An adapted form of the International Complementary and Alternative Medicine Questionnaire (I-CAM-Q) was utilised as the survey instrument. 88.5% of respondents had a formal diagnosis of Sjögren’s. The majority (93.6%) were female, across all age groups. Over half (52%) of non-retired respondents were at least partially unable to work due to their diagnosis. Over half of all respondents (58.8%) listed at least one concomitant health problem. Most respondents (248, 83.8%) had used some form of CAM within the preceding 12 months. One-in-four had attended a CAM practitioner, most commonly chiropractors (8.4%) or acupuncturists (7.8%). Conventional healthcare and CAM providers were both consulted more commonly for management of chronic conditions or for well-being than for acute symptom management, although this was particularly stark for CAM consultations. 196 respondents (66.2%) reported use of self-administered CAM, predominantly vitamins/minerals or dietary supplements. 69.9% used various self-care practices, with the most reported being meditation, relaxation techniques and prayer. People living with Sjögren’s attend both conventional healthcare providers and CAM practitioners to a high degree and use a diverse range of complementary therapies and practices. Health care professionals need to consider and discuss potential CAM use by this patient cohort and offer evidence-based patient education about therapies and practices encountered.
Purpose Sjogren’s syndrome (SS) is a systemic autoimmune disorder characterized by inflammation that affects exocrine glands notably the salivary and lacrimal glands leading to sicca complex. Dry eye disease in primary SS (pSS) is a combination of reduced lacrimal flow from gland destruction and tear hyperosmolarity leading to inflammatory damage on the ocular surface. Several studies have shown differential expression of certain miRs in PBMCs and salivary glands from SS patients compared to healthy controls, however no functional role has been shown. This study aims to isolate miRs and mRNA from conjunctival epithelial cells by impression cytology to determine if dysregulated miR expression contributes disease pathogenesis in pSS. Methods Impression cytology (IC) was optimized using different membranes. miRs and mRNAs were isolated from conjunctival epithelial cells (CEC) obtained from pSS patients and healthy controls by IC and sent for screening to Ocean Ridge Biosciences. qPCR was performed to evaluate expression of miRs from CEC. Results Milicell biopore was the best membrane with significant yield of miRs (47.5ng ± 0.6) and mRNA (158.0 ng ± 21.6) as well as patient comfort. Appreciable levels of miRs and targeted genes were detected from the CEC from healthy controls, confirming that it is possible to isolate miRs and miRs targeted genes from CEC. Screening studies in CECs demonstrated differential expression of miRs and mRNA between pSS patients and healthy controls. Conclusion Future work will identify and confirm specific roles of these miRs for future diagnostics, prognostics and therapeutics of pSS patients as well as other ocular surface conditions.
Systemic Lupus Erythematosus(SLE) is characterised by complex interactions between both the innate and adaptive immune systems. Natural Killer(NK) cells and NK T cells(NKT) are increasingly recognised to play a significant role in the dysregulated immune response seen in SLE, with members of the Toll like receptor(TLR) family, specifically TLR7 and TLR9, identified as key players also.
Objectives
To characterise the activation state of SLE NK and NKT cells in their resting state and following TLR stimulation.
Methods
Following PBMC isolation from SLE patients surface activation of CD56+CD3-(NK) and CD56+CD3+(NKT) cells was characterised in the resting start and following TLR stimulation by flow cytometry using the following markers:CD69 and CD25. All samples were stimulated with TLR 3,4,7 and 9. Serum cytokine levels were determined by multiplex technology. Disease Activity was recorded by SLEDAI with a score >6 reflecting active disease. Differences in activation states were examined using the Mann Whitney test whilst Spearmans correlation coefficient was used to assess the relationship between cytokine levels, disease activity and monocyte activation.
Results
25 Patients with SLE were recruited. In the resting state SLE patients NK cells and NKT cells have higher expression of surface CD69 compared to controls(NK Cell 30.1% v 20.3%, p=.013)(NKT Cell 7.4% v 2.3 %, p =0.002). In contrast a significant difference for CD 25 expression was seen in SLE patients NK cells only(0.9% v 0.5%, p=0.0142). In addition active SLE patients have higher NKT cell CD69 surface expression than inactive patients, a finding not seen in SLE patients NK Cells with a significant correlation observed between disease activity and resting NK T cell CD69 expression(r = 0.55, p=.012). A significant relationship was observed between NK cell percentage CD69 surface expression and serum IL-1β production(r= -0.72, p=0.01) and percentage CD25 and IL-8 production(r= -0.69, p=0.015) in SLE patients. NK T cell CD25 levels also showed significant correlation with both serum IL-6(r=0.63, p=0.032) and IFN-Y(r = 0.66, p=0.023). Regarding responses to TLR ligands, TLR 7 stimulation resulted in a significant increase in both NK cell and NKT cell surface expression of CD69 and CD25 from the resting state in patients. In addition stimulation with all the TLR ligands resulted in increased NK Cell CD25 expression in SLE patients as compared to stimulated healthy controls, a result that was also seen following TLR 4 stimulation for NK T cell CD69 expression (8.7% v 3.9%, p = 0.005). Finally TLR 3 and TLR 9 stimulation resulted in a significant increase in NK T cell CD69 expression in patients compared to their resting state (TLR3 14.9% V 7.4%, p = 0.02)(TLR9 12.9% v 7.4%, p=0.008).
Conclusions
Our results suggest that SLE patient NK cells and NK T cells are hyperactivated in their resting state compared to healthy controls with a significant relationship seen between resting NK T Cell CD69 expression and disease activity. Despite this baseline hyperactivated state SLE patients demonstrate increased responsiveness to TLR ligands. Disclosure of Interest: None Declared
Systemic lupus erythematosus (SLE) is a complex disease targeting multiple organs as a result of overactivation of the type I interferon (IFN) system, a feature currently being targeted by multiple biologic therapies against IFN-α. We have identified an estrogen-regulated microRNA, miR-302d, whose expression is decreased in SLE patient monocytes and identify its target as interferon regulatory factor (IRF)-9, a critical component of the transcriptional complex that regulates expression of interferon-stimulated genes (ISGs). In keeping with the reduced expression of miR-302d in SLE patient monocytes, IRF9 levels were increased, as was expression of a number of ISGs including MX1 and OAS1. In vivo evaluation revealed that miR-302d protects against pristane-induced inflammation in mice by targeting IRF9 and hence ISG expression. Importantly, patients with enhanced disease activity have markedly reduced expression of miR-302d and enhanced IRF9 and ISG expression, with miR-302d negatively correlating with IFN score. Together these findings identify miR-302d as a key regulator of type I IFN driven gene expression via its ability to target IRF9 and regulate ISG expression, underscoring the importance of non-coding RNA in regulating the IFN pathway in SLE.
Elevated levels of B Lymphocyte Stimulator(BLyS) play an important role in the pathogenesis of Systemic Lupus Erythematosus. Although anti BLyS-targeted therapies have shown promise in the treatment of SLE, results of clinical trials highlight that a number of patients remain unresponsive to BLyS pathway blockade. The optimal timing of anti BLyS therapy remains to be determined.
Objectives
To identify clinical, serologic and cytokine profiles that are associated with elevated BLyS levels in a homogenous Caucasian SLE population and thereby identify patient subtypes that are more likely to respond to BLyS blockade.
Methods
BLyS levels in addition to a range of other proinflammatory cytokines were determined by ELISA. Elevated BLyS levels were defined as values above the 95% percentile in a cohort of normal healthy controls. For analysis patients with SLE (as per ACR criteria) were divided into two groups: those with elevated BLyS levels or normal BLyS levels. Clinical history, lab measures of disease activity and lupus-associated autoantibodies were recorded for all patients. Categorical variables were analyzed using Fisher's exact test and continuous variables by unpaired t-tests. The Mann-Whitney test was used in instances of non-normality. Spearman's correlation coefficient was calculated for all cytokines assayed.
Results
Twenty two patients were included in both groups. BLyS levels were significantly different (1173 pg/ml v 558 pg/ml, p<.001) between groups. Elevated BLyS levels failed to show correlation with any of the individual cytokines assayed. However in patients with elevated BLyS levels the strongest proinflammatory cytokine signatures were seen between IL-1 v IL-6 (r=0.84 p<0.001) and IL-6 v TNF(r=0.83 p<0.001). Elevated levels of BLyS were seen in both younger patients (33.4yrs v 43.6 yrs, p<0.006) and in those that had a shorter disease duration (5 yrs v 8.95 yrs, p<0.02). Patients with elevated BLyS displayed a trend towards younger age at diagnosis(28.4 yrs v 34.7 yrs, p=0.07). Patients with elevated BLyS were more likely to be dsDNA positive (p<0.05) and to demonstrate higher titres of dsDNA (232iu/ml v 121iu/ml,p<.01). The presence of Sm antibody significantly predicted elevated BLys levels (p<0.05, odds ratio 13.5). All other lupus autoantibodies recorded failed to predict BLyS elevation. Other laboratory measures of disease activity failed to differentiate between those with elevated and normal BLyS levels although there was a trend towards low complement in those with BLyS elevation (p=0.07). BLyS levels were significantly higher in those with musculoskeletal involvement(930 pg/ml v 591 pg/ml, p<0.04) and malar rash (920 pg/ml v 594 pg/ml, p<0.05). Whilst there was no significant difference in the absolute number of patients with renal involvement between groups mean BLyS levels were higher in those with renal involvement (1126 pg/ml v 751 pg/ml).
Conclusions
BLyS levels are higher in younger patients and those with shorter disease duration. Sm antibody and dsDNA positivity predict elevated levels of BLyS. BLyS blockade may be most beneficial if introduced early in the course of disease in young patients presenting with renal, musculoskeletal and skin disease with these autoantibody profiles.
Background Systemic Lupus Erythematosus (SLE) involves complex interactions between the innate and adaptive immune systems. Monocytes are increasingly recognised to play a key role in the dysregulated immune response seen in SLE whilst more recently B Lymphocyte Stimulator (BLyS) has been demonstrated to play a key role in the pathogenesis of SLE. Despite the fact that monocytes are one of the key producers of BLyS, the effect of BLyS on monocyte activation in SLE patients has not been determined. Objectives To characterise the activation state of SLE monocytes in their resting state and in response to BLyS. Methods Activation of CD14+ monocytes was characterised in the resting state and following BLyS stimulation in both healthy controls and SLE patients by flow cytometry. Both antigen presenting capacity and co-stimulatory molecule expression were assessed using the following surface markers: CD80, CD86 and HLA-DR. Differences in activation states between groups were examined using the Mann Whitney whilst within group analysis was performed using the Wilcoxon signed-rank test. Spearman's correlation coefficient was also used to assess the relationship between HLA-DR expression and CD80/CD86. Results 25 SLE Patients (as per ACR diagnostic criteria) were recruited. Basal expression of CD80 and HLA-DR was increased on patient monocytes compared to controls (CD80 6.35% v 1.5%, p=0.036, HLA-DR 61.65% v 47.30%, p=0.048). No relationship was observed between disease activity as per SLEDAI and resting SLE patient monocyte function. Interestingly despite their baseline hyper-activated state, following stimulation with BLyS, SLE patients significantly upregulated CD80, CD86 and HLA-DR expression [(CD80 6.35% v 8.4%, p=0.007, CD86 80.8% v 84.6%, p=0.03, HLA-DR 61.65% v 74.95%, p=0.001). In contrast the healthy control volunteers failed to significantly upregulate any of the surface markers following BLyS stimulation indicating that SLE patients monocytes are more responsive to the effects of BLyS. In support of this SLE patients expressed more CD80 and HLA-DR following stimulation than controls (CD 80 8.4% v 2.5%, p=0.0031, HLA-DR 74.95% v 52.90%, p=0.018). When the relationship between CD80/CD86 and HLA-DR surface expression was examined no significant correlation was observed between them in the resting state. However following BLyS stimulation a strong correlation was seen between both CD80/CD86 and HLA-DR expression in SLE patients (CD80 vs HLA-DR:Spearman r =0.64, p=0.005, CD86 vs HLA-DR: Spearman r =0.60, p=0.012) Conclusions Our results suggest that SLE patient monocytes have a hyperactivated phenotype which consequentially results in an enhanced response to BLyS exposure compared to healthy control monocytes. As BLyS plays a significant role in monocyte function in SLE this finding warrants further investigation. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2174
Abstract Background Sjögren's (‘SHOW‐grins’) is a chronic debilitating autoimmune disease characterised by dry eyes and dry mouth, secondary to reduced exocrine function of both the lacrimal and salivary glands. The persistent, severe and serious systemic complications of Sjögren's are poorly understood and often unappreciated, resulting in significant morbidity and treatment burden. This study aimed to explore the experiences of those living with Sjögren's, specifically access to healthcare and attitude towards telemedicine. Additionally, we sought to collect information regarding the impact of the pandemic on their quality of life (QoL). Methods One hundred and ninety‐four individuals attended an Irish Sjögren's Webinar. Attendees were invited to participate in two online surveys after the webinar. The first survey gathered information related to demographics, disease and experiences during the COVID‐19 pandemic. A combination of bespoke items and validated questionnaires (EULAR Sjögren's Syndrome Patient Reported Index [ESSPRI], COVID‐19 Impact on Quality of Life [COV19‐QoL]) was used. The second survey consisted of a shortened Telehealth Usability Questionnaire. Both were prepared in collaboration with a patient advocate. Results Survey 1: n = 76; response rate = 39.2%. Thirty‐one respondents (41.4%) to survey 1 reported a delay of ≥5 years between the onset of symptoms and diagnosis. Dry mouth was the most common symptom experienced (76.8%, n = 63), followed by dry eye (74.4%, n = 61), fatigue (57.3%, n = 47) and joint pain (53.7%, n = 44), but a range of other symptoms were also reported. COV19‐QoL results indicated that the pandemic had a detrimental effect on participants' overall QoL (4.0 ± 1.0) and physical health (4.0 ± 0.8) in particular. COV19‐QoL and ESSPRI scores were moderately correlated (0.36, p = .002). Over 70% of respondents had a medical appointment cancelled, delayed or rescheduled ( n = 60). Survey 2: n = 57; response rate = 29.4%. Those that had interacted with telemedicine reported largely positive experiences with the virtual model. Conclusion Clinicians should be aware of the range of symptoms experienced by patients with Sjögren's beyond those of sicca (dry eye and dry mouth) and fatigue. COVID‐19 has negatively influenced the self‐reported health and well‐being of those with Sjögren's, particularly those with higher symptom scores. It is vital that optimised telemedicine models are implemented to ensure continuity in the provision of healthcare for those with chronic illness such as Sjögren's and in preparation for possible future pandemics. Patient or Public Contribution A group of people living with Sjögren's co‐designed the structure and content of the webinar where the survey was shared. A public and patient involvement (PPI) contributor also collaborated in the selection of questionnaires used in the study, ensuring that the questions asked would best reflect the priorities of patients. They contributed to the writing of this manuscript as co‐authors. Additionally, the research team and Sjögren's patients who contributed to this work have gone on to establish Sjögren's Research Ireland, a collaboration between patient advocates, researchers and PPI facilitators.
Ro52 is a member of the TRIM family of single-protein E3 ligases and is also a target for autoantibody production in systemic lupus erythematosus and Sjögren's syndrome. We previously demonstrated a novel function of Ro52 in the ubiquitination and proteasomal degradation of IRF3 following TLR3/4 stimulation. We now present evidence that Ro52 has a similar role in regulating the stability and activity of IRF7. Endogenous immunoprecipitation of Ro52-bound proteins revealed that IRF7 associates with Ro52, an effect which increases following TLR7 and TLR9 stimulation, suggesting that Ro52 interacts with IRF7 post-pathogen recognition. Furthermore, we show that Ro52 ubiquitinates IRF7 in a dose-dependent manner, resulting in a decrease in total IRF7 expression and a subsequent decrease in IFN-α production. IRF7 stability was increased in bone marrow-derived macrophages from Ro52-deficient mice stimulated with imiquimod or CpG-B, consistent with a role for Ro52 in the negative regulation of IRF7 signalling. Taken together, these results suggest that Ro52-mediated ubiquitination promotes the degradation of IRF7 following TLR7 and TLR9 stimulation. As Ro52 is known to be IFN-inducible, this system constitutes a negative-feedback loop that acts to protect the host from the prolonged activation of the immune response.
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