Pain, Depression, and Fatigue in Sjögren’s syndrome - a study

Pain, Depression, and Fatigue in Sjögren’s syndrome

Pain and depression are associated with both physical and mental fatigue independently of comorbidities and medications in primary Sjögren’s syndrome. 
On behalf of the UK primary Sjögren’s Syndrome Registry

To report on fatigue in patients from the United Kingdom primary Sjögren’s syndrome (pSS) registry identifying factors associated with fatigue and robust to assignable causes such as comorbidities and medications associated with drowsiness.

From our cohort (n = 608), we identified those with comorbidities associated with fatigue, and those taking medications associated with drowsiness. We constructed dummy variables, permitting the contribution of these potentially assignable causes of fatigue to be assessed. Using multiple regression analysis, we modelled the relationship between Profile of Fatigue and Discomfort physical and mental fatigue scores and potentially related variables. Results Pain, depression and daytime sleepiness scores were closely associated with both physical and mental fatigue (all p ≤ 0.0001). In addition, dryness was strongly associated with physical fatigue (p ≤ 0.0001). These effects were observed even after adjustment for comorbidities associated with fatigue or medications associated with drowsiness.

These findings support further research and clinical interventions targeting pain, dryness, depression and sleep to improve fatigue in patients with pSS. This finding is robust to both the effect of other comorbidities associated with fatigue and medications associated with drowsiness. Introduction Primary Sjögren’s syndrome

Our data confirm the importance of fatigue symptoms— both mental and physical—to patients with pSS and permit identification of factors contributing to fatigue including other comorbidities and medications associated with drowsiness. Given the wide variety of potential factors contributing to fatigue, we support the view that a multidisciplinary approach is essential for the clinical management of fatigue in pSS.32

  •  We observe that many patients with pSS are taking multiple medications and we recommend a medication review be undertaken to identify drowsy medications which could be contributing to fatigue. If these medications are discontinued, then a review should be arranged and if the fatigue does not improve, then treatment of comorbidities should be considered. However, as pain is a major contributor of both mental and physical fatigue, the contribution of some pain-modifying medications may be beneficial, despite their association with drowsiness.
  • Patients with pSS should be tested for common comorbidities which can contribute to fatigue, including anaemia or hypothyroidism and offered appropriate treatments. 
  • We recommend screening for depression and anxiety and offering patients appropriate interventions to address these symptoms. Non-pharmacological interventions (such as talking therapies) may reduce the need for antidepressants and anti-anxiolytics, many of which are associated with drowsiness.  
  • We recommend that patients undergo a more detailed sleep assessment in order to screen for a primary sleep disorder. Patients identified with conditions such as obstructive sleep apnoea should be offered assignable causes such as Continuous Positive Airway Pressure (CPAP) treatment. Interventions such as cognitive behavioural therapy for insomnia (CBT-I) are a first-line treatment for insomnia associated with other medical conditions and may prove beneficial to patients with pSS. 
  • Patients with pSS should be offered appropriate pain management interventions. If pain is associated with poor sleep, then CBT-I with a pain adjunct has been suggested as a feasible treatment.
  • Finally, in the absence of good evidence to support effective drug treatments, fatigue interventions in pSS might focus on a multidisciplinary approach incorporating activity management, graded exercise/ activity and CBT.




Common bacteria that reside in the human gut may be partly to blame for a serious autoimmune disease called antiphospholipid syndrome that frequently affects young women, report researchers.


For their study, the research team focused on cells from patients with the immune system disorder, which raises the risk of blood clots. This chronic condition can lead to lung clots, strokes, heart attacks, and in pregnant women, miscarriages or stillbirths.
Using patient immune cells and antibodies, as well as animal models of the disease, the investigators did several experiments to explore the phenomenon. They found that a common gut bacterium, Roseburia intestinalis, can trigger antiphospholipid syndrome in individuals who have a genetic predisposition.
In those patients, the immune system’s defender T and B cells react to a blood protein involved in clotting, and also to the bacteria, in certain amino acids found in the bacteria. Over time, this ongoing “cross-reactive” response leads to tissue damage and chronic disease.
By identifying a gut bacterium, instead of the immune system, as the target for treatment, the study could lead to new drugs for these patients, according to the scientists.
The research was also the first to show cross-reactivity of gut bacteria in humans with this disease, says senior author Martin Kriegel, assistant professor of immunobiology and of medicine (rheumatology) at the Yale University School of Medicine—a finding that could impact the understanding and treatment of other autoimmune diseases.
The study appears in Cell Host & Microbe. The National Institutes of Health, Yale Rheumatic Diseases Research Core, Women’s Health Research at Yale, O’Brien Center at Yale, Arthritis National Research Foundation, Arthritis Foundation, and Lupus Research Alliance, as well as the American Heart Association and Lupus Research Institute, supported the research.
Source: Yale University


Painful Small‐Fiber Neuropathy in Primary Sjogren's Syndrome

Painful Small‐Fiber Neuropathy in Primary Sjogren's Syndrome
The Clinical Features of Painful Small‐Fiber Neuropathy Suggesting an Origin Linked to Primary Sjögren's Syndrome

Small fiber neuropathy is a condition characterized by severe pain attacks that typically begin in the feet or hands. Some people initially experience a more generalized, whole-body pain. The attacks usually consist of pain described as stabbing or burning, or abnormal skin sensations such as tingling or itchiness. In some individuals, the pain is more severe during times of rest or at night. NIH


Researchers attempted to determine whether clinical features could tell the difference between painful small‐fiber neuropathy (SFN) related to primary Sjogren's syndrome from idiopathic SFN. Idiopathic means that no specific cause can be identified. 


They conducted questionnaires and neuro-physiological examinations specific for pain and SFN assessment on 25 patients with pSS‐SFN and 25 patients with idiopathic SFN.


Patients with idio‐SFN had more frequent severe burning sensations and higher mean anxiety scores and daily pain intensity compared to patients with pSS SFN. Conversely, patients with pSS‐SFN had reduced electrochemical skin conductance measured by Sudoscan, and almost half of them had the sensation of walking on cotton wool.


The results suggest that:

  •  idiopathic‐SFN  involved more small sensory fibers than pSS‐SFN
  • subtle dysfunction of larger sensory fibers and damage of distal autonomic sudomotor innervation may occur in  pSS‐SFN. 
  • A practical algorithm is proposed to help to differentiate SFN associated with pSS from idio‐SFN, based on information very easy to obtain by clinical interview.



Stressed-Out Bacteria May Trigger Autoimmune Response

 Stressed-Out Bacteria May Trigger Autoimmune Response
American Society for Microbiology.

Stressful life events most likely contribute to autoimmune diseases, but scientists don’t have a deep understanding of the underlying chain of events. 

study on mice published this week in mSystems suggests that the gut microbiota may play a significant role in that connection. Researchers found that the onset of stress caused changes in the intestinal bacteria that, in turn, stimulated the activity of immune cells in a way that increased the likelihood that the body would attack itself.

The factors behind autoimmune diseases, conditions in which the body’s immune defense attacks its own tissues and systems, can be difficult to pin down. That’s partly because these diseases vary in severity and presentation. They include multiple sclerosis, lupus, rheumatoid arthritis, juvenile diabetes, scleroderma, and pulmonary fibrosis. 

The National Institutes of Health estimates that more than 20 million people in the United States have autoimmune diseases, the vast majority of whom are women.

In the study published in mSystems, immunologist Orly Avni, PhD, at Bar Ilan University, worked with graduate student Michal Werbner and other collaborators to investigate environmental risks, like psychological and social stress, because those offer opportunities for potential treatment.

A study on mice and the gut microbiota

“We know that there’s strong cross talk between the immune system and the microbiota,” Avni said. An important step in understanding how stress may lead to autoimmune conditions, she said, is to identify the genetic responses of bacteria. Her group’s study showed that social stress changed both the composition and transcriptional patterns in the microbiota. “And the consequent immune response to that threat jeopardized the tolerance to self,” she said.

The study shows that gut bacteria can sense and respond to social stress, but Avni notes that researchers need to better understand how that long-lasting interaction works between bacteria and their hosts.
“It’s not enough to study the composition, or the increase or decrease of a species,” she said. “We also have to understand how the microbiota sense us, and how they change their 'behavior' accordingly.”
 That knowledge, she added, could potentially lead to tailored microbial interventions that could dampen autoimmunity and additional stress-inducible illness.

Read the full article with the explanation of how the study was carried out.

Social-Stress-Responsive Microbiota Induces Stimulation of Self-Reactive Effector T Helper Cells. Michal Werbner, Yiftah Barsheshet, Nir Werbner, Mor Zigdon, Itamar Averbuch, Oren Ziv, Boris Brant, Evan Elliott, Shachaf Gelberg, Moran Titelbaum, Omry Koren, Orly Avni. msystems, July/August 2019 Volume 4 Issue 4 e00292-18, DOI: 10.1128/mSystems.00292-18.


New treatment for severe dry eye disease promising

Treatment for severe dry eye disease

Participants in a clinical trial of a new enzyme-based treatment for severe dry eye disease experienced reduced signs of both disease and discomfort. 
The trial compared eye drops containing a biosynthetic form of an enzyme called DNase with eye drops without the enzyme. 
DNase breaks up nucleic acid-based material on the surface of the eye.
“Participants in the trial who used the drops with DNase reported less eye discomfort and their corneas were healthier,” said Dr. Sandeep Jain, professor of ophthalmology and visual sciences in the University of Illinois at Chicago College of Medicine and principal investigator of the clinical trial.
The researchers found that participants in the DNase group had a statistically significant and clinically meaningful reduction in corneal damage at eight weeks compared with the placebo group.

“The data from this early clinical trial suggests that DNase eye drops may be safe and effective for treating severe dry eye, and we look forward to conducting larger randomized trials to definitively prove its efficacy,” Jain said.

Read the full article


Counselling patients with Sjögren’s syndrome is critical

Counseling patients with Sjögren’s syndrome
DESTIN, Fla. — An expert emphasized how important it is to counsel patients with Sjögren’s syndrome to reduce the occurrence of organ failure or adult failure to thrive, here at the Congress of Clinical Rheumatology.
“If we don’t advise our patients, if we are not cognizant of what can happen in these patients who complain of dry eye and dry mouth, they can go onto severe organ damage,” said Steven E. Carsons, MD, chief of Rheumatology, Allergy and Immunolog, at NYU Winthrop Hospital. “That is, they can lose vision, or they can become edentulous and lose all their teeth.”
Carsons said edentulism “has significant affect on nutrition and can cause inanition, malnutrition and adult failure to thrive.”

Rheumatologists need to take time to counsel patients with Sjögren’s syndrome to be examined by an ophthalmologist every 6 months even if they do not have symptoms, he said.
Additionally, patients should use their eyedrops that are prescribed, for instance Restasis. Emphasize that patients should use their eyedrops regardless of symptoms or lack of symptoms to prevent ocular damage, he said.
Patients with Sjögren’s syndrome should be examined by their dentist every 3 months and request a fluoride treatment regularly, as well as a prophylaxis cleaning.


Autoimmune Research updates April

Autoimmune Research April

Following is an update of recent autoimmune medical research: 

Clinical Trial Investigates Treatment for Two Autoimmune Liver Diseases​​​​​​​

Revolutionizing the Diagnosis of Autoimmune Diseases

Joseph DeRisi, PhD; Samuel Pleasure, MD, PhD; and Michael Wilson, MD
2016 - 2019 Weill Innovation Award

Unlocking the female bias in lupus.
New research on the X chromosome from the School of Veterinary Medicine points to an abnormality in the immune system’s T cells as a possible contributing factor in lupus and other autoimmune diseases.

Hypertension in Rheumatic Diseases:
A Closer Look at Immune Mediators and Hormone Changes

FDA approves new oral treatment for multiple sclerosis 
The approval of Mavenclad represents an additional option for patients who have tried another treatment without success.

Patients With Higher RA Disease Activity More Likely to Reduce Alcohol Intake.

Update on Vaccines in Autoimmune Patients

Infectious disease specialist provides overview for rheumatologists

Purdue University researchers discover a probe that detects autoimmune diseases ​​​​​​​Tumor necrosis factor is a protein found in the human body.

Doctors link it with many inflammatory conditions, including forms of arthritis. In a healthy person, tumor necrosis factor (TNF) helps the body to fight off infections. In people with autoimmune diseases, however, high levels of TNF in the blood can cause unnecessary inflammation, resulting in painful symptoms.

Will investigate why we get autoimmune diseases.

Wallenberg Clinical Scholar Olle Kämpe will examine this question.

Genome-Wide Analysis Reveals New Strategies to Target Pancreatic Cancer.

Researchers discover unexpected role of an immune system receptor; blocking it halts human cancer cell growth and improves survival in animal models.

Four Biomarkers Linked to Methotrexate Response in Rheumatoid Arthritis.
“If validated, these biomarkers could become a useful complement when choosing the treatment strategy for patients with eRA,” the researchers wrote.

Autoimmune thyroid disease and sex life:

This study aimed to describe the frequency of self-reported thyroid-related impaired sex life in patients with thyroid diseases.

Did you know that April is Sjogren's Awareness Month?
Sjogren's Syndrome is the 2nd most common autoimmune disease in the USA, after RA, but still many patients wait years to get a diagnosis and feel their doctors and specialists do not understand the full range of symptoms, often just treating the dry eyes and dry mouth symptoms.

If you need to know more visit Sjogren's Syndrome Info.

You can help spread Sjogren's Awareness this month on twitter by joining in at Autoimmune List @AutoimmuneList using these hashtags  #SjogrensAwarenessMonth #ThisIsSjogrens


Do infections increase the risk of developing Sjögren's syndrome?

Wiley Online Library

Do infections increase the risk of developing Sjögren's syndrome?


Environmental factors have been suggested in the pathogenesis of rheumatic diseases. We here investigated whether infections increase the risk of developing primary Sjögren's syndrome (pSS).


Patients with pSS in Sweden (n=945) and matched controls from the general population (n=9,048) were included, and data extracted from the National Patient Register to identify infections occurring before pSS diagnosis during a mean observational time of 16.0 years.

Data were analyzed using conditional logistic regression models. Sensitivity analyses were performed by varying exposure definition and adjusting for previous health care consumption.


A history of infection associated with an increased risk of pSS (OR 1.9, 95% CI 1.6‐2.3). Infections were more prominently associated with development of SSA/SSB autoantibody positive pSS (OR 2.7, 95% CI 2.0‐3.5).
When stratifying the analysis by organ system infected, respiratory infections increased the risk of developing pSS, both in patients with (OR 2.9, 95% CI 1.8‐4.7) and without autoantibodies (OR 2.1, 95% CI 1.1‐3.8), while skin and urogenital infections only significantly associated with development of autoantibody‐positive pSS (OR 3.2, 95% CI 1.8‐5.5 and OR 2.7, 95% CI 1.7‐4.2). Furthermore, a dose‐response relationship was observed for infections and a risk to develop pSS with Ro/SSA and La/SSB antibodies. Gastrointestinal infections were not significantly associated with a risk of pSS.


Infections increase the risk of developing pSS, most prominently SSA/SSB autoantibody positive disease, suggesting that microbial triggers of immunity may partake in the pathogenetic process of pSS.

19 benefits of eating watermelon

19 benefits of eating watermelon

What are the benefits of eating watermelon? Get the fast facts here and a recipe too.

  1. helps you hydrate as it's 90% water. 
  2. contains the anti-inflammatory antioxidants lycopene and vitamin C
  3. helps protect against oxidative damage in the eye.
  4. lowers blood pressure.
  5. amino acids in watermelon may reduce muscle soreness.
  6. protects against diabetes.
  7. helps with a quicker recovery time after strenuous exercise.
  8. helps reduce cholesterol levels.
  9. is good for your skin.
  10. is good for your hair.
  11. can improve digestion.
  12. promotes healthy bowel movements.
  13. may help reduce cancer risk.
  14. protects nerve function.
  15. helps with weight loss as only 46 calories per cup (154 grams).
  16. helps to neutralize the acidic western diet.
  17. reduces risk of heat exhaustion.
  18. reduces the development of periodontal disease.
  19. helps support the kidneys.
19 benefits of eating watermelon
Interesting way to serve melon.
My favorite watermelon dish for guests and summer barbques is 

Marinated bocconcini on watermelon from SAQ

bocconcini and watermelon recipe

225 g (1/2 lb.) fresh bocconcini cheese, cut into small quarters
125 ml (1/2 cup) olive oil
80 ml (1/3 cup) fresh basil, chopped
10 ml (2 tsp.) fresh mint, chopped
Freshly ground black pepper to taste
1 watermelon quarter
A few leaves of lettuce of your choice

  1. Mix the cheese, olive oil, herbs, and pepper in a bowl.
  2. Set aside for 15 minutes.
  3. Cut the melon into strips.
  4. Lay out a bit of lettuce on four plates.
  5. Add the melon strips and garnish with cheese quarters.
  6. Use the marinade as a dressing and serve immediately.
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