Sherring. This is because the stretching of the lid may disrupt the delicate neural interconnections within the network of glands (these are the same glands that you stimulate when you massage your eyes). Another problem that we have encountered after blepharoplasty is increased zones of exposure keratitis. Particularly when sleeping, the lower lid may not make adequate contact with the upper lid, leading to a zone of increased evaporative loss and resulting desiccative injury.

Finally, a standard model for induction of keratoconjunctivitis sicca is Botox R [113].

3.5.6 Pearl

SS patients have unique and particular needs at the time of anesthesia and surgery.

Comments: Operating rooms typically have low humidity and patients are at risk for flare of their KCS or corneal abrasions. We have found this to be particularly true in the post-operative recovery room, where the patient is partially awake with ßuttering eyelids, receiving direct ßow of oxygen (usually not humidiÞed) to the face, and not really aware of their eye symptoms as they awaken from anesthesia. Therefore, we recommend the use of ocular lubricants during surgery to prevent complications.

Also, the anesthesiologist must be careful with the amount of anticholinergic agents given during intubation, as the SS patient may be unduly sensitive and develop inspissated secretions that cannot easily be cleared in the postoperative period (i.e., after abdominal or chest surgery) when raising tenacious secretions is difÞcult.

Finally, the use of oral saliva substitutes should be encouraged. It is expected that patients will be ÒNPOÓ (nothing by mouth) prior to many surgeries. In the absence of normal saliva, they will have unnecessary discomfort if they are not allowed to have their artiÞcial saliva. We have found this particularly true when the patient is a Òlate in the dayÓ case for elective procedures such as joint replacement.

3.5.7 Pearl

A wide range of peripheral neuropathies may be present in SS and constitute one of the most difficult aspects to treat.

Comments: Early attention to peripheral neuropathies is extremely important. The types of neuropathy include sensory including pure sensory and ganglionic neuronopathy. Sural nerve biopsy [114] frequently shows vascular or perivascular inßammation of small epineurial vessels (both arterioles and venules) and in some cases necrotizing vasculitis. Loss of myelinated nerve Þbers was relatively common and loss of small diameter type I nerve Þbers occurs.

Pathology in cases of sensory (doral root ganglion) consists of loss of neuronal cell bodies and inÞltration of T cells [114]. Also, peripheral motor neuropathies can include mononeuritis multiplex (that derives from vasculitis) and CIPD (Òchronic idiopathic peripheral demyelinationÓ) associated with anti-MAG (myelin-associated glycoprotein) disease. In addition, patients may suffer from trigeminal and other cranial neuropathies, autonomic neuropathy, and mixed patterns of neuropathy [114].

Sural nerve biopsy may show vascular or perivascular inßammation of small epineurial vessels (both arterioles and venules) and in some cases necrotizing vasculitis [114]. Loss of myelinated nerve Þbers is common and loss of small diameter nerve Þbers occurs. Peripheral neuropathy in PSS often is refractory to treatment although newer biological agents may provide more effective treatment options.

References

1.Vitali C, Palombi G, Baldini C, Benucci M, Bombardieri S, Covelli M, Del Papa N, De Vita S, Epis O, Franceschini F, Gerli R, Govoni M, Bongi SM, Maglione W, Migliaresi S, Montecucco C, OreÞce M, Priori R, Tavoni A, Valesini G. SjogrenÕs syndrome disease damage index and disease activity index: scoring systems for the assessment of disease damage and disease activity in SjogrenÕs syndrome, derived from an analysis of a cohort of Italian patients. Arthritis Rheum. 2007;56:2223Ð31.

2.Vitali C. ClassiÞcation criteria for SjogrenÕs syndrome. Ann Rheum Dis. 2003;62:94Ð5; author reply 5.

3.Tan EM, Feltkamp TE, Smolen JS, Butcher B, Dawkins R, Fritzler MJ, Gordon T, Hardin JA, Kalden JR, Lahita RG, Maini RN, McDougal JS, RothÞeld NF, Smeenk RJ, Takasaki Y, Wiik A, Wilson MR, Koziol JA. Range of antinuclear antibodies in ÒhealthyÓ individuals. Arthritis Rheum. 1997;40:1601Ð11.

4.Tan EM, Smolen JS, McDougal JS, Butcher BT, Conn D, Dawkins R, Fritzler MJ, Gordon T, Hardin JA, Kalden JR, Lahita RG, Maini RN, RothÞeld NF, Smeenk R, Takasaki Y, van Venrooij WJ, Wiik A, Wilson M, Koziol JA. A critical evaluation of enzyme immunoassays for detection of antinuclear autoantibodies of deÞned speciÞcities. I. Precision, sensitivity, and speciÞcity. Arthritis Rheum. 1999;42:455Ð64.

5.Ramos-Casals M, Nardi N, Brito-Zeron P, Aguilo S, Gil V, Delgado G, Bove A, Font J. Atypical autoantibodies in patients with primary Sjogren syndrome: clinical characteristics and follow-up of 82 cases. Semin Arthritis Rheum. 2006;35: 312Ð21.

6.Ramos-Casals M, Solans R, Rosas J, Camps MT, Gil A, Del Pino-Montes J, Calvo-Alen J, JimenezAlonso J, Mico ML, Beltran J, Belenguer R, Pallares L. Primary Sjogren syndrome in Spain: clinical and immunologic expression in 1010 patients. Medicine (Baltimore) 2008;87:210Ð19.

7.Lopez-Hoyos M, Rodriguez-Valverde V, Martinez-Taboada V. Performance of antinuclear antibody connective tissue disease screen. Ann NY Acad Sci. 2007;1109:322Ð9.

8.Liberatore G, Jackson-Lewis V, Vukosavic S, Mandir A, Vila M, McAuliffe W, Dawson V, Dawson T, Przedborski S. Inducible nitric oxide synthase stimulates dopaminergic neurodegeneration in the MPTP model of Parkinson disease. Nat Med. 1999;5:1403Ð9.

9.Arnett F. Histocompatibility typing in the rheumatic diseases: diagnostic and prognostic implications. Med Clin NA. 20:371Ð87.

10.Arnett FC, Hamilton RG, Reveille JD, Bias

WB, Harley JB, Reichlin M. Genetic studies of Ro (SS-A) and La (SS-B) autoantibodies in families with systemic lupus erythematosus and primary SjogrenÕs syndrome. Arthritis Rheum. 1989;32:413Ð9.

11.Eracleous E, Kallis S, Tziakouri C, Blease S, Gourtsoyiannis N. Sonography, CT, CT sialography, MRI and MRI sialography in investigation of the facial nerve and the differentiation between deep and superÞcial parotid lesions. Neuroradiology 1997;39:506Ð11.

12.Makula E, Pokorny G, Kiss M, Voros E, Kovacs L, Kovacs A, Csernay L, Palko A. The place of magnetic resonance and ultrasonographic

examinations of the parotid gland in the diagnosis and follow-up of primary SjogrenÕs syndrome. Rheumatology (Oxford) 2000;39:97Ð104.

13.Hakansson U, Jacobsson L, Lilja B, Manthorpe R, Henriksson V. Salivary gland scintigraphy in subjects with and without symptoms of dry mouth and/or eyes, and in patients with primary SjogrenÕs syndrome. Scand J Rheumatol. 1994;23:326Ð33.

14.Helman J, Turner RJ, Fox PC, Baum BJ. 99mTc-

pertechnetate uptake in parotid acinar cells by the Na+/K+/Cl− co-transport system. J Clin Invest. 1987;79:1310Ð3.

15.Kohn WG, Ship JA, Atkinson JC, Patton LL, Fox PC. Salivary gland 99mTc-scintigraphy: a grading scale and correlation with major salivary gland ßow rates. J Oral Pathol Med. 1992;21:70Ð4.

16.Burlage FR, Pijpe J, Coppes RP, Hemels ME, Meertens H, Canrinus A, Vissink A. Variability of ßow rate when collecting stimulated human parotid saliva. Eur J Oral Sci. 2005;113:386Ð90.

17.Rosas J, Ramos-Casals M, Ena J, Garcia-Carrasco M, Verdu J, Cervera R, Font J, Caballero O,

Ingelmo M, Pascual E. Usefulness of basal and pilocarpine-stimulated salivary ßow in primary SjogrenÕs syndrome. Correlation with clinical, immunological and histological features. Rheumatology (Oxford) 2002;41:670Ð5.

18.Kohler PF, Winter ME. A quantitative test for xerostomia. The Saxon test, an oral equivalent of the Schirmer test. Arthritis Rheum. 1985;28: 1128Ð32.

19.Stevens WJ, Swartele FE, Empsten FA, De Clerck LS. Use of the Saxon test as a measure of saliva production in a reference population of schoolchildren. Am J Dis Child. 1990;144:570Ð1.

20.Isenberg DA. Systemic lupus erythematosus and SjogrenÕs syndrome: historical perspective and ongoing concerns. Arthritis Rheum. 2004;50: 681Ð3.

21.Diamond B. Systemic lupus erythematosus and SjogrenÕs syndrome. Curr Opin Rheumatol. 2007;19:405.

22.Garcia-Carrasco M, Cervera R, Rosas J, RamosCasals M, Morla RM, Siso A, Jimenez S, Pallares L, Font J, Ingelmo M. Primary SjogrenÕs syndrome in the elderly: clinical and immunological characteristics. Lupus 1999;8:20Ð3.

23.Isenberg D. SjogrenÕs syndrome Ð a house of cards. Clin Rheumatol. 1995;14 Suppl 1:8Ð10.

24.Moutsopoulos HM. SjogrenÕs syndrome or autoimmune epithelitis? Clin Rev Allergy Immunol. 2007;32:199Ð200.

26.Fox RI. SjogrenÕs syndrome. Lancet 2005;366: 321Ð31.

27.Macri A, Pßugfelder S. Correlation of the Schirmer 1 and ßuorescein clearance tests with the

severity of corneal epithelial and eyelid disease. Arch Ophthalmol. 2000;118:1632Ð8.

28.Spiteri A, Mitra M, Menon G, Casini A, Adams D, Ricketts C, Hickling P, Fuller ET, Fuller JR. Tear lipid layer thickness and ocular comfort with a novel device in dry eye patients with and without SjogrenÕs syndrome. J Fr Ophtalmol. 2007;30:357Ð64.

29.Pßugfelder SC, Liu Z, Monroy D, Li DQ, Carvajal ME, Price-Schiavi SA, Idris N, Solomon A, Perez A, Carraway KL. Detection of sialomucin complex (MUC4) in human ocular surface epithelium and tear ßuid. Invest Ophthalmol Vis Sci. 2000;41:1316Ð26.

30.Afonso AA, Monroy D, Stern ME, Feuer WJ, Tseng SC, Pßugfelder SC. Correlation of tear ßuorescein clearance and Schirmer test scores with ocular irritation symptoms. Ophthalmology 1999;106:803Ð10.

31.Behrens A, Doyle JJ, Stern L, Chuck RS, McDonnell PJ, Azar DT, Dua HS, Hom M, Karpecki PM, Laibson PR, Lemp MA, Meisler DM, Castillo JM, OÕBrien T P, Pßugfelder SC, Rolando M, Schein OD, Seitz B, Tseng SC, Setten GV, Wilson SE, Yiu SC. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea 2006;25:900Ð7.

32.de Paiva CS, Pßugfelder SC. Tear clearance implications for ocular surface health. Exp Eye Res. 2004;78:395Ð7.

33.De Paiva CS, Villarreal AL, Corrales RM, Rahman HT, Chang VY, Farley WJ, Stern ME, Niederkorn JY, Li DQ, Pßugfelder SC. Dry eye-induced conjunctival epithelial squamous metaplasia is modulated by interferon-gamma. Invest Ophthalmol Vis Sci. 2007;48:2553Ð60.

34.Luo L, Li DQ, Corrales RM, Pßugfelder SC. Hyperosmolar saline is a proinßammatory stress on the mouse ocular surface. Eye Contact Lens. 2005;31:186Ð93.

35.Pßugfelder SC, Huang AJ, Feuer W, Chuchovski PT, Pereira IC, Tseng SC. Conjunctival cytologic features of primary SjogrenÕs syndrome. Ophthalmology 1990;97:985Ð91.

36.Pßugfelder SC, Jones D, Ji Z, Afonso A, Monroy D. Altered cytokine balance in the tear ßuid and conjunctiva of patients with SjogrenÕs syndrome keratoconjunctivitis sicca. Curr Eye Res. 1999;19:201Ð11.

37.Pßugfelder SC, Solomon A, Stern ME. The diagnosis and management of dry eye: a twenty-Þve- year review. Cornea 2000;19:644Ð9.

38.Yoon KC, Jeong IY, Park YG, Yang SY. Interleukin-6 and tumor necrosis factor-alpha levels in tears of patients with dry eye syndrome. Cornea 2007;26:431Ð7.

39.Goto E, Matsumoto Y, Kamoi M, Endo K, Ishida R, Dogru M, Kaido M, Kojima T, Tsubota K. Tear evaporation rates in Sjogren syndrome and

non-Sjogren dry eye patients. Am J Ophthalmol. 2007;144:81Ð5.

40.Atkinson JC, Fox PC. SjogrenÕs syndrome: oral and dental considerations. J Am Dent Assoc. 1993;124:74Ð6.

41.Fox PC, Mandel ID. Effects of pilocarpine on salivary ßow in patients with SjogrenÕs syndrome [letter; comment]. Oral Surg Oral Med Oral Pathol. 1992;74:315Ð8.

42.Wolff A, Fox PC, Ship JA, Atkinson JC, Macynski AA, Baum BJ. Oral mucosal status and major salivary gland function. Oral Surg Oral Med Oral Pathol. 1990;70:49Ð54.

43.Wu AJ, Fox PC. SjogrenÕs syndrome. Semin Dermatol. 1994;13:138Ð43.

44.Daniels S. We all need to know about SjogrenÕs syndrome. Nurs Times. 2007;103:15.

45.Hershkovich O, Shafat I, Nagler RM. Age-related changes in salivary antioxidant proÞle: possible implications for oral cancer. J Gerontol A Biol Sci Med Sci. 2007;62:361Ð6.

46.Nagler RM. Salivary glands and the aging process: mechanistic aspects, health-status and medicinal-efÞcacy monitoring. Biogerontology 2004;5:223Ð33.

47.Abraham CM, al-Hashimi I, Haghighat N. Evaluation of the levels of oral Candida in patients with SjogrenÕs syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;86:65Ð8.

48.Almstahl A, Kroneld U, Tarkowski A, Wikstrom M. Oral microbial ßora in SjogrenÕs syndrome. J Rheumatol. 1999;26:110Ð4.

49.Rhodus NL, Michalowicz BS. Periodontal status and sulcular Candida albicans colonization in patients with primary SjogrenÕs syndrome. Quintessence Int. 2005;36:228Ð33.

50.Sweet SP, Denbury AN, Challacombe SJ. Salivary calprotectin levels are raised in patients with oral candidiasis or SjogrenÕs syndrome but decreased by HIV infection. Oral Microbiol Immunol. 2001;16:119Ð23.

51.Tsai H, Bobek LA. Human salivary histatins: promising anti-fungal therapeutic agents. Crit Rev Oral Biol Med. 1998;9:480Ð97.

52.Peluso G, De Santis M, Inzitari R, Fanali C, Cabras T, Messana I, Castagnola M, Ferraccioli GF. Proteomic study of salivary peptides and proteins in patients with SjogrenÕs syndrome before and after pilocarpine treatment. Arthritis Rheum. 2007;56:2216Ð22.

53.Nagler RM, Hershkovich O. Relationships between age, drugs, oral sensorial complaints and salivary proÞle. Arch Oral Biol. 2005;50:7Ð16.

54.Daniels TE, Fox PC. Salivary and oral components of SjogrenÕs syndrome. Rheum Dis Clin North Am. 1992;18:571Ð89.

55.Daniels TE, Wu AJ. Xerostomia Ð clinical evaluation and treatment in general practice. J Calif Dent Assoc. 2000;28:933Ð41.

56.Maltsman-Tseikhin A, Moricca P, Niv D. Burning mouth syndrome: will better understanding yield better management? Pain Pract. 2007;7: 151Ð62.

57.Patton L, Siegel M, Benoliel R, De Laat A. Management of burning mouth syndrome: systematic review and management recommendations. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol. 2007;S39:1Ð13.

58.Belafsky PC, Postma GN. The laryngeal and esophageal manifestations of SjogrenÕs syndrome. Curr Rheumatol Rep. 2003;5:297Ð303.

59.Postma GN, Belafsky PC, Aviv JE, Koufman JA. Laryngopharyngeal reßux testing. Ear Nose Throat J. 2002;81:14Ð8.

60.Jara LJ, Navarro C, Brito-Zeron Mdel P, GarciaCarrasco M, Escarcega RO, Ramos-Casals M. Thyroid disease in SjogrenÕs syndrome. Clin Rheumatol. 2007;26:1601Ð6.

61.DÕArbonneau F, Ansart S, Le Berre R, Dueymes M, Youinou P, Pennec YL. Thyroid dysfunction in primary SjogrenÕs syndrome: a long-term followup study. Arthritis Rheum. 2003;49:804Ð9.

62.Fox PC. An Autoimmune Exocrinopathy. Ann NY Acad Sci. 2007;1098:15Ð21.

63. Stojanovich L, Milovanovich B, de Luka SR, Popovich-Kuzmanovich D, Bisenich V, Djukanovich B, Randjelovich T, Krotin M. Cardiovascular autonomic dysfunction in systemic lupus, rheumatoid arthritis, primary Sjogren syndrome and other autoimmune diseases. Lupus. 2007;16:181Ð5.

64.Mandl T, Wollmer P, Manthorpe R, Jacobsson LT. Autonomic and orthostatic dysfunction in primary SjogrenÕs syndrome. J Rheumatol. 2007;34: 1869Ð74.

65.Cervera R, Font J, Ramos-Casals M, GarciaCarrasco M, Rosas J, Morla RM, Munoz FJ, Artigues A, Pallares L, Ingelmo M. Primary SjogrenÕs syndrome in men: clinical and immunological characteristics. Lupus. 2000;9:61Ð4.

66.Launay D, Hachulla E, Hatron PY, Jais X, Simonneau G, Humbert M. Pulmonary arterial hypertension: a rare complication of primary Sjogren syndrome: report of 9 new cases and review of the literature. Medicine (Baltimore) 2007;86:299Ð315.

67.Ramos-Casals M, Anaya J, García-Carrasco M, Rosas J, Bové A, Claver G, Diaz L, Herrero C, Font J. Cutaneous vasculitis in primary Sjogren syndrome: classiÞcation and clinical signiÞcance of 52 patients. Medicine 2004;83:96.

68.Ramos-Casals M, Font J. Extrahepatic manifestations in patients with chronic hepatitis C virus infection. Curr Opin Rheumatol. 2005;17: 447Ð55.

69.Ramos-Casals M, Font J. Primary SjogrenÕs syndrome: current and emergent aetiopathogenic concepts. Rheumatology (Oxford) 2005.

70.Ramos-Casals M, Jara LJ, Medina F, Rosas J, Calvo-Alen J, Mana J, Anaya JM, Font J. Systemic autoimmune diseases co-existing with chronic hepatitis C virus infection (the HISPAMEC Registry): patterns of clinical and immunological expression in 180 cases. J Intern Med. 2005;257:549Ð57.

71.Boki KA, Ioannidis JP, Segas JV, Maragkoudakis PV, Petrou D, Adamopoulos GK, Moutsopoulos HM. How signiÞcant is sensorineural hearing loss in primary SjogrenÕs syndrome? An individually matched caseÐcontrol study. J Rheumatol. 2001;28:798Ð801.

72.Ramos-Casals M, Tzioufas A, Font J. Primary SjogrenÕs syndrome: new clinical and therapeutic concepts. Br Med J. 2005;64:347.

73.Walker J, Gordon T, Lester S, Downie-Doyle S, McEvoy D, Pile K, Waterman S, Rischmueller M. Increased severity of lower urinary tract symptoms and daytime somnolence in primary SjšgrenÕs syndrome. J Rheumatol. 2003;30:2406.

74.Leppilahti M, Tammela TL, Huhtala H, Kiilholma P, Leppilahti K, Auvinen A. Interstitial cystitis-like urinary symptoms among patients with SjogrenÕs syndrome: a population-based study in Finland. Am J Med. 2003;115:62Ð5.

75.Rosamilia A. Painful bladder syndrome/interstitial cystitis. Best Pract Res Clin Obstet Gynaecol. 2005;19:843Ð59.

76.Lindvall B, Bengtsson A, Ernerudh J, Eriksson P. Subclinical myositis is common in primary SjšgrenÕs syndrome and is not related to muscle pain. J Rheumatol. 2002;29:717.

77.Silverman B, Brown L, Bright R, Kaczmarek R, Arrowsmith-Lowe J, Kessler D. Reported complications of silicone gel breast implants: an epidemiologic review. Ann Int Med. 1996;124:744Ð56.

78.Fox RI, Stern M. SjogrenÕs syndrome: mechanisms of pathogenesis involve interaction of immune and neurosecretory systems. Scand J Rheumatol Suppl. 2002;3Ð13.

79.Konttinen YT, Hukkanen M, Kemppinen P, Segerberg M, et al. Peptide-containing nerves in labial salivary glands in SjšgrenÕs syndrome. Arthritis Rheum. 1992;35:815Ð20.

80.Beroukas D, Goodfellow R, Hiscock J, Jonsson R, Gordon TP, Waterman SA. Up-regulation of M3-muscarinic receptors in labial salivary gland

acini in primary SjogrenÕs syndrome. Lab Invest. 2002;82:203Ð10.

in primary SjogrenÕs syndrome. Lab Invest. 2002;82:1547Ð52.

82.Beroukas D, Hiscock J, Jonsson R, Waterman SA, Gordon TP. Subcellular distribution of aquaporin 5 in salivary glands in primary SjogrenÕs syndrome. Lancet 2001;358:1875Ð6.

83.Fox RI, Konttinen Y, Fisher A. Use of muscarinic agonists in the treatment of SjogrenÕs syndrome. Clin Immunol. 2001;101:249Ð63.

84.Hurst S, Collins S. Interleukin-1 beta modulation of norepinephrine release from rat myenteric nerves. Am J Physiol. 1993;264:G30ÐG5.

85.Hurst SM, Collins SM. Mechanism underlying tumor necrosis factor-alpha suppression of norepinephrine release from rat myenteric plexus. Am J Physiol. 1994;266:G1123Ð9.

86.Baum BJ, Dai Y, Hiramatsu Y, Horn VJ, Ambudkar IS. Signaling mechanisms that regulate saliva formation. Crit Rev Oral Biol Med. 1993;4:379Ð84.

87.Bacman S, Sterin-Borda L, Camusso JJ, Arana R, Hubscher O, Borda E. Circulating antibodies against rat parotid gland M3 muscarinic receptors in primary SjogrenÕs syndrome. Clin Exp Immunol. 1996;104:454Ð9.

88.Bacman SR, Berra A, Sterin-Borda L, Borda ES. Human primary SjogrenÕs syndrome autoantibodies as mediators of nitric oxide release coupled to lacrimal gland muscarinic acetylcholine receptors. Curr Eye Res. 1998;17:1135Ð42.

89.Wolkoff P, Nojgaard JK, Franck C, Skov P. The modern ofÞce environment desiccates the eyes? Indoor Air 2006;16:258Ð65.

90.Nakamori K, Odawara M, Nakajima T, Mizutani T, Tsubota K. Blinking is controlled primarily by ocular surface conditions. Am J Ophthalmol. 1997;124:24Ð30.

91.Tsubota K. Tear dynamics and dry eye. Prog Retin Eye Res. 1998;17:565Ð96.

92.Hu S, Loo JA, Wong DT. Human saliva proteome analysis and disease biomarker discovery. Expert Rev Proteomics. 2007;4:531Ð8.

93.Hu S, Loo JA, Wong DT. Human saliva proteome analysis. Ann NY Acad Sci. 2007;1098: 323Ð9.

94.Hu S, Wang J, Meijer J, Ieong S, Xie Y, Yu T, Zhou H, Henry S, Vissink A, Pijpe J, Kallenberg C, Elashoff D, Loo JA, Wong DT. Salivary proteomic and genomic biomarkers for primary SjogrenÕs syndrome. Arthritis Rheum. 2007;56:

3588Ð600.

95. Giusti L, Baldini C, Bazzichi L, Ciregia F, Tonazzini I, Mascia G, Giannaccini G, Bombardieri S, Lucacchini A. Proteome analysis of whole saliva: a new tool for rheumatic diseases Ð the example of SjogrenÕs syndrome. Proteomics 2007;7:1634Ð43.

96.Laine M, Porola P, Udby L, Kjeldsen L, Cowland JB, Borregaard N, Hietanen J, Stahle M, Pihakari A, Konttinen YT. Low salivary dehydroepiandrosterone and androgen-regulated cysteine-rich secretory protein 3 levels in SjogrenÕs syndrome. Arthritis Rheum. 2007;56:2575Ð84.

97.Steinfeld SD, Demols P, Salmon I, Kiss R, Appelboom T. Inßiximab in patients with primary

SjogrenÕs syndrome: a pilot study. Arthritis Rheum. 2001;44:2371Ð5.

98.Mariette X, Ravaud P, Steinfeld S, Baron G, Goetz J, Hachulla E, Combe B, Puechal X, Pennec Y, Sauvezie B, Perdriger A, Hayem G, Janin A, Sibilia J. InefÞcacy of inßiximab in primary SjogrenÕs syndrome: results of the randomized, controlled Trial of Remicade in Primary SjogrenÕs Syndrome (TRIPSS). Arthritis Rheum.

2004;50:1270Ð6.

99. Sankar V, Brennan MT, Kok MR, Leakan RA, Smith JA, Manny J, Baum BJ, Pillemer SR. Etanercept in SjogrenÕs syndrome: a twelve-week randomized, double-blind, placebocontrolled pilot clinical trial. Arthritis Rheum. 2004;50:2240Ð5.

100.Zandbelt MM, de Wilde P, van Damme P, Hoyng CB, van de Putte L, van den Hoogen F. Etanercept in the treatment of patients with primary SjogrenÕs syndrome: a pilot study. J Rheumatol. 2004;31: 96Ð101.

101.Hyer S, Kong A, Pratt B, Harmer C. Salivary gland toxicity after radioiodine therapy for thyroid cancer. Clin Oncol (R Coll Radiol). 2007;19:83Ð6.

102.Kawakami A, Nakashima K, Tamai M, Nakamura H, Iwanaga N, Fujikawa K, Aramaki T, Arima K, Iwamoto N, Ichinose K, Kamachi M, Ida H, Origuchi T, Eguchi K. Toll-like receptor in salivary glands from patients with SjogrenÕs syndrome: functional analysis by human salivary gland cell line. J Rheumatol. 2007;34:1019Ð26.

103.Mavragani CP, Moutsopoulos HM. The geoepidemiology of SjogrenÕs syndrome. Autoimmun Rev. 2010;9:A305ÐA10.

104.Theander E, Vasaitis L, Baecklund E, Nordmark G, Warfvinge G, Liedholm R, Brokstad K, Jonsson R, Jonsson MV. Lymphoid organisation in labial salivary gland biopsies is a possible predictor for the development of malignant lymphoma in primary SjogrenÕs syndrome. Ann Rheum Dis. 2011;70:1363Ð70.

105.Mariette X, Gottenberg JE. Pathogenesis of SjogrenÕs syndrome and therapeutic consequences. Curr Opin Rheumatol. 2010;22:471.

106.Atalar K, Afzali B, Lams B, Tungekar MF, Goldsmith DJ. Falls, hypokalaemia, and a dry mouth. Lancet 2007;370:192.

107.Chan K. Chinese medicinal materials and their interface with Western medical concepts. J Ethnopharmacol. 2005;96:1Ð18.

108.Chang YH, Lin HJ, Li WC. Clinical evaluation of the traditional Chinese prescription Chi- Ju-Di-Huang-Wan for dry eye. Phytother Res. 2005;19:349Ð54.

109.Ernst E. Harmless herbs? A review of the recent literature. Am J Med. 1998;104:170Ð8.

110.Ernst E. HerbÐdrug interactions: potentially important but woefully under-researched. Eur J Clin Pharmacol. 2000;56:523Ð4.