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as part of the diagnosis&#44; was first proposed in 1970 by Waterhouse&#44; Chisholm and Mason&#59; the latter were those establishing the score using foci of inflammatory cells aggregates&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In order to obtain the material for pathology&#44; a minor salivary gland biopsy &#40;MSGB&#41; is performed&#46; While this is an invasive procedure&#44; it is easy to perform and several studies show a low frequency of complications&#44; which are usually mild&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">8&#8211;14</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; despite the simplicity of the technique&#44; MSGB is not incorporated into daily practice in all centers&#44; which leads to inconvenience in defining the presence of SS according to the American&#8211;European 2002 classification criteria currently in force&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">According to these criteria&#44; the presence of a compatible MSGB and&#47;or the presence of anti-Ro&#47;SS-A and&#47;or anti La&#47;SS-B are necessary to diagnose pSS&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Furthermore&#44; the 1993 European criteria and<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a> the 2012 preliminary criteria<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a> include&#44; in addition to anti Ro&#47;SS-A and La&#47;SS-B antibodies&#44; anti-nuclear &#40;ANA&#41; and rheumatoid factor &#40;RF&#41; as part of the serological criteria&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Because there is still difficulty in obtaining a MSGB for the diagnosis of SS in daily practice&#44; we set out to estimate the association between the presence of histological stages III and IV affection in the classification proposed by Chisholm and the presence of anti Ro&#47;SS-A and&#47;anti-La SS-B&#59; and assess the value of these antibodies as a diagnostic test&#44; compared with MSGB&#44; which was taken as a reference test or gold standard&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The secondary objectives evaluated were the association between the presence of infiltrates stages III and IV in MSGB with ANA and RF positivity and analyze the value of such antibodies as a diagnostic test&#44; compared with MSGB&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0050" class="elsevierStylePara elsevierViewall">The study design was observational&#44; analytical and cross-sectional&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">We included consecutive patients with suspected pSS derived from different centers of Argentina to the Rheumatology Department&#44; Hospital Rivadavia&#44; for a MSGB&#44; between October 2007 and December 2011&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Exclusion criteria were related to the procedure&#58; use of aspirin or other NSAIDs within the week before the study&#44; clinical signs of local infection at the site of the biopsy&#44; patients with anticoagulation or a clotting disorder or other causes of sicca symptoms and treatment with anticholinergic drugs or radiotherapy of the head and neck&#46; Biopsies in which the material obtained was insufficient or non-glandular&#44; patients with other autoimmune associated rheumatic disease&#44; cases where results of anti-Ro&#47;SS-A or anti-La&#47;SS-B were not available were also excluded as well as those who refused inclusion into the protocol&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Demographics &#40;age&#44; gender&#41;&#44; duration of sicca symptoms when performing the biopsy&#44; concomitant disease &#40;hypothyroidism and diabetes&#41;&#44; treatment at the time of the biopsy &#40;corticosteroids&#44; immunomodulatory&#47;immunosuppressive drugs&#41;&#44; antibody results &#40;ANA in Hep 2&#44; anti Ro&#47;SS-A&#44; 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independent and blinded pathologist&#44; the Chair of Anatomic Pathology at the Faculty of Medicine of Buenos Aires&#44; with over 15 years experience in the evaluation of histological material from MSGB&#46; Antibodies were determined in different centers of reference of the country&#44; mainly in the city of Buenos Aires&#44; and the cutoff used to define the results as positive or negative was defined by the laboratory of each center&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The study was approved by the education&#44; research and ethics committee of the hospital&#46; Patients signed informed consent&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0090" class="elsevierStylePara elsevierViewall">The data were fed into a Microsoft Excel database and analyzed using the STATA 11 statistical package&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The general characteristics of the population were described&#59; continuous variables were reported as means and standard deviations &#40;SD&#41; or medians and interquartile ranges &#40;IQR&#41; according to their distribution&#46; Frequency distribution analysis of categorical variables was performed&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">For the bivariate analysis a <span class="elsevierStyleItalic">t</span> test or Mann&#8211;Whitney test for continuous variables&#44; such as distribution and sample size&#44; was used&#46; Categorical variables were analyzed using chi-square or Fisher exact test according to a distribution table as expected frequency&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">To assess the association and the presence of potential confounders in the relationship between the positivity of each of the antibodies and MSGB&#44; three models of multiple logistic regression were performed&#58; 1&#8211;MSGB and anti Ro&#47;SS-A&#44; anti-La&#47;SS B antibodies&#44; 2&#8211;MSGB and ANA and 3&#8211;MSGB and RF&#44; considering the biopsy as the dependent variable&#46; Odds ratios &#40;OR&#41; and corresponding 95&#37; CI were calculated&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">P</span><span class="elsevierStyleMonospace">&#60;</span>&#46;05 was considered as significant&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Sensitivity &#40;S&#41;&#44; specificity &#40;Sp&#41;&#44; positive predictive value &#40;PPV&#41;&#44; negative predictive value &#40;NPV&#41; and positive likelihood ratio &#40;PLR&#41; were calculated with their respective 95&#37; confidence intervals &#40;95&#37;CI&#41; for each antibody and compared with MSGB&#44; which was taken as the gold standard&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0120" class="elsevierStylePara elsevierViewall">From October 2007 to December 2011&#44; 400 patients referred by their GP with suspected pSS underwent a MSGB&#46; One hundred and eighty-two patients were excluded&#58; 130 for lacking anti Ro&#47;SS-A or anti-La&#47;SS-B antibody results&#44; 31 had an associated autoimmune rheumatic disease&#44; 21 had insufficient or no glandular material&#59; 218 patients were included for analysis&#46; The 130 patients excluded due to lack of anti Ro&#47;SS-A or anti-La&#47;SS-B antibody results were similar to those included in the study&#58; 96&#37; female &#40;92 of 96 patients&#41;&#44; median age 53 years &#40;ric&#58; 41&#8211;60&#46;92 patients&#41;&#44; 91&#37; had xerophthalmia &#40;88 of 91 patients&#41;&#44; 85&#37; xerostomia &#40;78 of 92 patients&#41;&#44; 80&#37; mentioned both manifestations &#40;74 of 92 patients&#41; and 49&#37; had a positive sialometry &#40;21 of 43 patients&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The reason of the referral for a biopsy of all patients included in the study was the presence of xerophthalmia and&#47;or xerostomia in the context of suspected pSS&#46; 95&#37; &#40;208&#47;218&#41; of patients were female&#44; with a median age of 54 years &#40;ric&#58; 44&#8211;62&#41; and median time of disease progression of 12 months with sicca symptoms &#40;ric&#58; 12&#8211;36&#41;&#46; 92&#37; had xerophthalmia&#44; and 86&#37; xerostomia&#59; 79&#37; had both manifestations &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Of the 218 biopsies&#44; 36&#37; &#40;78&#41; were positive &#40;stage III or IV&#41; and 64&#37; &#40;140&#41; negative &#40;stage 0&#44; I or II&#41;&#46; 33&#37; &#40;71&#47;218&#41; of patients had anti-Ro&#47;SS-A&#44; La&#47;SS-B positive antibodies&#44; 62&#37; &#40;126&#47;203&#41; had positive ANA and 31&#37; &#40;42&#47;136&#41; positive RF &#40;the result of RF and ANA was not counted in all of the cases&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Comparing the demographic and clinical characteristics of patients with positive MSGB with patients with negative MSGB in the univariate analysis&#44; no statistically significant differences in any of the analyzed variables &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; were found&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">When analyzing the presence of the association between antibodies and MSGB in a univariate analysis&#44; statistically significant associations with ANA &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;01&#41;&#44; anti Ro&#47;SS-A and&#47;or anti-La&#47;SS-B antibodies &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;01<span class="elsevierStyleMonospace">&#41;</span> and RF &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleMonospace">&#60;</span>&#46;01&#41; were found &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Considering the MSGB as a dependent variable&#44; and anti Ro&#47;SS-A La&#47;SS-B antibodies as a variable of interest&#44; in a multivariate analysis adjusted for age&#44; duration of symptoms&#44; hypothyroidism&#44; treatment with immunomodulatory&#47;immunosuppressive drugs and the confounding effect of ANA antibodies&#44; a confounding effect was found in the relationship between MSGB and anti-Ro&#47;SS-A anti-La&#47;SS-B &#40;crude OR MSGB-anti Ro&#47;SS-A anti-La&#47;SS-B&#58; 3&#46;70&#44; CI 95&#37; CI 2&#46;04&#8211;6&#46;72&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;01&#46; ANA adjusted OR&#58; 2&#46;59&#44; 95&#37; CI 1&#46;29&#8211;5&#46;22&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleMonospace">&#60;</span>&#46;01&#41;&#46; By including in the analysis the RF&#44; a confounding effect was also exerted&#44; losing the anti La&#47;SS-B anti Ro&#47;SS-A antibodies association with a positive biopsy &#40;OR&#58; 1&#46;98&#59; 95&#37; CI 0&#44; 79&#8211;5&#46;00&#44; <span class="elsevierStyleItalic">P</span>&#58; &#46;15&#41;&#46; The remaining variables did not exert a confounding effect or show significant associations in the multivariate model&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">By analyzing the relationship between ANA and MSGB&#44; a significant and independent association was observed between ANA and MSGB&#44; with the anti Ro&#47;SS-A La&#47;SS-B antibodies being a confounder of the relationship &#40;crude OR ANA MSGB-5&#46;25&#44; 95&#37; CI 2&#46;59&#8211;10&#46;65&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleMonospace">&#60;</span>&#46;01&#46; OR adjusted for anti Ro&#47;SS-A anti-La&#47;SS-B&#58; 3&#46;36&#44; 95&#37; CI 1&#46;53&#8211;7&#46;36&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleMonospace">&#60;</span>&#46;01&#41;&#46; RF remained associated significantly and independently to the MSGB without exerting a confounding effect in the relationship between the ANA and MSGB&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">By adjusting the relationship between RF and MSGB&#44; neither the ANA nor the anti Ro&#47;SS-A La&#47;SS-B antibodies exerted confounding effects &#40;OR crude MSGB-FR&#58; 3&#46;17&#44; 95&#37; CI 1&#46;48&#8211;6&#44; 75&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;01&#46; Adjusted OR&#58; 2&#46;99&#44; 95&#37; CI 1&#46;30&#8211;6&#46;87&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;010<span class="elsevierStyleMonospace">&#41;</span>&#46; All other variables remained without association and did not behave as confounders&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Finally&#44; we calculated the S&#44; Sp&#44; PPV&#44; NPV and PLR of each of the antibodies using the MSGB as a reference test&#46; ANA proved to be the most sensitive &#40;0&#46;84&#44; 95&#37; CI 0&#46;75&#8211;0&#46;92&#41; and had the best NPV &#40;0&#46;84&#44; 95&#37; CI 0&#46;76&#8211;0&#46;93&#41;&#44; whereas anti-Ro&#47;SS-A and&#47;or anti-La&#47;SS-B and RF yielded similar results&#44; being the most specific &#40;95&#37; CI 0&#46;71&#8211;0&#46;85 0&#46;78 and 0&#46;78&#44; 95&#37; CI 0&#46;69&#8211;0&#46;87&#44; respectively&#41; and having the best PPV &#40;0&#46;56 95&#37; CI 0&#46;45&#8211;0&#44; 58 and 0&#46;55 95&#37; CI 0&#46;40&#8211;0&#46;70&#44; respectively&#41;&#46; All showed good PLR &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">To date&#44; different classification criteria pSS have been proposed&#44; which are based on a combination of clinical&#44; serological and histological findings&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">2&#8211;8</span></a> There have been many classifications&#44; from the publication of the San Francisco<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a> &#40;which prioritize the histopathological appearance&#41; and the San Diego criteria&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a> in which the MSGB is essential for the diagnosis of defined pSS&#44; as well as the Copenhagen<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">4</span></a> Greeks&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">5</span></a> Japanese<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">6</span></a> and the European Community criteria&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a> which do not require a MSGB nor the presence of antibodies&#44; to the American&#8211;European criteria 2002<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a> and the 2012<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a> US Preliminary Criteria which require the presence of histological or serological criteria&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Given the diversity of criteria used throughout the years and the lack of training for obtaining and reading the material from a biopsy&#44; combined with the minor risks associated to the procedure&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">8&#8211;14</span></a> determining where it would be desirable to histologically define the diagnosis of pSS often poses problems in daily practice&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Our study aims to provide information to help define the usefulness of antibodies as an alternative to biopsies for the classification of pSS&#44; using the MSGB as a gold standard&#46; We found not only a significant association of anti Ro&#47;SS-A La&#47;SS-B antibodies with MSGB&#44; but also with ANA and RF&#46; In turn&#44; given the PLR of all such antibodies&#44; one can consider each as good study in relation to glandular inflammatory damage&#44; although given the low specificity of ANA&#44; its combination with another antibody such as RF&#44; as proposed in the 2012 preliminary criteria&#44; appears to be an option&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Other studies also analyzed the relationship between antibodies and MSGB&#46; Manoussakis et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">15</span></a> in a study conducted with 54 patients with a clinical diagnosis of pSS and 92 patients with rheumatoid arthritis&#44; found that anti-Ro&#47;SS-A&#44; anti-La&#47;SS-B antibodies and the titers of ANA and RF correlated with the histological stage of the biopsy&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Saito et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a> in a study of 107 patients with SS&#44; found that both RF and the anti Ro&#47;SS-A and anti-La&#47;SS-B antibodies were significantly more frequent in patients with periductal lymphocytic infiltrate&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In turn&#44; Wise et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">17</span></a> in their analysis of 187 patients in whom MSGB was performed to study pSS&#44; found that patients with foci score over 1 on biopsy had a significantly higher frequency of ANA&#44; RF&#44; anti Ro&#47;SS-A and anti-La&#47;SS-B&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Regarding anti Ro&#47;SS-A and anti La&#47;SS-B antibodies&#44; it has been described that patients with anti La&#47;SS-B show a greater inflammatory infiltrate in subjects only having positive anti Ro&#47;SS-A and those who are seronegative&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">18&#44;19</span></a> Halse et al&#46; showed the presence of a good correlation between the foci score and the presence of Ro 52<span class="elsevierStyleHsp" style=""></span>kD and 48<span class="elsevierStyleHsp" style=""></span>kD in saliva&#44; indicating a strong relationship between local inflammation and autoantibody production&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">18</span></a> Moreover&#44; a strong correlation between the presence of autoantibodies in serum and 52-kD Ro&#44; Ro 60<span class="elsevierStyleHsp" style=""></span>kD and La&#47;SSB in the salivary glands was found&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">A study conducted in 181 Chinese patients with an initial diagnosis of pSS compared different methods of detection of serum anti Ro&#47;SS-A &#40;double immunodiffusion&#44; Western blot and ELISA&#41; and found a significant association with MSGB with the three methods&#44; although the degree of agreement between the foci histological score and the antibody detected by Western blot was not very good&#44; concluding that the positive results of such antibodies in serum may indicate higher than 1 scores on biopsy&#44; therefore in these cases could obviate the<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">22</span></a> performance thereof&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">On the other hand&#44; Peen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">23</span></a> revalidated the association between RF positivity and the presence of lymphocytic foci at histology&#44; while Bamba et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">24</span></a> found a significant association between anti-Ro&#47;SS-A and anti-La&#47;SS-B antibodies and a positive biopsy&#44; but not with the ANA&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Daniels et al&#46; in a multicenter study with a large number of patients also observed this association between the four serological markers and MSGB<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">25</span></a> and the same group even proposed new classification criteria of the disease which include RF and ANA&#44; the latter with a titer greater or equal to 1&#47;320&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">26</span></a> Thus arose the 2012 American preliminary criteria&#44; in which the domain considered positive is the immunology laboratory&#44; before the positivity of anti-Ro&#47;SS-A and&#47;or anti La&#47;SS-B and&#47;or ANA &#40;a titer greater or equal to 1&#47;320&#41; plus RF&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">However&#44; controversy exists on the inclusion of ANA and RF in the new set of proposed criteria&#44; given that this decision stems from a consensus of experts of the sicca cohort in which there were patients with other autoimmune rheumatic diseases analyzed&#44; leading many experts to suggest further studies regarding this point&#44; before defining its true role within the 2012 criteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">27&#44;28</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">With respect to our study&#44; it has limitations due in large part because the data come from normal clinical practice&#46; We believe there may be a bias in patient selection because many times in daily practice a MSGB is performed only in the presence of negative anti Ro&#47;SS-A and anti-La&#47;SS-B antibody results&#59; there could also be a bias in the results of antibody testing&#44; since they were conducted in different centers&#46; On the other hand&#44; a weakness of the study was the lack of additional information on other clinical manifestations of patients&#44; in addition to ocular and oral dryness&#44; due to the difficulty in collecting this information from patients who&#44; in many cases&#44; come from other health care centers&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">On the other hand&#44; although the sample size was not calculated for diagnostic tests&#44; the number of observations available allowed for no empty cells or very few observations in the contingency table&#44; impeding ample 95&#37;CI&#44; which also speaks of a small number of patients&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">In any case&#44; we believe that the results of this study reinforce the notion that while the clinician can do without the MSGB in patients with positive anti-Ro&#47;SS-A&#44; anti-La&#47;SS-B antibodies&#44; it is of fundamental importance in seronegative patients&#46; On the other hand&#44; the significant and independent relationship found between ANA and MSGB and between RF and MSGB and the results of their value as diagnostic tests&#44; suggest that these antibodies&#44; bu themselves in the case of RF &#40;due to their higher specificity&#41;&#44; or possibly in combination &#40;ANA plus RF&#41; could be useful in assessing the immunology laboratory domain in the pSS classification&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical Responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of people and animals</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors declare that this research did not perform experiments on humans or animals&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Data confidentiality</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace regarding the publication of patient data&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of patients and&#47;or subjects referred to in the article&#46; This document is in the possession of the corresponding author&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of Interest</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to state&#46;</p></span></span>"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the association between histologic findings in the minor salivary gland biopsy &#40;MSGB&#41; and anti La &#40;La&#47;SS-B&#41; and antiRo antibodies &#40;Ro&#47;SS-A&#41;&#44; antinuclear antibodies &#40;ANA&#41; and rheumatoid factor &#40;RF&#41;&#44; and compare the value of the latter as diagnostic tests with MSGB&#44; considered as the gold standard&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patients with suspected primary Sj&#246;gren syndrome &#40;PSS&#41; referred for MSGB were included&#46; Antibody measurements were performed&#46; Grades III and IV biopsy results were considered positive&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Two hundred and eighteen &#40;218&#41; patients were included&#44; 95&#37; females&#44; with a median age of 54 years and 12 months median duration of sicca symptoms&#46; Thirty-six of the biopsies were positive&#46; 33&#37; of patients had positive anti Ro&#47;SS-A anti La&#47;SS-B antibodies&#44; 62&#37; had positive ANA&#44; and 31&#37; positive RF&#46; A statistically significant association was found between MSGB and anti Ro&#47;SS-A anti La&#47;SS-B&#44; ANA and RF&#46; ANA were the most sensitive antibodies &#40;84&#37;&#46; 95&#37; CI&#58; 75&#8211; 92&#41;&#44; and the most specific were&#58; anti Ro&#47;SS-A and&#47;or anti La&#47;SS-B &#40;78&#37;&#46; 95&#37; CI&#58; 71&#8211;85&#41; and RF &#40;78&#37;&#46; 95&#37; CI&#58; 69&#8211;87&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">On PSS clinical suspicion&#44; anti Ro&#47;SS-A and anti La&#47;SS-B antibodies have a great value to achieve the diagnosis&#44; with MSGB useful for diagnosis of seronegative patients&#46; The results also suggest the importance of ANA and RF for PSS classification&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materials and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar la asociaci&#243;n entre los hallazgos histol&#243;gicos de la biopsia de gl&#225;ndula salival menor &#40;BGSM&#41; y los anticuerpos anti La &#40;La&#47;SS-B&#41;&#44; anti Ro &#40;Ro&#47;SS-A&#41;&#44; anticuerpos antinucleares &#40;FAN&#41; y factor reumatoideo &#40;FR&#41;&#44; y comparar el valor de estos como test diagn&#243;stico con la BGSM considerada como patr&#243;n oro&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron pacientes con sospecha de s&#237;ndrome de Sj&#246;gren primario &#40;SSp&#41; derivados para realizaci&#243;n de BGSM&#46; Se realiz&#243; medici&#243;n de anticuerpos y se consider&#243; BGSM positiva a los grados III y IV de la clasificaci&#243;n de Chisholm&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 218 pacientes&#44; 95&#37; g&#233;nero femenino&#44; con una mediana de edad de 54 a&#241;os y de tiempo de evoluci&#243;n de los s&#237;ntomas sicca de 12 meses&#46; El 36&#37; de las biopsias fueron positivas&#46; El 33&#37; de los pacientes presentaban anticuerpos anti Ro&#47;SS-A anti La&#47;SS-B positivos&#44; 62&#37; FAN positivo y el 31&#37; FR positivo&#46; Se encontr&#243; asociaci&#243;n estad&#237;sticamente significativa entre la BGSM y anti Ro&#47;SS-A&#44; anti La&#47;SS-B&#44; FAN y FR&#46; El FAN result&#243; ser el anticuerpo m&#225;s sensible &#40;84&#37; IC95&#37;&#58; 75-92&#41;&#44; siendo los m&#225;s espec&#237;ficos&#58; anti Ro&#47;SS-A y&#47;o anti La&#47;SS-B &#40;78&#37; IC95&#37;&#58; 71-85&#41; y el FR &#40;78&#37; IC95&#37;&#58; 69-87&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Ante la sospecha cl&#237;nica de SSp&#44; los anticuerpos anti Ro&#47;SS-A y anti La&#47;SS-B son de gran valor para arribar al diagn&#243;stico&#44; siendo la BGSM especialmente &#250;til en los pacientes seronegativos&#46; Los resultados tambi&#233;n sugieren la utilidad del FAN y el FR para la clasificaci&#243;n de SSp&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivos"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Santiago ML&#44; Seisdedos MR&#44; Garcia Salinas RN&#44; Catal&#225;n Pellet A&#44; Villal&#243;n L&#44; Secco A&#46; Utilidad de los anticuerpos y de la biopsia de gl&#225;ndula salival menor en el estudio del complejo sicca en la pr&#225;ctica diaria&#46; Reumatol Clin&#46; 2015&#59;11&#58;156&#8211;160&#46;</p>"
      ]
    ]
    "multimedia" => array:3 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">m&#58;</span> median&#59; IQR&#58; interquartile range&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of patients &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Gender &#40;female&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">208&#47;218 &#40;9541&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age in years&#44; <span class="elsevierStyleItalic">m</span> &#40;ric&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54 &#40;44&#8211;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sicca symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">218&#47;218 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Time since onset of symptoms &#40;Months&#41;&#44; <span class="elsevierStyleItalic">m</span> &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;12&#8211;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Xerophthalmia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">195&#47;213 &#40;91&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Xerostomia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">183&#47;212 &#40;86&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Xerophthalmia plus xerostomia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">167&#47;212 &#40;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Positive eye tests<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">144&#47;176 &#40;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Positive sialometry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#47;105 &#40;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hypothyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&#47;208 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#47;209 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Treatment with corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#47;194 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Treatment with immunomodulatory&#47;immunosuppressive drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#47;190 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Biopsies stages III and IV &#40;&#43;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&#47;218 &#40;36&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">ANA &#40;&#43;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">126&#47;203 &#40;62&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Anti Ro&#47;SS-A anti-La&#47;SS-B &#40;&#43;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&#47;218 &#40;33&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">RF &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&#47;136 &#40;31&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab784586.png"
              ]
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          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Positive eye test&#58; Schirmer and&#47;or rose bengal&#47;lissamine green&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Demographic and Clinical Characteristics&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">SD&#44; standard deviation&#59; <span class="elsevierStyleItalic">m</span>&#44; median&#59; IQR&#44; interquartile range&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MSGB&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MSGB&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age&#44; mean &#40;SD&#41;&#44; years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5136 &#40;1424&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53 &#40;1325&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Gender &#40;male&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Time since onset of symptoms &#40;months&#41;&#44; <span class="elsevierStyleItalic">m</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;ric&#58; 8&#8211;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;ric&#58; 12&#8211;48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Xerophthalmia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Xerostomia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Xerophthalmia plus xerostomia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Positive eye test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Positive sialometry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hypothyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#37;&nbsp;\t\t\t\t\t\t\n
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Original Article
Usefulness of Antibodies and Minor Salivary Gland Biopsy in the Study of Sicca Syndrome in Daily Clinical Practice
Utilidad de los anticuerpos y de la biopsia de glándula salival menor en el estudio del complejo sicca en la práctica diaria
Maria Lida Santiagoa,
Corresponding author
lidasantiagor@yahoo.com.ar

Corresponding author.
, Maria Renata Seisdedosa, Rodrigo Nicolás Garcia Salinasa, Antonio Catalán Pelleta, Liliana Villalónb, Anastasia Seccoa
a Servicio de Reumatología, Hospital General de Agudos Bernardino Rivadavia, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
b Cátedra de Anatomía Patológica, Facultad de Medicina, Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Sj&#246;gren&#39;s syndrome &#40;SS&#41; is a systemic autoimmune disease involving the exocrine glands&#44; manifesting with symptoms arising from hyposecretion thereof&#46; In addition to symptoms arising from the exocrine affection&#44; the disease can produce various extraglandular manifestations&#46; SS can occur alone&#44; as primary SS &#40;pSS&#41; or associated with other autoimmune diseases&#44; as secondary SS&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">To date different classification criteria have been proposed&#44; which are based on a combination of clinical&#44; serological and histological findings&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">2&#8211;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Histology&#44; as part of the diagnosis&#44; was first proposed in 1970 by Waterhouse&#44; Chisholm and Mason&#59; the latter were those establishing the score using foci of inflammatory cells aggregates&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In order to obtain the material for pathology&#44; a minor salivary gland biopsy &#40;MSGB&#41; is performed&#46; While this is an invasive procedure&#44; it is easy to perform and several studies show a low frequency of complications&#44; which are usually mild&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">8&#8211;14</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; despite the simplicity of the technique&#44; MSGB is not incorporated into daily practice in all centers&#44; which leads to inconvenience in defining the presence of SS according to the American&#8211;European 2002 classification criteria currently in force&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">According to these criteria&#44; the presence of a compatible MSGB and&#47;or the presence of anti-Ro&#47;SS-A and&#47;or anti La&#47;SS-B are necessary to diagnose pSS&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Furthermore&#44; the 1993 European criteria and<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a> the 2012 preliminary criteria<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a> include&#44; in addition to anti Ro&#47;SS-A and La&#47;SS-B antibodies&#44; anti-nuclear &#40;ANA&#41; and rheumatoid factor &#40;RF&#41; as part of the serological criteria&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Because there is still difficulty in obtaining a MSGB for the diagnosis of SS in daily practice&#44; we set out to estimate the association between the presence of histological stages III and IV affection in the classification proposed by Chisholm and the presence of anti Ro&#47;SS-A and&#47;anti-La SS-B&#59; and assess the value of these antibodies as a diagnostic test&#44; compared with MSGB&#44; which was taken as a reference test or gold standard&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The secondary objectives evaluated were the association between the presence of infiltrates stages III and IV in MSGB with ANA and RF positivity and analyze the value of such antibodies as a diagnostic test&#44; compared with MSGB&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0050" class="elsevierStylePara elsevierViewall">The study design was observational&#44; analytical and cross-sectional&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">We included consecutive patients with suspected pSS derived from different centers of Argentina to the Rheumatology Department&#44; Hospital Rivadavia&#44; for a MSGB&#44; between October 2007 and December 2011&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Exclusion criteria were related to the procedure&#58; use of aspirin or other NSAIDs within the week before the study&#44; clinical signs of local infection at the site of the biopsy&#44; patients with anticoagulation or a clotting disorder or other causes of sicca symptoms and treatment with anticholinergic drugs or radiotherapy of the head and neck&#46; Biopsies in which the material obtained was insufficient or non-glandular&#44; patients with other autoimmune associated rheumatic disease&#44; cases where results of anti-Ro&#47;SS-A or anti-La&#47;SS-B were not available were also excluded as well as those who refused inclusion into the protocol&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Demographics &#40;age&#44; gender&#41;&#44; duration of sicca symptoms when performing the biopsy&#44; concomitant disease &#40;hypothyroidism and diabetes&#41;&#44; treatment at the time of the biopsy &#40;corticosteroids&#44; immunomodulatory&#47;immunosuppressive drugs&#41;&#44; antibody results &#40;ANA in Hep 2&#44; anti Ro&#47;SS-A&#44; anti-La&#47;SS-B by ELISA&#44; latex nephelometry and turbidimetry RF&#44;&#41; as well as MSGB results according to the classification proposed by Chisholm&#8211;Mason were recorded&#46; The results of biopsies stages III and IV were considered as positive 9&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Xerophthalmia and xerostomia were defined as the presence of symptoms of ocular and oral dryness according to the classification criteria proposed in 2002&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Since the 2002 classification criteria require positivity for anti Ro&#47;SS-A and&#47;or anti La&#47;SS-B or a positive MSGB to classify a patient with pSS and the latter being an invasive biopsy procedure&#44; we decided to choose the latter as the gold standard&#44; with the objective of assessing the value of the antibodies and their usefulness as a replacement for MSGB&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The pathologic study was carried out by a single&#44; independent and blinded pathologist&#44; the Chair of Anatomic Pathology at the Faculty of Medicine of Buenos Aires&#44; with over 15 years experience in the evaluation of histological material from MSGB&#46; Antibodies were determined in different centers of reference of the country&#44; mainly in the city of Buenos Aires&#44; and the cutoff used to define the results as positive or negative was defined by the laboratory of each center&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The study was approved by the education&#44; research and ethics committee of the hospital&#46; Patients signed informed consent&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0090" class="elsevierStylePara elsevierViewall">The data were fed into a Microsoft Excel database and analyzed using the STATA 11 statistical package&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The general characteristics of the population were described&#59; continuous variables were reported as means and standard deviations &#40;SD&#41; or medians and interquartile ranges &#40;IQR&#41; according to their distribution&#46; Frequency distribution analysis of categorical variables was performed&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">For the bivariate analysis a <span class="elsevierStyleItalic">t</span> test or Mann&#8211;Whitney test for continuous variables&#44; such as distribution and sample size&#44; was used&#46; Categorical variables were analyzed using chi-square or Fisher exact test according to a distribution table as expected frequency&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">To assess the association and the presence of potential confounders in the relationship between the positivity of each of the antibodies and MSGB&#44; three models of multiple logistic regression were performed&#58; 1&#8211;MSGB and anti Ro&#47;SS-A&#44; anti-La&#47;SS B antibodies&#44; 2&#8211;MSGB and ANA and 3&#8211;MSGB and RF&#44; considering the biopsy as the dependent variable&#46; Odds ratios &#40;OR&#41; and corresponding 95&#37; CI were calculated&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">P</span><span class="elsevierStyleMonospace">&#60;</span>&#46;05 was considered as significant&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Sensitivity &#40;S&#41;&#44; specificity &#40;Sp&#41;&#44; positive predictive value &#40;PPV&#41;&#44; negative predictive value &#40;NPV&#41; and positive likelihood ratio &#40;PLR&#41; were calculated with their respective 95&#37; confidence intervals &#40;95&#37;CI&#41; for each antibody and compared with MSGB&#44; which was taken as the gold standard&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0120" class="elsevierStylePara elsevierViewall">From October 2007 to December 2011&#44; 400 patients referred by their GP with suspected pSS underwent a MSGB&#46; One hundred and eighty-two patients were excluded&#58; 130 for lacking anti Ro&#47;SS-A or anti-La&#47;SS-B antibody results&#44; 31 had an associated autoimmune rheumatic disease&#44; 21 had insufficient or no glandular material&#59; 218 patients were included for analysis&#46; The 130 patients excluded due to lack of anti Ro&#47;SS-A or anti-La&#47;SS-B antibody results were similar to those included in the study&#58; 96&#37; female &#40;92 of 96 patients&#41;&#44; median age 53 years &#40;ric&#58; 41&#8211;60&#46;92 patients&#41;&#44; 91&#37; had xerophthalmia &#40;88 of 91 patients&#41;&#44; 85&#37; xerostomia &#40;78 of 92 patients&#41;&#44; 80&#37; mentioned both manifestations &#40;74 of 92 patients&#41; and 49&#37; had a positive sialometry &#40;21 of 43 patients&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The reason of the referral for a biopsy of all patients included in the study was the presence of xerophthalmia and&#47;or xerostomia in the context of suspected pSS&#46; 95&#37; &#40;208&#47;218&#41; of patients were female&#44; with a median age of 54 years &#40;ric&#58; 44&#8211;62&#41; and median time of disease progression of 12 months with sicca symptoms &#40;ric&#58; 12&#8211;36&#41;&#46; 92&#37; had xerophthalmia&#44; and 86&#37; xerostomia&#59; 79&#37; had both manifestations &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Of the 218 biopsies&#44; 36&#37; &#40;78&#41; were positive &#40;stage III or IV&#41; and 64&#37; &#40;140&#41; negative &#40;stage 0&#44; I or II&#41;&#46; 33&#37; &#40;71&#47;218&#41; of patients had anti-Ro&#47;SS-A&#44; La&#47;SS-B positive antibodies&#44; 62&#37; &#40;126&#47;203&#41; had positive ANA and 31&#37; &#40;42&#47;136&#41; positive RF &#40;the result of RF and ANA was not counted in all of the cases&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Comparing the demographic and clinical characteristics of patients with positive MSGB with patients with negative MSGB in the univariate analysis&#44; no statistically significant differences in any of the analyzed variables &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; were found&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">When analyzing the presence of the association between antibodies and MSGB in a univariate analysis&#44; statistically significant associations with ANA &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;01&#41;&#44; anti Ro&#47;SS-A and&#47;or anti-La&#47;SS-B antibodies &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;01<span class="elsevierStyleMonospace">&#41;</span> and RF &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleMonospace">&#60;</span>&#46;01&#41; were found &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Considering the MSGB as a dependent variable&#44; and anti Ro&#47;SS-A La&#47;SS-B antibodies as a variable of interest&#44; in a multivariate analysis adjusted for age&#44; duration of symptoms&#44; hypothyroidism&#44; treatment with immunomodulatory&#47;immunosuppressive drugs and the confounding effect of ANA antibodies&#44; a confounding effect was found in the relationship between MSGB and anti-Ro&#47;SS-A anti-La&#47;SS-B &#40;crude OR MSGB-anti Ro&#47;SS-A anti-La&#47;SS-B&#58; 3&#46;70&#44; CI 95&#37; CI 2&#46;04&#8211;6&#46;72&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;01&#46; ANA adjusted OR&#58; 2&#46;59&#44; 95&#37; CI 1&#46;29&#8211;5&#46;22&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleMonospace">&#60;</span>&#46;01&#41;&#46; By including in the analysis the RF&#44; a confounding effect was also exerted&#44; losing the anti La&#47;SS-B anti Ro&#47;SS-A antibodies association with a positive biopsy &#40;OR&#58; 1&#46;98&#59; 95&#37; CI 0&#44; 79&#8211;5&#46;00&#44; <span class="elsevierStyleItalic">P</span>&#58; &#46;15&#41;&#46; The remaining variables did not exert a confounding effect or show significant associations in the multivariate model&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">By analyzing the relationship between ANA and MSGB&#44; a significant and independent association was observed between ANA and MSGB&#44; with the anti Ro&#47;SS-A La&#47;SS-B antibodies being a confounder of the relationship &#40;crude OR ANA MSGB-5&#46;25&#44; 95&#37; CI 2&#46;59&#8211;10&#46;65&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleMonospace">&#60;</span>&#46;01&#46; OR adjusted for anti Ro&#47;SS-A anti-La&#47;SS-B&#58; 3&#46;36&#44; 95&#37; CI 1&#46;53&#8211;7&#46;36&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleMonospace">&#60;</span>&#46;01&#41;&#46; RF remained associated significantly and independently to the MSGB without exerting a confounding effect in the relationship between the ANA and MSGB&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">By adjusting the relationship between RF and MSGB&#44; neither the ANA nor the anti Ro&#47;SS-A La&#47;SS-B antibodies exerted confounding effects &#40;OR crude MSGB-FR&#58; 3&#46;17&#44; 95&#37; CI 1&#46;48&#8211;6&#44; 75&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;01&#46; Adjusted OR&#58; 2&#46;99&#44; 95&#37; CI 1&#46;30&#8211;6&#46;87&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;010<span class="elsevierStyleMonospace">&#41;</span>&#46; All other variables remained without association and did not behave as confounders&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Finally&#44; we calculated the S&#44; Sp&#44; PPV&#44; NPV and PLR of each of the antibodies using the MSGB as a reference test&#46; ANA proved to be the most sensitive &#40;0&#46;84&#44; 95&#37; CI 0&#46;75&#8211;0&#46;92&#41; and had the best NPV &#40;0&#46;84&#44; 95&#37; CI 0&#46;76&#8211;0&#46;93&#41;&#44; whereas anti-Ro&#47;SS-A and&#47;or anti-La&#47;SS-B and RF yielded similar results&#44; being the most specific &#40;95&#37; CI 0&#46;71&#8211;0&#46;85 0&#46;78 and 0&#46;78&#44; 95&#37; CI 0&#46;69&#8211;0&#46;87&#44; respectively&#41; and having the best PPV &#40;0&#46;56 95&#37; CI 0&#46;45&#8211;0&#44; 58 and 0&#46;55 95&#37; CI 0&#46;40&#8211;0&#46;70&#44; respectively&#41;&#46; All showed good PLR &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">To date&#44; different classification criteria pSS have been proposed&#44; which are based on a combination of clinical&#44; serological and histological findings&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">2&#8211;8</span></a> There have been many classifications&#44; from the publication of the San Francisco<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a> &#40;which prioritize the histopathological appearance&#41; and the San Diego criteria&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a> in which the MSGB is essential for the diagnosis of defined pSS&#44; as well as the Copenhagen<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">4</span></a> Greeks&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">5</span></a> Japanese<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">6</span></a> and the European Community criteria&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a> which do not require a MSGB nor the presence of antibodies&#44; to the American&#8211;European criteria 2002<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a> and the 2012<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a> US Preliminary Criteria which require the presence of histological or serological criteria&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Given the diversity of criteria used throughout the years and the lack of training for obtaining and reading the material from a biopsy&#44; combined with the minor risks associated to the procedure&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">8&#8211;14</span></a> determining where it would be desirable to histologically define the diagnosis of pSS often poses problems in daily practice&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Our study aims to provide information to help define the usefulness of antibodies as an alternative to biopsies for the classification of pSS&#44; using the MSGB as a gold standard&#46; We found not only a significant association of anti Ro&#47;SS-A La&#47;SS-B antibodies with MSGB&#44; but also with ANA and RF&#46; In turn&#44; given the PLR of all such antibodies&#44; one can consider each as good study in relation to glandular inflammatory damage&#44; although given the low specificity of ANA&#44; its combination with another antibody such as RF&#44; as proposed in the 2012 preliminary criteria&#44; appears to be an option&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Other studies also analyzed the relationship between antibodies and MSGB&#46; Manoussakis et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">15</span></a> in a study conducted with 54 patients with a clinical diagnosis of pSS and 92 patients with rheumatoid arthritis&#44; found that anti-Ro&#47;SS-A&#44; anti-La&#47;SS-B antibodies and the titers of ANA and RF correlated with the histological stage of the biopsy&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Saito et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a> in a study of 107 patients with SS&#44; found that both RF and the anti Ro&#47;SS-A and anti-La&#47;SS-B antibodies were significantly more frequent in patients with periductal lymphocytic infiltrate&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In turn&#44; Wise et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">17</span></a> in their analysis of 187 patients in whom MSGB was performed to study pSS&#44; found that patients with foci score over 1 on biopsy had a significantly higher frequency of ANA&#44; RF&#44; anti Ro&#47;SS-A and anti-La&#47;SS-B&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Regarding anti Ro&#47;SS-A and anti La&#47;SS-B antibodies&#44; it has been described that patients with anti La&#47;SS-B show a greater inflammatory infiltrate in subjects only having positive anti Ro&#47;SS-A and those who are seronegative&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">18&#44;19</span></a> Halse et al&#46; showed the presence of a good correlation between the foci score and the presence of Ro 52<span class="elsevierStyleHsp" style=""></span>kD and 48<span class="elsevierStyleHsp" style=""></span>kD in saliva&#44; indicating a strong relationship between local inflammation and autoantibody production&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">18</span></a> Moreover&#44; a strong correlation between the presence of autoantibodies in serum and 52-kD Ro&#44; Ro 60<span class="elsevierStyleHsp" style=""></span>kD and La&#47;SSB in the salivary glands was found&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">A study conducted in 181 Chinese patients with an initial diagnosis of pSS compared different methods of detection of serum anti Ro&#47;SS-A &#40;double immunodiffusion&#44; Western blot and ELISA&#41; and found a significant association with MSGB with the three methods&#44; although the degree of agreement between the foci histological score and the antibody detected by Western blot was not very good&#44; concluding that the positive results of such antibodies in serum may indicate higher than 1 scores on biopsy&#44; therefore in these cases could obviate the<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">22</span></a> performance thereof&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">On the other hand&#44; Peen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">23</span></a> revalidated the association between RF positivity and the presence of lymphocytic foci at histology&#44; while Bamba et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">24</span></a> found a significant association between anti-Ro&#47;SS-A and anti-La&#47;SS-B antibodies and a positive biopsy&#44; but not with the ANA&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Daniels et al&#46; in a multicenter study with a large number of patients also observed this association between the four serological markers and MSGB<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">25</span></a> and the same group even proposed new classification criteria of the disease which include RF and ANA&#44; the latter with a titer greater or equal to 1&#47;320&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">26</span></a> Thus arose the 2012 American preliminary criteria&#44; in which the domain considered positive is the immunology laboratory&#44; before the positivity of anti-Ro&#47;SS-A and&#47;or anti La&#47;SS-B and&#47;or ANA &#40;a titer greater or equal to 1&#47;320&#41; plus RF&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">However&#44; controversy exists on the inclusion of ANA and RF in the new set of proposed criteria&#44; given that this decision stems from a consensus of experts of the sicca cohort in which there were patients with other autoimmune rheumatic diseases analyzed&#44; leading many experts to suggest further studies regarding this point&#44; before defining its true role within the 2012 criteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">27&#44;28</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">With respect to our study&#44; it has limitations due in large part because the data come from normal clinical practice&#46; We believe there may be a bias in patient selection because many times in daily practice a MSGB is performed only in the presence of negative anti Ro&#47;SS-A and anti-La&#47;SS-B antibody results&#59; there could also be a bias in the results of antibody testing&#44; since they were conducted in different centers&#46; On the other hand&#44; a weakness of the study was the lack of additional information on other clinical manifestations of patients&#44; in addition to ocular and oral dryness&#44; due to the difficulty in collecting this information from patients who&#44; in many cases&#44; come from other health care centers&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">On the other hand&#44; although the sample size was not calculated for diagnostic tests&#44; the number of observations available allowed for no empty cells or very few observations in the contingency table&#44; impeding ample 95&#37;CI&#44; which also speaks of a small number of patients&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">In any case&#44; we believe that the results of this study reinforce the notion that while the clinician can do without the MSGB in patients with positive anti-Ro&#47;SS-A&#44; anti-La&#47;SS-B antibodies&#44; it is of fundamental importance in seronegative patients&#46; On the other hand&#44; the significant and independent relationship found between ANA and MSGB and between RF and MSGB and the results of their value as diagnostic tests&#44; suggest that these antibodies&#44; bu themselves in the case of RF &#40;due to their higher specificity&#41;&#44; or possibly in combination &#40;ANA plus RF&#41; could be useful in assessing the immunology laboratory domain in the pSS classification&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical Responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of people and animals</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors declare that this research did not perform experiments on humans or animals&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Data confidentiality</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace regarding the publication of patient data&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of patients and&#47;or subjects referred to in the article&#46; This document is in the possession of the corresponding author&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of Interest</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to state&#46;</p></span></span>"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the association between histologic findings in the minor salivary gland biopsy &#40;MSGB&#41; and anti La &#40;La&#47;SS-B&#41; and antiRo antibodies &#40;Ro&#47;SS-A&#41;&#44; antinuclear antibodies &#40;ANA&#41; and rheumatoid factor &#40;RF&#41;&#44; and compare the value of the latter as diagnostic tests with MSGB&#44; considered as the gold standard&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patients with suspected primary Sj&#246;gren syndrome &#40;PSS&#41; referred for MSGB were included&#46; Antibody measurements were performed&#46; Grades III and IV biopsy results were considered positive&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Two hundred and eighteen &#40;218&#41; patients were included&#44; 95&#37; females&#44; with a median age of 54 years and 12 months median duration of sicca symptoms&#46; Thirty-six of the biopsies were positive&#46; 33&#37; of patients had positive anti Ro&#47;SS-A anti La&#47;SS-B antibodies&#44; 62&#37; had positive ANA&#44; and 31&#37; positive RF&#46; A statistically significant association was found between MSGB and anti Ro&#47;SS-A anti La&#47;SS-B&#44; ANA and RF&#46; ANA were the most sensitive antibodies &#40;84&#37;&#46; 95&#37; CI&#58; 75&#8211; 92&#41;&#44; and the most specific were&#58; anti Ro&#47;SS-A and&#47;or anti La&#47;SS-B &#40;78&#37;&#46; 95&#37; CI&#58; 71&#8211;85&#41; and RF &#40;78&#37;&#46; 95&#37; CI&#58; 69&#8211;87&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">On PSS clinical suspicion&#44; anti Ro&#47;SS-A and anti La&#47;SS-B antibodies have a great value to achieve the diagnosis&#44; with MSGB useful for diagnosis of seronegative patients&#46; The results also suggest the importance of ANA and RF for PSS classification&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materials and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar la asociaci&#243;n entre los hallazgos histol&#243;gicos de la biopsia de gl&#225;ndula salival menor &#40;BGSM&#41; y los anticuerpos anti La &#40;La&#47;SS-B&#41;&#44; anti Ro &#40;Ro&#47;SS-A&#41;&#44; anticuerpos antinucleares &#40;FAN&#41; y factor reumatoideo &#40;FR&#41;&#44; y comparar el valor de estos como test diagn&#243;stico con la BGSM considerada como patr&#243;n oro&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron pacientes con sospecha de s&#237;ndrome de Sj&#246;gren primario &#40;SSp&#41; derivados para realizaci&#243;n de BGSM&#46; Se realiz&#243; medici&#243;n de anticuerpos y se consider&#243; BGSM positiva a los grados III y IV de la clasificaci&#243;n de Chisholm&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 218 pacientes&#44; 95&#37; g&#233;nero femenino&#44; con una mediana de edad de 54 a&#241;os y de tiempo de evoluci&#243;n de los s&#237;ntomas sicca de 12 meses&#46; El 36&#37; de las biopsias fueron positivas&#46; El 33&#37; de los pacientes presentaban anticuerpos anti Ro&#47;SS-A anti La&#47;SS-B positivos&#44; 62&#37; FAN positivo y el 31&#37; FR positivo&#46; Se encontr&#243; asociaci&#243;n estad&#237;sticamente significativa entre la BGSM y anti Ro&#47;SS-A&#44; anti La&#47;SS-B&#44; FAN y FR&#46; El FAN result&#243; ser el anticuerpo m&#225;s sensible &#40;84&#37; IC95&#37;&#58; 75-92&#41;&#44; siendo los m&#225;s espec&#237;ficos&#58; anti Ro&#47;SS-A y&#47;o anti La&#47;SS-B &#40;78&#37; IC95&#37;&#58; 71-85&#41; y el FR &#40;78&#37; IC95&#37;&#58; 69-87&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Ante la sospecha cl&#237;nica de SSp&#44; los anticuerpos anti Ro&#47;SS-A y anti La&#47;SS-B son de gran valor para arribar al diagn&#243;stico&#44; siendo la BGSM especialmente &#250;til en los pacientes seronegativos&#46; Los resultados tambi&#233;n sugieren la utilidad del FAN y el FR para la clasificaci&#243;n de SSp&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivos"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Santiago ML&#44; Seisdedos MR&#44; Garcia Salinas RN&#44; Catal&#225;n Pellet A&#44; Villal&#243;n L&#44; Secco A&#46; Utilidad de los anticuerpos y de la biopsia de gl&#225;ndula salival menor en el estudio del complejo sicca en la pr&#225;ctica diaria&#46; Reumatol Clin&#46; 2015&#59;11&#58;156&#8211;160&#46;</p>"
      ]
    ]
    "multimedia" => array:3 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">m&#58;</span> median&#59; IQR&#58; interquartile range&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of patients &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Gender &#40;female&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">208&#47;218 &#40;9541&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age in years&#44; <span class="elsevierStyleItalic">m</span> &#40;ric&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54 &#40;44&#8211;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sicca symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">218&#47;218 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Time since onset of symptoms &#40;Months&#41;&#44; <span class="elsevierStyleItalic">m</span> &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;12&#8211;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Xerophthalmia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">195&#47;213 &#40;91&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Xerostomia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">183&#47;212 &#40;86&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Xerophthalmia plus xerostomia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">167&#47;212 &#40;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Positive eye tests<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">144&#47;176 &#40;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Positive sialometry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#47;105 &#40;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hypothyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&#47;208 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#47;209 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Treatment with corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#47;194 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Treatment with immunomodulatory&#47;immunosuppressive drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#47;190 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Biopsies stages III and IV &#40;&#43;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&#47;218 &#40;36&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">ANA &#40;&#43;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">126&#47;203 &#40;62&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Anti Ro&#47;SS-A anti-La&#47;SS-B &#40;&#43;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&#47;218 &#40;33&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">RF &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&#47;136 &#40;31&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab784586.png"
              ]
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          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Positive eye test&#58; Schirmer and&#47;or rose bengal&#47;lissamine green&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Demographic and Clinical Characteristics&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">SD&#44; standard deviation&#59; <span class="elsevierStyleItalic">m</span>&#44; median&#59; IQR&#44; interquartile range&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MSGB&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MSGB&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age&#44; mean &#40;SD&#41;&#44; years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5136 &#40;1424&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53 &#40;1325&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Gender &#40;male&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Time since onset of symptoms &#40;months&#41;&#44; <span class="elsevierStyleItalic">m</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;ric&#58; 8&#8211;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;ric&#58; 12&#8211;48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Xerophthalmia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Xerostomia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Xerophthalmia plus xerostomia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Positive eye test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Positive sialometry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hypothyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#37;&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 21735743
Original language: English
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2024 November 10 12 22
2024 October 24 53 77
2024 September 36 60 96
2024 August 49 89 138
2024 July 51 51 102
2024 June 48 70 118
2024 May 53 66 119
2024 April 45 66 111
2024 March 39 72 111
2024 February 27 55 82
2024 January 30 47 77
2023 December 70 65 135
2023 November 50 57 107
2023 October 30 58 88
2023 September 84 63 147
2023 August 39 31 70
2023 July 25 57 82
2023 June 32 48 80
2023 May 34 43 77
2023 April 17 29 46
2023 March 54 43 97
2023 February 41 44 85
2023 January 46 48 94
2022 December 63 70 133
2022 November 43 48 91
2022 October 53 44 97
2022 September 44 43 87
2022 August 32 50 82
2022 July 33 50 83
2022 June 27 39 66
2022 May 34 50 84
2022 April 42 43 85
2022 March 35 61 96
2022 February 36 37 73
2022 January 34 41 75
2021 December 28 51 79
2021 November 34 51 85
2021 October 46 56 102
2021 September 50 51 101
2021 August 40 73 113
2021 July 29 37 66
2021 June 38 41 79
2021 May 39 42 81
2021 April 90 94 184
2021 March 72 31 103
2021 February 44 29 73
2021 January 53 35 88
2020 December 50 25 75
2020 November 33 17 50
2020 October 30 15 45
2020 September 43 25 68
2020 August 25 22 47
2020 July 19 18 37
2020 June 48 39 87
2020 May 42 30 72
2020 April 25 15 40
2020 March 12 5 17
2018 May 4 0 4
2018 April 49 7 56
2018 March 50 9 59
2018 February 33 4 37
2018 January 34 13 47
2017 December 38 17 55
2017 November 40 11 51
2017 October 35 14 49
2017 September 26 16 42
2017 August 33 23 56
2017 July 37 37 74
2017 June 60 31 91
2017 May 108 31 139
2017 April 102 22 124
2017 March 31 24 55
2017 February 24 17 41
2017 January 28 15 43
2016 December 49 25 74
2016 November 32 15 47
2016 October 44 17 61
2016 September 58 9 67
2016 August 58 11 69
2016 July 39 15 54
2015 December 2 0 2
2015 November 1 16 17
2015 October 1 17 18
2015 September 3 0 3
2015 August 2 19 21
2015 July 26 5 31
2015 June 59 17 76
2015 May 73 34 107
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