Minor salivary gland biopsy (MSGB) is a cornerstone in the diagnosis and classification of Sjögren's disease (SjD). remain limited, particularly from the Middle East. To describe referral patterns, histopathological findings, and diagnostic yield of MSGB in patients with suspected SjD over 10 years at a tertiary center in Jordan. This retrospective cross-sectional study included 125 MSGB specimens collected between January 2015 and December 2024 at Jordan University Hospital. Clinical, laboratory, imaging, and histopathological data were retrieved and analyzed. Biopsy positivity was defined as a focus score ≥ 1. Univariable and multivariable logistic regression analyses were performed to identify independent predictors of biopsy positivity. Most patients were female (84.8%), with a median age of 55 (range: 11-81 years). Rheumatologists were the predominant referring specialty (70.2%). A progressive increase in biopsy utilization was observed from 2021 onward. Focal lymphocytic sialadenitis (FLS) was the most frequent histopathological diagnosis (36%). On multivariable analysis, positive ANA (aOR 3.04, 95% CI 1.03-8.95) and RF (aOR 3.82, 95% CI 1.26-11.54) were independent predictors of biopsy positivity. No significant associations were found with anti-SSA, anti-SSB, or inflammatory markers. MSGB demonstrates moderate diagnostic yield in a real-world tertiary setting, with ANA and RF positivity as independent predictors of positive histology. These findings add valuable insights into SjD diagnosis from an underrepresented region.

Hydroxychloroquine (HCQ) is a cornerstone in treating autoimmune diseases and is generally well-tolerated. Cardiotoxicity is a rare but serious adverse effect of prolonged HCQ therapy. The progression of cardiac dysfunction may evade early detection with standard noninvasive investigations. This case report was prepared in accordance with the CABARET guidelines from the EQUATOR Network. The patient underwent comprehensive clinical evaluation for diagnostic clarification. A 57-year-old woman with Sjogren's disease (SjD) who was treated with HCQ 400 mg daily for nearly 21 years (cumulative dose ~ 3,000 g). The patient started to develop symptoms of syncope, shortness of breath and lower extremity edema. Noninvasive evaluation including echocardiography, coronary angiography, and cardiac magnetic resonance imaging failed to identify a clear etiology, demonstrating preserved ventricular size and systolic function without evidence of infiltrative or inflammatory cardiomyopathy. Continued decline in the patient's clinical status in addition to lack of response to medical therapy, an endomyocardial biopsy (EMB) was performed and revealed findings consistent with HCQ induced cardiotoxicity. HCQ was stopped; however, the damage was beyond reversal, so the patient ended up having an orthotopic heart transplantation. This case sheds light on an irreversible HCQ-induced cardiotoxicity that ended up with a heart transplantation. Despite extensive cardiac workup this adverse effect remained undetected until advanced disease. Delayed diagnosis can lead to irreversible cardiac damage and EMB should be considered in patients on prolonged HCQ therapy with unexplained cardiac symptoms and nondiagnostic workup. This can prompt early discontinuation of HCQ with potentially reversible damage and more favorable outcomes.

Integrative oncology interventions for patients undergoing radiation therapy (RT) may relieve symptoms (including procedural anxiety) and improve quality of life, though gaps remain in the evidence base to adequately guide implementation efforts. In this article we review clinical trials specifically for psychological (ie, mindfulness), physical (ie, exercise, acupuncture), and combination approaches (ie, yoga, tai chi, and qigong), in which several symptom-based clinical outcomes are impacted (ie, fatigue, sleep disturbance, pain, mood, and xerostomia). We identified at least 90 clinical trials and 15 systematic reviews and meta-analyses related to this topic, but note the predominance of early-phase investigations and some heterogeneity in study findings. We also assess opportunities across the radiation treatment continuum, noting most interventions were targeted during active radiation treatment. Future research ought to leverage novel hybrid study designs and multi-center community-based clinical settings (including cooperative groups) to confirm effectiveness and generalizability of findings of existing earlier phase clinical trials. Meanwhile, opportunities to improve clinical trial efficiency such as integrating advanced practice providers and patient-reported outcomes in routine care should be considered. As a field with procedural elements, established symptom trajectories, and often daily patient engagement, radiation oncology is poised to develop and implement interventions that advance symptom science and clinical outcomes for patients with cancer.

Hematological malignancies are the fourth most common cancer type, with lymphoma as one of the most common hematological malignancies in this group. Radiation therapy plays a critical role in the treatment of hematological malignancies, particularly lymphoma, plasmacytoma, and leukemia. Radiation toxicities include side effects such as pain, dermatitis, mucositis, xerostomia, nausea, fatigue, anxiety, and pneumonitis. With emerging therapies in hematology, including chimeric antigen receptor T-cell therapy, bispecific antibodies, and transplant, patients are presented with unique side effects that may impact their ability to tolerate radiation. Integrative therapies, such as mindfulness-based interventions and yoga, have shown to have strong evidence in managing radiation-related fatigue, anxiety, and depression. Acupuncture has shown to be efficacious for radiation-related pain, xerostomia, and anxiety. As survival has continued to increase over the years, survivorship has become crucial. For patients who have undergone radiation, survivorship concerns such as increased cardiovascular risk, psycho-social concerns, secondary malignancy risk, and others may uniquely be addressed with integrative approaches. This review aims to give an overview of the current evidence for integrative therapies in managing toxicities secondary to radiation and improving the survivorship of patients who have received radiation therapy.

Radiation therapy is a cornerstone of cancer treatment, but it is often associated with a range of acute and late toxicities that can significantly impact patients' quality of life. Integrative oncology, which combines conventional cancer treatments with evidence-based complementary therapies, is gaining increasing recognition as a means of managing these side effects and improving patient well-being. Acupuncture, a key component of traditional Chinese medicine, has emerged as a promising intervention for a variety of radiation-induced toxicities. This review synthesizes the current evidence for the use of acupuncture in managing common side effects of radiation therapy, including xerostomia, fatigue, pain, nausea and vomiting, and oral mucositis. We also discuss the proposed mechanisms of action of acupuncture, the challenges in acupuncture research, and future directions for the field. The evidence suggests that acupuncture is a safe and effective intervention for several radiation-induced toxicities, and its integration into routine oncology care has the potential to improve patient outcomes and enhance survivorship.

Primary Sjögren disease (pSjD) is a systemic autoimmune disease with heterogeneous clinical, serological, and hematological manifestations. Because symptom onset and diagnostic delay may be difficult to determine retrospectively, age at diagnosis may provide a pragmatic framework for describing clinical heterogeneity. This study compared clinical, serological, and hematological profiles across diagnosis-age groups in pSjD. This retrospective cross-sectional study included 258 patients with definite primary Sjögren disease fulfilling the 2016 ACR/EULAR classification criteria after exclusion of cases with uncertain primary/secondary status. Patients were stratified according to age at diagnosis into young-adult (< 40 years, n = 54), middle-age (40-59 years, n = 137), and late (≥ 60 years, n = 67) groups. Demographic, clinical, serological, hematological, and composite inflammatory indices were compared. Logistic regression was used to evaluate exploratory sex-adjusted associations with pulmonary involvement. ROC analysis was performed to evaluate the modest discriminative performance of RDW-SD for late versus young-adult diagnosis-age groups. Pulmonary involvement was observed in 2/54 (3.7%) young-adult, 7/137 (5.1%) middle-age, and 19/67 (28.4%) late diagnosis-age patients (p < 0.001). In exploratory sex-adjusted logistic regression, late diagnosis-age was associated with pulmonary involvement compared with young-adult diagnosis-age (OR 8.20, 95% CI 1.75-38.32), whereas middle-age diagnosis was not (OR 1.34, 95% CI 0.26-6.83). Extraglandular involvement also differed across groups (31.5%, 16.8%, and 35.8%, respectively; p = 0.006). Corticosteroid exposure was more frequent in the late diagnosis-age group (7.4%, 18.2%, and 32.8%; p = 0.002), but was interpreted as a treatment variable rather than an intrinsic disease phenotype. CRP, neutrophil count, monocyte count, RDW-SD, NLR, SIRI, SII, and AISI differed across groups. RDW-SD showed only modest discriminatory ability for late versus young-adult diagnosis-age groups (AUC 0.645, 95% CI 0.538-0.746). Autoantibody profiles were broadly comparable, although anti- SSB/La positivity was more frequent in the young-adult group. In this single-center cohort, age at diagnosis was associated with differences in selected clinical and hematological characteristics in pSjD. Late diagnosis-age was associated with a higher frequency of clinically recognized pulmonary involvement; however, this finding should be interpreted cautiously because smoking data were incomplete, HRCT screening was not systematic, age-related comorbidities were more common in older patients, and reverse causality related to ILD workup cannot be excluded. RDW-SD should be considered an exploratory CBC-derived marker with modest performance rather than a clinically established biomarker.

Background: Immune checkpoint inhibitors (ICIs) can induce a sicca-like syndrome that differs from primary Sjögren's disease in both immunopathogenesis and clinical phenotype. Despite growing recognition of this entity, data describing real-world management and outcomes, particularly in the context of ICI discontinuation and rechallenge, remain limited. Methods: Patients with new onset of sicca syndrome or exacerbation of previous symptoms following ICI therapy were retrospectively identified and assessed. Results: Fifty-nine patients with diverse malignancies (including melanoma, gastrointestinal, genitourinary, etc.) and sicca syndrome following treatment with ICIs (most often pembrolizumab or nivolumab +/- ipilimumab) were evaluated. Acute-onset dry mouth, primarily CTCAE v6.0 grades 1 (n = 24, 40.7%) and 2 (n = 34, 57.6%), occurred at a median of 104 days after ICI initiation, sometimes with associated dry eye (n = 8, 13.6%). Most were managed conservatively with behavioral modification and over-the-counter therapies alone (n = 37, 62.7%) while others received sialagogues (n = 9, 15.3%), dexamethasone oral rinse (n = 11, 18.6%), and/or systemic corticosteroids (n = 16, 27.1%). Additional management strategies included de-escalation to ICI monotherapy (n = 5, 8.5%) or discontinued ICI (n = 6, 10.2%). Half of patients treated with corticosteroids demonstrated subjective improvement in symptoms while 75% improved following ICI discontinuation. Four patients underwent rechallenge after a median interruption of 564 days; all (n = 4) demonstrated sicca recurrence. Conclusions: In this largest cohort to date of ICI-associated sicca syndrome, we confirm frequent improvement with steroids and/or supportive care and suggest a greater than previously appreciated risk of recurrence with rechallenge.