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In the June issue of the Annals Manthorpe comments on the recently proposed US-European classification criteria for Sjögren's syndrome (SS).1 We would like to deal with some of the issues he raises, and add some comments.
Now that the classification criteria have evolved from rather subjectively biased ones to more objective assessments, it is surprising that the two most disease-specific objective parameters currently available for SS are subject to considerable criticism. Of course, when serological and histological items are emphasised in the new SS classification criteria, their individual disease sensitivity and specificity should always be kept in mind.
In fact, all six items that are included in the classification criteria may be subject to discussion. For example, the Schirmer-I test, and unstimulated whole salivary flow test have been criticised in a number of papers,2–5 but these items are recommended in Manthorpe's paper.
Manthorpe expresses his concerns about the accuracy of sublabial salivary gland biopsies (SLGBs), referring to one paper in which a change of diagnosis of >50% is reported after a second examination of the SLGBs. However, the authors themselves report that not using the focus scoring system was probably the most important reason for the change of diagnosis on the second examination. They did not conclude that the focus score itself—which is mandatory to fulfil item VI—changed dramatically upon re-examination of the specimens!
Other ways of bypassing interobserver variability are also available—for example, measuring two parameters instead of one (for example IgA% and focus score) provides a synergistic value for the accuracy of diagnosis,6 and, moreover, computer aided scoring methods may provide non-observer dependent data. For measuring the IgA% reliable and reproducible objective data from the biopsies are obtained by combining microscope, computer, and …
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