Background Heterogeneity is a major obstacle to developing effective treatments for patients with primary Sjögren's syndrome. We aimed to develop a robust method for stratification, exploiting heterogeneity in patient-reported symptoms, and to relate these differences to pathobiology and therapeutic response. MethodsWe did hierarchical cluster analysis using five common symptoms associated with primary Sjögren's syndrome (pain, fatigue, dryness, anxiety, and depression), followed by multinomial logistic regression to identify subgroups in the UK Primary Sjögren's Syndrome Registry (UKPSSR). We assessed clinical and biological differences between these subgroups, including transcriptional differences in peripheral blood. Patients from two independent validation cohorts in Norway and France were used to confirm patient stratification. Data from two phase 3 clinical trials were similarly stratified to assess the differences between subgroups in treatment response to hydroxychloroquine and rituximab. FindingsIn the UKPSSR cohort (n=608), we identified four subgroups: Low symptom burden (LSB), high symptom burden (HSB), dryness dominant with fatigue (DDF), and pain dominant with fatigue (PDF). Significant differences in peripheral blood lymphocyte counts, anti-SSA and anti-SSB antibody positivity, as well as serum IgG, κ-free light chain, β2-microglobulin, and CXCL13 concentrations were observed between these subgroups, along with differentially expressed transcriptomic modules in peripheral blood. Similar findings were observed in the independent validation cohorts (n=396). Reanalysis of trial data stratifying patients into these subgroups suggested a treatment effect with hydroxychloroquine in the HSB subgroup and with rituximab in the DDF subgroup compared with placebo.Interpretation Stratification on the basis of patient-reported symptoms of patients with primary Sjögren's syndrome revealed distinct pathobiological endotypes with distinct responses to immunomodulatory treatments. Our data have important implications for clinical management, trial design, and therapeutic development. Similar stratification approaches might be useful for patients with other chronic immune-mediated diseases.

Evidence is presented that indicates that the decarboxylative route to azomethine ylides from both primary and secondary, cyclic and acyclic, a-amino acids involves an intermediate oxatolidin-5-one which loses carbon dioxide in a 1,3-dipolar cycloreversion reaction to generate an azomethine ylide stereospecifically.

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The binding modes of a series of penicillin-derived C2 symmetric dimer inhibitors of HIV-1 proteinase were investigated by NMR, protein crystallography, and molecular modeling. The compounds were found to bind in a symmetrical fashion, tracing and S-shaped course through the active site, with good hydrophobic interactions in the S1/S1' and S2/S2' pockets and hydrogen bonding of inhibitor amide groups. Interactions with the catalytic aspartates appeared poor and the protein conformation was very similar to that seen in complexes with peptidomimetics, in spite of the major differences in ligand structure.

The effect of temperature, solvent, and type of aldehyde on the stereospecific or stereoselective formation of azomethine ylides by the decarboxylative condensation of aldehydes with three types of aamino acids, (i) cyclic secondary a-amino acids, (ii) cyclic secondary a-amino acids with a benzylic carboxy group, and (iii) acyclic primary a-amino acids, has been studied. Stereospecific anti-dipole formation in (i) and temperature dependent stereoselective anti-dipole formation in (ii) and (iii) is inferred from the stereochemistry of cycloadducts of the azomethine ylides with N-methylmaleimide. These results are used to support a mechanistic scheme involving loss of carbon dioxide from in termed iate oxazol id i n -5 -ones in a stereospecif ic cycloreversion react ion. * This conclusion assumes the two dipoles react with N-methylmaleimide faster than they interconvert. Our previous studies 1,9 support this view but with less active dipolarophiles a different situation might obtain. C02 H Ar Ar ( 2 0 ) H H----H OAN AO Me Me (21) a ; A r = Ph ( 2 2 ) b ; A r = 2pyridyl H H H * The results of M.N.D.O. and STO-3G calculations on (34a)-(37a) and other aspects of dipole formation are being prepared for publication (R. Grigg, J. Idle, and P. McMeekin, unpublished observations).