This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

The protocol demonstrated a clinical protocol for conduction of SGUS and the demonstration of scanning is performed on a de-identified healthy volunteer. Ethical approval is not required as the study is beyond the common rule and FDA definition of human research subject. Verbal consent from patients was obtained for taking clinical photos and their publication.
1. Transducer and machine settings
<ol>
	<li>Select a high-frequency linear transducer of 10 MHz (see the Table of Materials).</li>
	<li>Set to B mode.</li>
	<li>Use the highest frequency of the probe.</li>
	<li>Adjust the depth (3 cm) and gain (50%-60%). 
	NOTE: The depth is usually 1 cm deeper than the target structure. Auto-gain function is available for some ultrasound consoles.</li>
	<li>For a right-handed examiner, place the ultrasound machine next to the patient&#39;s right shoulder.</li>
</ol>
2. Patient preparation
<ol>
	<li>Position the patient in the supine position with the neck slightly extended. Use a pillow to support the patient&#39;s head.</li>
	<li>Remove any clothing or jewelry around the neck that may obstruct the ultrasound transducer.</li>
</ol>
3. Scanning of the thyroid gland
<ol>
	<li>Orient the probe with the marker pointing towards the patient&#39;s right side for transverse images. For longitudinal scanning, orient the marker at the cephalic side.</li>
	<li>Apply gel to the probe surface.</li>
	<li>Place the probe below the thyroid cartilage for scanning of the thyroid gland. The right and left lobes of the thyroid gland are connected by the isthmus. Save the images and take the echogenicity of the thyroid gland as a reference (Figure 1).</li>
	<li>If there is concomitant thyroid disease, compare the echogenicity to that of the surrounding muscles. Normal salivary glands are usually more echogenic than muscle.</li>
</ol>
4. Scanning of the parotid gland
<ol>
	<li>Turn the patient&#39;s head to the opposite side of the gland being examined.</li>
	<li>Place the transducer longitudinally along the anterior border of the parotid gland, just anterior to the ear and parallel to the tragus, moving from the superior to the inferior pole of the gland (Figure 2).</li>
	<li>Place the probe transversely at the angle of the mandible to obtain the transverse scan. Ideally, the parotid gland is located between the mastoid and mandible ramus in transverse view. Scan the parotid gland transversely from the superior to the inferior pole (Figure 3).</li>
	<li>Slide the probe below the ramus of the mandible to visualize the deep part of the parotid gland, which could be partially obscured by the mandible. Place the probe between the mastoid process and the angle of the mandible.</li>
	<li>Save and label the images in both the longitudinal and transverse views.</li>
	<li>Assess the size of the parotid gland.</li>
	<li>Compare the echogenicity with that of the thyroid gland. The echogenicity of the normal parotid gland is similar to that of the thyroid gland.</li>
	<li>The retromandibular vein and external carotid artery divide the superficial and deep parotid lobes. Turn on the color doppler to differentiate blood vessels from the dilated intraglandular duct.</li>
	<li>Capture the degree of inhomogeneity, the clearness of the gland margin, and the presence of hypo-/an-echoic areas within the glands.</li>
	<li>Note the presence of focal lesions and document the size, location, shape, and echogenicity. Turn on the color doppler to look for vascularity.</li>
	<li>Score the degree of sonographic involvement on a scale of 0-3 as defined: Grade 0: normal, homogenous parenchyma; grade 1: mild inhomogeneity without hypo-/an-echoic areas; grade 2: moderate inhomogeneity with the presence of scattered hypo-/an-echoic areas; grade 3: Diffuse inhomogeneity with the presence of hypo-/an-echoic areas in the entire gland4.</li>
	<li>The presence of lymph nodes within the parotid gland could be normal and common, especially when located in the superficial lobe. Measure the diameter of the lymph nodes. Evaluate the shape, echogenicity, and preservation of fatty hilum.</li>
	<li>Repeat the scanning at the contralateral parotid gland. Compare the size and echotexture between the two parotid glands.</li>
</ol>
5. Scanning of the submandibular gland
<ol>
	<li>Position the patient in the supine position with the head maximally tilted to the back.</li>
	<li>To obtain the transverse view of the submandibular gland, position the transducer just below the angle of the mandible at the submandibular area, which is bounded by the mandible, mylohyoid muscles, and the anterior belly of the digastric muscles. Examine the entire submandibular gland from anterior to posterior (Figure 4).</li>
	<li>Obtain the longitudinal view by placing the probe medial to the horizontal body of the mandible. Visualize the facial artery in this plane (Figure 5).</li>
	<li>Save and label the images in both transverse and longitudinal views of the submandibular gland.</li>
	<li>Assess the size of the submandibular gland.</li>
	<li>Examine the echogenicity of the submandibular gland, which is usually less echogenic than the parotid gland.</li>
	<li>Assess the degree of inhomogeneity, the clearness of the gland margin, and the presence of hypo-/an-echoic areas within the glands. Note the presence of focal lesions.</li>
	<li>Grade the degree of inhomogeneity using the OMERACT score: Grade 0: normal parenchyma; Grade 1: minimal change with mild inhomogeneity without hypo-/an-echoic areas; Grade 2: moderate change with moderate inhomogeneity with focal hypo-/an-echoic areas; Grade 3: severe change with diffuse inhomogeneity with hypo-/an-echoic areas occupying all the surface of the gland. If the evaluation of the gland is not possible due to qualitative parameters, the fatty gland refers to grade 1, and the fibrous gland indistinguishable from adjacent tissue corresponds to grade 34.</li>
	<li>Measure the size of the submandibular lymph nodes. Evaluate the shape, echogenicity, and preservation of fatty hilum.</li>
	<li>Repeat the scanning at the contralateral submandibular gland. Compare the size and echotexture between the two submandibular glands.</li>
</ol>
6. Documentation
<ol>
	<li>Document the sonographic involvement on a scale of 0-3 at all four major salivary glands. A Score of &#8805;2 at any gland is considered compatible with SS.</li>
	<li>Document the presence of lymph nodes if any. Record the diameter, shape, and whether fatty hilum is preserved.</li>
	<li>Document the presence of focal abnormalities if any.</li>
</ol>

Technique for Salivary Gland Ultrasound Examination of Sjogren's Syndrome

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H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=American+College+of+Rheumatology/European+League+Against+Rheumatism+Classification+Criteria+for+Primary+Sj&#246;gren's+Syndrome:+a+consensus+and+data-driven+methodology+involving+three+international+patient+cohorts.">American College of Rheumatology/European League Against Rheumatism Classification Criteria for Primary Sj&#246;gren's Syndrome: a consensus and data-driven methodology involving three international patient cohorts.</a> Arthritis Rheumatol. 69 (1), 35-45 (2017).</li><li>Varoni, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Local+complications+associated+with+labial+salivary+gland+biopsy+for+diagnosis+of+Sj&#246;gren's+Syndrome:+A+retrospective+cohort+study.">Local complications associated with labial salivary gland biopsy for diagnosis of Sj&#246;gren's Syndrome: A retrospective cohort study.</a> J Clin Exp Dent. , e713-e718 (2020).</li><li>Hoc&#780;evar, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasonographic+changes+of+major+salivary+glands+in+primary+Sjo&#776;gren's+syndrome.+Diagnostic+value+of+a+novel+scoring+system.">Ultrasonographic changes of major salivary glands in primary Sjo&#776;gren's syndrome. Diagnostic value of a novel scoring system.</a> Rheumatology. 44 (6), 768-772 (2005).</li><li>Jousse-Joulin, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Video+clip+assessment+of+a+salivary+gland+ultrasound+scoring+system+in+Sj&#246;gren's+syndrome+using+consensual+definitions:+an+OMERACT+ultrasound+working+group+reliability+exercise.">Video clip assessment of a salivary gland ultrasound scoring system in Sj&#246;gren's syndrome using consensual definitions: an OMERACT ultrasound working group reliability exercise.</a> Ann Rheum Dis. 78 (7), 967-973 (2019).</li><li>Fana, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Application+of+the+OMERACT+Grey-scale+Ultrasound+Scoring+System+for+salivary+glands+in+a+single-centre+cohort+of+patients+with+suspected+Sj&#246;gren's+syndrome.">Application of the OMERACT Grey-scale Ultrasound Scoring System for salivary glands in a single-centre cohort of patients with suspected Sj&#246;gren's syndrome.</a> RMD Open. 7 (2), e001516 (2021).</li><li>Ahuja, A. T., Ying, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sonographic+evaluation+of+cervical+lymph+nodes.">Sonographic evaluation of cervical lymph nodes.</a> Am J Roentgenol. 184 (5), 1691-1699 (2005).</li><li>Jousse-Joulin, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+salivary+gland+ultrasonography+a+useful+tool+in+Sj&#246;gren's+syndrome?+A+systematic+review.">Is salivary gland ultrasonography a useful tool in Sj&#246;gren's syndrome? A systematic review.</a> Rheumatology. 55 (5), 789-800 (2016).</li><li>De Vita, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Salivary+gland+echography+in+primary+and+secondary+Sj&#246;gren's+syndrome.">Salivary gland echography in primary and secondary Sj&#246;gren's syndrome.</a> Clin Exp Rheumatol. 10 (4), 351-356 (1992).</li><li>Cornec, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Contribution+of+salivary+gland+ultrasonography+to+the+diagnosis+of+Sj&#246;gren's+syndrome:+Toward+new+diagnostic+criteria.">Contribution of salivary gland ultrasonography to the diagnosis of Sj&#246;gren's syndrome: Toward new diagnostic criteria.</a> Arthritis Rheum. 65 (1), 216-225 (2013).</li><li>Milic, V. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Major+salivary+gland+sonography+in+Sj&#246;gren's+syndrome:+diagnostic+value+of+a+novel+ultrasonography+score+(0-12)+for+parenchymal+inhomogeneity.">Major salivary gland sonography in Sj&#246;gren's syndrome: diagnostic value of a novel ultrasonography score (0-12) for parenchymal inhomogeneity.</a> Scand J Rheumatol. 39 (2), 160-166 (2010).</li><li>Finzel, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Patient-based+reliability+of+the+Outcome+Measures+in+Rheumatology+(OMERACT)+ultrasound+scoring+system+for+salivary+gland+assessment+in+patients+with+Sj&#246;gren's+syndrome.">Patient-based reliability of the Outcome Measures in Rheumatology (OMERACT) ultrasound scoring system for salivary gland assessment in patients with Sj&#246;gren's syndrome.</a> Rheumatology. 60 (5), 2169-2176 (2021).</li><li>Barrio-Nogal, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasonography+in+the+diagnosis+of+suspected+primary+Sj&#246;gren's+syndrome+and+concordance+with+salivary+gland+biopsy:+a+Spanish+single-center+study.">Ultrasonography in the diagnosis of suspected primary Sj&#246;gren's syndrome and concordance with salivary gland biopsy: a Spanish single-center study.</a> Clin Rheumatol. 42 (9), 2409-2417 (2023).</li><li>Robin, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+performances+of+ultrasound+evaluation+of+major+salivary+glands+according+to+the+2019+Outcome+Measures+in+Rheumatology+ultrasound+scoring+system.">Diagnostic performances of ultrasound evaluation of major salivary glands according to the 2019 Outcome Measures in Rheumatology ultrasound scoring system.</a> Arthritis Care Res. 74 (11), 1924-1932 (2022).</li><li>Zhang, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Salivary+gland+ultrasonography+in+primary+Sj&#246;gren's+syndrome+from+diagnosis+to+clinical+stratification:+a+multicentre+study.">Salivary gland ultrasonography in primary Sj&#246;gren's syndrome from diagnosis to clinical stratification: a multicentre study.</a> Arthritis Res Ther. 23 (1), 305 (2021).</li><li>Tang, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+value+of+ultrasound+evaluation+of+major+salivary+glands+for+Sj&#246;gren's+syndrome+based+on+the+novel+OMERACT+scoring+system.">Diagnostic value of ultrasound evaluation of major salivary glands for Sj&#246;gren's syndrome based on the novel OMERACT scoring system.</a> Eur J Radiol. 162, 110765 (2023).</li><li>Jousse-Joulin, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Weight+of+salivary+gland+ultrasonography+compared+to+other+items+of+the+2016+ACR/EULAR+classification+criteria+for+Primary+Sj&#246;gren's+syndrome.">Weight of salivary gland ultrasonography compared to other items of the 2016 ACR/EULAR classification criteria for Primary Sj&#246;gren's syndrome.</a> J Intern Med. 287 (2), 180-188 (2020).</li><li>van Nimwegen, J. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incorporation+of+salivary+gland+ultrasonography+into+the+American+College+of+Rheumatology/European+League+Against+Rheumatism+Criteria+for+Primary+Sj&#246;gren's+Syndrome.">Incorporation of salivary gland ultrasonography into the American College of Rheumatology/European League Against Rheumatism Criteria for Primary Sj&#246;gren's Syndrome.</a> Arthritis Care &amp; Res. 72 (4), 583-590 (2020).</li><li>Esther, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasonography+of+major+salivary+glands+compared+with+parotid+and+labial+gland+biopsy+and+classification+criteria+in+patients+with+clinically+suspected+primary+Sj&#246;gren's+syndrome.">Ultrasonography of major salivary glands compared with parotid and labial gland biopsy and classification criteria in patients with clinically suspected primary Sj&#246;gren's syndrome.</a> Ann Rheum Dis. 76 (11), 1883-1889 (2017).</li><li>Omar Al, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Normal+salivary+gland+ultrasonography+could+rule+out+the+diagnosis+of+Sj&#246;gren's+syndrome+in+anti-SSA-negative+patients+with+sicca+syndrome.">Normal salivary gland ultrasonography could rule out the diagnosis of Sj&#246;gren's syndrome in anti-SSA-negative patients with sicca syndrome.</a> RMD Open. 7 (1), ee001503 (2021).</li><li>Milic, V., Colic, J., Cirkovic, A., Stanojlovic, S., Damjanov, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Disease+activity+and+damage+in+patients+with+primary+Sjogren's+syndrome:+Prognostic+value+of+salivary+gland+ultrasonography.">Disease activity and damage in patients with primary Sjogren's syndrome: Prognostic value of salivary gland ultrasonography.</a> PLOS ONE. 14 (12), e0226498 (2019).</li><li>Chen, Y. F., Hsieh, A. H., Fang, Y. F., Kuo, C. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+evaluation+using+salivary+gland+ultrasonography+in+primary+Sj&#246;gren's+Syndrome.">Diagnostic evaluation using salivary gland ultrasonography in primary Sj&#246;gren's Syndrome.</a> J Clin Med. 12 (6), 2428 (2023).</li><li>Ho&#269;evar, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+a+new+ultrasound+scoring+system+to+evaluate+glandular+inflammation+in+Sj&#246;gren's+syndrome:+an+OMERACT+reliability+exercise.">Development of a new ultrasound scoring system to evaluate glandular inflammation in Sj&#246;gren's syndrome: an OMERACT reliability exercise.</a> Rheumatology. 61 (8), 3341-3350 (2022).</li><li>Voulgarelis, M., Dafni, U. G., Isenberg, D. A., Moutsopoulos, H. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Malignant+lymphoma+in+primary+Sj&#246;gren's+syndrome:+A+multicenter,+retrospective,+clinical+study+by+the+European+concerted+action+on+Sj&#246;gren's+syndrome.">Malignant lymphoma in primary Sj&#246;gren's syndrome: A multicenter, retrospective, clinical study by the European concerted action on Sj&#246;gren's syndrome.</a> Arthritis Rheum. 42 (8), 1765-1772 (1999).</li><li>Nocturne, G., Pontarini, E., Bombardieri, M., Mariette, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lymphomas+complicating+primary+Sj&#246;gren's+syndrome:+from+autoimmunity+to+lymphoma.">Lymphomas complicating primary Sj&#246;gren's syndrome: from autoimmunity to lymphoma.</a> Rheumatology. 60 (8), 3513-3521 (2021).</li><li>Lorenzon, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sonographic+features+of+lymphoma+of+the+major+salivary+glands+diagnosed+with+ultrasound-guided+core+needle+biopsy+in+Sj&#246;gren's+syndrome.">Sonographic features of lymphoma of the major salivary glands diagnosed with ultrasound-guided core needle biopsy in Sj&#246;gren's syndrome.</a> Clin Exp Rheumatol. 39 Suppl 133 (6), 175-183 (2021).</li><li>&#214;zer, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+performance+of+gray-scale+ultrasound+and+shear+wave+elastography+in+assessing+salivary+gland+involvement+in+patients+with+primary+Sj&#246;gren's+syndrome.">Diagnostic performance of gray-scale ultrasound and shear wave elastography in assessing salivary gland involvement in patients with primary Sj&#246;gren's syndrome.</a> J Clin Ultrasound. 51 (1), 187-194 (2023).</li></ol>

The authors have no conflicts of interest to declare.

Ultrasonography of the major salivary glands is a non-invasive and accessible imaging modality with high spatial resolution. The procedure of performing SGUS at the major salivary glands for patients with suspected SS is described in this article to facilitate reproducible and standardized examination. Parotid and submandibular glands are superficially located, which permits detailed examination by high-frequency ultrasound. SGUS is useful in evaluating various clinical conditions, including SS, sialadenitis, sialolithia...

Sjogren's syndrome (SS) is an autoimmune disease characterized by lymphocytic infiltration in exocrine glands, including the salivary and lacrimal glands. Xerostomia, keratoconjunctivitis sicca, and extraglandular manifestations, including arthralgia, cytopenia, and lymphoma, are described in patients with SS. SS can be divided into primary and secondary types, in which the latter occurs in association with other connective tissue diseases. In the 2016 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for primary SS, anti-SSA/Ro positivity and lymphocytic infiltration in labial salivary gland biopsy contributed to the two major criteria, whereas Schirmer's test, ocular staining score, and unstimulated salivary flow represented the rest of the minor criteria1. The criteria are summarized in Table 1. Labial biopsy is an invasive procedure with potential complications, including sampling error, sensory loss, and hematoma formation2. Ocular staining tests and salivary flow assessment require specialized settings and might not be widely available. 
Salivary gland ultrasonography (SGUS) is a non-invasive imaging modality that provides a detailed examination of the superficial salivary gland structure, which is commonly affected in patients with SS. Lymphocytic infiltration and inflammation in the salivary glands often lead to fatty infiltration, fibrosis, and loss of parenchyma, resulting in parenchymal inhomogeneity detected in SGUS3. The Outcome Measures in Rheumatology Clinical Trials (OMERACT) working group derived an ultrasound scoring system from grades 0 to 3 to semi-quantify inhomogeneity and the presence of hypoechoic areas within the parotid or submandibular glands4. A cutoff of grade 2 or above in at least one gland was found to correlate with positive labial biopsies, sialometry, and positive autoantibodies5. It demonstrated excellent specificity and good sensitivity in fulfilling the 2016 ACR/EULAR classification criteria for primary SS when given similar weight as the minor criteria. This protocol presents a standardized and practical approach for diagnosing SGUS in SS in clinical settings.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Examination couch</td>
			<td></td>
			<td>/</td>
			<td>Quantity: 1</td>
		</tr>
		<tr>
			<td>High frequency linear transducer of at least 10 MHz</td>
			<td></td>
			<td>SL2325 18-6 MHz linear transducer</td>
			<td>Quantity:&#160;1</td>
		</tr>
		<tr>
			<td>Ultrasound console</td>
			<td></td>
			<td>Esaote my lab seven</td>
			<td>Quantity:&#160;1</td>
		</tr>
		<tr>
			<td>Ultrasound gel</td>
			<td></td>
			<td>/</td>
			<td>Quantity:&#160;1</td>
		</tr>
	</tbody>
</table>

ultrasonographic evaluation of salivary glands for sjogren's syndrome: diagnostic and monitoring insights

Sjogren's syndrome (SS) is a chronic autoimmune condition commonly affecting the exocrine glands, causing oral or ocular dryness and extraglandular manifestations including arthralgia, cytopenia, and lymphoma. The presence of autoantibodies against SSA/Ro, labial salivary gland biopsy, ocular staining, Schirmer's test, or salivary flow assessment are included in the current classification criteria of SS. However, the availability and invasiveness of these procedures limit their widespread use in clinical settings. Salivary gland ultrasonography (SGUS) is a non-invasive imaging modality for the evaluation of the salivary gland parenchyma and is increasingly utilized to aid diagnosis and monitoring in SS. 
This article presents the protocol of SGUS for image acquisition at the parotid and submandibular glands. The objective is to present a standardized, reproducible, and practical approach to diagnostic SGUS for SS in daily clinical settings. Major salivary glands are scanned in a stepwise approach, beginning at the angle of the mandible for the superficial lobe of the parotid gland, followed by the deep lobe below the ramus of the mandible. Submandibular areas are then scanned for the submandibular glands. The steps in obtaining salivary gland images at each anatomical site are explained in the accompanying video. The echogenicity and echotexture at the thyroid gland are taken as a reference. The homogeneity, the presence and distribution of hypoechoic areas within the glands, and the border of the salivary glands are examined. The sizes and features of intra-/peri-glandular lymph nodes are recorded. The most distinctive sonographic feature in SS is glandular heterogeneity with the presence of hypoechoic/hyperechoic areas within the glands. 
In summary, while SGUS cannot diagnose SS on its own, it can supplement the current classification criteria of SS and guide the clinical decision for salivary gland biopsy to support the diagnosis of SS in patients with sicca syndrome or suspicious systemic features, combined with autoantibody testing.

Here we described the interpretation of salivary gland ultrasound images to aid diagnosis of SS. The anatomical annotation at the scanning sites is summarized in Figure 1, Figure 2, and Figure 3. The echotexture of the thyroid gland is taken as the reference. Normal parotid glands should appear homogeneous with clear demarcation with overlying tissues and muscles. The echotexture of normal parotid glands is comparable to that of the...

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Author Spotlight: A Focus on Standardized Salivary Gland Ultrasound Protocol in Connective Tissue Disease Research

Salivary gland ultrasonography is a promising tool for the diagnosis and evaluation of disease activity and complications in Sjogren's syndrome (SS). The scanning technique for salivary gland ultrasound examination relevant to SS is described in the article.

Ultrasonographic Evaluation of Salivary Glands for Sjogren's Syndrome: Diagnostic and Monitoring Insights

Sjogren's syndrome (SS) is a chronic autoimmune condition commonly affecting the exocrine glands, causing oral or ocular dryness and extraglandular ...

ultrasonographic-evaluation-salivary-glands-for-sjogren-s-syndrome

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1.5K Views.  The University of Hong Kong. Salivary gland ultrasonography is a promising tool for the diagnosis and evaluation of disease activity and complications in Sjogren's syndrome (SS). The scanning technique for salivary gland ultrasound examination relevant to SS is described in the article.

Video: Author Spotlight: A Focus on Standardized Salivary Gland Ultrasound Protocol in Connective Tissue Disease Research

Collecting Saliva and Measuring Salivary Cortisol and Alpha-amylase in Frail Community Residing Older Adults via Family Caregivers

Salivary measures have emerged in bio-behavioral research that are easy-to-collect, minimally invasive, and relatively inexpensive biologic markers of stress. This article we present the steps for collection and analysis of two salivary assays in research with frail, community residing older adults-salivary cortisol and salivary alpha amylase. The field of salivary bioscience is rapidly advancing and the purpose of this presentation is to provide an update on the developments for investigators interested in integrating these measures into research on aging. Strategies are presented for instructing family caregivers in collecting saliva in the home, and for conducting laboratory analyses of salivary analytes that have demonstrated feasibility, high compliance, and yield quality specimens. The protocol for sample collection includes: (1) consistent use of collection materials; (2) standardized methods that promote adherence and minimize subject burden; and (3) procedures for controlling certain confounding agents. We also provide strategies for laboratory analyses include: (1) saliva handling and processing; (2) salivary cortisol and salivary alpha amylase assay procedures; and (3) analytic considerations.

We demonstrate: (1) procedures for collection of salivary samples in cognitive impaired older adults by family caregivers in the home setting, (2) procedures for measuring stress activity via salivary cortisol and alpha amylase, and (3) representative profiles. Protocols that allow researchers to study stress-linked processes advance our understanding of biological sensitivity and susceptibility.

Salivary measures have emerged in bio-behavioral research  that are easy-to-collect, minimally invasive, and relatively inexpensive  biologic markers of ...

Diagnostic Ultrasound Imaging of Mouse Diaphragm Function

Function analysis of rodent respiratory skeletal muscles, particularly the diaphragm, is commonly performed by isolating muscle strips using invasive surgical procedures. Although this is an effective method of assessing in vitro diaphragm activity, it involves non-survival surgery. The application of non-invasive ultrasound imaging as an in vivo procedure is beneficial since it not only reduces the number of animals sacrificed, but is also suitable for monitoring disease progression in live mice. Thus, our ultrasound imaging method may likely assist in the development of novel therapies that alleviate muscle injury induced by various respiratory diseases. Particularly, in clinical diagnoses of obstructive lung diseases, ultrasound imaging has the potential to be used in conjunction with other standard tests to detect the early onset of diaphragm muscle fatigue. In the current protocol, we describe how to accurately evaluate diaphragm contractility in a mouse model using a diagnostic ultrasound imaging technique.

Diagnostic ultrasound imaging has proven to be effective in diagnosing various respiratory diseases in human and animal subjects. We demonstrate a comprehensive ultrasound protocol utilized by Dr. Zuo's lab to analyze diaphragm kinetics specifically in mouse models. This is also a non-invasive research technique which can provide quantitative information on mouse respiratory muscle function.

Function analysis of rodent respiratory skeletal muscles, particularly the diaphragm, is commonly performed by isolating muscle strips using invasive ...

Evaluation of the Efficacy of the H. pylori Protein HP-NAP as a Therapeutic Tool for Treatment of Bladder Cancer in an Orthotopic Murine Model

Bladder cancer is one of the most common malignancies of the urogenital tract. Intravesical injection of Bacillus Calmette-Gu&#233;rin (BCG) is the gold standard treatment for the high-grade non-muscle invasive bladder cancer (NMIBC). However, since the treatment-related side effects are relevant, newer biological response modifiers with a better benefit/side effects ratio are needed.
The tumour microenvironment can influence both tumour development and therapy efficacy. In order to obtain a good model, it is desirable to implant tumour cells in the organ from which the cancer originates.
In this protocol, we describe a method for establishing a tumour in the bladder cavity of female mice and subsequent delivery of therapeutic agents; the latter are exemplified by our use of Helicobacter pylori neutrophil activating protein (HP-NAP). A preliminary chemical burn of the mucosa, followed by the injection of mouse urothelial carcinoma cell line MB49 via urethral catheterization, enables the cells to attach to the bladder mucosa. After a period, required to allow an initial proliferation of the cells, mice are treated with HP-NAP, administrated again via catheterization. The anti-tumour activity of HP-NAP is evaluated comparing the tumour volume, the extent of necrosis and the degree of vascularization between vehicle- and HP-NAP-treated animals.

Evaluation of the Efficacy of the H. pylori Protein HP-NAP as a Therapeutic Tool for Treatment of Bladder Cancer in an Orthotopic Murine Model

Here the method to establish a syngeneic mouse model of orthotopic bladder tumour to evaluate the anti-tumour efficacy of the bacterial protein HP-NAP is described.

Bladder cancer is one of the most common malignancies of the urogenital tract. Intravesical injection of Bacillus Calmette-Gu&#233;rin (BCG) is the gold ...

Cardiac Magnetic Resonance for the Evaluation of Suspected Cardiac Thrombus: Conventional and Emerging Techniques

We present the conventional cardiac magnetic resonance (CMR) protocol for evaluating a suspected thrombus and highlight emerging techniques.&#160;The appearance of a mass on certain magnetic resonance (MR) sequences can help differentiate a thrombus from competing diagnoses such as a tumor. T1 and T2 signal characteristics of a thrombus are related to the evolution of hemoglobin properties. A thrombus typically does not enhance following contrast administration, which also helps differentiation from a tumor. We also highlight the emerging role of T1 mapping in the evaluation of a thrombus, which can add another level of support in diagnosis. Prior to any CMR exam, patient screening and interviews are critical to ensure safety and to optimize patient comfort. Effective communication during the exam between the technologist and the patient promotes proper breath holding technique and higher quality images. Volumetric post processing and structured reporting are helpful to ensure that the radiologist answers the ordering services&#39; question and communicates these results effectively. Optimal pre-MR safety evaluation, CMR exam execution, and post exam processing and reporting allow for delivery of high quality radiological service in the evaluation of a suspected cardiac thrombus.

The goal of this article is to describe how cardiac magnetic resonance can be used for the evaluation and diagnosis of a suspected cardiac thrombus. The method presented will describe data acquisition as well as the pre-procedure and post-procedure protocol.

We present the conventional cardiac magnetic resonance (CMR) protocol for evaluating a suspected thrombus and highlight emerging techniques.&#160;The ...

Ultrasonographic Assessment During Cardiopulmonary Resuscitation

The US-CAB (Ultrasound, Circulation/Airway/Breathing) protocol integrates several sonographic techniques into a structured assessment of the circulation, airway, and breathing status of a patient during cardiopulmonary resuscitation (CPR) in an advanced life support-compliant manner. US-C provides a subxiphoid view of the heart, to look for potentially reversible causes of disease, such as pericardial effusion, pulmonary embolism, hypovolemia, and acute coronary thrombosis. Sonographic cardiac activity during CPR not only helps differentiate pseudo-pulseless electrical activity (PEA) from true PEA but also represents a higher chance of the return of spontaneous circulation (ROSC) and survival. Evaluation of the inferior vena cava (IVC) shows the fluid status of the patient and indicates the best methods to use for fluid resuscitation. If aortic dissection is suspected, a subxiphoid view of the aorta is suggested for identifying an intimal flap. Once intubation is done, tracheal ultrasound (US-A) at the suprasternal notch helps differentiate endotracheal intubation (one air-mucosal interface with one comet-tail) from esophageal intubation (double tract sign). Immediately following US-A, bilateral lung US (US-B) should be done to confirm proper bilateral ventilation using the lung sliding sign. In addition, US-C can be serially followed to see the dynamic changes in the cardiac chambers and IVC, or any cardiac contraction suggestive of ROSC. US-B can also detect coexisting lung or pleural pathologies without interfering with the performance of CPR. The main concern when implementing this method is maintaining high-quality CPR without delays in chest compressions when performing US-CAB. Rigorous training and continued practice are key to minimize any interruptions during resuscitation.

Here, we present a US-CAB (Ultrasound, Circulation/Airway/Breathing) protocol for use during cardiopulmonary resuscitation (CPR). US-C evaluates the subxiphoid view of the heart and inferior vena cava. After intubation, tracheal US (US-A) and lung US (US-B) help confirm endotracheal intubation and proper ventilation.

The US-CAB (Ultrasound, Circulation/Airway/Breathing) protocol integrates several sonographic techniques into a structured assessment of the circulation, ...

Radiation Treatment of Organotypic Cultures from Submandibular and Parotid Salivary Glands Models Key In Vivo Characteristics

Hyposalivation and xerostomia create chronic oral complications that decrease the quality of life in head and neck cancer patients who are treated with radiotherapy. Experimental approaches to understanding mechanisms of salivary gland dysfunction and restoration have focused on in vivo models, which are handicapped by an inability to systematically screen therapeutic candidates and efficiencies in transfection capability to manipulate specific genes. The purpose of this salivary gland organotypic culture protocol is to evaluate maximal time of culture viability and characterize cellular changes following ex vivo radiation treatment. We utilized immunofluorescent staining and confocal microscopy to determine when specific cell populations and markers are present during a 30-day culture period. In addition, cellular markers previously reported in in vivo radiation models are evaluated in cultures that are irradiated ex vivo. Moving forward, this method is an attractive platform for rapid ex vivo assessment of murine and human salivary gland tissue responses to therapeutic agents that improve salivary function.

Using three-dimensional organotypic cultures to visualize morphology and functional markers of salivary glands may provide novel insights into the mechanisms of tissue damage following radiation. Described here is a protocol to section, culture, irradiate, stain, and image 50&#8211;90 &#956;m thick salivary gland sections prior to and following exposure to ionizing radiation.

Hyposalivation and xerostomia create chronic oral complications that decrease the quality of life in head and neck cancer patients who are treated with ...

Evaluation of Capnography Sampling Line Compatibility and Accuracy when Used with a Portable Capnography Monitor

Capnography is commonly used to monitor patient&#8217;s ventilatory status. While sidestream capnography has been shown to provide a reliable assessment of end-tidal CO2 (ETCO2), its accuracy is commonly validated using commercial kits composed of a capnography monitor and its matching disposable nasal cannula sampling lines. The purpose of this study was to assess the compatibility and accuracy of cross-paired capnography sampling lines with a single portable bedside capnography monitor. A series of 4 bench tests were performed to evaluate the tensile strength, rise time, ETCO2 accuracy as a function of respiratory rate, and ETCO2 accuracy in the presence of supplemental O2. Each bench test was performed using specialized, validated equipment to allow for a full evaluation of sampling line performance. The 4 bench tests successfully differentiated between sampling lines from different commercial sources and suggested that due to increased rise time and decreased ETCO2 accuracy, not all nasal cannula sampling lines provide reliable clinical data when cross-paired with a commercial capnography monitor. Care should be taken to ensure that any cross-pairing of capnography monitors and disposable sampling lines is fully validated for use across respiratory rates and supplemental O2 flow rates commonly encountered in clinical settings.

The goal of this study was to evaluate the accuracy of capnography sampling lines used in conjunction with a portable bedside capnography monitor. Sampling lines from 7 manufacturers were evaluated for tensile strength, rise time, and ETCO2 accuracy as a function of respiratory rate or supplemental oxygen flow rate.

Capnography is commonly used to monitor patient&#8217;s ventilatory status. While sidestream capnography has been shown to provide a reliable assessment ...

Evaluation of Hepatic Glucose Production in a Polycystic Ovary Syndrome Mouse Model

Polycystic ovary syndrome (PCOS) is a common disease that results in disorders of glucose metabolism, such as insulin resistance and glucose intolerance. Dysregulated glucose metabolism is an important manifestation of the disease and is the key to its pathogenesis. Therefore, studies involving evaluation of glucose metabolism in PCOS are of utmost importance. Very few studies have quantified hepatic glucose production directly in PCOS models using non-radioactive glucose tracers. In this study, we discuss step-by-step instructions for the quantification of the rate of hepatic glucose production in a PCOS mouse model by measuring M+2 enrichment of [6,6-2H2]glucose, a stable isotopic glucose tracer, via gas chromatography - mass spectrometry (GCMS). This procedure involves creation of stable isotopic glucose tracer solution, use of tail vein catheter placement and infusion of the glucose tracer in both fasting and glucose-rich states in the same mouse in tandem. The enrichment of [6,6-2H2]glucose is measured using pentaacetate derivative in GCMS. This technique can be applied to a wide variety of studies involving direct measurement of the rate of hepatic glucose production.

This study describes the direct measurement of hepatic glucose production in a polycystic ovary syndrome mouse model by using a stable isotopic glucose tracer via tail vein in both fasting and glucose-rich states in tandem.

Polycystic ovary syndrome (PCOS) is a common disease that results in disorders of glucose metabolism, such as insulin resistance and glucose intolerance. ...

Repetitive Blood Sampling from the Subclavian Vein of Conscious Rat

Rats are widely used in pharmacokinetics (PK) and toxicokinetic (TK) studies that need to collect a certain amount of blood at specific time points to detect drug exposure. The rat blood sampling method determines the quality of the plasma and further affects the precision of the test results. The subclavian vein blood collection method described in this protocol collects blood samples repeatedly in the conscious state of animals to meet the needs of PK and TK tests. The skills of restraint handling and appropriate procedure of needle incision ensure the success rate of blood collection. It is easy to operate while ensuring the quality of plasma and at the same time catering to animal welfare. However, this method requires skilled operation, and an improper one may cause animal weakness, pain, lameness, and even mortality. The current method has been used in the testing facility for a 4-week oral toxicity study in Sprague Dawley (SD) rats with TK. The maximum amount of blood collected within 24 h did not exceed 20% of the animal's total blood. The animals' body weight was more than 200 g for males and females. The data showed that the animals' bodyweight increased steadily every week, and the clinical observation was normal after repetitive sample collection.

The present protocol describes a simple and efficient method for collecting blood from the subclavian vein in rats. It enables rapid, timely, and easily identifiable sampling without anesthesia and obtains high-quality blood through repetitive sample collection.

Rats are widely used in pharmacokinetics (PK) and toxicokinetic (TK) studies that need to collect a certain amount of blood at specific time points to ...

Rectal Organoid Morphology Analysis (ROMA): A Diagnostic Assay in Cystic Fibrosis

Diagnosis of cystic fibrosis (CF) is not always straightforward, especially when sweat chloride concentration is intermediate and/or less than two disease-causing CFTR mutations can be identified. Physiological CFTR assays (nasal potential difference, intestinal current measurement) have been included in the diagnostic algorithm but are not always readily available or feasible (e.g., in infants). Rectal organoids are 3D structures that grow from stem cells isolated from crypts of a rectal biopsy when cultured under specific conditions. Organoids from non-CF subjects have a round shape and a fluid-filled lumen, as CFTR-mediated chloride transport drives water into the lumen. Organoids with defective CFTR function do not swell, retaining an irregular shape and having no visible lumen. Differences in morphology between CF and non-CF organoids are quantified in the &#39;Rectal Organoid Morphology Analysis&#39; (ROMA) as a novel CFTR physiological assay. For the ROMA assay, organoids are plated in 96-well plates, stained with calcein, and imaged in a confocal microscope. Morphological differences are quantified using two indexes: The circularity index (CI) quantifies the roundness of organoids, and the intensity ratio (IR) is a measure of the presence of a central lumen. Non-CF organoids have a high CI and low IR compared to CF organoids. ROMA indexes perfectly discriminated 167 subjects with CF from 22 subjects without CF, making ROMA an appealing physiological CFTR assay to aid in CF diagnosis. Rectal biopsies can be routinely performed at all ages in most hospitals and tissue can be sent to a central lab for organoid culture and ROMA. In the future, ROMA might also be applied to test the efficacy of CFTR modulators in vitro. The aim of the present report is to fully explain the methods used for ROMA, to allow replication in other labs.

Rectal Organoid Morphology Analysis ROMA: A Diagnostic Assay in Cystic Fibrosis

This protocol describes rectal organoid morphology analysis (ROMA), a novel diagnostic assay for cystic fibrosis (CF). Morphological characteristics, namely the roundness (circularity index, CI) and the presence of a lumen (intensity ratio, IR), are a measure of CFTR function. Analysis of 189 subjects showed perfect discrimination between CF and non-CF.