Ocular syphilis: the re-establishment of an old disease.

PurposeTo present the patient profiles, clinical presentations and visual outcomes in those diagnosed with ocular syphilis, attending a subspecialist uveitis service in northern England over a 15-year period.Patients and methodsRetrospective observational case series of patients presenting between January 2002 and December 2016.ResultsA total of 50 eyes of 34 patients had intraocular inflammation due to syphilis. Of these, 94% were male, and 75% were men who had sex with men. Ten (29%), all male, were HIV-positive. Presentations included isolated anterior non-granulomatous uveitis, intermediate uveitis, panuveitis, retinitis, placoid chorioretinitis and papillitis. Concurrent skin rash and/or headache were seen in 41%. Compliance with antibiotic treatment was complete, but there was a high rate of default from ophthalmological follow-up (38%). Visual improvement was seen in 92% of eyes, and at final assessment 71% had acuity of 6/9 or better.ConclusionsOcular syphilis is continuing to increase in incidence, in tandem with the continuing epidemic of early syphilis in the UK (the risk of ocular involvement being about 1%). Almost all are male, and most are men who have sex with men. Clinical presentation is variable; a high index of suspicion and a low threshold for serological testing is important; early treatment can reverse retinal changes and restore visual acuity.

UK national guidelines on the management of syphilis 2015.

These guidelines are an update for 2015 of the 2008 UK guidelines for the management of syphilis. The writing group have piloted the new BASHH guideline methodology, notably using the GRADE system for assessing evidence and making recommendations. We have made significant changes to the recommendations for screening infants born to mothers with positive syphilis serology and to facilitate accurate and timely communication between the teams caring for mother and baby we have developed a birth plan. Procaine penicillin is now an alternative, not preferred treatment, for all stages of syphilis except neurosyphilis, but the length of treatment for this is shortened. Other changes are summarised at the start of the guideline.

Is there an association between the individual anatomy of the scapula and the development of rotator cuff tears or osteoarthritis of the glenohumeral joint?: A radiological study of the critical shoulder angle.

We hypothesised that a large acromial cover with an upwardly tilted glenoid fossa would be associated with degenerative rotator cuff tears (RCTs), and conversely, that a short acromion with an inferiorly inclined glenoid would be associated with glenohumeral osteoarthritis (OA). This hypothesis was tested using a new radiological parameter, the critical shoulder angle (CSA), which combines the measurements of inclination of the glenoid and the lateral extension of the acromion (the acromion index). The CSA was measured on standardised radiographs of three groups: 1) a control group of 94 asymptomatic shoulders with normal rotator cuffs and no OA; 2) a group of 102 shoulders with MRI-documented full-thickness RCTs without OA; and 3) a group of 102 shoulders with primary OA and no RCTs noted during total shoulder replacement. The mean CSA was 33.1° (26.8° to 38.6°) in the control group, 38.0° (29.5° to 43.5°) in the RCT group and 28.1° (18.6° to 35.8°) in the OA group. Of patients with a CSA > 35°, 84% were in the RCT group and of those with a CSA < 30°, 93% were in the OA group. We therefore concluded that primary glenohumeral OA is associated with significantly smaller degenerative RCTs with significantly larger CSAs than asymptomatic shoulders without these pathologies. These findings suggest that individual quantitative anatomy may imply biomechanics that are likely to induce specific types of degenerative joint disorders.

The anterior center edge angle in Lequesne's false profile view: interrater correlation, dependence on pelvic tilt and correlation to anterior acetabular coverage in the sagital plane. A cadaver study.

INTRODUCTION: Lequesne's vertical-center-anterior margin (VCA) angle measured on the false profile view of the pelvis aims at quantifying the anterior acetabular coverage of the femoral head. The anterior delimitation of the acetabular roof is often defined on the false profile view but there are no data on its interrater reliability. Additionally, it is not known how pelvic tilt may influence this angle. Finally, the plane in which this angle is measured lies at an angle of 65 degrees to the sagittal plane and we wondered if this angle would be transposable to the anterior acetabular coverage measured in the sagittal plane. METHODS: Eight hips from four cadaver pelvises were investigated by means of a total of 72 false profile views, each taken in defined pelvic inclinations at 5 degrees increments ranging from -20 degrees to +20 degrees , and the VCA angle measured by three independent raters. A computed tomography (CT) of each hip was performed in a neutral pelvic tilt position and a sagittal 2D reconstruction calculated in order to measure anterior coverage in the sagittal plane. The interrater reliability of the VCA angles was assessed using the intra-class correlation coefficient (ICC). The dependence of the VCA angle on pelvic tilt was assessed by regression analysis. The Correlation between the VCA angle and anterior coverage in the sagittal plane of the CT was analyzed using a simple linear regression model. RESULTS: The interrater reliability for measurements of the VCA angle was almost perfect (ICC:0.97). Regression analysis showed that each degree of pelvic tilt was accompanied by a change of the VCA angle by a value of 0.63 degrees (P < 0.001). A low correlation between the VCA angle measured in the false profile view and the anterior coverage in the sagittal plane was statistically not significant (r = 0.667, P = 0.06). CONCLUSIONS: Lequesne's VCA angle has an excellent interrater reliability and represents a reliable measure of acetabular dysplasia for comparisons with published data. Lequesne's VCA angle is influenced by pelvic tilt in a linear manner. Performing the false profile view in a standing position may reduce the clinical relevance of this dependency on pelvic tilt. The correlation of Lequesne's VCA angle to anterior acetabular coverage in the sagittal plane is low and therefore unsuitable to be transposed into the sagittal plane.

Clinical and structural outcomes of nonoperative management of massive rotator cuff tears.

BACKGROUND: The natural history of massive rotator cuff tears is not well known. The purpose of this study was to determine the clinical and structural mid-term outcomes in a series of nonoperatively managed massive rotator cuff tears. METHODS: Nineteen consecutive patients (twelve men and seven women; average age, sixty-four years) with a massive rotator cuff tear, documented by magnetic resonance imaging, were identified retrospectively. There were six complete tears of two rotator cuff tendons and thirteen complete tears of three rotator cuff tendons. All patients were managed exclusively with nonoperative means. Nonoperative management was chosen when a patient had low functional demands and relatively few symptoms and/or if he or she refused to have surgery. For the purpose of this study, patients were examined clinically and with standard radiographs and magnetic resonance imaging. RESULTS: After a mean duration of follow-up of forty-eight months, the mean relative Constant score was 83% and the mean subjective shoulder value was 68%. The score for pain averaged 11.5 points on a 0 to 15-point visual analogue scale in which 15 points represented no pain. The active range of motion did not change over time. Forward flexion and abduction averaged 136 degrees; external rotation, 39 degrees; and internal rotation, 66 degrees. Glenohumeral osteoarthritis progressed (p = 0.014), the acromiohumeral distance decreased (p = 0.005), the size of the tendon tear increased (p = 0.003), and fatty infiltration increased by approximately one stage in all three muscles (p = 0.001). Patients with a three-tendon tear showed more progression of osteoarthritis (p = 0.01) than did patients with a two-tendon tear. Four of the eight rotator cuff tears that were graded as reparable at the time of the diagnosis became irreparable at the time of final follow-up. CONCLUSIONS: Patients with a nonoperatively managed, moderately symptomatic massive rotator cuff tear can maintain satisfactory shoulder function for at least four years despite significant progression of degenerative structural joint changes. There is a risk of a reparable tear progressing to an irreparable tear within four years.

Single-stage bilateral total shoulder arthroplasty: a preliminary study.

We compared six patients with a mean age of 70 years (49 to 80) with severe bilateral, painful glenohumeral joint destruction who underwent a single-stage bilateral total shoulder replacement, with eight patients of mean age 61 years (22 to 89) who underwent bilateral total shoulder replacement in two stages, at a mean interval of 18 months (6 to 43). The overall function, pain and strength improved significantly in both groups. The subjective shoulder value, relative Constant score, active external rotation and the strength were improved significantly more in the single-stage group. Active elevation, abduction and overall function improved, significantly more in the single-stage group. Both the total duration of hospitalisation and the time off work per shoulder were substantially shorter in the single-stage group. The overall rate of complication was lower in the single-stage group. Our findings indicated that single-stage bilateral total shoulder replacement yielded significantly better clinical results with shorter hospitalisation and rehabilitation than staged replacement, and was not associated with any increase in complications.

Ocular syphilis: the new epidemic.

AIM: To present the clinical presentation, diagnosis, and management of syphilitic uveitis in the context of an epidemic of syphilis in the UK. METHOD: Retrospective clinical case series. RESULTS: Six new cases of syphilitic uveitis presented to the Manchester Uveitis Clinic in 2004, after a 15-fold increase in the incidence of syphilis in the UK, including 615 cases in Greater Manchester in the 5 years to 2004. Four cases had secondary syphilis, two had latent disease, two had no rash, and two were HIV positive. Ocular involvement included anterior or panuveitis, retinitis, retinal vasculitis, and papillitis. All resolved on treatment including intramuscular procaine penicillin G with oral probenecid. CONCLUSIONS: Syphilis is much more common recently and syphilitic uveitis should be considered in all patients with rash and/or headache, where there is retinitis and/or retinal vasculitis, or in any uveitis of uncertain origin. Treatment is that of neurosyphilis.

Re-emerging syphilis in the UK: a behavioural analysis of infected individuals.

In-depth interviews with 27 individuals infected with syphilis in a recent UK outbreak (out of a total of 58 diagnosed between May 1999 and August 2000 in three city hospitals) were carried out to examine behaviour and attitudes. Most (23/27) participants were homosexual men, seven of whom were HIV positive. Between them, the 23 gay men had 1,494 different contacts in the twelve months prior to their awareness of having syphilis, but only 10% of these contacts could be named. While oral sex (usually unprotected) was the most prevalent behaviour (median = 30 partners per year), only 39% perceived unprotected oral sex as a syphilis risk (c.f. 70% for anal sex). Many gay men (61%) used gamma hydroxybutyrate (GHB) during sex as an aphrodisiac. This syphilis-infected subset of the population had high levels of unprotected and anonymous sex, which brings into question the usefulness of contact tracing to control syphilis outbreaks. The majority of partners were casual oral sex partners. More awareness is urgently needed around syphilis symptoms and risks, and risks of using drugs to reduce sexual inhibitions.

Do the factors associated with successful contact tracing of patients with gonorrhoea and Chlamydia differ?

OBJECTIVE: To assess and compare factors which may be associated with successful contact tracing in patients with gonorrhoea and chlamydia. STUDY DESIGN: Prospective observational study of patients attending a genitourinary medicine clinic with a diagnosis of gonorrhoea or chlamydia. Multivariate analysis model including demographic, socioeconomic, and behavioural variables. RESULTS: The attendance of at least one sexual contact was associated with naming more contacts for patients with gonorrhoea (OR 1.44, 95% CI 1.04-2.01). A history of gonorrhoea was associated with successful contact tracing for patients with chlamydia (OR 1.46, 95% CI 1.12-1.9). Successful contact tracing, as defined by at least one confirmed contact attendance after the index case, was not associated with age, sex, sexual orientation, history of chlamydia, use of condoms, marital status, ethnicity, or socioeconomic status for either gonorrhoea or chlamydia. CONCLUSIONS: Differences in the composition of the core groups infected with gonorrhoea and chlamydia are not explained by differences in contact tracing success. In the clinic setting studied, the outcome of contact tracing was not associated with a variety of demographic, socioeconomic, and behaviour factors.

Peripheral blood T cell proliferative response to chlamydial organisms in gonococcal and non-gonococcal urethritis and presumed pelvic inflammatory disease.

OBJECTIVE: To study peripheral blood mononuclear cell (PBMC) proliferative response to Chlamydia trachomatis elementary bodies in (a) controls, (b) various stages of gonococcal (c) and non-gonococcal urethritis, and (d) women with a clinical diagnosis of pelvic inflammatory disease (PID). METHODS: We categorised 102 men presenting to a GUM clinic with urethritis by organisms (C trachomatis (CT) or Neisseria gonorrhoeae (NG) (both by culture), and whether it was their first (urethritis naive) or subsequent (urethritis experienced) attack. 23 women presenting to the clinic with a clinical diagnosis of PID were also investigated. We measured PBMC proliferative responses to C trachomatis (DK20--an oculogenital strain, serovar E), lysate of McCoy cells (used to propagate chlamydiae), and the recall antigen PPD. Controls were 37 men and women without present or past history of urethritis or chlamydial infection. Results were expressed as the ratio of the stimulation index (SI) obtained with DK20 compared with McCoy cells (DK index), and the ratio of the SI obtained with DK20 compared with PPD (PPD index). RESULTS: The median SI to DK20 in the urethritis was 12.7 which was significantly higher than the controls (7.6, p < 0.003). The median SI to the recall antigen PPD was similar in the urethritis patients (17.4) and the controls (22.4). All urethritis patient subgroups had a significantly higher DK index and PPD index than the controls. There was no difference in the PPD and DK index between urethritis naive and urethritis experienced patients and between the culture positive and culture negative urethritis subgroups. In PID patients only the PPD index was significantly higher than the controls. CONCLUSION: Men presenting with urethritis and women presenting with PID both have significantly greater peripheral blood mononuclear cell proliferative responses to the DK20 strain of C trachomatis than controls. A similar T cell proliferative response pattern in urethritis naive patients with either gonococcal or non-gonococcal urethritis could be because low sensitivity of CT culture failed to diagnose some cases of C trachomatis. However, it may also signify earlier exposure of the patients to chlamydial antigens (for example, C pneumoniae), cross reacting antigens such as heat shock proteins from other microbial species, or a "bystander" activation of chlamydia specific memory T cells trafficking through mucosal lymphoid tissue during urethritis. These results suggest evidence of T cell mediated response to C trachomatis cannot be used as a diagnostic tool.

Isolation and characterisation of T lymphocytes from the urethra of patients with acute urethritis.

OBJECTIVES: To investigate local cellular immune responses in patients with acute urethritis. METHODS: We have established T cell lines from the urethral exudate and examined their phenotype by flow cytometry. As controls, T cell lines were cultured from first pass urine specimens of asymptomatic healthy individuals. RESULTS: Using interleukin 2 (IL-2) alone a T cell line was obtained on only one occasion. Following culture with IL-2, and subsequent expansion by a single stimulation with irradiated allogenic peripheral blood mononuclear cells (PBMC), phytohaemagglutinin (PHA), and IL-2, it was possible to establish T cell lines from 6/6 acute urethritis patients. T cell lines were also obtained from 4/12 controls subjects, but required repetitive rounds of stimulation with mitogen and allogeneic PBMC to produce sufficient cell numbers for analysis. Three of the patient T cell lines were dominated by T cells expressing the gamma delta receptor. CONCLUSION: The gamma delta T cell subset has been associated with immune responses at mucosal surfaces and has the ability to recognise certain bacterial antigens. The gamma delta T cell response may represent an important aspect of the immune response to organisms associated with acute urethritis.