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BACKGROUND: The primary goals of total shoulder arthroplasty (TSA) are to relieve pain, improve range of motion, and restore function. Physical therapy is commonly used to help achieve these goals. Recent evidence has pointed to the success and safety of a purely physician-guided, home-based or internet-based, program versus the traditional therapist guided program. The purpose of this study was to evaluate outcomes of TSA in patients using a web-based, home therapy program. METHODS: A retrospective review was performed of TSA patients who were given the option of using a web-based, home therapy program. Functional outcomes were collected preoperatively, 6-month, and 12-month post-operative examinations. Physical examination parameters were recorded at preoperative, 3-month, 6-month, and 12-month time-points. RESULTS: Forty-seven patients used the web-based, home therapy program and had complete follow-up data at all time intervals. All mean range of motion parameters and functional scores improved significantly from preoperatively to postoperatively. There was one reported complication in a patient who sustained a subscapularis rupture and underwent subsequent open repair at 10 months postoperatively. CONCLUSION: This study demonstrates successful improvements in range of motion and functional outcomes in a subset of patients who utilized an online therapy program after TSA. Future study will be necessary to directly compare results in patients enrolled in formal, outpatient therapy programs and to determine barriers to utilization of web-based therapy programs.

BACKGROUND: The projected increase in revision shoulder arthroplasty has increased interest in the outcomes of these procedures. Glenoid component removal and conversion to a hemiarthroplasty (HA) is an option for aseptic glenoid loosening after anatomic total shoulder arthroplasty (aTSA). METHODS: We identified patients who had undergone revision shoulder arthroplasty over a 15-year period. 17 patients met inclusion and exclusion criteria, and a retrospective chart review was conducted for pre-surgical and operative data. We contacted patients at a mean follow-up of 70 months from revision surgery for implant survival, reoperations and functional outcomes scores. RESULTS: Implant survival was estimated to be 88% at 2 years and 67% at 5 years. Mean ASES score for surviving implants was 58 ± 22. Mean SANE score was 54 ± 24, and mean VAS pain score was 3.5 ± 2.8. Mean SF-12 Mental and Physical scores were 46 ± 15 and 38 ± 10, respectively. Five patients (50% of those with surviving implants) reported being either very satisfied or satisfied with the status of their shoulder. There were complications in 6 patients (35%) and 5 patients (29%) required reoperation. CONCLUSION: HA following failed aTSA due to glenoid loosening produced modest clinical results and satisfaction rates. Reverse arthroplasty may be a more reliable treatment strategy in this patient population.

Introduction Idiopathic inflammatory myopathies (IIM) have long been diagnosed using a defined number of clinical criteria (Bohan and Peter). The emergence of new myositis specific antibodies (MSAs) and their relation to specific disease phenotypes may be useful in establishing a new clinical-serological diagnostic criteria for different disease presentations and thus help to determine management and prognosis. We present a case of dermatomyositis (DM) where limb subcutaneous oedema; a rare manifestation of the disease, and severe dysphagia were prominent clinical features in addition with the presence of anti-small ubiquitin-like modifier activating enzyme (SAE) antibodies. Case description A 63-year-old Pakistani male presented with weight loss, anorexia, odynophagia, and a rash over his scalp, chest, face and flexor surfaces. Initial blood results revealed hypoalbuminaemia, CRP 7mg/L and ESR 37mm/h. A CT chest revealed an anterior mediastinum soft tissue mass suggestive of necrosis, with multiple ill-defined nodes throughout the lungs. An endoscopy revealed severe gastritis. Oropharyngeal examination revealed pooling of saliva and mucositis. Ceftriaxone was commenced for a presumed infective aetiology. Video fluoroscopy confirmed pharyngeal dysphagia with aspiration. Examination demonstrated a non-fatigable bulbar sounding dysarthria. There was no tongue wasting or fasciculations. Power was globally reduced, with marked proximal upper and lower limb weakness. Nerve conduction studies revealed normal sensation, and most motor nerves had normal conduction velocities with small nerve responses. Electromyography showed areas with denervation. With no improvement in the patient’s condition, anti-tuberculosis and anti-fungal therapy were commenced, with pulsed methylprednisolone for three days followed by 80mg daily to cover for an organizing pneumonia. Subsequent cultures were negative. Progressive weight loss with muscle wasting ensued and later, facial hyperpigmentation was noted in addition to the development of facial, lip and arms swelling. He was rheumatoid factor positive >500 iu/ml, with a raised IgE 2912 g/L and IgG 37.6 g/L. A CT-PET scan revealed intense uptake in the muscles posterior of the neck, tongue and masticators. An MRI scan of his arms revealed several abnormal signals around the shoulder girdle, long muscles of the back, and upper arm, which guided the site for muscle biopsy. This revealed highly abnormal skeletal muscle with frequent atrophic and necrotic fibres overrun by macrophages and T-cell rich inflammation. These findings in addition to serology reporting the presence of anti-SAE antibodies confirmed the diagnosis. Pulsed methylprednisolone, immunoglobulin therapy, and azathioprine were initiated with reducing prednisolone dose. Discussion This case of DM with a generalised rash, severe dysphagia and limb subcutaneous oedema were salient features in addition to the presence of anti-SAE antibodies. Anti-SAE has been shown to be present exclusively in DM patients where rash and severe dysphagia are common clinical findings. Our patient presented with severe dysphagia, which can be difficult to manage requiring enteral feeding. Video fluoroscopy was particularly useful in this case helping to stratify the severity of dysphagia and we would urge other clinicians to use this tool when investigating patients with suspected dermatomyositis to avoid potential complications of poor swallow including aspiration pneumonia. The additional imaging modality of PET-CT in our case confirmed the involvement of the muscles of mastication thus could prove a useful tool when investigating involvement of swallowing muscles in patients with anti-SAE DM. Skin features are another common finding in the anti-SAE group and our patient had a heliotrophic rash and shawl sign, which responded poorly to treatment. We describe the additional feature of severe subcutaneous limb and facial oedema, a rare manifestation of the disease, described in only a few other cases. Limb subcutaneous oedema is thought to reflect underlying severe muscle disease, is difficult to treat, and often is unresponsive to conventional treatment. Our case, and several other cases with the presence of limb oedema as reported in a literature search, required treatment with intravenous immunoglobulin and glucocorticoids, in addition with azathioprine and methotrexate. This is the first reported case to our knowledge of a patient with positive ANA, RF, anti-ccp, and anti-small ubiquitin-like modifier activating enzyme (anti-SAE) antibodies. Key learning points The finding of anti-SAE in our case where severe dysphagia was present provides further weight to this antibody being a useful serological marker to identify this subgroup of DM patients. Identifying this antibody may be helpful in creating management strategies for these patients and determining disease progression and prognosis. The presence of limb and facial oedema may be an overlying feature of the anti-SAE group; however, previous cases of limb oedema have not identified this antibody as the SAE test was unavailable. The presence of severe dysphagia and subcutaneous oedema suggests the presence of anti-SAE lends itself to a clinical phenotype of DM that is particularly severe and requires multidisciplinary input. Conflicts of interest The authors have declared no conflicts of interest.

Background: Anti-centromere antibodies (ACA) are commonly associated with systemic sclerosis (SSc). The presence of ACAs in patients with SSc is known to increase the likelihood of developing Pulmonary Hypertension, which has a high mortality rate. ACAs are also seen in patients with other connective tissue diseases (CTD) and can sometimes be identified after testing for antinuclear antibodies in patients who have not reported any rheumatological symptoms. It is possible that connective tissue diseases are being under diagnosed due to a lack of awareness by physicians of the clinical significance of ACAs. Objectives: To investigate whether patients with ACAs are being appropriately referred to the Rheumatology service. Methods: All patients who were positive for ACAs in Southend university hospital between April 2016 and October 2018 were included in this single centre retrospective observational study. We identified patients’ demographics, diagnosis, ANA titre, additional diagnosis and immunosuppressive therapy. We also captured their monitoring with pulmonary function testing and echocardiography. Results: A total of 75 patients were identified with ACAs. The average age was 65 years, 61 females, 14 Male. Fifty-six patients were referred to rheumatology team and were found to have the following diagnosis, LcSSc (21), Sjogren’s syndrome (SS) (10), undifferentiated connective tissue disease (UCTD) (6), Rheumatoid arthritis (RA) (5), ANCA associated vasculitis (AAV) (3), Raynaud’s phenomenon (3), Lupus (2), Antiphospholipid syndrome (APS) (1), Primary biliary cirrhosis with Sjogren’s syndrome (SS) (1), Juvenile idiopathic arthritis (1), Antisynthetase syndrome (AS) (1), Autoimmune hepatitis (1) and osteoarthritis (1). Of those 33 patients had a routine screening with an Echocardiogram and 26 had pulmonary function tests. One patient with LcSSc developed pulmonary hypertension. The remaining 19 patients were not referred and did not have the adequate screening for pulmonary hypertension. ANA titre was 1:80 in one patient, 1:320 for 4 patients, unknown for three and 1:640 for the remaining 67. 11 patients were treated with Hydroxchloroquine (4 SS, 4 UCTD, 1 lupus, 1 APS and 1 Lc SSc), 5 on Methotrexate (4 RA and 1 AS), 2 on MMF and steroid (AAV). Conclusion: Nearly all patients with ACAs that were seen in the Rheumatology clinic had an autoimmune rheumatic disease. However, we found that 25% of people with ACAs were not referred to the Rheumatology service. The reasons for this are unclear. It is possible that patients did not report symptoms that would have prompted a referral. Some of the CTDs in which ACAs are typically found (LcSSc and SS) are associated with symptoms that can be mild and might not be reported by the patients or general physicians do not associate them with rheumatological disorders (e.g. sicca symptoms, gastro-oesophageal reflux and Raynaud’s phenomenon). Early diagnosis might enable earlier treatment and prevent complications from these diseases. General physicians should therefore be made aware of these antibodies and the disorders that they can be associated with. Disclosure of Interests: None declared

IL-10 is an anti-inflammatory cytokine which may modulate disease expression in RA. Three dimorphic polymorphisms within the IL-10 gene promoter have recently been identified and appear to influence regulation of its expression. The -1082*A allele has been associated with low and the -1082*G allele with high in vitro IL-10 production. We have analysed 117 unrelated Caucasoid RA patients and 119 ethnically matched controls. No significant differences in the allele frequencies of the three polymorphisms were found between controls and RA patients. In contrast, a significant association between the -1082*A allele and the (-1082*A/ -819*C/ -592*C) haplotype and IgA RF+ve/IgG RF-ve patients was observed. The association of genotypes encoding low IL-10 production with IgA RF in RA is incompatible with its suggested role in antibody isotype switching. IgA RF has been associated with severe RA and may thus be indirectly correlated with a genotype encoding low IL-10 production.

SUMMARY Interleukin-10 (IL-10) has been described as an anti-inflammatory cytokine and B-cell proliferation factor and has been implicated in autoimmunity, tumorigenesis and transplantation tolerance. We have identified three single base pair substitutions in the IL-10 gene promoter and have investigated whether this polymorphism correlates with IL-10 protein production in vitro.

Cytokines are molecular mediators of intercellular signaling that function to regulate homeostasis of the immune system. There are five families of cytokines classified by their receptor usage. The effects of individual cytokines on immunity depend on several factors, including the local cytokine concentration, the pattern of cytokine receptor expression, and the integration of multiple signaling pathways in responding immune cells. Cytokines have shown therapeutic potential for the initiation and potentiation of antitumor immunity. Interferon-α and interleukin-2 (IL-2) have been approved as single agents for the treatment of metastatic melanoma and renal cell carcinoma, and several other cytokines have shown promise in preclinical tumor models. New strategies for improving the therapeutic benefit of cytokines are in development and include cytokine-antibody fusion molecules, delivery in recombinant viral vectors, expression by irradiated whole tumor cells, PEGylation, DNA vaccination, and ex vivo exposure to immune effector cells.

The American Cancer Society estimates that melanoma accounts for less than 5% of skin cancer cases. Even so, it causes the majority of skin cancer deaths and its incidence continues to increase at an alarming rate [1]. Immunosuppression has also been linked to melanoma development in various populations, including patients with solid organ allografts, Hodgkin’s disease, and human immunodeficiency virus (HIV), which is presumably related to exogenous or endogenous suppression of the innate immune response [2–4]. Corticosteroids represent a class of widely used immunosuppressive agents whose precise mechanism of immune system suppression is incompletely understood. Nonetheless, various studies have highlighted its carcinogenic potential. Karagas et al. examined the potentials risks of developing squamous cell and basal cell carcinoma in non-transplant recipients who had used glucocorticoids and found that oral steroid use correlated with an increased risk of developing non-melanoma skin cancers [5]. Case reports of iatrogenically induced Kaposi’s sarcoma appearing in patients taking corticosteroids and remitting upon drug withdrawal further bolster the hypothesis that the immunosuppressive and carcinogenic properties of steroids may have a link [6, 7]. To our knowledge, there has been no description so far of the incidence of melanoma in patients using steroids in the non-transplant setting (Figs. 1, 2).

This study elucidated the rate and type of complications after two-incision distal biceps tendon repairs. The study examined the predictive value of patient variables in identifying patients at risk for specific complications, and lastly, it evaluated the placement of the dorsal incision as a predictor of proximal radioulnar synostosis after two-incision repair. A single surgeon's series of 84 consecutive patients who had distal biceps tendon repair using the two-incision, modified Boyd and Anderson approach were retrospectively reviewed. A rate and complication profile was developed. Variable analysis was performed on the study. A second series, a referral group diagnosed with radioulnar synostosis after two-incision biceps repair, was also reviewed for comparison. Measurement of nearest distance of dorsal incision to the ulnar crest was made and compared between the study group and the referral group. Six different types of complications occurred with a total of 20 complications. Three complications required repeat operation. No patient variables were found to be statistically significant predictors of complications. The proximity of the dorsal incision to the ulnar crest correlated with the development of radioulnar synostosis. Two-incision distal biceps tendon repair has a low rate of major complications. Patient specific variables do not appear to be associated with the rate or type of complications. Placement of the dorsal incision on the ulnar crest may be associated with the development of radioulnar synostosis.

We report the case of a 20-year-old woman who presented with a subconjunctival maggot. The maggot was removed and identified as the larval form of the horse bot fly (Gasterophilus spp.). The patient had been grooming infected horses in a stable prior to presentation. To our knowledge, this is the first well documented case in the ophthalmic literature of external ophthalmomyiasis caused by Gasterophilus spp.

Two cases of contact lens contamination by the fungus, Alternaria alternata, are described. In both patients, mild ocular irritation was the presenting symptom but neither suffered fungal infection of the eye. To our knowledge, A alternata has not previously been reported as a contaminant of contact lenses, although it is an ubiquitous saprophyte and has been reported as causing infections in humans. The close succession in which these two patients presented may indicate that such fungal contamination of contact lenses is not uncommon. The importance of adequate cleaning regimens for daily-wear contact lenses (which are inserted and removed each day), and the necessity for patients with extended-wear contact lenses (which are worn continuously) to seek medical attention immediately should any problems arise, are emphasized.