Articles Archive - Healthed

Articles

Read the latest articles relevant to your clinical practice, including exclusive insights from Healthed surveys and polls.

By reading selected clinical articles, you earn CPD in the Educational Activities (EA) category whenever you click the “Claim CPD” button and follow the prompts.

Gastroenterology

Clinical Articles

Rectal Exams Still Important – Sorry

Most GPs of a certain vintage would have heard the old adage “if you don’t put your finger in, you put your foot in.” It refers of course to the digital rectal examination and its importance as part of a thorough physical examination especially when symptoms indicate some potential pathology in that area. However it would be fair to say that most doctors, let alone patients are not particularly enthusiastic about this particular test. Indeed you could almost hear the collective sigh of relief when the authoritative guidelines suggested regular DRE was not useful as a means of screening for prostate cancer. The downside of this change in recommendation and general avoidance behaviour is that one can become deskilled in this examination, potentially missing an opportunity to diagnose a variety of conditions from prostate abnormalities to cancer. In the latest MJA, Dr Christopher Pokorny from the South Western Sydney Medical School at UNSW gives a synopsis of indications for DRE and a run through of the appropriate technique. “About 25% of colorectal cancers occur in the rectum and up to half can be palpated, but accuracy depends on training, experience, examination technique and the length of the examining finger,” Dr Pokorny writes. His list of indications for the procedure include the more obvious symptoms such as PR bleeding or mucus, change in bowel habit and prostatic symptoms but also a history of faecal urgency, difficult defaecation, faecal incontinence and anorectal pain (with the caveat that DRE should be avoided if there is an obvious anal fissure). Placing the patient in the left lateral position for the procedure is recommended with the patient drawing their knees to their chest and assuming that the patient is safe from falling off the examination couch. Assessment is made of the skin around the anus – looking for fissures, fistulae, skin tags, skin diseases such as warts or psoriasis, abscesses and haemorrhoids. The well-lubricated, gloved finger is then gently inserted, rotated in a clockwise direction into the rectum. Dr Pokorny suggests a systematic examination of the rectal mucosa anteriorly, posteriorly and laterally for masses that should be described as soft, hard, irregular or smooth. Prostatic abnormalities in men and ovarian or uterine abnormalities in women may be noted being careful not to confuse a palpable cervix in a woman with a mass. Finally, the doctor needs to check for any blood, including malaena on the glove. Dr Pokorny does concede the value of this examination is limited by the body habitus of the patient, and the length of the examiner’s fingers. Nonetheless, it is unwise to miss this diagnostic opportunity in general practice. “DRE is an often neglected but important part of the physical examination and should be performed whenever symptoms suggest anorectal or prostatic pathology,” he concludes. MJA doi:10.5694/mja17.00373

By Dr Linda Calabresi

Sexual health

Clinical Articles

The Handmaid’s Tale and counting sperm: are fertility rates actually declining?

With the release of a new TV series based on Margaret Atwood’s The Handmaid’s Tale, and a recent study claiming male sperm count is decreasing globally, fertility is in the spotlight. Many want to know if the dystopian future Atwood created in which the world has largely become infertile, is in fact possible. And are we on our way there already?

What this latest study found

The recent paper that hit headlines all over the world highlighted the issue of declining sperm numbers in Western men. The study is a meta-analysis, which gathers together similar studies and combines the results. Each of the studies in the analysis has different men assessed at different times by different researchers. This means, as a whole, it is not as powerful as a study examining the same men over time. And many of the individual studies assessed have their own problems.

Read more - Health Check: when does fertility decline?

So is fertility actually declining?

The current estimate is that Western men produce 50 million sperm per millilitre in an ejaculate, which is lower than previously. However, only one sperm is needed to fertilise an egg, so 50 million sperm per ml suggests human males don’t have a problem just yet. There are data indicating that from below 40 million sperm per ml there is a linear relationship between sperm numbers and probability of pregnancy. The World Health Organisation (WHO) suggests 15 million per ml sperm is a minimum to be considered fertile. The minimum is based on men who have successfully fathered a child in the last 12 months. By definition, 5% of the men with numbers below 15 million per ml will still be able to reproduce. For females the issue that needs to be understood is that there is already a small window of time women are fertile, and this is decreasing as women are more educated and career-focused. Women have their highest number of eggs when they are still a fetus in their mother’s womb. About one sixth of the eggs are left at birth and by puberty the number is 500,000 eggs or less. From puberty until 37 years of age there is a steady decline from 500,000 to 25,000 eggs. After 37 years, the rate of decline increases and by menopause (average age of 51 in the US) only 1,000 eggs remain. It’s important to realise these are average numbers and there is no guarantee a woman will have 25,000 eggs at 37. The other issue is quality. Chromosomal issues (such as Down’s syndrome - where a person has three copies of chromosome 21 instead of two) increase with maternal age. IVF is seen as a way of rescuing fertility, but the success rate of 41.5% is for women younger than 35, and measures pregnancies, not live births. By 40 years old, that success rate is 22% and by 43 years it’s 5%.

Read more - Explainer: what causes women’s fertility to decline with age?

In short, the situation for women is not great, but the numbers are not changing with time (estimates of fertility from 1600 to 1950 don’t differ).

What is affecting fertility today?

The key determinant in women’s fertility is education - not individuals’ education but that of the community as a whole. If your community becomes educated, your fertility declines, as women become educated and less likely to have children in their youth. Choosing to delay having a child is not the only issue. Lifestyle choices matter. We know smoking, alcohol and obesity all affect the number and quality of eggs a woman has. As a female has all the eggs she will ever have when she is in her mother’s womb, the mother smoking will affect those eggs. Smoking in pregnancy is declining slowly (from 15% in 2009 to 11% in 2014) but is still very high in the Indigenous population (45%).

Read more: Why women’s eggs run out and what can be done about it

Smoking and alcohol are said to be major factors contributing to male sperm numbers but the evidence is limited by the nature of the studies. The effects of obesity and stress have the clearest evidence. For example, increased levels of anxiety and stress have been associated with lower sperm count. Life stress (defined as two or more stressful events in the last 12 months) has been found to have an effect, but not job stress. For men, the numbers themselves represent a blunt measure of fertility. It’s the quality of the sperm produced that’s of concern. The WHO minimum is that only 4% of male sperm need to be of good appearance to be considered fertile. It’s not really possible for us to be able to tell which of many factors may be influencing sperm appearance.

Problems with studying fertility

While we can talk about what research says on fertility, there are a few inherent problems with researching in this field. Most of the data we have on sperm count come from two sources: men attending an infertility clinic, and those undergoing a medical prior to military service. The first is restricted to those who likely already have a problem. The second is limited to one age group. Meta-analyses, which combine the results from lots of studies, are limited to those all using the same tools and approaches so they can be compared. As a result, a large meta-analysis that suggested smoking is detrimental was limited to men attending an infertility clinic, which would indicate many of them are likely to be infertile anyway. Another big study used conscripts in the US and Europe but failed to find an association between fertility and alcohol consumption. This is because it only assessed the alcohol consumed the week prior to the medical - and most recruits probably wouldn’t be out drinking in the days leading up to their medical.

So could we become extinct?

The reproduction rate is below that required for total population replacement in the US, Australia, and many other countries. But the human population in total is still growing as it ages.

Read more: Most men don’t realise age is a factor in their fertility too

The start of this millennium also represented the time when births for women aged 30-34 overtook those in the 25-29 age group, and the 35-39 age group overtook the 20-24 age group. Teenage pregnancy (15-19 years) is now level with older mums (40-44) in Australia. The quality of the sperm and egg is more important than the numbers. While we are still investigating what quality means to future generations, we do know that infertility represents a predictor of increased death rates. Men diagnosed with infertility had a higher risk of developing diabetes, ischaemic heart disease, alcohol abuse and drug abuse. Ultimately it’s not a numbers game but a quality game. This is true not just for the chances of having a child but having a healthy child. More immediately, fertility is a predictor of general health. While it does not appear that we are going to be extinct soon (at least not through reproductive failure), sperm quality could be a signal of wider health problems and should be investigated further. Shaun Roman, Senior Lecturer, University of Newcastle This article was originally published on The Conversation. Read the original article.

By Prof Shaun Roman

Psychiatry

Clinical Articles

New Autism Guidelines Miss The Mark

The first national guidelines for diagnosing autism were released for public consultation last week. The report by research group Autism CRC was commissioned and funded by the National Disability Insurance Scheme (NDIS) in October 2016. The NDIS has taken over the running of federal government early intervention programs that provide specialist services for families and children with disabilities. In doing so, they have inherited the problem of diagnostic variability. Biological diagnoses are definable. The genetic condition fragile X xyndrome, for instance, which causes intellectual disability and development problems, can be diagnosed using a blood test. Autism diagnosis, by contrast, is imprecise. It’s based on a child’s behaviour and function at a point in time, benchmarked against age expectations and comprising multiple simultaneous components. Complexity and imprecision arise at each stage, implicit to the condition as well as the process. So, it makes sense the NDIS requested an objective approach to autism diagnosis.
Read more: The difficulties doctors face in diagnosing autism
The presumption of the Autism CRC report is that standardising the method of diagnosis will address this problem of diagnostic uncertainty. But rather than striving to secure diagnostic precision in the complexity and imprecision of the real world, a more salient question is how best to help children when diagnostic uncertainty is unavoidable.

What’s in the report?

The report recommends a two-tiered diagnostic strategy. The first tier is used when a child’s development and behaviour clearly meet the diagnostic criteria. The process proposed does not differ markedly from current recommended practice, with one important exception. Currently, the only professionals who can “sign off” on a diagnosis of autism are certain medical specialists such as paediatricians, child and adolescent psychiatrists, and neurologists. The range of accepted diagnosticians has now been expanded to include allied health professionals such as psychologists, speech pathologists and occupational therapists. This exposes the program to several risks. Rates of diagnosed children may further increase with greater numbers of diagnosticians. Conflict of interest may occur if diagnosticians potentially receive later benefit as providers of funded treatment interventions. And while psychologists and other therapists may have expertise in autism, they may not necessarily recognise the important conditions that can present similarly to it, as well as other problems the child may have alongside autism. The second recommended tier of diagnosis is for complex situations, when it is not clear a child meets one or more diagnostic criteria. In this case, the report recommends assessment and agreement by a set of professionals – known as a multidisciplinary assessment. This poses important challenges:

Early intervention starts early. Multidisciplinary often means late, with delays on waiting lists for limited services. This is likely to worsen if more children require this type of assessment.
Multidisciplinary assessments are expensive. If health systems pay, capacity to subsequently help children in the health sector will be correspondingly reduced.
Groups of private providers may set up diagnostic one-stop shops. This may inadvertently discriminate against those who can’t pay and potentially bias towards diagnosis for those who can.
Multidisciplinary assessments discriminate against those in regional and rural areas, where professionals are not readily available. Telehealth (consultation over the phone or computer) is a poor substitute for direct observation and interaction. Those in rural and regional areas are already disadvantaged by limited access to intervention services, so diagnostic delays present an additional obstacle.

A diagnostic approach reflects a deeper, more fundamental problem. Methodological rigour is necessary for academic research validity, with the assumption autism has distinct and definable boundaries. But consider two children almost identical in need. One just gets over the diagnostic threshold, the other not. This may be acceptable for academic studies, but it’s not acceptable in community practice. An arbitrary diagnostic boundary does not address complexities of need.

We’re asking the wrong question

The federal government’s first initiative to fund early intervention services for children diagnosed with autism was introduced in 2008. The Helping Children With Autism program provided A$12,000 for each diagnosed child, along with limited services through Medicare. The Better Start program was introduced later in 2011. Under Better Start, intervention programs also became available for children diagnosed with cerebral palsy, Down syndrome, fragile X syndrome and hearing and vision impairments. While this broadened the range of disabilities to be funded, it did not address the core problem of discrimination by diagnosis. This is where children who have equal needs but who for various reasons aren’t officially diagnosed are excluded from support services. Something is better than nothing, however, and these programs have helped about 60,000 children at a cost of over A$400 million. Yet the NDIS now also faces a philosophical challenge. The NDIS considers funding based on a person’s ability to function and participate in life and society, regardless of diagnosis. By contrast, entry to both these early intervention programs is determined by diagnosis, irrespective of functional limitation.

Read more: Understanding the NDIS: will parents of newly diagnosed children with disability be left in the dark?

While funding incentives cannot change prevalence of fragile X syndrome in our community (because of its biological certainty), rates of autism diagnoses have more than doubled since the Helping Children with Autism program began in 2008. Autism has become a default consideration for any child who struggles socially, behaviourally, or with sensory stimuli. Clinicians have developed alternative ways of thinking about this “grey zone” problem. One strategy is to provide support in proportion to functional need, in line with the NDIS philosophy. Another strategy is to undertake response-to-intervention. This is well developed in education, where support is provided early and uncertainty is accepted. By observing a child’s pattern and rate of response over time, more information emerges about the nature of the child’s ongoing needs. The proposed assessment strategy in the Autism CRC report addresses the question, “does this child meet criteria for autism?”. This is not the same as “what is going on for this child, and how do we best help them?”. And those are arguably the more important questions for our children.

This article was co-authored by Dr Jane Lesslie, a specialist developmental paediatrician. Until recently she was vice president of the Neurodevelopmental and Behavioural Paediatric Society of Australasia. Michael McDowell, Associate Professor, The University of Queensland This article was originally published on The Conversation. Read the original article.

By A/Prof Michael McDowell

Surgery

Clinical Articles

Obesity Surgery – Worth The Money

For most patients in Australia, obesity surgery is an expensive exercise. The surgery alone is likely to see you out of pocket to the tune of several thousand at least. And then there’s the time off work, specialist appointments, follow-up etc etc. So you can understand patients being hesitant about the prospect. And then there’s the worry about effectiveness. Will it work? And if so for how long? Well, new research, published in The New England Journal of Medicine goes a long way to alleviating those fears. The prospective US study, showed that not only did more than 400 severely obese patients who underwent gastric bypass surgery lose a significant amount of weight but that weight loss and the health benefits obtained because of it, were sustained 12 years later. Two years after undergoing the Roux-en-Y surgery, these patients had lost an average of 45kg. Over the following decade there was some weight gain, but at the end of the 12 years the average weight loss from baseline was still a massive 35kg. The impressiveness of this statistic is put into perspective by researchers who compared this cohort with a similar number of severely obese people who had sought but did not undergo gastric bypass. Over the duration of the study this group lost an average of only 2.9kg. And another group, also obese patients who had not sought surgery lost no weight at all on average over this time period. What is even more significant is the difference in morbidity associated with the surgery. The researchers found that of the patients who had type 2 diabetes at baseline, 75% no longer had the disease at two years. And despite the progressive nature of type 2 diabetes, 51% were still diabetes-free at 12 years. In addition, the surgery group had higher remission rates and lower incidence rates of hypertension and lipid disorders. “This study showed long-term durability of weight loss and effective remission and prevention of type 2 diabetes, hypertension and dyslipidaemia after Roux-en-Y gastric bypass,” the study authors concluded. Even though this surgery is done less commonly in Australia than laparoscopic procedures, the reality is that bariatric surgery, for the most part represents enormous value for severely obese patients. The dramatic results and the significant health benefits will no doubt increase pressure on the government and private health insurers to improve access to what could well be described as life-changing surgery. Ref: NEJM 2017; 377: 1143-1155. DOI: 10.1056/NEJMoa1700459

By Dr Linda Calabresi

Men's health

Clinical Articles

Science or Snake Oil: do men need sperm health supplements?

Infertility, defined as the inability of a couple to conceive after at least 12 months of regular, unprotected sex, affects about 15% of couples worldwide. Several factors can lead to infertility, but specific to men, infertility has been linked to lower levels of antioxidants in their semen. This exposes them to an increased risk of chemically reactive species containing oxygen, which can damage sperm. These reactive oxygen species are naturally involved in various pathways essential for normal reproduction. But uncontrolled and excessive levels of reactive oxygen species results in damage to your cells (or “oxidative stress”). This can affect semen health, and damage the DNA carried in the sperm, leading to the onset of male infertility.
Read more: Science or Snake Oil: is A2 milk better for you than regular cow’s milk?

Can supplements improve sperm health?

Antioxidants have long been used to manage male infertility as they can help alleviate the detrimental role of reactive oxygen species and oxidative stress on sperm health. Generally speaking, studies have shown favourable effects with supplementation, but results have been rather inconsistent due to large variations in study design, antioxidant formulations, and dosages. Several lab studies have reported beneficial effects of antioxidants such as vitamins E and C on the mobility of the sperm and DNA integrity (absence of breaks or nicks in the DNA). But these haven’t been able to be replicated in humans. There is some research suggesting six months of supplementation with vitamin E and selenium can increase sperm motility and the percentage of healthy, living sperm, as well as pregnancy rates. Other studies have found improvements in sperm volume, DNA damage, and pregnancy rate following treatment with supplements l-carnitine (an amino acid), Coenzyme Q10, and zinc. But there seems to be an equal number of studies showing no improvements in sperm motility, sperm concentration, the size or shape of sperm, or other measures. Perhaps it’s the inconsistency in results, and the overall desire to improve fertility rates that has led some companies to create their own sperm-saving cocktails.

The research behind Menevit

Menevit is a male fertility supplement aimed at promoting sperm health. It’s a combination of antioxidants, including vitamins C and E, zinc, folic acid, and selenium, formulated to maintain sperm health.

Read more: Most men don’t realise age is a factor in their fertility too

The makers of Menevit claim the antioxidants it contains can help maintain normal sperm numbers, improve sperm swimming, improve sperm-egg development, and protect against DNA damage. Following three months of supplementation, participants taking Menevit recorded a statistically significant improvement in pregnancy rate compared to the control group (38.5% versus 16%). But no significant changes in egg fertilisation or embryo quality were detected between the two groups.To date, there has only been one published study conducted on the actual product. The lead author of the study is also the inventor of the product. At first glance these findings may seem promising, but a few things warrant attention. As mentioned, the principle investigator of the study is also the inventor of the product, something many would argue is a conflict of interest. The study also reported no improvements in DNA integrity or sperm motility, the two most cited benefits of supplementing with antioxidants. Furthermore, the study looked at who was pregnant three months later, not who actually gave birth to a child. The dosages used in the Menevit product are also much lower than what’s been in previous studies. For example, significant improvements in total sperm count have been observed following 26 weeks of supplementation with folic acid and zinc. But this study used 66mg of zinc (compared to 25mg in Menevit) and 5mg of folic acid (compared to 500 micrograms in Menevit). It’s hard to say you would get the same results from the lower doses. And studies showing improvements in sperm motility and DNA integrity following vitamin E and selenium supplementation used much larger doses than what is found in Menevit. The dosage of vitamin E used in previous studies has ranged from 600-1,490 international units, Menevit has 400 international units. The dose of selenium studied was 225 micrograms, compared to only 26 micrograms in the Menevit product.

Your best bet for healthy sperm

Before you stock up on every antioxidant out there, take a quick look at your lifestyle. Sperm health can be affected by unhealthy lifestyle factors like poor diet, alcohol consumption, smoking, and stress.

Read more: The Handmaid’s Tale and counting sperm: are fertility rates actually declining?

Following a diet comprised of whole foods (not packaged, processed foods), avoiding excessive consumption of alcohol, engaging in regular physical activity, and not smoking can go a long way when it comes to improving the health of your sperm. As for sperm supplements such as Menevit, there’s a great deal of research that still needs to be done before we can say for sure it’s a worthwhile investment. Krissy Kendall, Lecturer of Exercise and Sports Science, Edith Cowan University This article was originally published on The Conversation. Read the original article.

By Dr Krissy Kendall

Immunology and allergy

Clinical Articles

New hope for kids with severe food allergies

One of the new class of biologics may have a pivotal role in desensitising children with severe food allergies, US researchers say. That was the conclusion after their placebo-controlled study showed that a preliminary short course of the monoclonal antibody, omalizumab (Xolair) improved the safety and efficacy of oral immunotherapy in children with multiple severe Ig-E mediated food allergies. Admittedly the study was small, involving only 48 children aged 4-15 years, and only looked at children with Ig-E mediated allergies to multiple foods but the implications, the study authors say are important. These patients are a highly atopic population who are at risk of near-fatal or fatal food allergic reactions to multiple foods. There is plenty of evidence that oral immunotherapy is effective for single food desensitisation. However there has been little proof that immunotherapy works in children with allergies to multiple foods, and these are the ones more likely to accidentally ingest a food that may trigger anaphylaxis. Children with multiple food allergies are also far more likely to be unable to tolerate the oral immunotherapy. So in this phase 2 trial, those children in the treatment group were given omalizumab for eight weeks before commencing oral immunotherapy against a range of allergens including peanuts, cows milk and several different tree nuts. Outcomes were assessed by a food challenge at week 36 that looked at the ability to tolerate 2g of the trigger food. At the 36 week mark, 83% of children could now tolerate the allergenic food in the omalizumab-primed group compared with only 33% in the placebo group. It also appeared that omalizumab was well-tolerated with no serious or severe adverse events occurring in those who received it. The impact of these findings on the lives of affected children should not be underestimated, the researchers suggest in The Lancet Gastroenterology and Hepatology. “[The] ability to increase an individual’s threshold of food ingestion to a serving of protein [for example] is important for their nutrition and overall quality of life,” they wrote. The study had its limitations, namely it remains unknown if the desensitisation was sustained but the finding that the anti-IgE cover made the oral immunotherapy more tolerable and therefore more effective is a major though incremental advance in the management of this increasingly prevalent condition. Ref: Lancet Gastroenterology and Hepatology. Published Online Dec 11, 2017 http://dx.doi.org/10.1016/52468-1253(17)30392-8

By Dr Linda Calabresi

Drugs and devices

Clinical Articles

Green light for ginkgo

Ischaemic stroke patients are less likely to deteriorate mentally if they take ginkgo biloba extract in addition to low-dose aspirin in the acute phase, a new study suggests. “Cognitive decline after stroke can result in vascular cognitive impairment and Alzheimer’s disease,” the study authors wrote. Importantly then, this randomised controlled trial showed stroke patients who took ginkgo as well as aspirin had better memory function, executive functions, neurological function and daily life in the six months after experiencing their stroke than those patients who took aspirin alone. The Chinese study also showed that taking ginkgo was not associated with an increased incidence of adverse events. The results of the study, published in the journal, Stroke and Vascular Neurology support the long-held hypothesis that ginkgo protects against neuronal death caused by ischaemia, which had been demonstrated in animal stroke models. It has been suggested that the possible mechanism of ginkgo’s effectiveness may include anti-apoptosis and increasing cerebral blood flow. In the study, researchers randomised over 340 patients, from five hospitals who had had an ischaemic stroke in the previous seven days to receive either 450mg of ginkgo biloba extract with 100mg aspirin daily or only the 100mg of aspirin daily. Both groups were treated for six months and were various intervals over that period. From the very early assessments (at 12 days) and through until 180 days, the difference in the assessments of cognitive and executive function was statistically significant. Similarly neurological and global function was significantly better in the group that took ginkgo. “These data suggest that [ginkgo biloba extract] is effective and could be recommended in the treatment of acute ischaemic stroke,” the study authors concluded. Ref: Li S, et al. Stroke and Vascular Neurology 2017; 0:000104. doi:10.1136 /svn-2017-000104

By Dr Linda Calabresi

Sexual health

Pathologists from Sullivan Nicolaides Pathology

Clinical Articles

Syphilis – it’s back

Syphilis

Syphilis, caused by the spirochaete Treponema pallidum is an old disease. Many notable figures throughout history are thought to have suffered from this scourge. It remains exquisitely sensitive to penicillin so, in theory, should be easily treatable. Over the past two years, the number of notified cases of infectious syphilis – syphilis of less than two years' duration — has continued to grow. In the Northern Territory and Queensland, the emerging risk groups are young Aboriginal and Torres Strait Islanders (ATSI), particularly people from the north of the State. In this group, in which young females are infected, there is now a real risk of new cases of congenital syphilis. In other geographical areas, gay and bisexual males form the major risk group. Co-infections with other sexually transmitted infections (STIs) are common and should always be tested for simultaneously. Similarly, all STI screens should include a test for syphilis. At-risk patients require screening for co-existing chlamydia, gonorrhoea and/or and trichomonas if the patient belongs to the ATSI group. Screening for HIV, hepatitis A, B and C should also occur, with hepatitis A and B vaccination in those who are non-immune. The recommended regular screening for asymptomatic gay and bisexual males is outlined in the now renamed STIGMA guidelines (http://stipu.nsw.gov.au/wp-content/uploads/STIGMA_Testing_Guidelines_Final_v5.pdf).

Presentation

Early or infectious syphilis (less than two years' duration) includes primary, secondary and early latent syphilis (Algorithms 1 and 2). • Primary syphilis usually manifests as a chancre (an anogenital or, less commonly, extragenital painless, but also sometimes painful, ulcer with indurated edges). • Progression to secondary syphilis occurs over the following months and presents as an acute systemic illness with rash, which is usually truncal, but also involving palms and soles, condylomata lata (clusters of soft, moist lumps in skin folds of the anogenital area), mucosal lesions, alopecia, lymphadenopathy, hepatitis, or meningitis. • Early latent syphilis is infection of less than two years' duration where the patient is asymptomatic. Late latent syphilis is defined as latent (asymptomatic) syphilis of longer than two years' duration, or of unknown duration. Tertiary syphilis refers to syphilis of longer than two years' duration, or of unknown duration, with cardiovascular, central nervous system or skin and bone (gummatous syphilis) involvement. Risk of transmission of syphilis from a pregnant mother to her fetus depends on the stage of syphilis during pregnancy. Management is clearly outlined in the ASID Management of Perinatal Infections Guidelines (https://www.asid. net.au/documents/item/368)

General Practice Pathology is a new regular column each authored by an Australian expert pathologist on a topic of particular relevance and interest to practising GPs. The authors provide this editorial, free of charge as part of an educational initiative developed and coordinated by Sonic Pathology.

By Pathologists from Sullivan Nicolaides Pathology