Neonatal testicular torsion--a lost cause?

Twenty-four neonates presented with signs of testicular ischaemia over a 13-year period. They had a mean birth weight of 3.706 kg. The right testicle was affected in 13, the left in 9 and there was bilateral torsion in 2 babies. Two babies had no twist in the cord, but the testicles were nonviable macroscopically and microscopically. Twenty-one babies had primary exploration revealing necrotic testes in all patients and they underwent orchidectomies. The other three babies had conservative management and the affected testes had atrophied on follow-up. Sixteen babies had contralateral orchidopexy. Doppler ultrasound scans were reported as normal in 2 of 13 babies who had scans. No testes were salvaged following surgery. CONCLUSION: The incidence of testicular torsion in the neonatal period was calculated as 6.1 per 100,000 live births. No testis was salvaged following surgery in our series of 24 patients. This dismal outcome underlines that immediate surgical exploration, although commonly performed, rarely saves torted testes.     

Sphenochoanal polyp - a rare diagnosis in nasal obstruction

One of the most common nasal pathologies to present to an otolaryngologist is polyposis. Two well-recognized forms occur, the common antrochoanal polyp and the rare sphenochoanal polyp. Differentiation between the two is necessary for proper management by endoscopic sinus surgery.     

CHANGES IN THE CONTENT OF DOPAMINE AND ITS METABOLITES IN THE BASAL GANGLIA FOLLOWING RIGHT MIDDLE CEREBRAL ARTERY OCCLUSION AND REFLOW IN MONKEYS

Focal ischaemia was produced experimentally in Macaca radiata monkeys by occlusion of middle cerebral artery (MCA). There was a lowering of the dopamine (DA) content of basal ganglia after 4 and 12 h of occlusion. DA content was restored to normal in basal ganglia after restoration of blood flow. With the progress of time the DA content was increased above that of sham controls. Changes were also observed in the non-occluded left basal ganglia. The homovanillic acid (HVA) content was decreased significantly at 12 h after occlusion. After the onset of reflow, the HVA content of the right basal ganglia was higher than that of sham controls. The 3,4 dihydroxyphenylacetic acid (DOPAC) content of right basal ganglia was significantly decreased after 12 h occlusion. Reflow restored the level of DOPAC to normal within 1 h after removal of clip. Discrete changes were also observed in the left basal ganglia at some of the time intervals.     

Impact of Abdominal Wall Hernias and Repair on Patient Quality of Life

Background

The modified Activities Assessment Scale (AAS) is a 13-question abdominal wall quality of life (AW-QOL) survey validated in patients undergoing ventral hernia repair (VHR). No studies have assessed AW-QOL among individuals without abdominal wall pathology. The minimal clinically important difference (MCID) of the modified AAS and its implications for the threshold at which VHR should be offered also remain unknown. Our objectives were to (1) establish the AW-QOL of patients with a clinical abdominal wall hernia versus those with no hernia, (2) determine the MCID of the modified AAS, and (3) identify the baseline quality of life (QOL) score at which patients derive little clinical benefit from VHR.

Methods

Patient-centered outcomes data for all patients presenting to General Surgery and Hernia Clinics October–December 2016 at a single safety-net institution were collected via a prospective, cross-sectional observational study design. Primary outcome was QOL measured using the modified AAS. Secondary outcome was the MCID.

Results

Patients with no hernia had modified AAS scores of 81.6 (50.4–94.4), while patients with a clinically apparent hernia had lower modified AAS scores of 31.4 (12.6–58.7) (p < 0.001). The MCID threshold was 7.6 for a “slight” change and 14.9 for “definite” change. Above a modified AAS score of 81, the risk of worsening a patient’s QOL by surgery is higher than the chances of improvement.

Conclusions

VHR can improve 1-year postsurgical AW-QOL to levels similar to that of the general population. The MCID of the modified AAS is 7.6 points. Patients with high baseline scores should be counseled about the lack of potential benefit in QOL from elective VHR.

     

Pluripotent Very Small Embryonic-Like Stem Cells in Adult Testes – An Alternate Premise to Explain Testicular Germ Cell Tumors

Developmental exposure to endocrine disruptors has resulted in the increased incidence of infertility and testicular germ cell tumors (T2GCT) in young men residing in developed countries. Unlike T1GCT (infants and young children) and T3GCT (aged men), T2GCT arise from CIS/GCNIS that develops from pre-CIS. Pre-CIS represents undifferentiated, growth-arrested gonocytes that persist in fetal testes due to endocrine disruption. However, whether pre-CIS truly exist, do CIS develop into T2GCT, why no CIS in T1GCT/T3GCT, why germ cell tumors (GCT) also occur along midline at extra-gonadal sites, why T1GCT show partial erasure and T2GCT show complete erasure of genomic imprints are open questions that are awaiting answers. We propose that rather than pre-CIS, pluripotent, very small embryonic-like stem cells (VSELs) get affected by exposure to endocrine disruption. Since VSELs are developmentally equivalent to primordial germ cells (PGCs), T2GCT cells show complete erasure of genomic imprints and CIS represents growth-arrested clonally expanding stem/progenitor cells. PGCs/VSELs migrate along the midline to various organs and this explains why GCT occur along the midline, T1GCT show partial erasure of imprints as they develop from migrating PGCs. T3GCT possibly reflects effects of aging due to compromised differentiation and expansion of pre-meiotic spermatocytes. Absent spermatogenesis in pre-pubertal and aged testes explains absence of CIS in T1GCT and T3GCT. Endocrine disruptors possibly alter epigenetic state of VSELs and thus rather than maintaining normal tissue homeostasis, VSELs undergo increased proliferation and compromised differentiation resulting in reduced sperm count, infertility and TGCT. This newly emerging understanding offers alternate premise to explain TGCT and warrants further exploration.     

Prevalence and risk factors of peripheral vascular disease in a selected South Indian population: the Chennai Urban Population Study

OBJECTIVE: The epidemiology of peripheral vascular disease has rarely been studied in non-European populations. The purpose of this study was to determine the prevalence and risk factors of peripheral vascular disease (PVD) among South Indians. RESEARCH DESIGN AND METHODS: The Chennai Urban Population Study is an epidemiological study involving 2 residential areas in Chennai in South India. Of the 1,399 eligible subjects (> or =20 years of age), 1,262 (90.2%) participated in the study. All of the study subjects underwent an oral glucose tolerance test and were categorized as having normal glucose tolerance (NGT), impaired glucose tolerance (IGT), or diabetes. Peripheral Doppler studies were performed on 50% of the study subjects, and PVD was defined as an ankle-brachial index (ABI) <0.9. RESULTS: The prevalence rates of PVD were 2.7, 2.9, and 6.3% in individuals with NGT, IGT, and diabetes, respectively The overall prevalence rate was 3.2%. Known diabetic subjects had a higher prevalence of PVD (7.8%) compared with newly diagnosed diabetic subjects (3.5%). PVD was uncommon until middle-age and then the prevalence rate increased dramatically. Univariate regression analysis showed age >50 years (odds ratio [OR] 6.3, 95% CI 2.1-20.6, P<0.001) and hypertension (OR 2.7, 0.9-7.3, P = 0.08) to be associated with PVD, whereas smoking and serum lipid levels showed no association. Multivariate regression analysis identified age as the most significant risk factor for PVD. Of the 90 subjects who had coronary artery disease (CAD), only 6 had PVD, and the positive predictive value of the ABI for CAD was only 30%. CONCLUSIONS: The prevalence of PVD in this urban South Indian population is considerably lower than that reported in European and U.S. studies and is in marked contrast to the high prevalence rate of CAD reported in this population.