Impalpable testis: laparoscopy or inguinal canal exploration?

OBJECTIVE: There is great controversy regarding the best approach to impalpable testis. In this retrospective study we evaluated the accuracy of intraperitoneal laparoscopy, inguinal canal exploration and ultrasound in the diagnosis of impalpable testis. MATERIAL AND METHODS: Over a 2-year period (2004-06), 76 patients with a diagnosis of uni- or bilateral clinically impalpable testis were referred to our center. A preoperative ultrasound evaluation was done and all patients underwent intraperitoneal laparoscopy. An inguinal canal incision and exploration was done in all cases except for patients with high intra-abdominal testes (> 2 cm above the internal ring), for whom laparoscopic dissection, mobilization and orchidopexy were necessary. RESULTS: The mean age of the patients was 15.36 years (range 1-39 years). The undescended testis (UDT) was right-sided in 25% of patients, left-sided in 41% and bilateral in 34%. Intraperitoneal laparoscopy, inguinal canal exploration and ultrasound detected 70.6%, 78.4% and 15.6% of testes, respectively. CONCLUSIONS: Laparoscopy changed the management protocol of impalpable UDT in only 21% of cases. Inguinal canal exploration alone was sufficient in the majority of our cases. We recommend laparoscopy for those patients with impalpable UDT in whom an initial inguinal canal exploration proves negative.     

Left-sided inferior vena cava found incidentally during laparoscopic donor nephrectomy: report of three cases

Laparoscopic donor nephrectomy can be a challenging procedure in patients with abdominal great-vessel anomalies. We report our experience with three cases of laparoscopic donor nephrectomy with a rare incidentally found left-sided inferior vena cava.     

A new efficient protocol for directed differentiation of retinal pigmented epithelial cells from normal and retinal disease induced pluripotent stem cells

We describe a new, efficient protocol that involves the serial addition of noggin, basic fibroblast growth factor (bFGF), retinoic acid, and sonic hedgehog (Shh) for the differentiation of human induced pluripotent stem cells (hiPSC) to retinal pigmented epithelium (RPE) in a serum- and feeder-free adherent condition. hiPSC-RPE cells exhibited RPE morphology and specific molecular markers. Additionally, several hiPSC lines were generated from retinal-specific patients with Leber's congenital amaurosis, Usher syndrome, two patients with retinitis pigmentosa, and a patient with Leber's hereditary optic neuropathy. The RPE cells generated from these disease-specific hiPSCs expressed specific markers by the same RPE lineage-directed differentiation protocol. These findings indicate a new short-term, simple, and efficient protocol for differentiation of hiPSCs to RPE cells. Such specific retinal disease-specific hiPSCs offer an unprecedented opportunity to recapitulate normal and pathologic formation of human retinal cells in vitro, thereby enabling pharmaceutical screening, and potentially autologous cell replacement therapies for retinal diseases.     

Poor cognitive function and risk of severe hypoglycemia in type 2 diabetes: post hoc epidemiologic analysis of the ACCORD trial

OBJECTIVE

Self-management of type 2 diabetes including avoidance of hypoglycemia is complex, but the impact of cognition on safe self-management is not well understood. This study aimed to assess the effect of baseline cognitive function and cognitive decline on subsequent risk of severe hypoglycemia and to assess the effect of different glycemic strategies on these relationships.

RESEARCH DESIGN AND METHODS

Prospective cohort analysis of data from the ACCORD trial included 2,956 adults aged ≥55 years with type 2 diabetes and additional cardiovascular risk factors. Cognitive tests (Digit Symbol Substitution Test [DSST], Rey Auditory Verbal Learning Test, Stroop Test, and Mini Mental Status Examination) were conducted at baseline and 20 months. Study outcomes were incident confirmed severe hypoglycemia requiring medical assistance (HMA) and hypoglycemia requiring any assistance (HAA).

RESULTS

After a median 3.25-year follow-up, a 5-point-poorer baseline score on the DSST was predictive of a first episode of HMA (hazard ratio 1.13 [95% CI 1.08–1.18]). Analyses of the other cognitive tests and of HAA were consistent with the DSST results. Cognitive decline over 20 months increased the risk of subsequent hypoglycemia to a greater extent in those with lower baseline cognitive function (P_interaction = 0.037). Randomization to an intensive versus standard glycemic strategy had no impact on the relationship between cognitive function and the risk of severe hypoglycemia.

CONCLUSIONS

Poor cognitive function increases the risk of severe hypoglycemia in patients with type 2 diabetes. Clinicians should consider cognitive function in assessing and guiding their patients regarding safe diabetes self-management regardless of their glycemic targets.Type 2 diabetes is an increasingly common disease. Its optimal management requires the active participation of affected patients, who must perform home glucose monitoring and adjust glucose-lowering medication and insulin, in anticipation and avoidance of hypoglycemia (1–3). The complexity of many diabetes treatment regimens requires good cognitive function. Therefore, cognitive function may be an important determinant of the risk for treatment-related adverse events such as severe hypoglycemia. Prospective studies suggest that cognitive status may affect the functional ability of patients with type 2 diabetes (4), and patients with dementia are less likely to be involved in diabetes self-care (5). However, it has not been shown that cognitive impairment leads to a greater risk of severe hypoglycemia. Improved understanding of this relationship may assist providers, caregivers, and patients in developing new treatment and education guidelines for diabetes management for people with cognitive impairment.The ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial assessed the effects of two different glycemic control strategies among individuals with type 2 diabetes at high risk for cardiovascular disease. ACCORD prospectively and systematically ascertained all severe hypoglycemic episodes. In addition, the ACCORD-MIND (Memory IN Diabetes) study assessed several domains of cognition among a subset of ACCORD participants. Thus, ACCORD-MIND provides a unique opportunity to assess the effect of baseline cognitive function on subsequent risk of severe hypoglycemia, as well as the effect of declines in cognitive function on the ongoing risk for severe hypoglycemia, and whether intensive versus standard glycemic control strategies affect these relationships.     

Congenital aural atresia surgery: Transmastoid approach,complications and outcomes

Repair of complete congenital aural atresia (CAA) could be a challenging procedure due to complications reported with CAA surgery such as facial nerve palsy, canal stenosis, graft lateralization, sensorineural hearing loss or the difficulty involved in the surgical technique. From 2006 to 2009, we used a one stage-modified transmastoid approach for surgical repair of 33 ears with complete CAA via a non-randomized controlled clinical trial. Some modifications in the technique of mastoidectomy, ossiculoplasty, fascia and skin grafting and meatoplasty have been described. Patients were followed up for 12 months to assess audiometric results and post-operative complications. Changes in air-bone gap and need for revision surgery or hearing aids were assessed at follow-up. There were no cases of facial weakness, dead ear or bony canal stenosis. Hearing success in 2 months follow-up was achieved in 72.7% of all patients. Success rate increased to 92.3% in patients with Jahrsdoefer’s scores of 8 and above. Overall success rate decreased to 63.6% at 12 months follow-up. There were no significant difference in Jahrsdoerfer score of patients with successful first surgical attempt and those who needed revision surgery (P value >0.056). Also patients of lower age (less than 5-years-old) did not have more need for revision surgery when compared with older patients (P value >0.36). However, being a syndromic patient did increase the need for revision surgery (P value <0.04). Age was not a predictor of meatal/canal stenosis and patients with lower Jahrsdoerfer scores could also achieve good results.