Growth and Adult Height Attainment in Danish Transgender Adolescents Treated with GnRH Analog and Sex Hormones.

BACKGROUND: Endogenous sex steroids influence the pubertal growth spurt and adult height. However, the impact of puberty suppression and sex steroids on growth in transgender adolescents is sparsely studied. AIM: We investigated pubertal growth, serum IGF-I and IGFBP-3, and adult height of transgender adolescents receiving hormone therapy. METHODS: Observational study of a national cohort (2016-2023) comprising 219 transgender adolescents <18 years of age. Treatment consisted of gonadotropin-releasing hormone agonist (GnRHa) combined with estradiol or testosterone (adjusted to serum concentrations between 0 and +2 standard deviations (SDs) corresponding to the gender identity). RESULTS: Adult height was within ±2 SD for sex assigned at birth.Most trans girls reached adult height within references of girls. For trans girls (bone age ≤15 years before treatment), a growth spurt was observed during estradiol therapy. IGF-I and height SDS declined during oral estradiol administration (-0.13 SDS per month, p=0.059, and -0.02 SDS, p=0.001, respectively). We observed significantly lower adult height compared to target height for trans girls (-2.7 cm, p=0.01), and significant differences between height SDS before treatment and at adult height (-0.35 SDS, p<0.001).Half of the trans boys remained short (<-2 SD) compared to references for boys, and most completed growth spurt before initiation of treatment. IGFBP-3 declined following testosterone treatment. There was a significant difference between height SDS before treatment and at adult height (-0.17 SDS, p<0.001). DISCUSSION AND CONCLUSION: The minor reduction in adult height of trans girls after hormone treatment may be beneficial to some, whereas trans boys did not experience height gain.

Differentiation of Idiopathic Central Precocious Puberty From Premature Thelarche Using Principal Component Analysis.

CONTEXT: Nonprogressive premature thelarche (PT) is a self-limiting variant of early puberty, while idiopathic central precocious puberty (ICPP) is a disorder that causes progressive development of secondary sexual characteristics and often requires treatment. The diagnostic differentiation between these conditions is important but can be challenging since they often both initially present clinically with isolated breast development. OBJECTIVE: To describe relevant clinical variables in a large cohort of girls referred for early puberty, and to evaluate clinical and biochemical parameters to distinguish between girls with ICPP and PT. METHODS: This retrospective study included 1361 girls referred with signs of early puberty to a single, tertiary center from 2009 to 2019. We evaluated clinical presentation, medical history, growth velocity, bone age, hormonal serum concentrations, and gonadotropin-releasing hormone (GnRH) test results. RESULTS: Central precocious puberty was diagnosed in 11% (ICPP: n = 143, organic CPP: n = 11) girls, whereas 8% (n = 91 girls) presented with PT. Receiver operating characteristic (ROC) analysis showed several biochemical and anthropometric markers as potential parameters to differentiate between ICPP and PT; however, none were individually adequate. Principal component analysis (PCA)-derived clinical and hormone profiles could predict girls with ICPP from girls with PT with a specificity of 90% and sensitivity of 84%, outperforming any single marker. CONCLUSION: Differentiation of girls with ICPP and PT can be supported by individual clinical and biochemical parameters. However, dimension reduction of clinical and hormonal profiles by PCA improved the diagnostic value, which in the future may support the diagnostic process as a supplement to the GnRH test in evaluation of pubertal disorders.

Reduced serum concentrations of biomarkers reflecting Leydig and Sertoli cell function in male patients with congenital adrenal hyperplasia.

Congenital adrenal hyperplasia (CAH) is a recessive condition that affects the adrenal glands. Despite life-long replacement therapy with glucocorticoids and mineralocorticoids, adult patients with CAH often experience impaired gonadal function. In pubertal boys and in men with CAH, circulating testosterone is produced by the adrenal glands as well as the testicular, steroidogenic cells. In this European two-center study, we evaluated the function of Leydig and Sertoli cells in 61 boys and men with CAH, primarily due to 21-hydroxylase deficiency. Despite conventional hormone replacement therapy, our results indicated a significant reduction in serum concentrations of both Leydig cell-derived hormones (i.e. insulin-like factor 3 (INSL3) and testosterone) and Sertoli cell-derived hormones (i.e. inhibin B and anti-Müllerian hormone) in adult males with CAH. Serum concentrations of INSL3 were particularly reduced in those with testicular adrenal rest tumors. To our knowledge, this is the first study to evaluate circulating INSL3 as a candidate biomarker to monitor Leydig cell function in patients with CAH.

Reproductive hormones, bone mineral content, body composition, and testosterone therapy in boys and adolescents with Klinefelter syndrome.

Adult patients with Klinefelter syndrome (KS) are characterized by a highly variable phenotype, including tall stature, obesity, and hypergonadotropic hypogonadism, as well as an increased risk of developing insulin resistance, metabolic syndrome, and osteoporosis. Most adults need testosterone replacement therapy (TRT), whereas the use of TRT during puberty has been debated. In this retrospective, observational study, reproductive hormones and whole-body dual-energy x-ray absorptiometry-derived body composition and bone mineral content were standardized to age-related standard deviation scores in 62 patients with KS aged 5.9-20.6 years. Serum concentrations of total testosterone and inhibin B were low, whereas luteinizing hormone and follicle-stimulating hormone were high in patients before TRT. Despite normal body mass index, body fat percentage and the ratio between android fat percentage and gynoid fat percentage were significantly higher in the entire group irrespective of treatment status. In patients evaluated before and during TRT, a tendency toward a more beneficial body composition with a significant reduction in the ratio between android fat percentage and gynoid fat percentage during TRT was found. Bone mineral content (BMC) did not differ from the reference, but BMC corrected for bone area was significantly lower when compared to the reference. This study confirms that patients with KS have an unfavorable body composition and an impaired bone mineral status already during childhood and adolescence. Systematic studies are needed to evaluate whether TRT during puberty will improve these parameters.

Varian eclipse stereotactic 5 mm cone data commissioning.

Conical collimators are effective and readily available accessories for the field shaping of small stereotactic fields, however the measurements required to accurately characterise the smallest radiation fields are difficult, prone to large errors, and there is little published commissioning data to compare measurements against. The aim of this investigation was to commission the cone dose calculation algorithm of a Varian Eclipse treatment planning system for a Varian 5 mm cone attached to a Varian TrueBeam linear accelerator beam-matched to the Varian Golden Beam Data (GBD). Tissue maximum ratios (TMRs) and off-axis ratios (OARs) were measured using PTW 60019 microDiamond and PTW 60018 SRS Diode detectors for a flattening filter free 6MV beam. The output factor (OF) was measured with the microDiamond and EBT-XD film. Results were compared to the GBD for this cone and an OF measured by the Australian Clinical Dosimetry Service during an independent audit. Film dosimetry was used to evaluate Eclipse dose calculations in a solid water phantom and end-to-end accuracy with an anthropomorphic head phantom. Output correction factors were derived from IAEA TRS-483. Gamma analysis was used to compare measured TMRs and OARs, and to compare Eclipse dose planes with film dosimetry results. Comparisons between measured and GBD TMRs passed gamma analysis within the specified criteria, while differences between distances to agreement for OARs measured with different detectors was attributed to different volume averaging characteristics. The OFs measured with the microDiamond and film agreed within measurement uncertainty. It was decided to configure Eclipse with the microDiamond measured OF and the SRS Diode measured TMR and OAR data. This was validated with various comparisons carried out to confirm both measurement accuracy and Eclipse configuration.

Long-term testosterone undecanoate treatment in the elderly testosterone deficient male: An observational cohort study.

BACKGROUND: Quarterly intramuscular injections with long-acting testosterone undecanoate (TU) provide stable serum testosterone concentrations over time and are therefore preferred by many testosterone-deficient patients. However, the use of long-acting TU in elderly patients is limited due to lack of safety and feasibility studies. OBJECTIVE: To investigate long-acting TU pharmacokinetics and assess differences in treatment regimens and risk of adverse outcomes in younger versus elderly testosterone-deficient patients. MATERIALS AND METHODS: Single-center longitudinal observational study. Patients who initiated long-acting TU treatment between 2005 and 2010 were included. Elderly patients were born before 1956 and younger patients between 1965 and 1985. TU dose was adjusted yearly through shortening or prolongation of time between injections. Treatment targets were as follows: (1) free testosterone between 0 and -1 SD from the age-adjusted mean, (2) no symptoms of testosterone deficiency, and (3) hematocrit within the normal range. RESULTS: The study population consisted of 63 elderly and 63 younger patients. Median follow-up time during testosterone replacement was 12.1 years. Increasing intervals between TU injections were performed 44% more often in the elderly compared to younger patients and time between TU injections were prolonged 4% more in the elderly patients. The hematocrit, as well as the hematocrit for a given serum testosterone (hematocrit: testosterone ratio), increased with treatment time but did not differ between age groups. During follow-up, 40% of patients-both elderly and younger-experienced polycythemia. Risk of polycythemia did not differ with age. DISCUSSION AND CONCLUSION: An increased number of adjustments of TU dose are necessary in elderly patients in order to reach treatment targets. TU treatment in elderly testosterone-deficient patients is not associated with an increased risk of polycythemia compared to younger patients if age-adjusted treatment targets are reached.

Facilitators of and barriers to return to work after mild traumatic brain injury: A thematic analysis.

Individuals with mild traumatic brain injury (mTBI) may experience protracted symptoms affecting their ability to work. Several actors may facilitate or act as a barrier to a successful return to work (RTW). This qualitative study used semi-structured in-depth interviews with 22 adults with mTBI at 2-5 years post injury, targeting experiences of how different actors facilitated or acted as a barrier in the RTW process, and encompassed the mTBI trajectory from the acute phase to the post-acute phase. A thematic analysis with a hermeneutical phenomenological approach was used to analyse data. Three main themes emerged. (1) Worker-employer relationship: Workplace accommodations such as decreased working hours, modified working conditions, and support from co-workers were lacking. (2) The role of the general practitioner: The general practitioner was lacking treatment and referral opportunities and failed to provide the patient with relevant and individualized guidance. (3) Municipal case management: Participants perceived being met with distrust by social workers, follow-up assessments were too frequent, unnecessary, and did not target concussion, and rehabilitation was referred too late. Clinical practice guidelines to improve referral to relevant concussion rehabilitation in case of persistent symptoms are needed to inform clinicians, employers, and public institutions to facilitate a successful RTW.

Mini-open lateral retropleural/retroperitoneal approaches for thoracic and thoracolumbar junction anterior column pathologies.

OBJECTIVE: Advancements in less invasive lateral retropleural/retroperitoneal approaches aim to address the limitation of posterolateral approaches and avoid complications associated with anterior open thoracotomy or thoracoabdominal approaches. METHODS: Consecutive patients treated with a mini-open lateral approach for thoracic or thoracolumbar anterior column pathologies were analyzed in a retrospective case series including clinical and radiographic outcomes. Special attention is given to operative techniques and surgical nuances. RESULTS: Eleven patients underwent a mini-open lateral retropleural or combined retropleural/retroperitoneal approach for thoracic or thoracolumbar junction lesions. Surgical indications included chronic fracture/deformity (n = 5), acute fracture (n = 2), neoplasm (n = 2), and osteomyelitis (n = 2). The mean length of postoperative hospital stay was 7.2 days (range 2-19 days). All patients ultimately had successful decompression and reconstruction with a mean follow-up of 16.7 months (range 6-29 months). Axial back pain assessed by the visual analog scale improved from a mean score of 8.2 to 2.2. Complications included 1 patient with deep venous thrombosis and pulmonary embolism and 1 with pneumonia. One patient developed increased leg weakness, which subsequently improved. One patient undergoing corpectomy with only lateral plate fixation developed cage subsidence requiring posterior stabilization. CONCLUSIONS: Mini-open lateral retropleural and retroperitoneal corpectomies can safely achieve anterior column reconstruction and spinal deformity correction for various thoracic and thoracolumbar vertebral pathologies.

Coronal Correction Using Kickstand Rods for Adult Thoracolumbar/Lumbar Scoliosis: Case Series With Analysis of Early Outcomes and Complications.

BACKGROUND: The "kickstand rod technique" has been recently described for achieving and maintaining coronal correction in adult spinal deformity (ASD). Kickstand rods span scoliotic lumbar spine from the thoracolumbar junction proximally to a "kickstand iliac screw" distally. Using the iliac wing as a base, kickstand distraction produces powerful corrective forces. Limited literature exists for this technique, and its associated outcomes and complications are unknown. OBJECTIVE: To assess alignment changes, early outcomes, and complications associated with kickstand rod distraction for ASD. METHODS: Consecutive ASD patients treated with kickstand distraction at our institution were retrospectively analyzed. RESULTS: The cohort comprised 19 patients (mean age: 67 yr; 79% women; 63% prior fusion) with mean follow-up 21 wk (range: 2-72 wk). All patients had posterior-only approach surgery with tri-iliac fixation (third iliac screw for the kickstand) for mean fusion length 12 levels. Three-column osteotomy and lumbar transforaminal lumbar interbody fusion were performed in 5 (26%) and 15 (79%) patients, respectively. Postoperative alignment improved significantly (coronal balance: 8 to 1 cm [P < .001]; major curve: 37° to 12° [P < .001]; fractional curve: 20° to 10° [P < .001]; sagittal balance: 11 to 4 cm [P < .001]; pelvic incidence to lumbar lordosis mismatch: 38° to 9° [P < .001]). Pain Numerical Rating Scale scores improved significantly (back: 7.2 to 4.2 [P = .001]; leg: 5.9 to 1.7 [P = .001]). No instrumentation complications occurred. Motor weakness persisted in 1 patient. There were 3 reoperations (1-PJK, 1-wound dehiscence, and 1-overcorrection). CONCLUSION: Among 19 ASD patients treated with kickstand rod distraction, alignment, and back/leg pain improved significantly following surgery. Complication rates were reasonable.

Distinguishing between hidden testes and anorchia: the role of endocrine evaluation in infancy and childhood.

OBJECTIVE: Non-palpable testes remain a diagnostic challenge, often involving exploratory laparoscopy. We evaluated the diagnostic value of a wide range of reproductive hormones in order to distinguish between bilateral cryptorchidism and bilateral anorchia. DESIGN: In this retrospective study, we identified and included 36 boys with non-palpable testes (20 with cryptorchidism, 3 with congenital hypogonadotropic hypogonadism (CHH), and 13 with anorchia) at first examination during childhood. METHODS: Information on karyotype, phenotype, surgical results from laparoscopy, and biochemistry was retrieved from patient files. We compared serum concentrations of AMH, inhibin B, FSH, LH, testosterone, estradiol, and hCG stimulation testing in cryptorchid and anorchid boys to serum concentrations in a large, age-matched control group. Receiver-operating characteristic curves were used to determine the cut-off values of each reproductive hormone as a predictor of the presence of functional testicular tissue. RESULTS: Concentrations of AMH in 0-1 year olds: ≥155 pmol/L and >1-15 year olds: ≥19 pmol/L, inhibin B (≥22 pg/mL and ≥4 pg/mL), FSH (≤28.9 IU/L and ≤20.3 IU/L) and hCG-induced testosterone (>1-15 year olds: ≥2 nmol/L) were significantly sensitive and specific markers in predicting the presence of functional testicular tissue in boys with non-palpable testes. In infancy, anorchid infants had significantly elevated gonadotropin levels, while CHH had low levels. CONCLUSION: Our findings suggest that laparoscopy may not be necessary in all boys with non-palpable testes if reproductive hormones unequivocally confirm the presence of functional testicular tissue. However, proving the absence may still be a diagnostic challenge.

Mini-Open Lateral Corpectomy for Thoracolumbar Junction Lesions.

BACKGROUND: Neoplastic, traumatic, infectious, and degenerative pathologies affecting the thoracolumbar junction pose a unique challenge to spine surgeons. Posterior or anterior approaches have traditionally been utilized to treat these lesions. Although minimally invasive surgeries through a lateral approach to the thoracic or lumbar spine have gained popularity, lateral access to the thoracolumbar junction remains technically challenging due to the overlying diaphragm positioned at the interface of the peritoneum and pleura. OBJECTIVE: To describe a mini-open lateral retropleural retroperitoneal approach for pathologies with spinal cord/cauda equina compression at the thoracolumbar junction. METHODS: A mini-open lateral corpectomy is described in detail in a patient with an L1 metastatic tumor. RESULTS: Satisfactory decompression and spinal column reconstruction were achieved. The patient obtained neural function recovery following the procedure with no intra- or postoperative complications. CONCLUSION: The morbidities associated with traditional posterior or anterior approaches to thoracolumbar junction pathologies have led to a growing interest in minimally invasive alternatives. The mini-open lateral approach allows for a safe and efficacious corpectomy and reconstruction for thoracolumbar junction pathologies. Thorough understanding of the anatomy, particularly of the diaphragm, is critical. This approach will have expanded roles in the management of patients with thoracolumbar neoplasms, fractures, infections, deformities, or degenerative diseases.

Surgical correction of severe adult lumbar scoliosis (major curves ≥ 75°): retrospective analysis with minimum 2-year follow-up.

OBJECTIVE: Prior reports have demonstrated the efficacy of surgical correction for adult lumbar scoliosis. Many of these reports focused on mild to moderate scoliosis. The authors' objective was to report their experience and to assess outcomes and complications after deformity correction for severe adult scoliosis. METHODS: The authors retrospectively analyzed consecutive adult scoliosis patients with major thoracolumbar/lumbar (TL/L) curves ≥ 75° who underwent deformity correction at their institution. Those eligible with a minimum 2 years of follow-up were included. Demographic, surgical, coronal and sagittal plane radiographic measurements, and health-related quality of life (HRQL) scores were analyzed. RESULTS: Among 26 potentially eligible patients, 22 (85%) had a minimum 2 years of follow-up (range 24-89 months) and were included in the study (mean age 57 ± 11 years; 91% women). The cohort comprised 16 (73%), 4 (18%), and 2 (9%) patients with adult idiopathic scoliosis, de novo degenerative scoliosis, and iatrogenic scoliosis, respectively. The surgical approach was posterior-only and multistage anterior-posterior in 18 (82%) and 4 (18%) patients, respectively. Three-column osteotomy was performed in 5 (23%) patients. Transforaminal and anterior lumbar interbody fusion were performed in 14 (64%) and 4 (18%) patients, respectively. All patients had sacropelvic fixation with uppermost instrumented vertebra in the lower thoracic spine (46% [10/22]) versus upper thoracic spine (55% [12/22]). The mean fusion length was 14 ± 3 levels. Preoperative major TL/L and lumbosacral fractional (L4-S1) curves were corrected from 83° ± 8° to 28° ± 13° (p < 0.001) and 34° ± 8° to 13° ± 6° (p < 0.001), respectively. Global coronal and sagittal balance significantly improved from 5 ± 4 cm to 1 ± 1 cm (p = 0.001) and 9 ± 8 cm to 2 ± 3 cm (p < 0.001), respectively. Pelvic tilt significantly improved from 33° ± 9° to 23° ± 10° (p < 0.001). Significant improvement in HRQL measures included the following: Scoliosis Research Society (SRS) pain score (p = 0.009), SRS appearance score (p = 0.004), and SF-12/SF-36 physical component summary (PCS) score (p = 0.026). Transient and persistent neurological deficits occurred in 8 (36%) and 2 (9%) patients, respectively. Rod fracture/pseudarthrosis occurred in 6 (27%) patients (supplemental rods were utilized more recently in 23%). Revisions were performed in 7 (32%) patients. CONCLUSIONS: In this single-center surgical series for severe adult scoliosis (major curves ≥ 75°), a posterior-only or multistage anterior-posterior approach provided major curve correction of 66% and significant improvements in global coronal and sagittal spinopelvic alignment. Significant improvements were also demonstrated in HRQL measures (SRS pain, SRS appearance, and SF-12/SF-36 PCS). Complications and revisions were comparable to those of other reports involving less severe scoliosis. The results of this study warrant future prospective multicenter studies to further delineate outcomes and complication risks for severe adult scoliosis correction.

Specialized interdisciplinary rehabilitation reduces persistent post-concussive symptoms: a randomized clinical trial.

OBJECTIVE: To compare the effectiveness of a specialized, interdisciplinary rehabilitation (S-REHAB) with standard care (STAND) for people with persistent post-concussive symptoms (PPCS > 6 month). DESIGN: Randomized controlled trial. PARTICIPANTS: Eighty-nine adults. INTERVENTIONS: 22-week programme combining individual and group-based neuropsychological treatment with exercise therapy and physiotherapeutic coaching (S-REHAB), and the usual treatment offered by the public municipality services (STAND). OUTCOME MEASURES: The Rivermead Postconcussion Symptoms Questionnaire (RPSQ) (primary), The Headache Impact Test (HIT-6), Major Depression Inventory (MDI), Multidimensional Fatigue Inventory (MFI-20) and The Short Form (36) Health Survey (SF-36); all collected at baseline, post-treatment, and at 6-month follow-up. RESULTS: The S-REHAB group showed a significant reduction in symptoms measured by RPSQ compared to the STAND immediately post-treatment (effect size [ES] = 0.28) and at follow-up (ES = 0.26). The S-REHAB groups also showed significant improvements regarding HIT-6 post-treatment (ES = 0.38) and at follow-up (ES = 0.68), MFI-20 - dimension 'mental fatigue' post-treatment (ES = 0.42), MFI-20 - dimension 'reduced activities' at follow-up (ES = 0.74) and SF-36 - dimension 'social functioning' post-treatment (ES = 0.31). CONCLUSIONS: The S-REHAB is more effective than the STAND in reducing the PPCS affecting physical, cognitive and emotional domains. This symptom reduction was associated with experienced improvement in social functioning, increased levels of activity, a decrease in mental fatigue and increased life satisfaction.

Multi-Modal Detection and Mapping of Static and Dynamic Obstacles in Agriculture for Process Evaluation.

Today, agricultural vehicles are available that can automatically perform tasks such as weed detection and spraying, mowing, and sowing while being steered automatically. However, for such systems to be fully autonomous and self-driven, not only their specific agricultural tasks must be automated. An accurate and robust perception system automatically detecting and avoiding all obstacles must also be realized to ensure safety of humans, animals, and other surroundings. In this paper, we present a multi-modal obstacle and environment detection and recognition approach for process evaluation in agricultural fields. The proposed pipeline detects and maps static and dynamic obstacles globally, while providing process-relevant information along the traversed trajectory. Detection algorithms are introduced for a variety of sensor technologies, including range sensors (lidar and radar) and cameras (stereo and thermal). Detection information is mapped globally into semantical occupancy grid maps and fused across all sensors with late fusion, resulting in accurate traversability assessment and semantical mapping of process-relevant categories (e.g., crop, ground, and obstacles). Finally, a decoding step uses a Hidden Markov model to extract relevant process-specific parameters along the trajectory of the vehicle, thus informing a potential control system of unexpected structures in the planned path. The method is evaluated on a public dataset for multi-modal obstacle detection in agricultural fields. Results show that a combination of multiple sensor modalities increases detection performance and that different fusion strategies must be applied between algorithms detecting similar and dissimilar classes.

FieldSAFE: Dataset for Obstacle Detection in Agriculture.

In this paper, we present a multi-modal dataset for obstacle detection in agriculture. The dataset comprises approximately 2 h of raw sensor data from a tractor-mounted sensor system in a grass mowing scenario in Denmark, October 2016. Sensing modalities include stereo camera, thermal camera, web camera, 360 ∘ camera, LiDAR and radar, while precise localization is available from fused IMU and GNSS. Both static and moving obstacles are present, including humans, mannequin dolls, rocks, barrels, buildings, vehicles and vegetation. All obstacles have ground truth object labels and geographic coordinates.

Germ Cell Neoplasia in Situ and Preserved Fertility Despite Suppressed Gonadotropins in a Patient With Testotoxicosis.

Context: Testotoxicosis is an autosomal-dominant, male-limited disorder. Activating mutations in the luteinizing hormone receptor gene (LHCGR) cause high autonomous testosterone secretion, resulting in early-onset peripheral precocious puberty. Little is known about long-term consequences of testotoxicosis. Case Description: We present a rare case of a patient followed for 25 years with two remarkable outcomes: preserved fertility and germ cell neoplasia in situ (GCNIS). He presented with precocious puberty at 10 months of age and was diagnosed with testotoxicosis due to a de novo heterozygous Asp578Tyr mutation in LHCGR. Testicular biopsy in childhood showed Leydig cell hyperplasia with altered cell maturation. From infancy throughout adulthood, elevated testosterone and estradiol, low inhibin B and anti-Müllerian hormone, and completely suppressed follicle-stimulating hormone and luteinizing hormone were noted. Height acceleration and advanced bone age resulted in a reduced final height. Semen analysis revealed ongoing spermatogenesis, and the patient fathered a child by natural conception. Ketoconazole treatment decreased circulating testosterone in childhood, supported by experimental suppression of testosterone production in his adult testis tissue cultured ex vivo. At 25 years of age, ultrasound revealed a testicular tumor, identified as a Leydig cell adenoma, but unexpectedly with GCNIS present in adjacent seminiferous tubules. Conclusion: The case illustrates that absence of gonadotropins but high intratesticular testosterone concentration is sufficient for spermatogenesis and to allow fatherhood. Our study is also the first description, to our knowledge, of GCNIS in a patient with testotoxicosis. We recommend regular clinical examination and ultrasonic evaluation of the testes in these patients due to potential increased risk of malignancy.

Gynaecomastia in 786 adult men: clinical and biochemical findings.

OBJECTIVE: Gynaecomastia is a benign proliferation of glandular tissue of the breast; however, it is an important clinical observation because it can be the first symptom of an underlying disease. Some controversy exists concerning the clinical importance of an in-depth investigation of men who develop gynaecomastia. We hypothesise that a thorough work-up is required in adult men with gynaecomastia. DESIGN: All adult men (n = 818) referred to a secondary level andrological department at Rigshospitalet in Copenhagen, Denmark during a four-year period (2008-2011) under the diagnosis of gynaecomastia (ICD-10: N62) were included. METHODS: Thirty-two men who did not have gynaecomastia when examined were excluded; leaving 786 men for final analyses. They underwent an andrological examination, ultrasound of the testicles and analysis of endogenous serum hormones levels. RESULTS: In 43% of men with adult onset of gynaecomastia (≥18 years) an underlying, and often treatable, cause could be detected. In men younger at onset an underlying cause for gynaecomastia could be detected in merely 7.7%. The study is limited by the fact that we did not have access to investigate men who were referred directly by their GP to private clinics for plastic surgery or who sought cosmetic correction without consulting their GP first. CONCLUSIONS: Our study demonstrates the importance of a thorough examination and provides a comprehensible examination strategy to disclose the underlying pathology leading to the development of gynaecomastia in adulthood.

DeepAnomaly: Combining Background Subtraction and Deep Learning for Detecting Obstacles and Anomalies in an Agricultural Field.

Convolutional neural network (CNN)-based systems are increasingly used in autonomous vehicles for detecting obstacles. CNN-based object detection and per-pixel classification (semantic segmentation) algorithms are trained for detecting and classifying a predefined set of object types. These algorithms have difficulties in detecting distant and heavily occluded objects and are, by definition, not capable of detecting unknown object types or unusual scenarios. The visual characteristics of an agriculture field is homogeneous, and obstacles, like people, animals and other obstacles, occur rarely and are of distinct appearance compared to the field. This paper introduces DeepAnomaly, an algorithm combining deep learning and anomaly detection to exploit the homogenous characteristics of a field to perform anomaly detection. We demonstrate DeepAnomaly as a fast state-of-the-art detector for obstacles that are distant, heavily occluded and unknown. DeepAnomaly is compared to state-of-the-art obstacle detectors including "Faster R-CNN: Towards Real-Time Object Detection with Region Proposal Networks" (RCNN). In a human detector test case, we demonstrate that DeepAnomaly detects humans at longer ranges (45-90 m) than RCNN. RCNN has a similar performance at a short range (0-30 m). However, DeepAnomaly has much fewer model parameters and (182 ms/25 ms =) a 7.28-times faster processing time per image. Unlike most CNN-based methods, the high accuracy, the low computation time and the low memory footprint make it suitable for a real-time system running on a embedded GPU (Graphics Processing Unit).

Complications of surgical intervention in adult lumbar scoliosis.

If nonoperative measures are unsuccessful in managing the pain and disability of adult spinal deformities, surgical correction may provide the potential for significant improvement in a patient's quality of life. However, these procedures have a relatively high risk of complications. Identifying patients that may benefit from surgical intervention requires a thorough understanding of potential complications and managing the risks of any individual patient. Complications do not necessarily result in poor outcomes, and good outcomes are not always complication free. Higher risk patients potentially have more to gain, even if they experience complications. With the rapidly expanding senior population and expanded capabilities to manage high-risk patients, it is helpful to consider the lessons provided by ever expanding databases of outcome measures to refine the surgical decision-making process.