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Buy As Gift. Much like the first novel, it is set in Houston, Texas. Twisted Lies II revisits the lies and relationships from the first installment and after delving into the lives of the characters, it eventually answers the questions that were left unanswered. New characters are introduced in Twisted Lies II; which provides more understanding to some of the existing relationships while new relationships are exposed.

His business has become even more successful and Zina has a new job, new attitude, and a renewed faith in her husband.

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Robert is delighted to have her home and he caters to her every want and need as the two prepare to become parents. Although Zina has a pregnant glow, she still lives under a cloud of doubt and twisted lies. The recurrent attacks of ITT can result in ischemic damage to the testis especially if it lasts too long [ 4 ]. ITT may cause venous congestion with or without decreased arterial inflow, and can lead to testicular damage seen histologically as atrophic seminiferous tubules, peritubular fibrosis, or lack of spermatogenesis [ 11 , 12 , 13 , 14 ].

Hayn et al. Therefore, they recommended that urologists be proactive in recommending elective scrotal exploration when ITT is a likely diagnosis since the risk of testicular damage outweighs the morbidity of elective bilateral orchidopexy. Surgery appears also to result in pain relief in the majority of patients [ 11 ]. The most common presentation is the severe pain with rapid onset and resolution [ 11 ]. Significant physical findings include a very mobile testis and a long spermatic cord [ 13 ]. Classically, the affected testis has been described as lying horizontally instead of the usual vertical orientation [ 5 ].

The horizontal lie is thought to result from abnormal intrascrotal attachments of the testis the so-called bell clapper deformity with an abnormally high attachment of the tunica vaginalis to the spermatic cord, a long mesorchium, and a lack of the normal posterior attachment to the tunica vaginalis [ 1 , 10 ]. Our ultrasound findings done at the time of evaluation revealed normal blood flow to the testicles in all cases. Imaging studies are often misleading, as ITT may resolve before imaging [ 5 ].

Various ultrasound tools were utilized to help in diagnosis of testicular torsion, including the detection of spermatic cord spiral twist, but this finding is not always present [ 15 ]. Despite the lack of symptoms in the contralateral testicle in some cases, we performed bilateral fixation in all patients because of the association with future contralateral torsion [ 5 ].

Eaton et al. Although 1 or 2 suture technique orchidopexies is commonly used by urologists, it is our preference to do the 4-point suturing technique. We have not encountered any testicular trauma using this technique. The limitations of the present study included its short period of follow-up, nonrandomization, and the relatively small number of cases in the subgroups.

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However, the number of patients in the present study may be the largest number reported for ITT in adults. Although the clinical test that we suggested for ITT has not been validated, we hope this study will encourage other researchers to investigate this concept and reach a similar conclusion.

We propose an important area of future research, which is the use of Doppler ultrasound at the time of the testicular twisting test to confirm the diagnosis of ITT by detecting diminished blood flow to the testis in addition to producing a similar pain. Prospective studies with a larger number of patients and a longer follow-up period are needed to confirm this clinical condition in adult patients.

In this study, orchidopexy had a superior outcome in the management of this commonly overlooked condition in adults than conservative treatment. ITT is a condition that should be considered in the diagnosis of intermittent testicular pain in adults.


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Detailed history and focused clinical examination are essential to reach the diagnosis. National Center for Biotechnology Information , U. Journal List Med Princ Pract v. Med Princ Pract. Published online Sep Ahmed M.

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ElSheemy , c and Ahmed A. Shokeir d. Elijah O. Mohammed S.


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  • Ahmed A. Author information Article notes Copyright and License information Disclaimer. Box , Safat Kuwait , E-Mail moc. Received Feb 8; Accepted Sep Karger AG, Basel. Distribution permitted for non-commercial purposes only. This article has been cited by other articles in PMC.

    Abstract Objectives The aim of this study was to describe the management protocol for intermittent testicular torsion ITT in adults and report the outcome of this clinical condition, which is commonly overlooked in adults. Subjects and Methods Sixty-three patients were included in the study.

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    Results The median age of the patients was 28 years range: Conclusion In this study, scrotal orchidopexy proved to be superior to conservative measures in cases of ITT in adults. Introduction Testicular torsion is a known urological emergency. Subjects and Methods Sixty-three patients were included in this study during the period Table 1 Patient characteristics. Open in a separate window. Color marking of the testicle at the site of planned sutures to avoid the vessels.

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    Statistical Analysis Statistical analysis was done using the program Stata version 8. Results Of the 19 patients who underwent orchidopexy, resolution or improvement of scrotal pain was achieved in 18 Discussion In this study orchidopexy resulted in a better outcome of ITT pain in adult patients than conservative treatment. Conclusion In this study, orchidopexy had a superior outcome in the management of this commonly overlooked condition in adults than conservative treatment. References 1. Intermittent torsion. Looking at finite dimensional Lie algebras in general so not necessarily semisimple , I guess I can also understand this, since most of them are wild c.

    I guess also the Hom-spaces in the semisimple setting aren't very interesting due to Shur's Lemma, and hopeless to describe in generality in the wild setting? What about in the setting of infinite dimensional Lie algebras? For particular infinite dimensional Lie algebras for example twisted and untwisted loop algebras, current algebras, equivariant map algebras etc , I again often see this focus on irreducible representations and very little on the indecomposables in general even when the category of f.

    I see very little work on discussing the representation type and very little work on determining the Hom-spaces. I've seen some work on Ext groups for some Lie algebras, but it hasn't been a particularly broad theme from my reading so far.