Urethral carcinoma metastatic to bone: a case report and literature review

Distant urethral carcinoma metastasis is a very rare event. The following discussion presents a unique case of urethral carcinoma (adenocarcinoma) metastatic to bone and reviews the literature regarding this condition.

A three-cell cluster hypothesis for noncognate T-B collaboration via direct T cell recognition of allogeneic dendritic cells

In this article, we propose that T cell help for B cells can occur via an unusual three-cell cluster, with recipient CD4+ T helper cells interacting via direct allorecognition with donor dendritic cell class II MHC antigens, recipient B cells interacting with MHC class I (or any other) antigen on the donor dendritic cell surface, and noncognate (i.e., antigen nonspecific) T-B collaboration. In this noncognate pathway, antigen processing by B cells is not required and T cell help is potent because of the high precursor T cell frequency for direct recognition of allogeneic class II MHC molecules. The data supporting this hypothesis are: 1. LEW rat strain recipients of interstitial dendritic cell-free (DAxLEW)F1 kidney allografts were shown to have no detectable antibody to donor class I MHC antigens at day 7 after grafting. By contrast, LEW recipients of normal (DAxLEW)F1 kidneys had strong antibody responses. 2. Consistent wih important role for donor dendritic cells in the early antibody response to donor class I MHC antigens was the finding that it was dependent on donor class II MHC antigens. PVG recipients, previously immunized with pure DA RT1.B class II MHC antigens, had virtually no antibody response to the class I MHC antigens of DA kidney allografts. 3. We confirmed the low and high responder status of PVG and LEW rats, respectively, to DA class I antigens by studying antibody responses to pure DA class I antigens. However, PVG and LEW recipients of DA kidney allografts did not differ in their antibody response to the donor DA class I MHC antigens. This is consistent with this response not requiring the processing and presentation of DA class I antigen by PVG recipients. 4. LEW recipients of interstitial dendritic cell-free (DAxLEW)F1 kidney allografts did eventually develop a strong antibody response to DA class I antigens, but this was delayed by several weeks. That this delayed antibody response was probably mediated by conventional T-B collaboration and that T help was rate limiting in this situation, was demonstrated by immunizing LEW recipients with a DA class I peptide. This markedly accelerated the kinetics of the antibody response to the dendritic cell-free (DAxLEW)F1 kidneys.

Functional lower limb salvage with an osteocutaneous filet flap of the foot

An osteocutaneous foot filet flap based on the posterior tibial vessels was successfully used to provide tibial coverage in a patient requiring a below-knee amputation following a high-voltage electrical injury. Addition of the calcaneus to the standard foot filet flap provided a vascularized bone graft that served to both lengthen the tibia and secure the flap via a tibial-calcaneal synostosis. The synostosis provided firm anchoring of the flap and allowed for a partial end-bearing, below-knee prosthesis.

Surgical indications for Ewing's sarcoma of the pelvis

BACKGROUND

Despite advances in adjuvant therapy, Ewing's sarcoma of the pelvis remains an anatomic site with a poor prognosis. This study evaluate the role of surgery in the management of patients with pelvic Ewing's sarcoma who also received conventional radiation therapy and chemotherapy.

METHODS

From May 1978 to February 1994, 19 patients with Stage IIB Ewing's sarcoma of the pelvis were treated at the UCLA Medical Center (Los Angeles, CA). There were eight lesions of the ilium, two of the sacrum, and nine involving two adjoining regions of pelvis. All patients received conventional medical management. The 19 patients were divided into two groups according to treatment modality. A group of 12 patients (Group A) had surgical resection, and their results were compared with those of another group of 7 patients (Group B) who did not have surgery.

RESULTS

The 5-year cumulative survival (Kaplan-Meier method) was 39% for all patients, 51% for Group A, and 18% for Group B. The 3-year cumulative survival was 59% for all patients, 72% for Group A, and 36% for Group B. Although the survival rate of Group A seemed better than that of Group B, the difference was not statistically significant (P = 0.093, log rank method). This study also suggested that, regardless of treatment modality, the outcome of patients with lesions involving two adjoining pelvic bones was poorer than that of those with a single lesion. In Group A, the 3-year cumulative survival rate for patients with single bone lesions (n = 8) was 86% and for patients with lesions involving two adjoining pelvic bones (n = 4) was 50% (P = 0.045, log rank method). Furthermore, the statistical analysis of the combined data of the single pelvic bone lesions in UCLA and that of Mayo Clinic series (n = 16 for surgery group and n = 15 for nonsurgery group) confirmed the better results for the surgical patients, which was consistent with the results from the Mayo Clinic with an even greater significance (P < 0.002).

CONCLUSION

This study demonstrates that surgery plus chemotherapy and radiation therapy is helpful for treating patients with pelvic Ewing's sarcoma so long as the tumor is limited to a single pelvic bone.

X-linked lymphoproliferative disease: twenty-five years after the discovery

The X-linked lymphoproliferative disease (XLP), one of six described X-linked immunodeficiencies, stems from a mutation at Xq25 which renders males impotent to mount an effective immune response to the ubiquitous EBV. Purtilo, who first observed this disease in 1969, established a Registry in 1980 to serve as a worldwide resource for the diagnosis, treatment, and research of this condition. Since Purtilo's death in late 1992, the Registry and research unit have not only continued to function as a worldwide consultative service, but have contributed the following. First, the number of affected boys has continued to grow; some 272 among 80 kindreds have been identified. Second, some boys (10%) who inherit the mutated XLP gene are immunologically abnormal even before evidence of EBV exposure. Third, the search for the XLP gene has been narrowed to a small region on Xq25. Its identification is near at hand; once cloned, this gene may well illustrate how the body orchestrates the complex immune response to EBV. Therein lies the justification for the quest for this gene, not only for the benefit of the few surviving boys and those to be born to female carriers, but also for defining its role in defending the body against a ubiquitous DNA virus.

Insulin binding in non-insulin-dependent diabetes mellitus (NIDDM) is correlated with glycemic control: clinical evidence for abnormal receptor regulation in NIDDM

Insulin binding has been reported to be decreased in non-insulin-dependent diabetes mellitus (NIDDM). Although elevated basal insulin concentrations have been correlated with decreased insulin binding in obesity, this relationship has not been found in NIDDM. To determine the potential cause(s) of the decrease, we measured 125I-insulin binding to circulating monocytes isolated from 31 non-insulin-treated patients with NIDDM who had a fasting plasma glucose (FPG) concentration greater than 7.8 mmol/L and 13 control subjects. We examined the influence of obesity, insulin concentration, glycemic control, and treatment with oral hypoglycemic agents on insulin binding in a cross-sectional study. Insulin binding was significantly decreased in the entire NIDDM group (mean +/- SEM, %/10(7) monocytes: 4.65 +/- 0.33) as compared with controls (6.45 +/- .70, P < .02). Subgroups defined by obesity (relative body weight > 1.2) and poor glycemic control (FPG > 11.1 mmol/L) and those not taking oral hypoglycemic agents had significantly lower insulin binding (P < .02). However, neither relative body weight nor insulin concentrations (basal or stimulated) correlated with insulin binding. Stepwise linear regression analysis showed that only FPG significantly correlated with insulin binding (r = -.45, P = .002) even when oral hypoglycemic agent-treated patients were removed from the analysis (r = -.50, P = .003). There was no significant contribution to explain insulin binding by the other variables, including diagnosis of diabetes, obesity, insulin concentration, or treatment with oral hypoglycemic agents. We conclude that poor metabolic control is associated with an alteration in insulin receptor regulation in NIDDM.

Prostate biopsy in patients after proctectomy

Until the discovery of prostate specific antigen as a tool to detect prostate carcinoma, the rectum has always been necessary to allow the best evaluation and biopsy of the prostate, whether by digital examination or transrectal ultrasound. We describe a simple, accurate, computerized tomography-guided method to biopsy the prostate in men who have undergone proctectomy.

Time-averaged accommodation response to flickering stimuli

Experiments are described in which the steady-state accommodation response versus stimulus curve was measured with an infrared autorefractor for high-contrast stimuli having a 100% square-wave temporal modulation of luminance in the frequency band 1-200 Hz. Slightly more accurate responses were found at frequencies approximately 50-100 Hz, i.e. above flicker fusion. The relevance of the results to practical situations in which flicker may be experienced is discussed.

Risks of blood volume changes in hypogonadal men treated with testosterone enanthate for erectile impotence

Administration of anabolic steroids carries many risks. We present a series of 15 patients with primary hypogonadism who as a group had statistically significant increases in whole body hematocrit and red blood cell volume while on testosterone therapy of 300 mg. intramuscularly every 3 weeks. A small decrease in plasma volume over-all was not significant. Subsequent analyses compared subgroups whose whole body hematocrit during testosterone therapy was either 48% or greater (9) or less than 48% (6). Interaction effects indicated that the subgroups were similar when off testosterone but when on testosterone the former group exhibited an increase in red blood cell volume and a decrease in plasma volume, while the latter group had little change in either measurement. Subsequent to stopping testosterone therapy 2 patients in the whole body hematocrit 48% or greater group suffered strokes and 1 had transient ischemic attacks while on therapy. No one in the whole body hematocrit less than 48% group has had any cerebrovascular symptoms. Clinical implications, as well as cost-effective and practical suggestions for detecting possible dangerous hemoconcentration are discussed.

Late recurrence of varus deformity after proximal tibial osteotomy

One hundred thirteen knees with medial gonarthrosis in 95 patients were treated by valgus-producing proximal tibial osteotomy and followed clinically and roentgenographically for a minimum of five years (mean, 6.3 years). Sixty-four knees (57%) were pain free or had only mild discomfort when walking. The standing femorotibial angle decreased from a postoperative average of 9.3 degrees valgus to 7.8 degrees valgus at the final follow-up examination. The tendency for varus recurrence greater than 5 degrees and for medial- or lateral-compartment arthritic progression was evaluated using the Kaplan-Meier survival method. Varus recurred in 18%, lateral-compartment arthritic progression in 60%, and medial-compartment arthritic progression in 83% by nine years after surgery. The probability of arthritic progression is much higher than the probability of significant varus recurrence in long-term roentgenographic follow-up studies of patients with valgus-producing proximal tibial osteotomies.

In treating impotence, urology and sex therapy are complementary

Urologists and mental health professionals are neither competitors nor adversaries. The principles of sex therapy represent a thoughtful and sensitive way to approach patients with almost any clinical problem so that they are more comfortable with the recommended tests or treatments. Sex therapy may be very helpful as an adjunct in treating "organic" as well as primarily emotional erectile dysfunction. We believe that with information we can help build a bridge between urologists and mental health professionals.

Granuflex dressings in treatment of full thickness pressure sores

Granuflex Paste and Granuflex E extend the range of indications for using Granuflex products in pressure sore therapy. These dressings enable ulcers of any degree of severity to be treated, although they perform better on sores on limbs than on sacral sores.

Effect of 1,25-dihydroxyvitamin D3 on induction of chondrocyte maturation in culture: extracellular matrix gene expression and morphology

Chondrocytes, derived from a tissue that remains as permanent hyaline cartilage in vivo (embryonic chicken caudal sterna) were treated with 10(-8) to 10(-8) M 1,25-dihydroxyvitamin D3 [1,25(OH)2D3]. These nonadherent rounded chondrocytes acquired an adherent, polygonal morphology in a dose-dependent fashion with 1,25(OH)2D3 treatment. During the first 4 days of 1,25(OH)2D3 treatment cell flattening was associated with a 10-fold increase in beta-actin and fibronectin and their corresponding messenger RNAs (mRNAs). After adherence over the 12 days of continuous hormone treatment, a 2- to 4-fold increase in DNA synthesis and DNA accumulation were observed for the highest hormone dose (10(-8) M). Over the same time course total collagen synthesis decreased 35-50% primarily due to decreased type II collagen synthesis, which accompanied comparable decreases in its mRNA. In contrast, both alpha 1(I) and alpha 2(I) showed a continuous 5- to 10-fold increase; however, type I collagen protein synthesis remained undetectable, indicating translational control of the type I collagen synthesis. alpha 1(X) mRNAs showed a 2- 3-fold increase after 12 days of hormone treatment, and its polypeptide was clearly detected by sodium dodecyl sulfate polyacrylamide gel analysis. Type IX collagen synthesis showed a 2-fold increase in synthesis and its mRNA levels during the first 4 days of 1,25(OH)2D3 treatment but thereafter had levels comparable to control cultures. Analysis of proteoglycan synthesis and core protein mRNA levels showed there was a 2-fold increase in core protein mRNAs while proteoglycan synthesis, as assessed by 35S incorporation, showed only a 10-20% increase. Direct hormone effects vs. those secondary to altered cellular morphology were determined by blocking cell adherence by growth of the 1,25(OH)2D3-treated cultures on bacteriological petri dishes. All of the observed effects on cytoskeletal and collagen mRNAs were blocked except the elevations observed in proteoglycan core protein and alpha 1(IX) mRNAs. DNA contents in hormone-treated cultures also remained elevated. These results suggest that 1,25(OH)2D3 both activates and suppresses specific genes, promoting chondrocyte maturation toward a more hypertrophic phenotype. However, prevention of the initial morphological alterations that are induced by 1,25(OH)2D3 blocks many of the subsequent changes in connective tissue expression.

Comparative morphological and biochemical analysis of hypertrophic, non-hypertrophic and 1,25(OH)2D3 treated non-hypertrophic chondrocytes

A comparative study of Type X collagen expression, chondrocyte morphology, and the expression of two genes controlling chondrocyte morphology (beta-actin and fibronectin) was carried out on chondrocytes derived from a tissue that remains as permanent hyaline cartilage in vivo (embryonic chicken caudal sterna), from a tissue that undergoes endochondral replacement (embryonic chicken ventral vertebrae) and caudal sternal chondrocytes treated with 1,25(OH)2D3. Under identical in vitro growth conditions and times, sternal chondrocytes grew as rounded non-adherent cells, and vertebral chondrocytes grew as adherent polygonal cells. Upon treatment with 10(-8) M 1,25(OH)2D3 over a twelve day period the sternal chondrocytes showed complete adherence and took on an identical appearance as the vertebral chondrocytes. Cellular adherence of both vertebral and 1,25(OH)2D3 treated sternal chondrocytes was associated with 10 X increased beta-actin, fibronectin and their corresponding mRNA's. Changes in connective tissue expression were observed with altered cellular morphology. Total collagen synthesis was 35-50% lower in both hormone treated and vertebral chondrocytes. Type II collagen was the major collagen type produced by all chondrocyte cultures; however, in both vertebral and 1,25(OH)2D3 treated sternal chondrocytes, a 60 kD collagenous protein was identified. This short chain collagen was determined to be Type X collagen based on its molecular weight and its CNBr peptide maps. Analysis of Type X mRNA levels using a 33 base pair anti sense oligonucleotide sequence to Type X, demonstrated that vertebral cells showed six to seven times more mRNA than sternal chondrocytes. However, the low mRNA levels of type X mRNA in sternal chondrocytes were increased two to three times by 1,25(OH)2D3 treatment. These studies demonstrate that the steroid hormone 1,25(OH)2 vitamin D3 induced morphological, biochemical and molecular changes indicative of chondrocyte maturation from a hyaline to a more hypertrophic phenotype.

Use of the malleable penile prosthesis in the treatment of erectile dysfunction: a prospective study of postoperative adjustment

Much of the research on the postoperative adjustment of penile prosthesis recipients and their partners has been hampered by retrospective designs, unreliable assessment procedures and other methodological limitations. To address these shortcomings and to increase current knowledge regarding postoperative adjustment, we completed a prospective, longitudinal study of 19 implant recipients and their partners. Our results suggest that most patients and partners were satisfied with the prosthesis 1 year postoperatively, although use of the prosthesis sometimes was accompanied by short-term complications. Satisfaction tended to be lower among spouses than patients. Frequency of sexual intercourse increased during the followup period but there were no changes in sexual desire. Neither marital nor psychological adjustment changed significantly during this period.

In-vitro and in-vivo responsiveness of the corpus luteum of the mare to gonadotrophin stimulation

Dispersed horse luteal cells were used to evaluate the ability of horse LH, hCG and PMSG to stimulate progesterone secretion in vitro. Morphological characterization of these cells before gonadotrophin stimulation indicated the presence of two populations of cells based on cell diameters. In luteal cells incubated as suspended cells, horse LH and hCG stimulated (P less than or equal to 0.05) progesterone production at all levels of treatment. Stimulation of progesterone secretion by hCG was greater (P less than or equal to 0.05) than by horse LH over the range of concentrations utilized. When mares (N = 7) received an intramuscular injection of 1000 i.u. hCG on Days 3, 4 and 5 after the end of oestrus, there was an increase (P less than or equal to 0.05), in peripheral progesterone concentrations beginning on Day 7 and continuing until Day 14 compared with controls (N = 7). Peripheral progesterone concentrations continued to be elevated in hCG-treated mares for Days 15-30 after oestrus in those mares that conceived. Although treatment with hCG increased progesterone concentrations, it had no influence on anterior pituitary release of LH as measured by frequency and amplitude of LH discharge. We conclude that the mare corpus luteum is responsive to gonadotrophins in vitro and that exogenous hCG can enhance serum progesterone concentrations throughout the oestrous cycle and early pregnancy.

Late-onset tibia vara: a histopathologic analysis. A comparative evaluation with infantile tibia vara and slipped capital femoral epiphysis

Histopathologic and histochemical studies were performed on the entire physes and contiguous structures of five knees (three patients) with late-onset tibia vara (Blount's disease). A constellation of abnormalities of both medial and lateral physeal components resulted in disorganization and misalignment of the physeal zones. The changes were remarkably similar to those observed in both infantile tibia vara and slipped capital femoral epiphysis, suggesting a common etiology. Our evaluation indicates that asymmetric compressive and shear forces acting across the proximal tibial physis effect its disruption and causes suppression and deviation of normal endochondral ossification, thereby resulting in tibia vara.

Collagen expression, ultrastructural assembly, and mineralization in cultures of chicken embryo osteoblasts

A newly defined chick calvariae osteoblast culture system that undergoes a temporal sequence of differentiation of the osteoblast phenotype with subsequent mineralization (Gerstenfeld, L. C., S. Chipman, J. Glowacki, and J. B. Lian. 1987. Dev. Biol. 122:49-60) has been examined for the regulation of collagen synthesis, ultrastructural organization of collagen fibrils, and extracellular matrix mineralization. Collagen gene expression, protein synthesis, processing, and accumulation were studied in this system over a 30-d period. Steady state mRNA levels for pro alpha 1(I) and pro alpha 2 collagen and total collagen synthesis increased 1.2- and 1.8-fold, respectively, between days 3 and 12. Thereafter, total collagen synthesis decreased 10-fold while mRNA levels decreased 2.5-fold. In contrast to the decreasing protein synthesis after day 12, total accumulated collagen in the cell layers increased sixfold from day 12 to 30. Examination of the kinetics of procollagen processing demonstrated that there was a sixfold increase in the rate of procollagen conversion to alpha chains from days 3 to 30 and the newly synthesized collagen was more efficiently incorporated into the extracellular matrix at later culture times. The macrostructural assembly of collagen and its relationship to culture mineralization were also examined. High voltage electron microscopy demonstrated that culture cell layers were three to four cells thick. Each cell layer was associated with a layer of well developed collagen fibrils orthogonally arranged with respect to adjacent layers. Fibrils had distinct 64-70-nm periodicity typical of type I collagen. Electron opaque areas found principally associated with the deepest layers of the fibrils consisted of calcium and phosphorus determined by electron probe microanalysis and were identified by electron diffraction as a very poorly crystalline hydroxyapatite mineral phase. These data demonstrate for the first time that cultured osteoblasts are capable of assembling their collagen fibrils into a bone-specific macrostructure which mineralizes in a manner similar to that characterized in vivo. Further, this matrix maturation may influence the processing kinetics of the collagen molecule.

Gonadal regulation of LH secretion in prepubertal bull calves

In the present study we examined the influence of castration and exogenous estradiol on pulsatile LH release during the transition from infancy to the prepubertal period of development. Bull calves were assigned to treatments (N = 5 treatment) at 6 weeks of age. Treatments consisted of intact controls, castrates and castrates receiving estradiol implants. Plasma LH response was monitored over 8 hr periods at 7, 8, 9, 10, 11 and 13 weeks of age. Castration alone did not alter LH concentrations, compared to controls until 10 weeks of age. At 10, 11 and 13 weeks, mean LH concentration and the number of LH pulses/8 hr period were greater (P less than .05) in castrates than in controls. In castrates with estradiol implants, mean LH concentration and the number of LH pulses/8 hr period were suppressed at all ages compared to controls and castrate treatments. These results indicate that LH release is not inhibited by gonadal factors from 6 to 9 weeks of age in the bull calf. However, estradiol negative feedback on LH secretion is evident during this same developmental period.

Postoperative results of opponensplasty and flexor tendon transfer in patients with spinal cord injuries

Key pinch, palmar pinch, and grasp strength were evaluated after opponensplasty and flexor tendon transfer in 24 patients who had suffered cervical spinal cord injuries during a 17-year period. The patients had 57 tendon transfers: 35 opponensplasties and 22 flexor tendon transfers. The average follow-up was 4.2 years. The brachioradialis and pronator teres were the most frequently used motors for the opponensplasty and flexor tendon transfer. Key pinch strength averaged 1.47 kg (range of 0.13 to 4.70 kg). Grasp strength averaged 2.81 kg (range of trace to 10.0 kg). Palmar pinch was obtained in 45% of the extremities; the overall result was 1.04 kg (range of 0.20 to 3.00 kg). In general, patients with higher functional classifications achieved better results. We believe that intraoperative length-tension studies were an important factor in improving the results. The choice of muscle for opponensplasty or flexor transfer when two different adequate motors were available did not seem to affect the outcome of key pinch or grasp. We believe that tendon transfers are beneficial and should be considered in all patients with spinal cord injuries regardless of age at injury if at least 1 year has elapsed since injury and the patients are neurologically stable and have participated in a rehabilitation program.

Tendon transfer for the restoration of upper limb function after a cervical spinal cord injury

During the past 22 years, 68 patients with cervical spinal cord injuries had 142 tendon transfers and tenodeses. The procedures were performed to provide improved upper limb control, including elbow extension, finger grasp, and thumb pinch for better prehension. The operations were effective in increasing function in all but four patients, who did not improve because of insufficient muscle strength. The educational, vocational, recreational, and social aspects of life improved for many patients. Tendon surgery should be considered for all tetraplegics 1 year after injury, provided that they have undergone an effective rehabilitation program and that their neurologic examination is stable.