Proximal metatarsal osteotomy for hallux valgus: comparison of outcome for moderate and severe deformities

BACKGROUND: We compared the results of a distal soft-tissue procedure with a proximal crescentic osteotomy of the first metatarsal for moderate and severe hallux valgus. MATERIALS AND METHODS: The series consisted of 54 feet treated with this procedure. The average followup was 30 months. Fifty-four feet were divided into two groups including Group M (moderate) (24 feet, preoperative hallux valgus angle of 40 degrees or less and preoperative intermetatarsal angle of less than 18 degrees) and Group S (severe) (30 feet, preoperative hallux valgus angle of greater than 40 degrees or preoperative intermetatarsal angle of 18 degrees or greater). RESULTS: The difference between Group M and S was not significant with regard to the age of patients, duration of followup, or postoperative pain and function scores on the American Orthopaedic Foot and Ankle Society scale. However, postoperative alignment score in Group M was significantly greater than that in Group S (p = 0.038). Postoperative hallux valgus and intermetatarsal angles in Group S were significantly greater than those in Group M, respectively (p = 0.025, p = 0.001). The prevalence of recurrent hallux valgus (hallux valgus angle of 20 degrees or greater) in Group S was significantly higher than that in Group M (p = 0.013). CONCLUSION: This procedure is an effective method for relieving pain and improving function regardless of the severity of hallux valgus. However, the correction of moderate hallux valgus is likely to be better than that of severe hallux valgus.     

Three cases of small cell carcinoma of the urinary bladder: a case report

We report three cases of small cell carcinoma of the urinary bladder. Case 1: A 69-year-old man showed microscopic hematuria during follow up of prostate cancer of stage D2. The patient was diagnosed with small cell carcinoma of the urinary bladder at the stage of pT2N0M0. Complete remission was achieved by three courses of chemotherapy consisting of irinotecan and carboplatin. The patient was died by prostate cancer 16 months after the chemotherapy. Case 2: An 83-year-old woman presented with macroscopic hematuria. The patient was diagnosed with small cell carcinoma of the urinary bladder at the stage of pT2N0M0 and partial cystectomy was performed. The patient has been alive without any evidence of tumor recurrence at 6 months after surgery. Case 3: An 84-year-old man presented with macroscopic hematuria. The patient was diagnosed with small cell carcinoma of the urinary bladder at the stage ofcT3bN0M1 with multiple liver metastases. Complete remission was achieved by three courses of chemotherapy consisting of etoposide and carboplatin.     

Primary choriocarcinoma of the urinary bladder

A 72-year-old woman with asymptomatic macrohematuria was referred to our hospital. Cystoscopy revealed a 7 cm sessile tumor on the left lateral wall of the bladder. Subsequently an intravenous pyelography revealed left hydronephrosis. We performed transurethral biopsy and resection of the bladder tumor under the diagnosis of ordinary malignant bladder tumor. Histopathologically, the lesion was shown to be an undiffentiated urothelial carcinoma, G3, > or = pT2, containing syncytiotrophoblastic giant cells. The level of serum human chorionic gonadotropin-beta (hCG-beta) level was slightly elevated (0.3 ng/ml; normal value: < 0.1). Because a further examination revealed an invasion into the surrounding fat tissue of the bladder and left ureter, a total cystohysterectomy with an ileal conduit were performed. The final histopathological classification was choriocarcinoma of the urinary bladder, pT3a, pN1, pMx. An adjuvant combination chemotherapy was carried out using methotrexate, vinblastine, adriamycin and cisplatin (MVAC). After two courses of chemotherapy, the serum hCG-beta levels returned to normal. Eleven months postoperatively, however, there was evidence of multiple lung metastases. The patient died 12 months after the surgery as a result of complications caused by widespread metastases.     

Possible involvement of IkappaB kinase 2 and MKK7 in osteoclastogenesis induced by receptor activator of nuclear factor kappaB ligand.

Recent studies have revealed the essential role of the receptor activator of nuclear factor kappaB (NF-kappaB) ligand (RANKL) in osteoclast differentiation and activation. Adenovirus vector could efficiently transduce genes into RAW264.7 cells, which differentiate into osteoclast-like multinucleated cells in the presence of RANKL. The role of NF-kappaB and c-jun N-terminal kinase (JNK) activation in RANKL-induced osteoclast differentiation was investigated using an adenovirus vector carrying the dominant negative 1kappaB kinase 2 gene (AxIKK2DN) or dominant negative MKK7 gene (AxMKK7DN). IKK2DN and MKK7DN overexpression in RAW cells specifically suppressed the NF-kappaB activation and JNK activation in response to RANKL, respectively, without affecting other signaling pathways. Either inhibition of NF-kappaB or JNK pathways dose-dependently inhibited osteoclast formation induced by RANKL. These results suggest that both NF-kappaB and JNK activation are independently required for osteoclast differentiation.     

Relationship between sperm mitochondrial membrane potential,sperm motility,and fertility potential

AIM:To analyze the relationship between sperm mitochondrial membrane potential and sperm motility parameters by means of a computer-assisted sperm analyzer (CASA) and in-vitro fertilization rate(%FR). METHODS: Semen samples were obtained from 26 men undergoing in vitro fertilization-embryo transfer (IVF-ET). Informed consent was obtained from all men prior to the study. Samples were prepared using wash and swim-up method in HEPES-HTF medium. The sperm motility (%MOT), progressive motility (%PMOT), average path velocity (VAP) microm/s), straight line velocity (VSL) (micro m/s), curvilinear velocity (VCL) (microm/s) and %hyperactivated sperm (%HA), and the %FR were assessed. The samples were incubated in the presence of 2.0 mciromol/L of 5,5',6,6'-tetra-chloro-1,1',3,3'-tetraethylbenzimidazolyl-carbocyanine iodide (JC-1) for 30 min at 37 degrees C in air and washed in PBS before flow cytometry (FACSCalibur: Becton Dickinson) analysis. The mitochondrial probe JC-1 was used to identify the mitochondrial membrane potential. The sperm was divided into three populations according to the fluorescence pattern as follows: the high mitochondrial membrane potential group (n=8), the moderate group (n=5), and the low group (n=13). Statistical analysis was performed using unpaired t-test. RESULTS:Significant differences were found between the high and the low groups in %MOT (91.1+/-8.5 vs 63.0+/-32.7, mean+/-SD), VAP (73.0+/-14.2 vs 52.1+/-12.5), VCL (127.0+/-28.1 vs 87.0+/-22.6), %HA (27.3+/-23.6 vs 7.2+/-9.0) and %FR [73.2 (48/56) vs 59.0 (69/117)]. No significant differences were found in other CASA parameters. CONCLUSION: When the sperm mitochondrial membrane potential increases, sperm motility parameters and fertility potential will also increase. The JC-1 dye method is useful to predict sperm fertility potential.     

Treatment of 2019 cases with upper urinary tract calculi using a piezoelectric lithotriptor ESL-500A

PURPOSE: We evaluated the results of extracorporeal shock wave lithotripsy (ESWL) in a large number of cases with upper urinary tract calculi, and reported the strategy how to improve the efficacy and safety of ESWL. PATIENTS AND METHOD: Eight hundred fifteen patients with renal calculi and 1,204 patients with ureteral calculi were treated using a piezoelectric ultrasound-guided lithotriptor, Toshiba ESL-500A. Auxiliary measures were needed in 51 cases (2.5%) and 1,968 cases (97.5%) were treated by in situ procedures. ESWL was performed with the optimal positioning of the patient and under the continuous monitoring by ultrasound system. The visibility of stones was improved by removal of abdominal gas and administration of diuretic agent to dilate the ureter. Cases with urinary tract infection were medicated by antibiotics and the obstruction of the urinary tract was cleared away as soon as possible. RESULTS: Including the cases with residual fragments less than 4 mm, the success rates at one month after the treatment were 97.7% and 98.7% for the renal and ureteral calculi, respectively. The mean numbers of sessions were 1.49 for renal calculi and 1.16 for ureteral calculi. Multiple sessions were required in 24.2% of renal calculi and 12.0% of ureteral calculi. No serious complication has been observed except for three cases, which were sepsis after ESWL, anuria in a solitary kidney, and pyonephrosis caused by Steinstrasse with urinary infection, respectively. CONCLUSION: ESWL using ESL-500A is an efficient treatment of upper urinary tract calculi which has higher pulverization rate and fewer complications in the adequate procedure.     

Effects of 5-year treatment with elcatonin and alfacalcidol on lumbar bone mineral density and the incidence of vertebral fractures in postmenopausal women with osteoporosis: a retrospective study

 The purpose of this retrospective study was to compare the effects of long-term treatment (5 years) with elcatonin and alfacalcidol on bone mineral density (BMD) and the incidence of vertebral fractures in postmenopausal women with osteoporosis. Fifty-six osteoporotic women, more than 5 years after menopause and 58–79 years of age, were enrolled in the study and allocated to an elcatonin treatment group (20 units IM, weekly; n = 30) or an alfacalcidol treatment group (1 μg/day, daily; n = 26). BMD of the lumbar spine (L2-L4) was measured by dual energy X-ray absorptiometry at baseline and every year for 5 years. There were no significant differences in age, body mass index, years since menopause, BMD, or number of prevalent vertebral fractures at baseline between the two groups. One-way analysis of variance with repeated measurements showed no significant longitudinal changes in BMD in either group, suggesting that both treatments sustained the BMD over 5 years. Two-way analysis of variance with repeated measurements also showed no significant differences in longitudinal changes in BMD between the two groups, suggesting that the effects of the two treatments on BMD were similar. However, the number of incident vertebral fractures per patient was significantly lower in the alfacalcidol treatment group than in the elcatonin treatment group (0.80 ± 1.19 and 2.08 ± 2.73, respectively; P < 0.05). These findings indicate that both treatments appeared to sustain lumbar BMD similarly over a 5-year period in postmenopausal women with osteoporosis, but alfacalcidol treatment may be superior to elcatonin treatment regarding the incidence of vertebral fractures. Further study with prospective observations are needed to confirm the results of the present study. Received: April 2, 2002 / Accepted: July 13, 2002 Offprint requests to: J. Iwamoto     

Proximal dome-shaped osteotomy for symptomatic bunionette

The results of a dome-shaped osteotomy of the proximal third of the fifth metatarsal in patients with symptomatic bunionette deformity were reviewed. The series was comprised of eight patients (10 feet; mean age of patients, 21 years). The average followup was 30 months. All patients were free from pain at the fifth metatarsophalangeal joint and were satisfied with the results of this procedure. The mean angle between the longitudinal axes of the fifth metatarsal and the proximal phalanx was 18.9 degrees before surgery and 2.6 degrees after surgery. The mean angle between the longitudinal axes of the fourth and fifth metatarsals was 12.2 degrees before surgery and 4.8 degrees after surgery. The overall results were good in all 10 feet. Three feet had delayed union at the osteotomy site, but union was obtained in all feet. The osteotomy site of the fifth metatarsal in feet with delayed union was more proximal than that of the other feet. Therefore, proximal osteotomy of the fifth metatarsal should be done not at the base, but at the proximal site of the diaphysis to prevent delayed union. A proximal dome-shaped osteotomy corrects the deformity and relieves the symptoms, but careful attention should be paid to the osteotomy site.     

Permanent prostate brachytherapy for Japanese men: Results from initial 100 patients with prostate cancer

OBJECTIVE: To evaluate the initial results of brachytherapy for prostate cancer with permanent iodine-125 implant in Japan. METHODS: The results obtained with brachytherapy in the initial 100 Japanese patients treated at Nagano Municipal Hospital were reviewed. Patients with a prostate-specific antigen (PSA) level of less than 10 ng/mL and a Gleason's scores of 5, 6, 3 + 4 were classified as having a low risk of recurrence. Patients with a PSA level of 10-20 ng/mL and/or a Gleason's score of 4 + 3 were classified as having an intermediate risk for recurrence. Seventy-eight of the low-risk patients and 19 of the intermediate-risk patients were treated by seed implants alone, or seed implants combined with preceding external radiation, respectively. A total of 53 patients received neoadjuvant hormone therapy. The efficacy and morbidity of brachytherapy were investigated using the serum PSA, International Prostate Symptom Score, quality of life score and uroflowmetry data. RESULTS: The average V100 and D90 obtained by post-implant dosimetry was 94.3 and 113.7%, respectively. Serum PSA decreased gradually after treatment, although it had still not reached a nadir after 1 year. There was little difference of the PSA level between the patients with and without neoadjuvant hormone therapy even at 1 year after seed implantation. There were no PSA biochemical failure or clinical recurrence during the follow-up period. Voiding symptoms worsened until 3 months after treatment, and then gradually improved. Acute urinary retention occurred transiently in one patient (1%). Rectal bleeding and severe diarrhea did not occur. CONCLUSION: Brachytherapy is a feasible and effective option for the treatment of prostate cancer in Japanese men. Brachytherapy may have a different effect in Japanese patients with respect to voiding symptoms. Urinary retention was rare, but voiding symptoms were persistent in Japanese patients. Neoadjuvant hormone therapy deserves investigation to determine whether it can achieve better results, especially in patients with an intermediate risk.     

Sarcomatoid renal cell carcinoma with von Hippel-Lindau disease: a case report

We report a 68-year-old woman who had bilateral renal cell carcinoma (RCC) associated with von Hippel-Lindau (VHL) disease. Surgical resection of a central nervous system hemangioblastoma had been done previously. This time, synchronous bilateral RCCs were found in her kidneys, with metastases to lungs and liver. Right radical nephrectomy was performed to remove the primary tumor in the right kidney. Histopathological examination of the tumor revealed clear cell RCC with a sarcomatoid component. After surgery, transcatheter arterial embolization was performed for the tumor in the left kidney and interferon therapy was commenced. The left renal tumor decreased in size and interferon therapy was effective against the metastatic lung tumors. However, 4 years after resection of the right RCC, the tumor in the left kidney increased progressively in size and partial left nephrectomy was performed. Histopathological examination of the resected tumor also showed clear cell type RCC with a sarcomatoid component. The patient eventually died of her disease at 5 years after resection of the right RCC. RCC associated with VHL is usually of the clear cell type has a relatively good prognosis. Sarcomatoid RCC is rare in VHL patients and, to our knowledge, the present report is the first case of sarcomatoid RCC associated with VHL in the Japanese literature.