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We present a severe case of progressive autoimmune pneumonitis requiring surgical intervention in a patient with the monogenic syndrome, autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED). APECED is caused by loss-of-function mutations in the autoimmune regulator (AIRE) gene, which lead to impaired central immune tolerance and autoimmune organ destruction including pneumonitis, an underrecognized, life-threatening complication. When clinicians evaluate patients with pneumonitis, recurrent mucosal candidiasis, and autoimmunity, APECED should be considered in the differential. Additionally, in patients with established APECED, a chest computed tomography is preferred to identify pneumonitis early on and to promptly initiate lymphocyte-directed immunomodulatory treatment, which can prevent irreversible lung destruction.

The purpose of this study was to identify opportunities for reducing epinephrine administration errors after a sentinel event entailing an overdose of i.v. epinephrine occurred in a radiology department.A root cause analysis was performed that included review and analysis of current system protocols, a medication audit, and access to treatment algorithms. A proctored three-question multiple-choice test was administered to radiology attending physicians, fellows, residents, and nurses to gauge baseline knowledge of epinephrine use. Chi-square analysis was performed.Twelve of 13 radiology department central pharmacy automation system locations lacked epinephrine ampules. As a result, personnel had to access i.v. epinephrine stocked on hospital code carts designed for use during cardiac arrest. This led to errors related to appropriate dosing. Test participants included 46 attending physicians, 23 fellows, 28 residents, and 25 nurses (n = 122). Almost all (99%) correctly identified epinephrine as the medication to administer in this situation. Approximately one half (52%) correctly identified the dose of intramuscular epinephrine, but only 29% knew the dose and rate of administration of i.v. epinephrine (p0.001). Attending physicians were more likely to administer i.v. epinephrine correctly than were the other groups (p0.0001).Stocking and routine auditing of medication availability are essential. The use of epinephrine intended for cardiac arrest stocked on code carts should be avoided during contrast reactions. It would be optimal if first-line responders to contrast reactions included attending physicians, but this may not always be the case at academic institutions.

History of Present Illness A 23-year-old woman presented to the allergy/immunology clinic with a previous diagnosis of allergic rhinitis and asthma. The patient reported that she had started immunotherapy (IT) 34 weeks ago, prescribed by her prior allergist, and had been receiving IT at her college health clinic. Following graduation 2 months earlier, she had been giving herself IT injections at home. She denied any reactions and had injectable epinephrine available at home. She was new to our area and was interested in restarting her IT. Her nasal symptoms included congestion, rhinorrhea, sneezing, itching, and postnasal drip. She also complained of ocular watering, itching, injection, and discharge when around cats or dogs. Chest symptoms included a daily cough and occasional wheezing that she did not notice but others had pointed out to her. She denied any nocturnal symptoms. She had an albuterol metered-dose inhaler available but had not used it in the previous 3 months.

Intravascular lymphomatosis (IVL) is a rare lymphoid neoplasm that is typically of B-cell lineage and characterized by proliferation of malignant cells within small arterioles, capillaries, and venules. We report a patient with pulmonary IVL who presented clinically with progressive dyspnea, fever, and a dry cough. Pulmonary function tests revealed a marked decrease in diffusion capacity with airflow obstruction and severe air trapping. High-resolution CT (HRCT) of the chest with inspiratory and expiratory images revealed mosaic attenuation consistent with air trapping. Transbronchial biopsies revealed the diagnosis of IVL with capillary expansion in the alveolar and peribronchiolar interstitial tissue. IVL should be considered in the differential diagnosis of a patient with an interstitial lung disease, air trapping on pulmonary function tests, and mosaic attenuation on HRCT. Transbronchial biopsies may be the initial diagnostic procedure of choice.

This study presents the frequency and correlates of traumatic injury during sexual assaults for male and female victims. Sexual assaults (6,877 total, 6,213 among females, 664 among males) were reported in South Carolina from October 1991 to September 1994 through the Federal Bureau of Investigation's National Incident Based Reporting System. Sexual assaults were defined to include vaginal rape, sodomy, and sexual assaults with objects. Among sexually assaulted females, 28.5% had traumatic physical injuries compared with 18.4% of similarly assaulted males. Risk factors for nongenital traumatic injury during sexual assault included: increasing number of assailants (females only), being sodomized (females only), weapon use by assailant, being kidnapped (females only), being assaulted by intimates or strangers (females only), African American race (males only), and use of alcohol or other drugs. Avoiding environments in which drugs and alcohol are abused may reduce one's risk of traumatic physical injury during sexual assaults.

Appropriate staging procedures for patients with hormone-refractory prostate cancer are poorly defined. In particular, there are no studies correlating prostate-specific antigen (PSA) with more traditional methods of staging. We have evaluated the abdominal/pelvic CT scan, bone scan, and PSA results following initial diagnosis of hormone-refractory prostate cancer in 177 consecutive patients (median age = 63.1 years, range 45-80). Thirty-four patients (19.2%) had measurable lesions (or = 2 cm) on CT scan compatible with metastatic disease. Of the patients with measurable lesions, 29/34 (85.3%) had retroperitoneal and/or pelvic adenopathy; 5 patients (14.7%) had measurable lesions in the liver. Other sites of metastatic disease were detected in less than 1% of the patients receiving scans. All patients had bone scan abnormalities compatible with metastatic disease. Results of these imaging studies were then compared to PSA serum concentration (Abbott IMx). The mean PSA concentration was not different in those patients with soft tissue disease as compared to those without soft tissue involvement and there was no correlation between PSA concentration and the presence or absence of measurable soft tissue disease. In contrast to previously published studies in hormone-naïve prostate cancer patients, these studies in hormone-refractory patients indicate that the detection of metastatic disease by standard radiological procedures cannot be predicted by measurement of serum PSA.

Previous clinical trials have suggested that hydroxyurea may possess some activity against prostate cancer. The in vitro antiproliferative activity of hydroxyurea was evaluated in three hormone-refractory prostate cancer cell lines, PC-3, DU-145 and PC-3M. Fifty-percent inhibition of growth in all three cell lines required prolonged (120 h) exposure to hydroxyurea at a concentration of approximately 100 microM. Using pharmacokinetic data obtained during the course of a clinical trial of hydroxyurea, we simulated a dosing regimen that would sustain plasma drug concentrations above 100 microM for 120 h (1 g loading dose, followed by 500 mg every 6 h for 5 days in a 70 kg man). Since this dosing regimen is likely to generate an unacceptable degree of myelosuppression, in vitro combination studies were conducted with hydroxyurea and phenylbutyrate, a new differentiating agent with no myelosuppressive effects. These studies resulted in a reduction of the hydroxyurea concentration necessary for 50% growth inhibition (50 microM of hydroxyurea plus 0.5 mM of phenylbutyrate). A regimen designed to achieve that hydroxyurea concentration (400 mg loading dose, followed by 200 mg every 6 h for 5 days) should be clinically achievable. Based on these results, this combination deserves further evaluation in patients with stage D prostate cancer.

A case is described where an abdominal fistula was temporarily closed using a plug made from dental addition curing silicone rubber impression material. An effective seal was maintained using a stoma flange and a gentle pressure dressing; this still allowed normal gastric function.

A patient presented with recurrent facial dermatitis associated with dental work. Dermatology referral identified the cause as allergic contact dermatitis to the epoxy acrylate BIS-GMA. Occupationally-induced allergic contact dermatitis to epoxy resin was also demonstrated. A structurally distinct aliphatic acrylate was successfully substituted. Contact sensitivity to BIS-GMA is reviewed and the potential for epoxy sensitive patients to cross-react to BIS-GMA is discussed.