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The safety and efficacy of postcoital administration of oral contraceptives, commonly called "emergency contraception pills" (ECPs), have been well documented; nonetheless, this method of preventing pregnancy is underused in the United States. Through the use of surveys, the current study assessed providers' knowledge, prescribing practices, attitudes, and barriers regarding ECPs at a military treatment facility in the southwest United States. Results showed a lack of knowledge of ECP provision, with 34% believing treatment had to be initiated in 48 or fewer hours, and 60% believing two doses must be taken within 24 hours or more of each other. Slightly more than one- half (54.4%) of the providers reported having prescribed an ECP; those who had prescribed had more positive attitudes about ECPs. Perceived barriers included women not asking for ECPs, concerns about safety of ECPs, and issues regarding liability. A discrepancy between providers' perceived and actual knowledge about ECPs supports the need for better education for all providers who care for women. [ABSTRACT FROM AUTHOR]

When health professionals, including RNs, have negative attitudes toward women experiencing homelessness, they create barriers to services. It is incumbent on nursing faculty to develop curricula that address homelessness and associated stereotypes, as well as to prepare students to provide safe and appropriate care to the homeless population. The aim of this qualitative study was to examine the attitudes of RN-to-MSN students toward mothers living with their children in a transitional shelter. A convenience sample of 10 students enrolled in a community health nursing course at a university in southern California participated in the study. Two focus groups were conducted: one before and one after a 15-week clinical experience. Data analysis revealed that during the clinical experience, students discovered that they, or perhaps an individual like them, could become homeless. Their attitudes and views changed to include a bigger picture of homelessness, described by public health nursing researchers as 'moving upstream.' This article suggests strategies for integrating clinical experiences with socioeconomically vulnerable individuals into undergraduate nursing curricula. [ABSTRACT FROM AUTHOR]

Acute onset of surgical menopause rarely complicates a woman's psychological state. Although most women with acute surgical menopause have associated menopausal symptoms, few psychological consequences have been reported. This article presents the case report of a woman who developed immediate postoperative symptoms of severe anxiety that significantly impacted her quality of life. Physiological and psychological changes associated with surgical menopause and hormone replacement therapy are also discussed. [ABSTRACT FROM AUTHOR]

We report a case of gallbladder paraganglioma that was discovered during nonrelated surgery. Retrospective study disclosed a family history of pheochromocytoma. The occurrence of gallbladder paraganglioma in the presence of family history of endocrine neoplasia supports that gall-bladder paraganglioma may indeed occur as a part of the r multiple endocrine neoplasm syndrome. Gallbladder paraganglioma is a rare tumor, and so far to our knowledge a only 6 cases have been reported in the literature. Three cases were discovered incidentally during cholecystectomy s for cholelithiasis 2 presented with right upper quadrant t pain, and 1 manifested with gastrointestinal bleeding. We herein review all reported cases of paraganglioma of gall- bladder and biliary system. [ABSTRACT FROM AUTHOR]

Background: Smooth muscle tumors of the vulva are rare and sometimes create diagnostic difficulty because of unusual morphological features., Case: A 29-year-old African-American female presented with a vulval mass during her 5th week of pregnancy. The lesion was surgically removed under the clinical impression of a Bartholin cyst. Histopathological findings of the lesion and immunohistochemical stain results are characteristic of myxoid epithelioid leiomyoma., Conclusion: Up to now, there are only a few cases of myxoid epithelioid leiomyoma of the vulva reported in English literature. We review previously reported cases and discuss the morphologic differential diagnosis. The mass presented in this report was the largest benign epithelioid leiomyoma in the literature.

We report a case of gallbladder paraganglioma that was discovered during nonrelated surgery. Retrospective study disclosed a family history of pheochromocytoma. The occurrence of gallbladder paraganglioma in the presence of family history of endocrine neoplasia supports that gallbladder paraganglioma may indeed occur as a part of the multiple endocrine neoplasm syndrome. Gallbladder paraganglioma is a rare tumor, and so far to our knowledge only 6 cases have been reported in the literature. Three cases were discovered incidentally during cholecystectomy for cholelithiasis, 2 presented with right upper quadrant pain, and 1 manifested with gastrointestinal bleeding. We herein review all reported cases of paraganglioma of gallbladder and biliary system.

We report a case of an adenomatoid tumor (AT) of an adrenal gland with micronodular adrenal cortical hyperplasia (ACH). A 51-year-old man was found to have newly developed hypertension with clinical evidence of primary aldosteronism. A computerized tomogram of the abdomen revealed a solitary mass in the right adrenal gland. He underwent a right adrenalectomy for a presumptive clinical diagnosis of a solitary aldosterone-producing adrenal cortical adenoma. On histopathologic examination, the adrenal gland demonstrated an AT, diagnosed by the characteristic histological features, immunohistochemical stain results, and electron microscopic findings. The surrounding adrenal cortex showed multiple small hyperplastic cortical nodules. After the adrenalectomy, the patient's blood pressure normalized. Primary AT of the adrenal gland coexisting with micronodular ACH associated with hypertension has not been previously reported.

Ectopic breast tissue has been described rarely in the vulva and is known to develop a variety of pathologic changes. Our review of the literature found a total of 11 reported cases of primary infiltrating ductal adenocarcinoma arising in ectopic breast tissue of the vulva. We report what we believe is the first case of primary mucinous adenocarcinoma arising in ectopic breast tissue of the vulva diagnosed by characteristic histopathologic features and immunohistochemical stain results. We discuss the criteria used in diagnosis of primary breast carcinoma of the vulva and review previously reported cases.

Aroutine physical examination often includes a digital rectal examination (DRE) and a fecal occult blood test (FOBT). To determine the diagnostic yield of these tests in women younger than age 50, the author performed a literature review. This article reviews the most recent research on the DRE and FOBT, outlines guidelines for colorectal screening, and discusses the efficacy and benefits of these guidelines.

We report a rare case of isolated thrombocytopenia due to a large hamartoma of the pulposal type, which resolved with splenectomy in a 46-year-old man. Although hamartomas are usually found incidentally, they may cause hematologic disturbances such as thrombocytopenia, anemia, or splenic rupture. The diagnosis of splenic hamartoma is difficult to make preoperatively. Splenectomy is important in excluding malignant tumors from the diagnosis when the etiology of a splenic mass is unclear and ameliorating hematologic symptoms related to hamartomas.

Acute renal crisis as an early manifestation of scleroderma is underemphasized, and its recurrence after initial successful therapy is rare. We describe a 32-year-old woman who presented with scleroderma renal crisis. A second episode of apparent renal crisis, however, was complicated by thrombotic thrombocytopenic purpura, which led to pancreatitis, a large cerebral infarction, and fatal outcome despite intensive therapy. This case illustrates the complexity and severity of diffuse systemic sclerosis presenting with multiple, major organ complications.

We reviewed clinical data, autopsy reports, and microscopic slides on 10 patients with sleep apnea/obesity hypoventilation syndrome (SA/OHS) to define the cardiopulmonary pathological features and establish clinicopathologic correlations. Ten obese (>136 kg) patients without SA/OHS were studied as controls. Patients with SA/OHS exhibited biventricular cardiac failure and pulmonary hypertension with a higher prevalence of moderate/severe pulmonary hemosiderosis (8 v 0 patients), alveolar hemorrhage (7 v 4 patients), capillary proliferation (4 v 0 patients), iron encrustation of elastica (1 v 0 patients) and medial hypertrophy of muscular pulmonary arteries (11.9 +/- 2.4 v 9.7 +/- 1.6%) (P < .05). In two patients capillary proliferation resembled capillary hemangiomatosis. Mean right ventricular thickness was higher in the SA/OHS group (0.71 +/- 0.17 v 0.42 +/- 0.1 cm) (P < .01). Four patients with SA/OHS and three controls had moderate/severe myocardial fibrosis. Biventricular cardiac failure caused death in seven patients with SA/OHS. Hypoxia is probably the most important cause of pulmonary hypertension, arterial muscularization, and right ventricular hypertrophy in SA/ OHS. Left ventricular failure in some SA/OHS patients may be the result of hypertensive cardiac disease. In others, the etiology of left ventricular failure was not determined morphologically, suggesting functional abnormalities related to obesity and/or apneic episodes.

We report an HLA-B27 positive patient with severe psoriatic spondyloarthropathy who developed secondary reactive amyloidosis. The clinical course was characterized by progressive renal failure with nephrotic syndrome and cardiac dysfunction. He died suddenly and autopsy revealed diffuse amyloid deposits in the heart, kidneys, and many other organs. Amyloid deposits were present in the cardiac conduction system including the sinoatrial and atrioventricular nodes, myocardial interstitium, and intramyocardial small blood vessels. The severe AA amyloid deposit in the heart with involvement of conduction system is unusual, and has not been described in patients with psoriasis or psoriatic arthritis.

A case of benign inflammatory pseudotumor of the spleen is described in a 71-year-old man who presented with left upper quadrant pain and anemia. Definitive diagnosis was made by a combination of microscopic examination with immunohistochemical stains and flow cytometry studies. To our knowledge this is only the 24th reported case of inflammatory pseudotumor involving the spleen. Recognition of this rare entity is important because the clinical manifestations and radiographic features may be indistinguishable from a malignant lymphoproliferative disorder. The clinical presentation, radiographic findings, gross and microscopic features, results of surgery, and long-term follow up are reviewed for our case and the previously reported cases in the literature.

This study examines the indications for performing the Kleihauer-Betke (KB) test and makes recommendations for its use. Results of 523 KB tests performed during 1993 at our hospital (Cleveland, Ohio) are reviewed in conjunction with surgical pathology reports of placental findings, obstetric records, and toxicology results. We conclude that the KB test should be performed following a positive screening test on all Rh negative mothers of Rh positive infants. Additional indications include cases of maternal trauma, unexplained increased maternal alpha-fetoprotein levels, fetal distress with abnormal heart tracings, intrauterine fetal death, and cases of unexplained neonatal anemia. We note that the KB test should not be performed to detect suspected placental abruption.

Previous studies have suggested that immune mechanisms contribute to lung injury in cystic fibrosis (CF); however, there have been no comprehensive studies of immunofluorescent staining patterns in CF lung tissue. We performed immunofluorescence (IF) studies for immunoglobulins, C3, and fibrinogen on autopsy frozen lung tissue from 21 CF patients. Results were compared with lung findings in patients without CF. In CF-derived lung tissue fibrinogen was ubiquitous along the alveolar wall, alveolar space, and interstitium. Free immunoglobulin G (IgG) and IgA coated the alveolar surface segmentally in 14 and 6 cases, respectively. Unequivocal interstitial deposits were infrequent and IgM was present in blood vessels in one patient only. Intra-alveolar and interstitial inflammatory cells demonstrated cytoplasmic IgG, IgA, and IgM, respectively, in 18, 14, and 6 patients. C3 was seen only segmentally along the alveolar wall in two patients and in blood vessels in one. Antinuclear antibody (ANA) staining of interstitial cells for C3 and immunoglobulins was seen in five patients, four of whom had interstitial pneumonitis. Insignificant amounts of alveolar or interstitial fibrinogen and immunoglobulins in inflammatory cells were seen in controls in the absence of lung inflammation. The IF patterns were similar in the inflammatory lesions of CF and control specimens. The IF patterns observed in CF lung tissue are consistent with nonspecific vascular leakage and chronic inflammation with little evidence of immune complex deposition in the interstitium or blood vessels. This study confirms previous reports of ANA activity in CF patients, although the significance of this finding is unknown.

We describe a patient with hypocomplementemic urticarial vasculitis syndrome complicated by recurrent pericarditis and cardiac tamponade. The episodes of pericarditis were associated with urticarial vasculitis, hypocomplementemia, and circulating IgG antibodies to the collagen-like region of Clq. Histopathologic examination of the skin and pericardium demonstrated vasculitis associated with immunoglobulin and complement deposition suggesting an immune complex mediated etiology. Recurrent pericarditis should be included in the clinical spectrum of hypocomplementemic urticarial vasculitis syndrome.

A 67-yr-old man, known to have chronic obstructive lung disease, developed bilateral localized pulmonary densities on chest radiographs after cardiopulmonary resuscitation. An autopsy disclosed bilateral intrapulmonary hematomas without communication with bronchi, pulmonary arteries, or pleural cavities. We suggest blunt pulmonary injury is the most probable cause of the hematomas and discuss its pathogenic mechanism. Intrapulmonary hematomas should be considered in the differential diagnosis of pulmonary densities developing after a vigorous resuscitation.

A case of unusual cholecystitis that developed on completion of interleukin-2 and lymphokine-activated killer cell therapy is described. A 62-year-old man was treated with interleukin-2 and lymphokine-activated killer cells for disseminated renal cell carcinoma. During the course of the immunotherapy, his serum alkaline phosphatase level increased, as did the peripheral eosinophil count (0.31). Subsequently, clinical and radiologic evidence of acute cholecystitis was noted. The removed gallbladder showed acalculus cholecystitis with extensive diffuse infiltrates of numerous eosinophils and T lymphocytes, but sparse polymorphonuclear leukocytes. The authors name this unusual cholecystitis acalculus lymphoeosinophilic cholecystitis and believe it to be associated with interleukin-2 and lymphokine-activated killer cell therapy. The pathogenic relationship is discussed.

Round atelectasis (shrinking pleuritis) is typically a localized process characterized by focal pleural scarring and subjacent peripheral atelectasis. We report three patients, studied at autopsy, with an unusual variant of round atelectasis, termed shrinking pleuritis with lobar atelectasis, which is characterized by lobar atelectasis, visceral pleural fibrosis involving multiple lobes, interlobar fibrous cords, pleural effusion, and nonspecific, persistent infiltrates on chest radiogram. The possible causes of shrinking pleuritis with lobar atelectasis in our patients were multiple and included environmental dust exposure, infection, uremia, and recurrent pleural effusions. Our findings support both the folding (pleural effusion) and fibrosing (pleural injury) theories of pathogenesis of round atelectasis and emphasize the spectrum of morphologic variability in this condition.

We report a 20-year-old patient with arteriohepatic dysplasia (Alagille's syndrome) who developed progressive renal failure associated with extensive renal lipidosis. A renal biopsy showed diffuse thickening of glomerular basement membrane mimicking idiopathic membranous glomerulonephritis on light microscopy. Electron microscopy, however, demonstrated numerous intramembranous and mesangial lipid deposits, quite similar to those described in familial lecithin cholesterol acyltransferase deficiency. We believe the renal lipidosis developed secondary to hyperlipidemia associated with longstanding intrahepatic cholestasis. This case illustrates that extensive lipid deposition in the glomerular basement membrane may occur in patients with arteriohepatic dysplasia, and it may lead to progressive renal failure.

The renal extraction of beta 2-microglobulin (beta 2M) was investigated under steady-state conditions achieved by constant infusion of human beta 2M. Fifteen animal experiments were conducted. Beta 2 microglobulin was infused at rates ranging from 51 o 269 micrograms/min. The renal arterial and venous blood levels remained constant throughout the study period. The data showed that renal extraction of beta 2M exceeded the rate of filtration at all levels of beta 2M delivered to the kidney. The tubular uptake of filtered beta 2M increased linearly as did the extraglomerular extraction throughout the range investigated. There was no evidence of beta 2M (FE beta 2M) increased linearly with the fractional excretion of filtered water (FE H2O). The results are interpreted to indicate that beta 2M is extracted from renal blood by glomerular filtration and, in addition, by a mechanism independent of glomerular filtration rate (GFR). Under the conditions existing in these experimental animals, the linear relationship between FE beta 2M and FE H2O is evidence to suggest that factors affecting proximal tubular water reabsorption also affect beta 2M reabsorption.

Direct immunofluorescent staining with fluorescein isothiocyanate conjugated goat anti-human beta 2-microglobulin (beta 2M) was used to determine the localization of beta 2M in kidney tissue, obtained by biopsies or nephrectomies for various renal diseases. beta 2M was found in the renal tubular epithelial cell cytoplasm and occasionally in the tubular basement membranes in 48 out of 79 pathologic specimens tested, but not in 3 normals. beta 2M was seen in the tubular cells in all cases of primary tubulointerstitial disease and in all cases with secondary tubular damage associated with glomerular disease or systemic disease. This supports the concept that beta 2M is metabolized in proximal tubular epithelial cells, and its deposition indicates impairment of tubular handling.

We report 3 cases of acquired cystic disease of the kidneys with associated renal carcinoma in 2 of the cases. In all 3 cases, the patients had chronic renal insufficiency due to hypertension but had never required dialysis. Review of 176 reported cases of acquired cystic disease of the kidneys and renal tumors disclosed that 18 patients (including 1 previously reported by us) had never received dialysis treatment. These cases support the hypothesis that acquired cystic disease of the kidney is not restricted to patients treated with maintenance dialysis. Among the 18 patients, hypertension was the most common underlying cause of renal failure. Patients with chronic renal failure due to or associated with severe hypertension should be monitored carefully for the development of both renal cysts and tumors even though they have not started on chronic dialysis.

beta 2-microglobulin (beta 2M) is a protein of 11,800 daltons which occurs in the plasma of normal individuals at concentrations of approximately 2 microgram/ml. It is presumed to be relatively freely filterable. More than 99% of the filtered beta 2M is taken up by an active reabsorptive mechanism and catabolized by the renal tubule. The data presented here demonstrate that renal extraction is only slightly diminished by complete ureteral obstruction. The renal extraction of beta 2M is greater than can be accounted for by filtration alone. These data indicate that some uptake of beta 2M occurs from the peritubular capillary circulation. The loading of animals with beta 2M is associated with a marked tubular proteinuria suggesting that this protein may play a part in inducing tubular injury.

This paper reports two cases of acquired renal cysts and multiple renal cell tumors in end-stage kidneys with a discussion of the pathogenesis of these lesions. The first patient had been on maintenance dialysis for approximately three years when he was found to have multiple renal cysts and renal cell tumors. He subsequently developed multifocal urothelial carcinomas of the lower urinary tract. The second patient had progressive renal failure due to hypertensive vascular disease when he underwent left nephrectomy because of multiple renal cysts and renal cell carcinoma. He later developed terminal renal failure and was maintained on chronic dialysis. He expired three years later. At autopsy, the right kidney also demonstrated multiple cysts and renal cell tumors.