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Catastrophic antiphospholipid antibody syndrome (CAPS) is characterized by fulminant thrombosis of the arterial and venous beds of multiple organ systems over a relatively short period of time and with a high mortality rate. Mucosa-associated lymphoid tissue (MALT) lymphoma of the lung has never been reported as a causative or precipitating factor for CAPS in the CAPS registry database. The present study describes a rare case of pulmonary MALT lymphoma of the lung that presented as CAPS. A 19-year-old Hispanic female presented with shortness of breath and abdominal pain. Computed tomography (CT) scans of the chest and abdomen revealed multiple portal vein thromboses and bilateral pulmonary nodules. Within one week of presentation, the patient developed a straight sinus thrombosis and upper extremity deep vein thrombosis, which led to shortness of breath. A biopsy of the lung nodule revealed MALT lymphoma. The present case illustrates a rarely reported pulmonary MALT lymphoma presenting as CAPS in a young female. The patient was successfully treated with 90 mg/m2 bendamustine on days one and two and rituximab 375 mg/m2 on day one of each 28-day cycle. Complete remission of the lung nodules was observed following three cycles of treatment, as visualized by positron emission tomography (PET)/CT scan. Fondaparinux was identified as a feasible anticoagulation drug of choice for this case. At seven months post-treatment, the patient continues to be stable with no further evidence of thrombosis and is currently undergoing rituximab maintenance therapy every six months for two years. A repeat lupus anticoagulant antibody assay turned and remained negative during the clinical follow-up period. A prompt diagnosis and early aggressive treatment is potentially curative and may dramatically decrease the mortality risk. Future studies should explore the role of rituximab in the management of CAPS-associated B-cell lymphoid malignancies.

Prescribing opioids for chronic non-cancer pain (CNCP) is a challenge due to associated risks from abuse, addiction and adverse effects. We surveyed resident physicians on their knowledge, attitude and practices in opioid prescription practices in the ambulatory setting and conducted an educational module to address their knowledge gaps.A phase 1 survey assessed knowledge, attitudes and practices of residents in the out-patient management of CNCP with opioids. Demographics, numbers of patients seen, those with concerns for risky behaviors, adverse effects and the reasons for concern were also recorded. In Phase 2, an educational module in the form of didactics and case based discussions addressed the perceived deficiencies noted from results of phase 1 survey. Pre and post module surveys assessed the effectiveness of the educational module.In the phase 1 study (45/49, 92% response rate, M:F = 30:15) 33.3% (15/45) were in Post-Graduate Year (PGY) 1, 35.6% (16/45) PGY2s and 31.1% (14/45) PGY3s; 80% (36/45) saw more than one patient with CNCP in the previous 3 months; 62.2% (28/45) had at least one patient with concerns for misuse and addiction; 77.8% (35/45) and 86.7% (39/45) reported a lack of training and consistent documentation respectively, and 82.2% (37/45) were uncomfortable to refill for other provider's patients. All (100%, 45/45) consulted the clinical pharmacist; 86.7% (39/45) believed that either focused education would be beneficial. In the phase 2 study (44/49, 89.7% response rate, M: F = 29: 15), the pre- and post-module responses showed that90% of the residents perceived improvement in knowledge and confidence in management of CNCP with opioids after the educational module.Internal medicine residents perceived deficits in their ability to manage CNCP. Following a focused educational training, residents' knowledge and confidence in prescription of opioids improved, demonstrating the need to include management of CNCP with opioids into their curriculum.

Acknowledging the existence and development of sexuality in a person with a disability is difficult for society. There is a tendency to infantilize individuals, regardless of their age, denying their need to learn about themselves, their sexuality and their psychosocial development. Therefore, many individuals with physical or developmental disabilities find themselves in a position where no one in their environment is willing to deal with or even recognize their developing sexuality. SIECUS advocates that persons with physical and/or mental disabilities receive sexuality education, sexual health care, and opportunities for socializing and sexual expression. Social agencies and health care delivery systems should develop policies and procedures that will ensure that their services and benefits are provided on an equal basis to all persons without discrimination because of disability. Educational and training programs for health care workers and family members are suggested to enable them to understand and support the normal sexual development and behavior of persons with disabilities. Please note that SIECUS does not sell or distribute any of the listed publications, other than SIECUS publications. However, almost all of these resources are available for use at SIECUS' Mary S. Calderone Library. Copies of this bibliography can be purchased from SIECUS' publications department at the following costs: 1-4 copies/S2.50 each; 5-49 copies/S2.00 each; 50+ copies/S1.50 each; plus 15% postage and handling (p/h). SIECUS is located at 130 W. 42nd St., Suite 2500, New York, NY 10036; 212/ 819-9770. This annotated listing of sexuality and disability materials was prepared by James Shortridge, Director of Library Services; Laura Steele-Clapp, library assistant, and Jennifer Lamin, volunteer assistant.

Introduction: Brown recluse spider bites are encountered commonly in endemic areas of North and South America. Loxosceles reclusa is the species of Loxosceles most commonly seen in the states of MO, KS, OK, TX, AK, LA, KY, TN, MS, AL and parts of IL, IA, IN and GA. The incidence of hemolytic anemia with systemic loxoscelism in the USA seems to be significantly higher and more severe than the incidence and severity reported in studies from South America (13%-15% incidence). In our 6 cases of loxoscelism associated with severe hemolysis, we noticed that there are signs and symptoms that could be helpful to guide the follow up and facilitate early diagnosis. Method: We reviewed 6 cases of hemolytic anemia from Loxoscelism treated at the University of Missouri Hospitals. Of these 6 cases 4 were treated within 1 year. All of the cases presented with systemic and cutaneous manifestations. Each patient was initially treated symptomatically and discharged without a close follow up. This resulted in delayed presentations with symptoms of severe hemolytic anemia associated with significant morbidity [Syncope (1), Syncope with fracture (1), Hypotension needing ICU care (1), Necrotizing fasciitis (1), and severe hepatosplenomegaly with hyperbilirubinemia (1)]. We have summarized the systemic symptoms, peripheral blood smear and laboratory findings that correlate with hemolytic anemia. Results:Patients presented with Nausea (6/6), Vomiting (5/6), Fever (5/6), and Target lesion (6/6) within 48 hours after spider bite [Table 1]. Severe hemolysis developed at a median of 6.5 days after the spider bite. DAT was positive for IgG and C3 in all of the cases. Peripheral smear findings included leukocytosis with toxic granulations, Dohle bodies and left shift, Nucleated RBC, anisopoikilocytosis with some schistocytes, hemophagocytosis and normal to decreased platelets [[Figure 1][1]] [[Figure 3][2]]. When not recognized patients presented with sudden and severe hemolysis (median drop in Hb =7.5 g/dL) [Table2] resulting in hospitalization with severe morbidity ([Figure 2][3]). | | Initial Presentation | Significant Morbidity | | --------- | ------------------------------------------------------------------------------------------------ | --------------------------------------------------------- | | Patient 1 | Nausea and vomiting. Fever. Diffuse rash, RUQ pain Target lesion on back | Severe Jaundice Hepatomegaly Splenomegaly | | Patient 2 | Nausea, vomiting and diarrhea. Fever Target lesion on left arm | Syncope Ankle fracture | | Patient 3 | Nausea, fatigue and malaise. Target lesion on right back | Recurrent syncope | | Patient 4 | Nausea, Vomiting Fever Target lesion right arm. | Severe Hypotension ICU care | | Patient 5 | Nausea, dry heaves Fever. Thigh pain Target lesion right thigh. | Necrotizing fasciitis Fasciotomy | | Patient 6 | Nausea, vomiting and fatigue. Fever. Target lesion right shoulder. | | Table 1 ![Figure 1:][4] Figure 1: Peripheral Smear Findings of Systemic Loxoscelism ![Figure 2:][4] Figure 2: Significant Morbidity from Systemic Loxoscelism ![Figure 3:][4] Figure 3: Peripheral smear findings | | Patient 1 | Patient 2 | Patient 3 | Patient 4 | Patient 5 | Patient 6 | Median | | ------------------------------------ | --------- | --------- | --------- | --------- | --------- | --------- | ------ | | Age | 34 | 31 | 21 | 25 | 21 | 22 | 23.5 | | Days after bite to lowest Hemoglobin | 8 | 5 | 6 | 6 | 7 | 9 | 6.5 | | Baseline Hb (g/dL) | 11 | 12 | 15 | 13 | 13.8 | 15.7 | 13.4 | | Lowest Hb (g/dL) | 5.7 | 4 | 5 | 6 | 6.6 | 8.4 | 5.85 | | MCV with lowest Hb (fL) | 70 | 107 | 100 | 90 | 96.6 | 101 | 98.3 | | WBC (103/µL) | 12.6 | 42 | 32.3 | 14.5 | 33.4 | 26.6 | 29.45 | | Platelets (103/µL) | 160 | 141 | 234 | 64 | 261 | 576 | 197 | | LDH (unit/L) | hemolysed | 2080 | 951 | 1348 | 744 | 346 | 951 | | T. Bili (mg/dL) | 35.4 | 13.2 | 5 | 1.8 | 3.7 | 7.4 | | | D. Bili (mg/dL) | >10 | 9.2 | .3 | .5 | 0.3 | 1.4 | | | Ind. Bili (mg/dL) | | 3.9 | 4.7 | | | | | | AST (unit/L) | 100 | 52 | 25 | 201 | 120 | 156 | | | ALT (unit/L) | 86 | 95 | 19 | 91 | 104 | 294 | | | Alk phos (unit/L) | 94 | 88 | 67 | 36 | 160 | 159 | | | Blood group | A Pos | A Pos | O Pos | B Pos | O Pos | | | Table 2 Discussion: Systemic loxoscelism from Loxosceles reclusa in USA is associated with a high incidence of severe hemolytic anemia. Increased awareness of the delayed presentation with hemolysis after initial signs of systemic loxoscelism could avoid life threatening events. Initial symptoms developed within 48 hours of the spider bite and led to medical attention in all of the reported cases. With appropriate follow up, peripheral smear review and labs at 5-7 days after the spider bite most of the cases would have been recognized early and could have potentially avoided life threatening complications. The different species of Loxosceles prevalent in South America could explain the difference in the incidence of hemolytic anemia. Studies from Brazil have reported the use of antivenom in about 50% of loxoscelism cases. Effectiveness of antivenom is not established and is seldom used in the USA but, could account for some differences in the incidence of hemolysis. Disclosures No relevant conflicts of interest to declare. [1]: #F1 [2]: #F3 [3]: #F2 [4]: pending:yes

e19088 Background: Fluoro-deoxyglucose positron emission tomography-computed tomography 18F FDG PET-CT (PET) is a useful tool for diagnosis, staging, and confer prognostic information based on trea...