Ewing's sarcoma of the ilium presenting as unilateral sacroiliitis.

We describe a 24-year-old man who presented with unilateral sacroiliac pain associated with constitutional symptoms. Subsequent biopsy and pathohistologic evaluation demonstrated Ewing's sarcoma. We emphasize a consideration of Ewing's sarcoma in the differential diagnosis of unilateral sacroiliac pain.     

Symptomatic adult polycystic liver disease in a young woman.

Adult polycystic liver disease is an entity that is striking for the presence of extraordinary hepatomegaly. Very rarely do patients under 40 years of age experience problems and only a minority of middle-aged patients manifest symptoms due to organ compression or biliary tree obstruction. The clinical course is usually benign, and no specific therapy is required. The onset of right upper quadrant pain, back pain, and shortness of breath prompted evaluation of a 32-year-old woman with progressive hepatomegaly. CT scan revealed a massive cyst-riddled liver with posterior displacement of the spleen, compression of the pancreas, and renal cysts. Prothrombin time, albumin, and liver enzyme values were normal except for a mildly elevated gamma-glutamyl transpeptidase.     

Clear cell adenocarcinoma of the vagina and cervix: incidence, undetected disease, and diethylstilbestrol

We conducted an incidence study to determine the occurrence rates of clear cell adenocarcinoma (CCAC) of the vagina and cervix in young women (born in 1940 and thereafter), and a case-series analysis, focusing on the maternal history of pregnancy and delivery and in-utero exposure to diethylstilbestrol (DES). Overall, 10 cases of CCAC had been listed in the files of the Connecticut State Tumor Registry prior to the study, and each of the 10 cases were confirmed as valid. In addition, another 10 cases, all previously undetected, were found after the tissue slides of young women listed as having other cancers of the vagina and cervix were reviewed by expert pathologists, suggesting that prior estimates of the incidence rate for CCAC must be misleading unless special efforts are taken to identify undetected cases. The incidence rates of vaginal CCAC (11 cases total) were highest in 1975-1979, and decreased slightly during 1980-1982. In the cervix (nine cases total), the rate increased consistently since 1970. History of in-utero exposure to diethylstilbestrol was obtained for five of eight vaginal cases and four of eight cervical cases of CCAC. In all nine cases, exposure to diethylstilbestrol was associated with a history of bleeding during the pregnancy or prior miscarriage. We conclude that the finding of stable (or rising) incidence rates for CCAC occurring nearly 30 years after the marked decrease in diethylstilbestrol sales emphasizes the need for continued clinical and epidemiologic studies of the etiology and clinical course of CCAC.     

The shape of things to come: Part 3. Inspiring peak performance

New "contingent" compensation programs tailored to the hospital work unit provide employees with incentive payments for outstanding performance that augment--or replace--the annual merit increase.     

Risk factors for psychiatric inpatient assaults on staff

The risk of psychiatric patient assaults on staff members is increasing yearly, with resultant increases in employee victim suffering, medical expense, and lost productivity. Traditionally considered a clinician responsibility, the management of patient violence also has important administrative implications. This article presents a review of the risk factors associated with violence that includes the characteristics of patients who assault but adds the characteristics of employee victims of such assaults as well as contextual variables. Additional data from a two-year study of a peer-help crisis intervention program for employee victims of patient assaults are included. The mental health administrative implications of this approach are outlined.     

Critical incident stress management (CISM): the assaultive psychiatric patient

Critical Incident Stress Management (CISM; Everly & Mitchell, 1999) is an integrated, multicomponent crisis intervention approach that is helpful in mitigating and preventing the potentially adverse consequences associated with critical incidents. The CISM model may serve a valuable heuristic purpose in the planning and development of CISM approaches in a wide variety of organizations and industries. This paper reports on the use of the CISM approach (Everly & Mitchell, 1999) as a guide or template in developing an enhanced and updated Assaulted Staff Action Program (ASAP; Flannery, 1998) approach to service delivery. ASAP is a voluntary, peer-help, CISM approach for staff who are assaulted by patients. The updating of its comprehensive services was necessitated by recent research and clinical experience on the changing nature of the assaultive psychiatric patient.     

Victim identification and family support in mass casualties: the Massachusetts model

The Aviation Disaster Family Assistance Act of 1996 requires the National Transportation Safety Board (NTSB), air carriers, and the American Red Cross (ARC) to provide an integrated family assistance center to offer support to family survivors of mass casualties. A central component of post-incident response is the timely identification of victims and their personal belongings. This identification process occurs through antemortem interviews with family survivors. ARC of Massachusetts Bay determined that ARC volunteers would not play a major role in conducting antemortem interviews, and deferred primary responsibility for this task to the Massachusetts Office of the Chief Medical Examiner (OCMB). This paper presents the Massachusetts model for victim identification and family support at the local level. The structure and services of this model for on-site forensic processing, the fielding of antemortem interviewers, and a comprehensive training curriculum in psychological trauma and victim identification are presented. The implications are discussed.     

Aluminum is a weak agonist for the calcium-sensing receptor

BACKGROUND: Aluminum (Al3+) has diverse biological effects mediated through activation of a putative extracellular cation-sensing receptor. A recently identified calcium-sensing receptor (CaSR), which has been identified in target tissues for Al3+, may transduce some of the biological effects of Al3+. METHODS: To test this possibility, we transfected human embryonic kidney 293 (HEK 293) cells with a cDNA encoding the rat CaSR and evaluated CaSR expression by Western blot analysis and function by measurement of intracellular calcium ([Ca2+]i) levels and inositol monophosphate (IP1) generation following stimulation with Al3+ and a panel of CaSR agonists. RESULTS: The CaSR protein was detected by immunoblot analysis in cells transfected with the CaSR cDNA but not in nontransfected HEK 293 cells. In addition, [Ca2+]i levels and IP1 generation were enhanced in a dose-dependent fashion by additions of the CaSR agonists calcium (Ca2+), magnesium (Mg2+), gadolinium (Gd3+), and neomycin only in cells transfected with CaSR. To determine if Al3+ activated CaSR, we stimulated cells transfected with rat CaSR with 10 microM to 1 mM concentrations of Al3+. Concentrations of Al3+ in the range of 10 microM to 100 microM had no effect on [Ca2+]i levels or IP1 generation. In contrast, 1 mM Al3+ induced small but significant increases in both parameters. Whereas Gd3+ antagonized calcium-mediated activation of CaSR, pretreatment with Al3+ failed to block subsequent activation of rat CaSR by Ca2+, suggesting a distinct mechanism of Al3+ action. CONCLUSION: Al3+ is not a potent agonist for CaSR. Because Al3+ affects a variety of target tissues at micromolar concentrations, it seems unlikely that CaSR mediates these cellular actions of Al3+.