Carcinoma En Cuirasse: A Rare but Striking Cutaneous Manifestation of Metastatic Breast Cancer.

Carcinoma en cuirasse is a rare cutaneous metastatic presentation of breast cancer with a poor prognosis. We report a female in her 70s with a prior history of left breast ductal carcinoma in situ status post-radiation and lumpectomy who presented with skin thickening of the left breast and a few solid masses in bilateral breasts. Biopsy showed invasive ductal carcinoma of the left breast (estrogen receptor [ER]/progesterone receptor positive [PR], human epidermal growth factor receptor-2 [HER2] negative) and ductal carcinoma in situ of the right breast (ER/PR positive). She underwent a right breast lumpectomy; however, the left breast mastectomy was aborted due to the worsening of her skin findings on preoperative examination. A skin biopsy revealed poorly differentiated invasive ductal carcinoma. She was diagnosed with stage 4 breast cancer, specifically carcinoma en cuirasse. Systemic treatment was initiated, followed by a left breast mastectomy. A surgical biopsy was HER2-positive, and therefore anti-HER2 therapy was given. She remains on maintenance therapy with an excellent response at present.Any unexplained skin findings in breast cancer patients should prompt consideration of carcinoma en cuirasse. With ongoing treatment advances, many newer therapy options are available for metastatic breast cancer. Based on our case, we think that patients with this disease can have better outcomes.

Interventions to improve resident reporting of patient safety events: a quality improvement initiative.

BACKGROUND: Patient safety events (PSE) are opportunities to improve patient care but physicians rarely report them. In a previous study, residents identified knowledge regarding what constitutes a PSE, perceived lack of time, complexity of the reporting process, lack of feedback, and perceived failure to resolve the issue despite reporting to be barriers limiting their PSE reporting. The residency programs and system patient safety and quality improvement departments created targeted interventions to address identified barriers. OBJECTIVE: Assess effectiveness of targeted interventions on improving PSE reporting rates amongst residents. METHODS: As part of a multi-residency patient safety project, interventions were created to focus on the removal of barriers to reporting PSE identified previously. Post-interventions, an identical cross-sectional survey of the residents at the same two community teaching hospitals was conducted from Sept to Dec 2018 through an online questionnaire tool. RESULTS: 78 out of 149 residents (52.3%) completed the survey. We found a significant improvement in the number of residents who endorsed reporting a PSE in the past 1 year (51.2% vs 23.5%, p = 0.001), as well as during the course of their training (52.6% vs 26.5%, P = 0.001). There was also a significant decrease in the number of residents who were unsure of how to report a PSE (p = 0.031) as well as those who viewed medical error as a sign of incompetence (p = 0.036). CONCLUSION: Our study demonstrates that simplifying the PSE reporting process, improving knowledge and acceptance of patient safety/quality improvement principles and promotion of a just culture improves resident PSE reporting.

An Elusive Diagnosis: Case Reports of Secondary Hemophagocytic Lymphohistiocytosis and Review of Current Literature.

Hemophagocytic lymphohistiocytosis (HLH) is a rare and serious hematologic disorder characterized by severe immune system dysregulation with a cytokine storm and histologic evidence of hemophagocytosis. It can be inherited or develop secondary to other diseases. We present three cases of secondary HLH in patients with distinct backgrounds. Our objective is to characterize the unique features of the disease, its underlying associations, treatment, and potential prognostic variables. The first case was a 20-year-old male with a history of intravenous (IV) drug abuse who presented with multi-organ failure and septic shock. A diagnosis of HLH was suspected after finding a ferritin of >100,000 ng/mL and confirmed with bone marrow biopsy. Furthermore, the patient was found to have significant Epstein-Barr virus (EBV) viremia. He responded well to the HLH-94 protocol with the addition of rituximab and ganciclovir. The second case was a 50-year-old female with a history of human immunodeficiency virus (HIV) who presented with multi-organ failure and severe anemia. Ferritin was also significantly elevated and a bone marrow biopsy confirmed the diagnosis of HLH. She was started on HLH-94 protocol. Despite treatment, the patient expired due to worsening renal failure and shock. Her autopsy report also showed evidence of Hodgkin's lymphoma. The third case was a 57-year-old male with a history of Crohn's disease treated with infliximab and adalimumab, who presented with multi-organ failure and pancytopenia. A diagnosis of HLH was made based on clinical findings and later confirmed on bone marrow biopsy. He responded to HLH-94 protocol but experienced fatal gastrointestinal bleeding. Patients presenting with HLH are often critically ill and deteriorate rapidly. The diagnosis is often challenging to establish due to its variable presentation and association with other pathologies. A moderate index of suspicion should be present for patients who have febrile illness with pancytopenia, multi-organ failure, high ferritin, and low fibrinogen levels. We discuss associations with viral infections, hematologic malignancies and immunosuppressive therapy. Treatment is directed at suppressing the immune response and for secondary HLH, addressing the underlying conditions, such as use of rituximab for EBV viremia and treatment of lymphoma.