Case 2-2016. An 84-Year-Old Woman with Chest Pain, Dyspnea, and a Rash.

An 84-year-old woman was admitted to the hospital because of chest pain, respiratory distress, and a purpuric rash. Initial chest imaging showed bilateral patchy and confluent opacities, a finding consistent with pulmonary edema. A diagnostic procedure was performed.

Cutaneous reactions to chemotherapeutic drugs and targeted therapies for cancer: part I. Conventional chemotherapeutic drugs.

Conventional chemotherapy continues to be an important part of cancer management, but may cause various cutaneous reactions because it disturbs specific cell cycle phases. The alkylating agents cyclophosphamide, ifosfamide, and thiotepa can produce hyperpigmentation, while hypersensitivity reactions can be seen with platinum alkylating agents. Antimetabolites vary in reactions from exanthematous to bullous skin lesions. 5-fluorouracil and its derivatives and liposomal doxorubicin and daunorubicin are characteristically known to cause hand-foot syndrome, while bleomycin can cause fibrosis and flagellate dermatitis. Several hypersensitivity reactions may also occur from mitotic inhibitors and topoisomerase inhibitors. These different characteristic presentations are important to dermatologists in identifying the correct diagnosis and management for the cancer patient.

Cutaneous reactions to chemotherapeutic drugs and targeted therapy for cancer: Part II. Targeted therapy.

Targeted drugs are increasingly being used for cancer management. They are designed to block specific cancer cell processes, and are often better tolerated than conventional chemotherapeutic drugs. Cutaneous reactions, however, are not uncommon, because some target molecules are also present in the skin. Tyrosine kinase inhibitors can cause edema and macular rash, whereas papulopustular rash, paronychia, regulatory changes in hair, itching, and dryness caused by epidermal growth factor receptor inhibitors (PRIDE) syndrome can be seen in patients treated with these drugs. Vismodegib may result in muscle spasms and alopecia. Multiple rashes can be seen with bortezomib, while sunitinib and sorafenib cause hand-foot skin reactions. New melanoma therapies, such as ipilimumab, cause immune-related adverse events of dermatitis and pruritus, while BRAF inhibitors can produce exanthematous rash and lead to an increased risk of squamous cell carcinoma. Dermatologists should be aware of these new therapies and their cutaneous reactions to be able to provide appropriate care and management for cancer patients.

Evaluation of an intelligent tutoring system in pathology: effects of external representation on performance gains, metacognition, and acceptance.

OBJECTIVE: Determine effects of computer-based tutoring on diagnostic performance gains, meta-cognition, and acceptance using two different problem representations. Describe impact of tutoring on spectrum of diagnostic skills required for task performance. Identify key features of student-tutor interaction contributing to learning gains. DESIGN: Prospective, between-subjects study, controlled for participant level of training. Resident physicians in two academic pathology programs spent four hours using one of two interfaces which differed mainly in external problem representation. The case-focused representation provided an open-learning environment in which students were free to explore evidence-hypothesis relationships within a case, but could not visualize the entire diagnostic space. The knowledge-focused representation provided an interactive representation of the entire diagnostic space, which more tightly constrained student actions. MEASUREMENTS: Metrics included results of pretest, post-test and retention-test for multiple choice and case diagnosis tests, ratios of performance to student reported certainty, results of participant survey, learning curves, and interaction behaviors during tutoring. RESULTS: Students had highly significant learning gains after one tutoring session. Learning was retained at one week. There were no differences between the two interfaces in learning gains on post-test or retention test. Only students in the knowledge-focused interface exhibited significant metacognitive gains from pretest to post-test and pretest to retention test. Students rated the knowledge-focused interface significantly higher than the case-focused interface. CONCLUSIONS: Cognitive tutoring is associated with improved diagnostic performance in a complex medical domain. The effect is retained at one-week post-training. Knowledge-focused external problem representation shows an advantage over case-focused representation for metacognitive effects and user acceptance.

Scalp metastasis from esophageal adenocarcinoma.

There are few reported cases of cutaneous metastases of esophageal carcinoma, especially of esophageal adenocarcinoma, but reports may become more common as the incidence of esophageal cancer increases. We present a case of a 67-year-old man with metastatic esophageal cancer in the scalp. Clinical and histologic findings are discussed, and recommendations for clinicians are suggested.