Low-grade adenosquamous carcinoma of the breast: a clinical, morphological and immunohistochemical analysis of 25 patients.

AIMS: Due to its rarity and non-specific clinical and pathological features, low-grade adenosquamous carcinoma (LGASC) of the breast continues to pose diagnostic challenges. Unlike other triple-negative breast carcinomas, LGASC tends to have an indolent clinical behaviour. It is essential to recognise this lesion for accurate diagnosis and appropriate management. METHODS AND RESULTS: Twenty-five cases of LGASC were identified in our archives and collaborating institutes. Cases of LGASC with dominant coexisting other type carcinomas were excluded. We studied the clinical presentation, morphological features, patterns of the commonly used immunohistochemical stains and follow-up. In our cohort, LGASC was commonly located at the outer aspect of the breast and associated with intraductal papilloma. The morphology of LGASC is characterised by infiltrating small glands and nests with variable squamous differentiation. We also found cuffing desmoplastic (fibrolamellar) stromal change in 75% of patients and peripheral lymphocytic aggregates in 87.5% of patients. P63 and smooth muscle myosin (SMM) were the most common myoepithelial markers used to assist in diagnosis. P63 often stained peripheral tumour cells surrounding invasive glands (circumferential staining in 80% of the cases), mimicking myoepithelial cells. It also stained the small nests with squamous differentiation. However, SMM was negative in 63% of the cases. The vast majority of our cases were triple-negative; only a few had focal and weak expressions of ER and PR. One patient who did not have excision developed lymph node metastasis. Most patients underwent excision or mastectomy with negative margins as surgical treatment; there were no recurrences or metastases in these patients with clinical follow-ups up to 108 months. CONCLUSIONS: LGASC has some unique, although not entirely specific, morphological features and immunohistochemical staining patterns. Fibrolamellar stromal change, peripheral lymphocytic aggregates and variable staining of p63 and SMM are valuable features to facilitate the diagnosis.

Misdiagnosis of Bell's palsy: Case series and literature review.

Although Bell's palsy is a common etiology for isolated facial paralysis, it is important clinicians perform a complete neurologic examination to avoid misdiagnosis. Multiple cranial neuropathy is often caused by tumor or infection.

Mammary mesenchymal and fibroepithelial lesions: An illustrated cytomorphologic update with differential diagnoses.

The Uniform Approach to Breast Fine Needle Aspiration Biopsy was put forward by a learned group of breast physicians in 1997. This landmark manuscript focused predominantly on diagnosis and reporting of mammary epithelial lesions. Today, most American practitioners turn initially to core biopsy rather than aspiration biopsy for the first line diagnosis of solid breast lesions; however, recent efforts from the International Academy of Cytology have produced a system called the Standardized Reporting of Breast Fine Needle Aspiration Biopsy Cytology (colloquially labeled in 2017 as the "Yokohama System"), suggesting a new interest in breast fine needle aspiration (FNA), especially in resource limited settings or clinical practice settings with experienced breast cytopathologists. Fibroepithelial lesions of the breast comprise a heterogeneous group of biphasic tumors with epithelial and stromal elements. Mesenchymal lesions of the breast include a variety of neoplasms of fibroblastic, myofibroblastic, endothelial, neural, adipocytic, muscular, and osteo-cartilaginous derivations. The cytology of mesenchymal breast lesions is infrequently described in the literature and is mainly limited to case reports and small series. This illustrated review highlights the cytologic features of fibroepithelial and mesenchymal mammary proliferations and discusses differential diagnoses and histomorphologic correlates.

A Pilot Study of Computer-Based Simulation Training for Enhancing Family Medicine Residents' Competence in Computerized Settings.

We previously developed a prototype computer-based simulation to teach residents how to integrate better EMR use in the patient-physician interaction. To evaluate the prototype, we conducted usability tests with three non-clinician students, followed by a pilot study with 16 family medicine residents. The pilot study included pre- and post-test surveys of competencies and attitudes related to using the EMR in the consultation and the acceptability of the simulation, as well as 'think aloud' observations. After using the simulation prototypes, the mean scores for competencies and attitudes improved from 14.88/20 to 15.63/20 and from 22.25/30 to 23.13/30, respectively; however, only the difference for competencies was significant (paired t-test; t=-2.535, p=0.023). Mean scores for perceived usefulness and ease of use of the simulation were good (3.81 and 4.10 on a 5-point scale, respectively). Issues identified in usability testing include confusing interaction with some features, preferences for a more interactive representation of the EMR, and more options for shared decision making. In conclusion, computer-based simulation may be an effective and acceptable tool for teaching residents how to better use EMRs in clinical encounters.

MUC1 is expressed at high frequency in early-stage basal-like triple-negative breast cancer.

Triple-negative breast cancer comprises 10% to 15% of newly diagnosed breast cancer and lacks expression of the estrogen, progesterone, and human epidermal growth factor receptor 2/neu receptors. Many such tumors are basal like, a molecular intrinsic subtype of breast cancer associated with poor clinical outcomes. Patients with early-stage basal-like triple-negative breast cancer are at a high risk for relapse and may, therefore, benefit from novel therapies, including immunotherapy. MUC1 is a tumor antigen expressed on adenocarcinomas and represents an ideal target for MUC1-based vaccination. We evaluated 52 cases of early-stage basal-like triple-negative breast cancer for MUC1 expression by immunohistochemistry. The intensity of staining was graded according to the intensity (negative [0], positive [1], or strongly positive [2]) and percentage (0%-100%) of tumor cells staining for MUC1. An overall score of 0 to 2.0 was calculated for each case by multiplying the intensity of staining by the percentage of tumor cells staining positively. Four staining patterns for MUC1 were identified: apical, cytoplasmic, membranous, and combination. Of the 52 cases of basal-like triple-negative breast cancers, 49 (94%) were positive for MUC1 expression. The mean score was 0.90 (range, 0-1.9). Cases were evenly distributed over this range, where most (67%) exhibited moderate to strong MUC1 expression (score, 0.5-1.90), 27% demonstrated weak MUC1 expression, and 6% lacked MUC1 expression. There was a significant difference in MUC1 score and percent MUC1+ cells in favor of the combination pattern. This study indicates that a large proportion of early-stage basal-like triple-negative breast cancer expresses MUC1 and provides a rationale for MUC1-based immunotherapy in this high-risk patient cohort.

Rituximab-induced bronchiolitis obliterans organizing pneumonia.

Rituximab-induced lung disease (R-ILD) is a rare entity that should be considered in patients treated with rituximab who present with dyspnea, fever, and cough, but no clear evidence of infection. A variety of pathologic findings have been described in this setting. Bronchiolitis obliterans organizing pneumonia (BOOP) is the most common clinicopathologic diagnosis, followed by interstitial pneumonitis, acute respiratory distress syndrome (ARDS), and hypersensitivity pneumonitis. Prompt diagnosis and treatment with corticosteroids are essential as discussed by Wagner et al. (2007). Here we present a case of an 82-year-old man who was treated with rituximab for recurrent marginal zone lymphoma. After the first infusion of rituximab, he reported fever, chills, and dyspnea. On computed tomography imaging, he was found to have bilateral patchy infiltrates, consistent with BOOP on biopsy. In our patient, BOOP was caused by single-agent rituximab, in the first week after the first infusion of rituximab. We reviewed the relevant literature to clarify the different presentations and characteristics of R-ILD and raise awareness of this relatively overlooked entity.

Impact of a specialized multidisciplinary tracheostomy team on tracheostomy care in critically ill patients.

BACKGROUND: A multidisciplinary tracheostomy team was created in 2005 to follow critically ill patients who had undergone a tracheostomy until their discharge from hospital. Composed of a surgeon, surgical resident, respiratory therapist, speech-language pathologist and clinical nurse specialist, this team has been meeting twice a week for rounds involving patients who transitioned from the intensive care unit (ICU) to the medical and surgical wards. Our objective was to assess the impact of this multidisciplinary team on downsizing and decannulation times, on the incidence of speaking valve placement and on the incidence of tracheostomy-related complications on the ward. METHODS: This study was conducted at a tertiary care, level-1 trauma centre and teaching hospital and involved all patients who had received a tracheostomy during admission to the ICU from Jan. 1 to Dec. 31, 2004 (preservice group), and from Jan. 1 to Dec. 31, 2006 (postservice group). We compared the outcomes of patients who required tracheostomies in a 12-month period after the team was created with those of patients from a similar time frame before the establishment of the team. RESULTS: There were 32 patients in the preservice group and 54 patients in the postservice group. Under the new tracheostomy service, there was a decrease in incidence of tube blockage (5.5% v. 25.0%, p = 0.016) and calls for respiratory distress (16.7% v. 37.5%, p = 0.039) on the wards. A significantly larger proportion of patients also received speaking valves (67.4% v. 19.4%, p < 0.001) after creation of the team. Furthermore, there appeared to be a decreased time to first tube downsizing (26.0 to 9.4 d) and decreased time to decannulation (50.4 to 28.4 d), although this did not reach statistical significance owing to our small sample size. CONCLUSION: Standardized care provided by a specialized multidisciplinary tracheostomy team was associated with fewer tracheostomy-related complications and an increase in the use of a speaking valve.

Outcome in tracheostomized patients with severe traumatic brain injury following implementation of a specialized multidisciplinary tracheostomy team.

OBJECTIVE: To evaluate the effect of a specialized multidisciplinary tracheostomy team on outcome of patients with severe traumatic brain injury (sTBI). DESIGN: Retrospective study with historical controls. PARTICIPANTS: Twenty-seven patients with sTBI tracheostomized before implementation of the tracheostomy team approach and 34 patients followed by the team. SETTING: A regional level 1 tertiary care trauma center, McGill University Health Centre-Montreal General Hospital. MAIN OUTCOME MEASURES: Time to decannulation, length of stay (LOS), Passy-Muir speaking valve use, and extended Glasgow Outcome Scale (GOS-E) scores given at acute care discharge. RESULTS: The groups were similar for injury severity, age, and premorbid health conditions. Postteam patients had a significantly shorter LOS (P = .025) and more of them used Passy-Muir speaking valves (P = .004). Furthermore, there was a trend toward decreased time to decannulation in the postteam group. GOS-E scores did not differ significantly between groups (P > .05). CONCLUSION: Implementation of the tracheostomy team appears to have had positive clinical benefits for this population.

Heyde's syndrome: diagnosis and management by the novel single-balloon enteroscopy.

We present a case of obscure gastro-intestinal bleeding due to small bowel angiodysplasia in a 68-year-old woman with severe aortic valve stenosis. The diagnosis was confirmed and subsequently managed using single-balloon enteroscopy.