Papular lesion occurring within a longstanding warty plaque, in skin of colour Fitzpatrick type 4-5

A 23-year-old man of South Asian descent, Fitzpatrick type 4-5 skin, usually fit and well, presented with a 6-month history of a darkly-pigmented papular lesion growing within a pre-existing warty plaque on the left parietal scalp, present since birth. The base plaque measured 30 × 10 mm, whilst the new papule measured approximately 3 × 3 mm. These were asymptomatic and there was no preceding trauma to the area. Examination revealed a pearlescent darkly pigmented papule, growing within a warty pink-yellow hairless plaque. Dermoscopy showed non-specific features with evidence of some disorganized vasculature. A punch excisional biopsy of the papular lesion was obtained, histopathology indicated a polypoid lesion with basaloid nests in a superficial and nodular distribution extending to the superficial dermis. The base plaque was then completely excised, showing dermal scarring related to the previous excision, along with the presence of large sebaceous glands, heterotopic apocrine glands, defective hair follicles, acanthosis and epithelial papillomatosis. This is a case of a basal cell carcinoma (BCC) arising within a sebaceous naevus on the scalp, in a skin of colour patient. Sebaceous naevi (SN), also known as naevus sebaceous of Jadassohn, are benign hamartomatous malformations comprised of predominantly sebaceous glands. SN appear most commonly on the scalp, and start off as smooth yellowish well-circumscribed plaques in infancy which then develops a verrucous appearance in adolescence due to hormonally-driven maturation of sebaceous and apocrine glands. It is well known that benign neoplasms of various lineages of differentiation including follicular, sebaceous, apocrine or eccrine, may arise within SN. Malignant neoplasms occurring within SN almost exclusively occur in adults, and arise in about 2.5% of lesions. BCCs are the most common among these, and occur in 0.8% of SN. Other malignant tumours such as squamous cell carcinoma, sebaceous carcinoma, microcystic adnexal carcinoma and porocarcinoma can also arise within SN, but these are rarer. Our case is notable as our patient had Fitzpatrick skin type 4-5, hence may have been perceived to have a lower risk of developing BCCs. We hope that this report will highlight that BCCs do arise even in skin of colour.

A case series of shared delusional infestation: folie à deux revisited

Delusional infestation describes the unshakeable belief that one's skin is infected or infested with an external organism or inanimate material, in the absence of supportive medical evidence. It is one of the most challenging psychodermatological conditions to manage, given the rigidity of patients' physically focused health beliefs, and the competing need to introduce antipsychotic therapy to bring about resolution. This is rendered exponentially more complex when partners or family members are similarly afflicted. This situation is known as shared delusional infestation, shared psychotic disorder (SPD), or folie à deux. We present a series of three couples with SPD who were referred to our tertiary psychodermatology service during the same year. On examining the literature we were intrigued to discover that subtly different subtypes of SPD have been recognized since the late 1800s. These include folie simultanée, imposée, communiquée and induite. Our cases neatly demonstrate three of these variants, and highlight the difficulties in facilitating effective treatment.

Improving MRCP PACES pass rates through the introduction of a regional multifaceted support framework

Introduction

Practical Assessment of Clinical Examination Skills (PACES) constitutes the final part of the mandatory Royal College of Physicians exam series for progression to higher specialty training. Pass rates were lower for core medical trainees (CMTs) in Coventry and Warwickshire in comparison to other regions within the West Midlands and nationally.

Objectives

Our aim was to improve pass rates in the region through the introduction of a stimulating and supportive teaching framework, designed to enhance the quality and frequency of PACES teaching.

Methods

To identify key areas for change a baseline questionnaire, including Likert Scale and free text questions related to PACES teaching, was distributed to all CMTs in the region. Many trainees highlighted concern over lack of PACES-orientated teaching and support, with particular emphasis on: lack of bedside-teaching with feedback; infrequent opportunities for practising communication skills; and difficulty identifying suitable patients in an efficient manner. To address these concerns the following interventions were implemented over two Plan, Do, Study, Act (PDSA) cycles which were analysed at 6 months and 12months: a digital forum to highlight relevant inpatients for examination practice; a peer-to-peer mentoring scheme; a consultant-led bedside-teaching rota; and classroom-based communication skills sessions.

Results

Pass rates at Annual Review of Competence Progression improved from baseline to the end of the first year of implementation, 56.3% to 77.3%, respectively. Furthermore, following analysis of questionnaires at each PDSA cycle, we demonstrated a progressive improvement in trainee satisfaction in exposure, quality and relevance of teaching.

Conclusion

Our innovative, cost-effective teaching framework for PACES preparation has improved exam outcomes and facilitated swift junior doctor career progression, while raising the profile of the trust. Furthermore, this innovation provides a template for potential adoption in other National Health Service institutions.