Mosaic Muir Torre Syndrome: Keratoacanthoma as a Piece of the Puzzle.

ABSTRACT: Lynch syndrome is an inherited condition, which increases the risk of numerous visceral malignancies and cutaneous tumors such as keratoacanthomas and sebaceous tumors. It is typically identified by immunohistochemistry of tissue taken from tumors or through genetic testing with next-generation sequencing. Diagnosing Lynch syndrome becomes more complex when the individual is mosaic for the relevant pathogenic variant. There are very few cases of this reported in the medical literature. It is even more unusual for the diagnosis to be made based on testing of a keratoacanthoma lesion. We report a case where immunohistochemistry of a keratoacanthoma helped make a diagnosis of mosaic Lynch syndrome. We will explore how mosaicism should be considered when a phenotype is strong, even if next-generation sequencing reports no pathogenic or likely pathogenic variant and how lesions such as keratoacanthomas can have a role in the early detection and treatment of future malignancies.

Implementing prescribing safety indicators in prisons: A mixed methods study.

AIMS: To examine the prevalence of potentially hazardous prescribing in the prison setting using prescribing safety indicators (PSIs) and explore their implementation and use in practice. METHODS: PSIs were identified and reviewed by the project team following a literature review and a nominal group discussion. Pharmacists at 2 prison sites deployed the PSIs using search protocols within their electronic health record. Prevalence rates and 95% confidence intervals (CIs) were generated for each indicator. Semi-structured interviews with 20 prison healthcare staff across England and Wales were conducted to explore the feasibility of deploying and using PSIs in prison settings. RESULTS: Thirteen PSIs were successfully deployed mostly comprising drug-drug interactions (n = 9). Five yielded elevated prevalence rates: use of anticholinergics if aged ≥65 years (Site B: 25.8% [95%CI: 10.4-41.2%]), lack of antipsychotic monitoring for >12 months (Site A: 39.1% [95%CI: 27.1-52.1%]; Site B: 28.6% [95%CI: 17.9-41.4%]), prolonged use of hypnotics (Site B: 46.3% [95%CI: 35.6-57.1%]), antiplatelets prescribed with nonsteroidal anti-inflammatory drugs without gastrointestinal protection (Site A: 12.5% [95%CI: 0.0-35.4%]; Site B: 16.7% [95%CI: 0.4-64.1%]), and selective serotonin/norepinephrine reuptake inhibitors prescribed with nonsteroidal anti-inflammatory drugs/antiplatelets without gastrointestinal protection (Site A: 39.6% [95%CI: 31.2-48.4%]; Site B: 33.3% [95%CI: 20.8-47.9%]). Prison healthcare staff supported the use of PSIs and identified key considerations to guide its successful implementation, including staff engagement and PSI 'champions'. To respond to PSI searches, stakeholders suggested contextualised patient support through intraprofessional collaboration. CONCLUSION: We successfully implemented a suite of PSIs into 2 prisons, identifying those with higher prevalence values as intervention targets. When appropriately resourced and integrated into staff workflow, PSI searches may support prescribing safety in prisons.