European e-Delphi process to define expert consensus on electrochemotherapy treatment indications, procedural aspects, and quality indicators in melanoma.

BACKGROUND: Skin metastases are an important co-morbidity in melanoma. Despite broad adoption, electrochemotherapy implementation is hindered by a lack of treatment indications, uncertainty regarding procedural aspects, and the absence of quality indicators. An expert consensus may harmonize the approach among centres and facilitate comparison with other therapies. METHODS: An interdisciplinary panel was recruited for a three-round e-Delphi survey. A literature-based 113-item questionnaire was proposed to 160 professionals from 53 European centres. Participants rated each item for relevance and degree of agreement on a five-point Likert scale, and received anonymous controlled feedback to allow revision. The items that reached concordant agreement in two successive iterations were included in the final consensus list. In the third round, quality indicator benchmarks were defined using a real-time Delphi method. RESULTS: The initial working group included 122 respondents, of whom 100 (82 per cent) completed the first round, thus qualifying for inclusion in the expert panel (49 surgeons, 29 dermatologists, 15 medical oncologists, three radiotherapists, two nurse specialists, two clinician scientists). The completion rate was 97 per cent (97 of 100) and 93 per cent (90 of 97) in the second and third rounds respectively. The final consensus list included 54 statements with benchmarks (treatment indications, (37); procedural aspects, (1); quality indicators, (16)). CONCLUSION: An expert panel achieved consensus on the use of electrochemotherapy in melanoma, with a core set of statements providing general direction to electrochemotherapy users to refine indications, align clinical practices, and promote quality assurance programmes and local audits. The residual controversial topics set future research priorities to improve patient care.

Electrochemotherapy is an effective locoregional therapy for skin metastases from melanoma, a problem faced by almost half of patients with metastatic disease. The lack of comparative studies and the heterogeneity of its clinical application among centres make it challenging to support consistent, evidence-based recommendations. To address this unmet need, a three-round online survey was conducted to establish a consensus on treatment indications, standard operating procedures, and quality indicators. In the survey, a panel of 100 European melanoma experts agreed on 56 statements that can be used to improve patient selection, homogenize treatment application, and monitor outcomes.

A shift in psychiatry through AI? Ethical challenges.

The digital transformation has made its way into many areas of society, including medicine. While AI-based systems are widespread in medical disciplines, their use in psychiatry is progressing more slowly. However, they promise to revolutionize psychiatric practice in terms of prevention options, diagnostics, or even therapy. Psychiatry is in the midst of this digital transformation, so the question is no longer "whether" to use technology, but "how" we can use it to achieve goals of progress or improvement. The aim of this article is to argue that this revolution brings not only new opportunities but also new ethical challenges for psychiatry, especially with regard to safety, responsibility, autonomy, or transparency. As an example, the relationship between doctor and patient in psychiatry will be addressed, in which digitization is also leading to ethically relevant changes. Ethical reflection on the use of AI systems offers the opportunity to accompany these changes carefully in order to take advantage of the benefits that this change brings. The focus should therefore always be on balancing what is technically possible with what is ethically necessary.

Livedoid skin reaction to 2nd dose of mRNA Covid-19 vaccine.

Skin often represents a target organ for adverse drug reactions and this also applies to the mRNA vaccines against Sars-CoV-2. Here we present a case of extensive livedoid reaction after 2nd dose of BNT162b-2 vaccine with massive blood skin extravasation and no systemic symptoms apart from anemization. The 30-year-old woman developed progressively enlarging livedoid lesions on limbs and abdomen. Histology showed a near-normal epidermis and a very mild interstitial mixed inflammatory infiltrate with extensive blood extravasation in mid- and deep dermis. Diagnosis was adverse reaction to vaccine with skin capillary hyperpermeability and anaemization with lower than diagnostic features of cutaneous small vessel vasculitis. To date, no cases of a livedoid skin reaction associated to Covid-19 vaccine have been reported, and this case illustrates that massive livedoid reaction can be another kind of skin reaction to mRNA Covid-19 vaccine.

Use of self-adherent silicone sheets in a pediatric burn patient: A case report and instructions for use.

Burns and scalds are relatively common injuries in children. Formation of hypertrophic scars or keloids is feared complications. A 2-year-old girl who spilled a cup of hot coffee onto herself developed widespread hypertrophic scars and beginning keloids on her upper chest, despite application of pressure garments and daily massage with silicone gel. Herein, we describe instructions for use of prolonged continuous 24-hour occlusive application of self-adherent silicone sheets to help mitigate the formation of scar tissue.

Combining chemotherapy and autologous peptide-pulsed dendritic cells provides survival benefit in stage IV melanoma patients.

BACKGROUND AND OBJECTIVES: We examined retrospectively whether the combination of standard dacarbazine (DTIC) and/or fotemustine chemotherapy and autologous peptide-loaded dendritic cell (DC) vaccination may improve survival of stage IV melanoma patients. Furthermore, a small cohort of long-term survivors was studied in more detail. PATIENTS AND METHODS: Between 1998 and 2008, 41 patients were vaccinated at least three times with DCs while receiving chemotherapy and compared to all other 168 patients in our database who only received chemotherapy (1993-2008). RESULTS: Median life expectancy of patients receiving additional DC-vaccination was 18 months, compared to eleven months for patients under standard chemotherapy alone. In contrast to patients with other haplotypes, the HLA-A1/A1 subset of DC-treated patients showed significantly lower median survival (12 vs. 25 months). Autoantibodies were frequently detected in serum of both vaccinated and non-vaccinated patients, and there was no correlation between titers, loss or appearance of autoantibodies and survival. Additionally, phenotyping of DCs and PBMCs also did not reveal any conspicuous correlation with survival. CONCLUSIONS: Combining standard chemotherapy and DC vaccination appears superior to chemotherapy alone. The impact of HLA haplotypes on survival emphasizes the importance of a careful selection of patients with specific, well-defined HLA haplotypes for future vaccination trials using peptide-pulsed DCs, possibly combined with checkpoint inhibitors.

The SILVER study. Efficacy of topical nitric-zinc complex solution in the treatment of resistant warts: A postmarketing evaluation.

The treatment of cutaneous viral warts caused by human papillomavirus (HPV) infection is often subject to local recurrence and a long clinical and treatment course. Our aim was to analyze real-life data on the treatment of difficult-to-treat warts from a multicenter postmarketing surveillance assessment on the efficacy, tolerability, and safety of a commercially available nitric-zinc complex solution (NZCS). Dermatologists from 14 Italian centers completed a questionnaire about their clinical experience on treatment of "difficult-to-treat" warts, which included warts in the plantar, periungual, anogenital and aesthetically sensitive areas. The questionnaire was designed to obtain detailed information on wart treatment and compare NZCS efficacy with previous treatments. Of 106 questionnaires returned, 83 reported NZCS use; 67 had previous treatments (23 cryotherapy, 2 electrocoagulation, 12 other topical application, and 30 combined treatment, such as laser, cryotherapy, and/or electrocoagulation). NZCS had superior efficacy to that of previous treatments (p < .0001), resulting in 84.1% with a full or partial clearance (vs. 44.8% for previous treatments), and had better local tolerability (p < .0001). NZCS showed better efficacy and tolerability than other previous wart treatments.

Split-thickness skin grafting for reconstruction of auricular skin defects: a statistical analysis.

BACKGROUND AND OBJECTIVES: Surgical reconstruction following the removal of large malignant auricular lesions is challenging. While many options for defect closure have been described, in the elderly population usually affected flap surgery, long anesthesia times, patient compliance, and anticoagulant therapy pose additional risks. An alternative quick, simple, and effective method of defect closure is therefore highly desirable. The objective of the present study was to assess the aesthetic outcome, healing process, complications, and recurrence rates associated with unmeshed split-thickness skin grafts (STSGs) used for covering large auricular skin defects following cartilage-sparing skin cancer removal. PATIENTS AND METHODS: Under local tumescent anesthesia, 32 patients received STSGs for defect closure following the removal of malignant cutaneous neoplasms of the ear. RESULTS: The average defect size was 8.0 cm². In all cases, complete healing of the recipient site occurred within two weeks. There were no major complications. The aesthetic outcome was rated highly by patients as well as by the dermatosurgeon involved and two independent plastic surgeons. CONCLUSIONS: STSGs are a valid option for closing large auricular skin defects. Even large cutaneous tumors of the external ear do not necessarily infiltrate the cartilage. Thus, cartilage-sparing tumor resection with subsequent defect closure using a STSG is an excellent and quick method associated with high patient satisfaction.

Spalthauttransplantation zur Defektdeckung am Ohr: eine statistische Analyse.

HINTERGRUND UND ZIELE: Die Rekonstruktion nach Entfernung ausgedehnter maligner Hauttumoren am Ohr ist eine Herausforderung. Verschiedene Methoden der Defektdeckung wurden beschrieben. Lappenplastiken, längere Anästhesiezeiten, geringe Compliance und Antikoagulation stellen bei den oft älteren Patienten zusätzliche Risiken dar. Eine rasch, effizient und unkompliziert durchführbare Methode der Defektdeckung ist daher wünschenswert. Ziel der Studie war die Beurteilung des ästhetischen Resultats, des Heilungsprozesses, der Komplikations- und Rezidivrate nach Transplantation ungenetzter Spalthaut (SPHT) zur Defektdeckung nach knorpelerhaltender Resektion maligner Tumoren am Ohr. PATIENTEN UND METHODIK: 32 Patienten wurden nach Entfernung von Hauttumoren am Ohr einer Defektdeckung mittels SPHT unterzogen. ERGEBNISSE: Die durchschnittliche Defektgröße betrug 8,0 cm2 . Eine vollständige Einheilung des Transplantates erfolgte in allen Fällen innerhalb von zwei Wochen. Wesentliche Komplikationen traten nicht auf. Das ästhetische Resultat wurde sowohl von den Patienten als auch von einem Dermatochirurgen und zwei plastischen Chirurgen als gut bewertet. SCHLUSSFOLGERUNGEN: Die SPHT am Ohr ist eine zuverlässige Methode zur Deckung ausgedehnter Hautdefekte. Selbst bei großen Tumoren des äußeren Ohres ist der Ohrknorpel nicht immer infiltriert. Eine knorpelschonende Tumorresektion mit anschließender Defektdeckung mittels SPHT ist eine ausgezeichnete und rasch durchführbare Technik mit hoher Patientenzufriedenheit.

Impressive tissue regeneration of severe oral mucositis post stem cell transplantation using cord blood platelet gel.

BACKGROUND: Platelet gel from cord blood (CBPG) is a recently developed blood component for topical use. We report a case of life-threatening mucositis after high-dose chemotherapy with fotemustine and cytarabine that was successfully treated with CBPG. CASE REPORT: A patient with non-Hodgkin lymphoma who was undergoing autologous hematopoietic stem cell transplantation developed severe oral and esophageal mucositis with severe bacterial sepsis and cytomegalovirus infection, causing prolonged neutropenia. CBPG was topically administered daily to the oral cavity. The CBPG was partially reabsorbed and partially swallowed. RESULTS: After 8 consecutive days of administration, the patient's oral mucosa markedly improved, showing restitutio ad integrum, and the patient's clinical status progressively improved. No side effects were seen after CBPG application. CONCLUSION: This case supports the need to conduct controlled studies comparing the efficacy of autologous and allogeneic platelet gel from adult and umbilical cord blood for the topical treatment of severe oral mucositis occurring after high-dose chemotherapy.

Frequency, type and treatment of fungal pathogens in toenail onychomycosis in the central Alpine region of South Tyrol, northern Italy - a 10-year retrospective study from 2004 to 2013.

Onychomycosis is one of the most common dermatological diseases, primarily caused by dermatophytes, and sometimes, also by yeast and moulds. This study aims to clarify the frequency of isolated pathogens from mycotic toenails in the reference centre of the central Alpine mountain region of South Tyrol, northern Italy. Age and gender differences, types of pathogens and initial therapy used were also investigated. This is a retrospective study from 2004 to 2013 on the files of all patients with suspected onychomycosis in whom a cultural pathogen detection was performed. A total of 1565 patients were studied (943 women; 622 men), with a median age of 55 years. Fungal pathogens could be detected by culture in 49.5%. Significantly more pathogens could be grown in men (63.8%) than in women (39.9%, P < 0.0001). The most common pathogens grown were dermatophytes (53.3%), especially T. rubrum and T. interdigitale, followed by moulds (24.7%) and yeast (22%). Therapies prescribed were topical in 64.2% and systemic in 35.8% of the cases. Topical treatment was more frequent in older patients (P < 0.05). In northern Italy, dermatophytes are the most common causative agents for onychomycosis. Fungal pathogens were more commonly found in men than in women and topical treatment was more frequent in older patients.

Misdiagnosed microcystic adnexal carcinoma on the lateral forehead and challenges in reconstruction of a large and bone-deep defect.

BACKGROUND: Microcystic adnexal carcinoma (MAC) is a rare cutaneous malignancy characterized by aggressive local infiltration, including a high propensity for perineural invasion. Histologically it can be easily confused with benign adnexal tumors, which often leads to inappropriate initial treatment. As a consequence delayed surgical excision often requires removal of large cutaneous masses which can be followed by challenges in reconstruction. METHODS: We report the case of a challenging reconstruction of a large forehead defect by a modified AT flap with central Burow's triangle grafting and previous wound conditioning using hyaluronic acid after complete micrographic removal of MAC. RESULTS: A 80-year-old healthy female presented with an almost six year history of an asymptomatic slowly progressing skin mass previously biopsied and diagnosed as benign syringoma five years in advance. Deep biopsies confirmed MAC. She underwent staged surgical excision with Tübingen torte technique with removal of the frontal periostium. A skin substitute of esterified hyaluronic acid was applied for three weeks to the bone-deep 6 × 7 cm defect leading to good granulation tissue above the bone. Final reconstruction was achieved by an AT flap combined with full thickness skin transplantation of the central dog ear. The cosmetic outcome was satisfactory, no recurrence was observed within 18 months follow-up. CONCLUSIONS: We confirm the histological difficulties in the diagnosis of this tumor entity and the large extension of MAC due to delay in diagnosis and treatment. Deep tumor removal including the periostium might be necessary to achieve tumor free margins. Fast granulation tissue above the frontal bone might be achieved by applying hyaluronic acid products. The combination an AT flap with transplantation of the adjacent Burow's triangles gives optimal skin texture and color matching and seems to be a good option to close even large defects of the front especially for supra brow defects.

Aesthetic Breast Augmentation Mastopexy Followed by Post-surgical Pyoderma Gangrenosum (PSPG): Clinic, Treatment, and Review of the Literature.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare autoinflammatory neutrophilic ulcerative skin disease, often developing after a trauma or surgical wounds. In the literature there are several reports of post-surgical PG (PSPG) of the breast. The authors of this article experienced an impressive case of PSPG after an aesthetic breast augmentation mastopexy. PSPG is a rare but severe complication in this elective aesthetic surgical procedure. METHOD: A systematic review of the literature was performed, focusing on PSPG after aesthetic breast surgery (augmentation mammoplasty/mastopexy). The online databases Pubmed, Medline, and Cochrane were used and additionally a Google© search was conducted. We compared the data obtained from a systematic literature review to an index case of PSPG after esthetic augmentation mammoplasty. RESULTS: The literature search identified seven articles describing eight cases of PSPG after aesthetic breast surgery. In four of these cases augmentation mammoplasty had been carried out, in two cases mastopexy and in two cases augmentation mammoplasty and mastopexy (augmentation mastopexy). The patient we treated and describe in this paper underwent an augmentation mastopexy outside our clinic. Eight patients suffered from local disease, at the site of surgical wounds, one patient had disseminated disease. Leukocytosis was present in five cases (out of nine). Eight patients had received corticosteroid treatment, one patient refused such treatment. The duration of corticosteroid treatment was on average for 41 days (range 21-60 days). In all cases, the areola had been spared. Complete healing of PSPG was observed on average after 5 months (range 1.5 months-1 year). DISCUSSION: PSPG of the breast after aesthetic breast surgery is rare, but every plastic surgeon should consider this possibility, especially if skin disease develops post-surgery, mimicking wound infection that does not respond to broad-spectrum antibiotic treatment. CONCLUSION: Although the literature does not recommend this step, implant removal is recommended by the authors because bacterial wound infection normally cannot be ruled out definitely in the early stages of disease. Additional surgical intervention should be limited to the absolute necessary and performed only under adequate systemic immunosuppressive therapy.