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Electrochemotherapy has been proven to be an efficient treatment for cutaneous metastases of various cancers. Data on breast cancer (BC) patients with cutaneous metastases were retrieved from the INSPECT database. Patients were divided by their receptor status: HER2+, HR+ (ER/PgR+), and TN (triple negative). Groups were similar for histological subtype and location of the nodules. Most patients were previously treated with surgery/systemic therapy/radiotherapy. We found no differences in the three groups in terms of response ratio (OR per patient 86% HER2+, 80% HR+, 76% TN, p = 0.8664). The only factor positively affecting the complete response rate in all groups was small tumor size (

Background Patients presenting with early-stage melanoma (AJCC pT1b-pT2a) reportedly have a relatively low risk of a positive SNB (~5–10%). Those patients are usually found to have low-volume metastatic disease after SNB, typically reclassified to AJCC stage IIIA, with an excellent prognosis of ~90% 5-year survival. Currently, adjuvant systemic therapy is not routinely recommended for most patients with AJCC stage IIIA melanoma. The purpose was to assess the SN-positivity rate in early-stage melanoma and to identify primary tumor characteristics associated with high-risk nodal disease eligible for adjuvant systemic therapy Methods An international, multicenter retrospective cohort study from 7 large-volume cancer centers identified 3,610 patients with early primary cutaneous melanomas 0.8–2.0 mm in Breslow thickness (pT1b-pT2a; AJCC 8th edition). Patient demographics, primary tumor characteristics, and SNB status/details were analyzed. Results The overall SNB-positivity rate was 11.4% (412/3610). Virtually all SNB-positive patients (409/412; 99.3%) were reclassified to AJCC stage IIIA. Multivariate analysis identified age, T-stage, mitotic rate, primary site and subtype, and lymphovascular invasion as independent predictors of sentinel node status. A mitotic rate of >1/mm2 was associated with a significantly increased SN-positivity rate and was the only significant independent predictor of high-risk SNB metastases (>1 mm maximum diameter). Conclusions The new treatment paradigm brings into question the role of SNB for patients with early-stage melanoma. The results of this large international cohort study suggest that a reevaluation of the indications for SNB for some patients with early-stage melanoma is required.

Elektrochemotherapie (ECT) ist eine wirksame lokale Behandlung von Hauttumoren. Ziel dieser Studie war es, die Wirksamkeit der ECT bei ulzerierten gegenüber nichtulzerierten Tumoren zu vergleichen und den Effekt auf tumorassoziierte Symptome zu untersuchen.20 Krebszentren des International Network for Sharing Practices on Electrochemotherapy (InspECT) sammelten prospektiv Daten. Die ECT wurde nach dem ESOPE-Protokoll durchgeführt. Das Therapieansprechen wurde anhand der Entwicklung der Läsionsgröße bewertet. Zusätzlich wurden Schmerzen, Symptome, Leistungsstatus (ECOG-Index) und Gesundheitszustand (EQ-5D-Fragebogen) untersucht.716 Patienten mit ulzerierten (n = 302) und nichtulzerierten (n = 414) Hauttumoren und Metastasen wurden eingeschlossen (Mindest-Nachsorge 45 Tage). Nicht-ulzerierte Läsionen sprachen besser auf die ECT an als ulzerierte Läsionen (vollständiges Ansprechen: 65 % gegenüber 51 %, p = 0,0061). Nur 38 % (115/302) der Patienten mit ulzerierten Läsionen vor der ECT wiesen bei der letzten Nachuntersuchung ulzerierte Läsionen auf. Patienten mit ulzerierten Läsionen berichteten über stärkere Schmerzen und schwerere Symptome im Vergleich zu Patienten mit nichtulzerierten Läsionen, die sich nach der ECT signifikant und kontinuierlich besserten. Bei Patienten mit nichtulzerierten Läsionen hingegen nahmen die Schmerzen während der Behandlung vorübergehend zu. Es wurden keine schwerwiegenden Nebenwirkungen beobachtet.Die ECT ist eine sichere und wirksame lokale Behandlung von Hauttumoren. Während die ECT die Symptome insbesondere bei Patienten mit ulzerierten Läsionen verbessert, sollte auf Basis der Daten die Implementation eines perioperativen Schmerzmanagements besonders bei nichtulzerierten Läsionen während der ECT erwogen werden.

PURPOSE Indications for offering adjuvant systemic therapy for patients with early-stage melanomas with low disease burden sentinel node (SN) micrometastases, namely, American Joint Committee on Cancer (AJCC; eighth edition) stage IIIA disease, are presently controversial. The current study sought to identify high-risk SN-positive AJCC stage IIIA patients who are more likely to derive benefit from adjuvant systemic therapy. METHODS Patients were recruited from an intercontinental (Australia/Europe/North America) consortium of nine high-volume cancer centers. All were adult patients with pathologic stage pT1b/pT2a primary cutaneous melanomas who underwent SN biopsy between 2005 and 2020. Patient data, primary tumor and SN characteristics, and survival outcomes were analyzed. RESULTS Three thousand six hundred seven patients were included. The median follow-up was 34 months. Pairwise disease comparison demonstrated no significant survival difference between N1a and N2a subgroups. Survival analysis identified a SN tumor deposit maximum dimension of 0.3 mm as the optimal cut point for stratifying survival. Five-year disease-specific survival rates were 80.3% and 94.1% for patients with SN metastatic tumor deposits ≥ 0.3 mm and < 0.3 mm, respectively (hazard ratio, 1.26 [1.11 to 1.44]; P < .0001). Similar findings were seen for overall disease-free and distant metastasis-free survival. There were no survival differences between the AJCC IB patients and low-risk (< 0.3 mm) AJCC IIIA patients. The newly identified high-risk (≥ 0.3 mm) subgroup comprised 271 (66.4%) of the AJCC IIIA cohort, whereas only 142 (34.8%) patients had SN tumor deposits > 1 mm in maximum dimension. CONCLUSION Patients with AJCC IIIA melanoma with SN tumor deposits ≥ 0.3 mm in maximum dimension are at higher risk of disease progression and may benefit from adjuvant systemic therapy or enrollment into a clinical trial. Patients with SN deposits < 0.3 mm in maximum dimension can be managed similar to their SN-negative, AJCC IB counterparts, thereby avoiding regular radiological surveillance and more intensive follow-up.

Background: Electrochemotherapy (ECT) is an effective local treatment for cutaneous tumors. The aim of this study was to compare the effectiveness of ECT in ulcerated vs. non-ulcerated tumors and investigate the effect on tumor-associated symptoms.Methods: Twenty cancer centers in the International Network for Sharing Practices on Electrochemotherapy (InspECT) prospectively collected data. ECT was performed following ESOPE protocol. Response was evaluated by lesion size development. Pain, symptoms, performance status (ECOG-Index) and health status (EQ-5D questionnaire) were evaluated.Results: 716 patients with ulcerated (n = 302) and non-ulcerated (n = 414) cutaneous tumors and metastases were included (minimum follow-up of 45 days). Non-ulcerated lesions responded to ECT better than ulcerated lesions (complete response 65 % vs. 51 %, p = 0.0061). Only 38 % (115/302) with ulcerated lesions before ECT presented with ulcerated lesions at final follow-up. Patients with ulcerated lesions reported higher pain and more severe symptoms compared to non- ulcerated lesions, which significantly and continuously improved following ECT. In non-ulcerated lesions however, pain spiked during the treatment. No serious adverse events were reported.Conclusions: ECT is a safe and effective local treatment for cutaneous tumors. While ECT improves symptoms especially in patients with ulcerated lesions, data suggest the implementation of a perioperative pain management in non-ulcerated lesions during ECT.

IntroductionCutaneous squamous cell carcinoma (cSCC) is a frequent skin cancer with a high risk of recurrence characterized by tumor infiltration and, in advanced cases, a poor prognosis. ECT (electrochemotherapy) is an alternative treatment option for locally advanced or recurrent cSCC that is unsuitable for surgical resection. In this study, we aimed to evaluate the data in the InspECT (International Network for Sharing Practice on ECT) registry of the referral centers and to clarify the indications for the use of ECT as a treatment modality for cSCC.Materials and methodsPatients with primary, recurrent or locally advanced cSCC from 18 European centers were included. They underwent at least one ECT session with bleomycin between February 2008 and November 2020, which was performed following the European Standard Operating Procedures.ResultsThe analysis included 162 patients (mean age of 80 years; median, 1 lesion/patient). Side effects were mainly local and mild (hyperpigmentation, 11%; ulceration, 11%; suppuration, 4%). The response to treatment per patient was 62% complete and 21% partial. In the multivariate model, intravenous drug administration and small tumor size showed a significant association with a positive outcome (objective response). One-year local progression-free survival was significantly better (pConclusionIn the present study, ECT showed antitumor activity and a favorable safety profile in patients with complex cSCC for whom there was no widely accepted standard of care. Better results were obtained in primary and small tumors (

PurposeService research holds that as services become more technology dominated, new service provider roles emerge. On a conceptual level, the potential impact of different roles has been discussed with regard to service provider readiness, job performance and overall experience. However, as yet, there is sparse empirical support for these conceptual interpretations. The purpose of this paper is to provide an understanding of the new service provider roles that emerge due to the increase of technology mediation in services.Design/methodology/approachThis study follows a qualitative methodology. Insights are drawn from in-depth interviews with 32 junior and senior health-care service providers (across 12 specialties) and 5 information governance/management staff.FindingsThis analysis illustrates that new service provider roles include those of the enabler, differentiator, innovator, coordinator and sense-giver. By adopting these roles, health-care service providers reveal that they can encourage, support and advance technology mediation in services across different groups/audiences within their organizations (e.g. service delivery level, peer-to-peer level, organizational level). This paper further shows the relationships between these new service provider roles.Originality/valueThis study contributes to theory in technology-mediated services by illustrating empirically the range of activities that constitute each role. It also complements prior work by identifying that service providers adopt the additional role of sense-giver. Finally, this paper provides an understanding of how by taking on these roles service providers can encourage, support and advance technology mediation in services across different groups/audiences in their organization.

We explore individuals who take some of their technology use ‘underground’, described as ‘bootlegging’, to enhance healthcare work. We find that healthcare professionals’ informal use of mobile applications in healthcare work sometimes ‘sticks out’ and this produces professional identity tensions: (1) conflict with perceptions of professional behaviour, and (2) defilement of expert judgment. Our analysis, moreover, reveals that identity work (i.e. ‘accepting’ and ‘sensemaking’) provides a coping mechanism to deal with these unresolved professional identity tensions. This paper contributes to a better understanding of the constitutive entanglements and two-way interactions of discretionary technology bootlegging, professional identity and autonomy in institutional healthcare work.

Assessment of total body surface area of a burn injured patient is a crucial step in managing burn injury. The chapter describes a number of techniques from using the size of the patient’s palm as an estimate of 1% to the gold standard Lund and Browder Chart. Key caveats are explained, copies of the charts included as well as the use of the CE certified app Mersey Burns.

Background There is a lack of consensus regarding optimal surgical excision margins for primary cutaneous melanoma > 1 mm in Breslow thickness (BT). A narrower surgical margin is expected to be associated with lower morbidity, improved quality of life (QoL), and reduced cost. We report the results of a pilot international study (MelMarT) comparing a 1 versus 2-cm surgical margin for patients with primary melanoma > 1 mm in BT. Methods This phase III, multicentre trial [NCT02385214] administered by the Australia & New Zealand Medical Trials Group (ANZMTG 03.12) randomised patients with a primary cutaneous melanoma > 1 mm in BT to a 1 versus 2-cm wide excision margin to be performed with sentinel lymph node biopsy. Surgical closure technique was at the discretion of the treating surgeon. Patients’ QoL was measured (FACT-M questionnaire) at baseline, 3, 6, and 12 months after randomisation. Results Between January 2015 and June 2016, 400 patients were randomised from 17 centres in 5 countries. A total of 377 patients were available for analysis. Primary melanomas were located on the trunk (56.9%), extremities (35.6%), and head and neck (7.4%). More patients in the 2-cm margin group required reconstruction (34.9 vs. 13.6%; p p = 0.036). After 12 months’ follow-up, no differences were noted in QoL between groups. Discussion This pilot study demonstrates the feasibility of a large international RCT to provide a definitive answer to the optimal excision margin for patients with intermediate- to high-risk primary cutaneous melanoma.

Melanoma is the most lethal skin cancer with a high propensity to metastasis and conventionally is poorly responsive to non-surgical treatments including chemotherapy and radiotherapy. Considerable advances have been made recently targeting BRAF mutations and immune regulation and, for the first time, credible options exist for patients with metastatic disease. Angiogenesis, the growth of new blood vessels, is an absolute prerequisite for tumour growth beyond a few millimetres in size. Melanoma neovascularisation is correlated with poor prognosis, reduced overall survival, ulceration and increased rate of relapse. Melanoma cells secrete several proangiogenic cytokines including Vascular Endothelial Growth Factor VEGF-A and raised levels of expression are associated with the switch from indolent radial, to invasive vertical and then metastatic growth phases. Understanding the processes underlying angiogenesis and how it relates to tumour growth broadly and to melanoma specifically is instrumental in the current drive to develop new treatments that target a range of tumour cell receptors and intracellular processes from receptor antagonism to monoclonal antibodies aimed at the disruption of the process of tumour angiogenesis. We discuss recent and current trials for metastatic melanoma therapy, and discuss potential directions of future treatment scheduling considering different treatment scheduling approaches beyond the parameters of standard drug trials.

The investigation of health services is a major area of interest within the field of marketing (e.g. Berry and Bendapudi 2007; Crie and Chebat 2013). Research in the area is heterogeneous, covering the range from healthy individuals, people suffering from chronic diseases along with healthcare professionals. In previous studies, there is inherently an assumption that medical applications have the potential to improve the efficiency of healthcare service delivery and thereby deliver value to consumers, hence generate uptake. However, thousands of consumer-oriented applications have close to zero downloads (Campaign 2014), and the acceptance of medical applications is relatively low by professionals in the hospital context (Wu et al. 2011). This suggests a need to inform the service design cycle for medical applications with insights from technology and design disciplines in order to deliver relevant mobile services. In the contemporary ‘electronic’ marketplace, encompassing all aspects of service delivery in design appears daunting. Yet, it is crucial to identify those factors that drive positive service experiences in order to maximize consumer value (Sandstrom et al. 2008). A large and growing body of services research investigates the role of consumer perceptions of value creation as a driver for acceptance, use and/or purchase. S-D logic suggests that ‘value is defined by and co-created with the consumer rather than embedded in output’ (Vargo and Lusch 2004). When value is perceived as value in use, functional and economic benefits as well as emotional, social, ethical and environmental dimensions are of significance for consumers (Gronroos and Voima 2013). As a result, if the full potential of mobile services is to be realised in medical care, it is necessary to understand the interplay between technology issues, such as usability and the human side of assessments of experience in the creation of value for the user. We posit that optimal mobile service design could be achieved by using human–computer interaction design principles in conjunction with service design theories. The purpose of this chapter is to extend existing studies by investigating consumers’ perception of value in using mobile services in context and explore how medical service design and delivery can be optimised for mobile applications. To address these objectives, we follow an inductive approach aligned with grounded theory techniques and procedures (Glaser and Strauss 1967; Strauss and Corbin 1998), and we initially employ an exemplar case study. We report on data concerning a medical mobile application (Mersey Micro) for healthcare professionals intended for use inside the hospital. Data are gathered from in-context, in-depth, interviews with representative users, usability studies as well as an exploratory survey aiming at identifying clinicians’ interaction with the mobile application. The literature suggests that design of effective and efficient healthcare systems would benefit greatly from integrated models and frameworks that combine consumers’ emotions and technical features of service platforms (Ostrom et al. 2010). As a result, this chapter might be seen as an initial attempt towards this direction. Our initial findings are pointing the direction of (medical) mobile service design as a combination of technology issues, such as usability and the human side of assessments of experience in the creation of value for the user.

'Mersey Burns App' is a smartphone/tablet application that aids in the assessment of total burn surface area (TBSA) and calculation of fluid resuscitation protocols in burns. This paper presents two studies assessing the speed and accuracy of calculations using Mersey Burns (App) in comparison with a Lund and Browder chart (paper) when a burn is assessed by medical students and clinicians.The first study compared the speed and accuracy of TBSA and resuscitation calculation for a photograph of a burn with App and paper using burns and plastics and emergency medicine trainees and consultants. Developing on some of the feedback and results of that study, a second study was then carried out using burns-naive medical students assessing a fully simulated burn with both modalities. Preference and ease of use of each modality were assessed anonymously.The clinician study showed a lower variance in TBSA and fluid calculations using the App (p0.05). The student study showed no difference in mean TBSA estimations (p=0.7). Mean time to completion of calculations was faster and calculations were more likely to be correct with the App (p0.001). Students favoured the App in the following categories: preference in emergency setting, confidence in output, accuracy, speed, ease of calculation, overall use and shading (p0.0001).Mersey Burns App can facilitate quicker and more accurate calculations than Lund and Browder charts. Students also preferred the App. This suggests a useful role for the App in the care of patients with burns by inexperienced staff.

we define 'apps' as discrete, independent pieces of software that run on mobile devices. The use of such software on mobile devices within a health environment is not a new phenomenon – there is academic research discussing the opportunities of this technology as early as 1996. however, the proposition has only really become mainstream with the introduction of the Apple iPhone® and supporting App Store, backed by a hugely successful 'There's an app for that' advertising campaign. opening in July 2008 with a mere 500 applications available for download, the App Store now stocks around 500,000 applications and recently surpassed a staggering milestone: 15 billion downloads. Latterly it has been joined by rival application markets from Blackberry®, Microsoft® and, most successfully, AndroidTM.

After his surgical training, which included service in Italy and Trans-Jordan, Howell Pritchard Jones took up a consultant general surgeon position in Birkenhead in 1959. While performing a nephrectomy in 1964 he had a massive haemorrhagic stroke and underwent pioneering neurosurgery at Walton neurosurgical centre to evacuate the clot. After many weeks in a …