Ronen Glesinger

A graded work site intervention program to improve sun protection and skin cancer awareness in outdoor workers in Israel

AbstractObjectives: A graded worksite intervention program to improve sun protection and skin cancer awareness of outdoor workers was implemented and evaluated longitudinally over a period of 20 months. Methods: Outdoor male workers (144/213 recruits) from geographically separated units of the Israel National Water Company were allocated to complete (n = 37), partial (n = 72) or minimal (n = 35) intervention groups. Subsequent to the assignment and training of local safety officers, an educational and medical screening package was provided to the corresponding groups either once, or repeatedly a year later. Personal sun protective gear was provided upon repeated intervention. Outcome measures were evaluated through self-response questionnaires administered prior to the first intervention pulse, and 8 months after the first and second interventions. Results: A 15–61% improvement in sun-protection habits was noted in the entire study population 8 months after initialization, compared to no sunscreen use, 20% sun-exposed skin area and highest mean occupational exposure dose of 1.68 MED/day at pre-test. An even greater use of sunscreen was evident 1 year later in the complete and partial intervention groups, + 80% and + 52%, respectively. The baseline rate of self-examination of the skin in the same two groups (49%) increased significantly at post-test (+ 71% and + 53%, respectively). Conclusions: This integrated intervention program led to significantly improved sun protection and skin cancer awareness. Repeated intervention combined with the supply of sun-protective gear contributed to an even greater impact.

Risk Factors for Incomplete Excision of Basal Cell Carcinomas

Incomplete excision of basal cell carcinomas (BCCs) may be followed by recurrence of the tumor. In order to detect risk factors for incomplete excision of BCCs we performed a cross-sectional study of 1278 patients who underwent a primary excision of BCCs, during a four-year period, within an ambulatory and hospital plastic surgery department setting. Incomplete excision occurred in 159 of 1478 primary excisions of BCCs (10.8%) and was significantly associated with location of the tumors in the eyelids (OR 3.64, 95% CI 1.96-6.71), ears (OR 2.51, 95% CI 1.25-4.94), naso-labial folds (OR 2.26, 95% CI 0.99-5.04) and nose (OR 1.88, 95% CI 1.30-2.71). There was an inverse association with location of the tumors in the upper limbs (OR 0.44, 95% CI 0.21-0.90), back (OR 0.12, 95% CI 0.02-0.48) or chest (OR 0.09, 95% CI 0.00-0.57). Baso-squamous differentiation was associated with incomplete excision of BCCs (p = 0.03). No association was observed between incomplete excision of BCCs and gender, age, setting of the operation (ambulatory vs. hospital), clinical appearance of the lesion (suspected BCCs vs. other diagnoses) or diameter of the lesions. In conclusion, incomplete excision of BCCs was associated with location of the tumors in the eyelids, ears, naso-labial folds and nose. We recommend that in patients with BCCs located in these sites, surgeons should commence particular surgical measures to avoid inadequate excisions of the tumors.

Clinical and pathological findings in reexcision of incompletely excised basal cell carcinomas

In common practice, patients with incompletely excised basal cell carcinomas (BCCs) are referred to elective reexcision. In previous reports, it was observed that tumor cells are found in only 50% of the reexcised specimens. The authors performed a retrospective analysis of a large series of patients to evaluate clinical and pathological findings in patients who underwent reexcision of incompletely excised BCCs. A total of 1,478 BCCs arising in 1,278 patients were excised by plastic surgeons in a plastic and reconstructive surgery department during a 4-year period. In 159 patients (10.8%), the excision was incomplete according to the pathological report. These tumors were defined as an incompletely excised BCCs. One hundred of the 159 patients with incompletely excised BCCs (62.9%) were reoperated. Residual tumor cells were found in 28 of 100 patients (28%) within the pathological specimen of the reexcised tissue (defined as positive reexcision, or +veRE). There was no correlation between +veRE and the age or sex of the patient. Location of the BCCs in the cheeks, eyelids, or ears was associated with a low percent of +veRE (10.0%, 13.3%, and 22.2% respectively). Pathological factors associated with a low percent of +veRE were dermal inflammatory infiltrate in the pathological specimen (p = 0.003) and sun damage pathological changes (p = 0.03), but there was no correlation with the pathological subtype distribution of the tumors. The authors conclude that lack of tumor cells at reexcision of incompletely excised BCCs is associated with location of the tumors in the cheeks, eyelids, and ears, and with pathological findings of dermal inflammatory infiltrates or sun damage changes. The roles of inflammatory and solar changes in the destruction of residual carcinoma cells should be investigated further.

Risk factors for incomplete excision of squamous cell carcinomas

Objective: The aim of this study was to identify risk factors for incomplete excision of squamous cell carcinomas (SCCs). Patients and methods: A cross‐sectional study of 369 patients who underwent a primary excision of SCCs was performed within an outpatient and a hospital plastic surgery department setting. Results: Incomplete excision occurred in 25 of 369 primary excisions of SCC (6.8%). Location of the tumors on the forehead, temples, peri‐auricular region, ears, cheeks, nose, lips or neck was significantly associated with incomplete excision of the tumors. In particular, high incomplete excision proportions were observed for tumors located on the ears (16.7%), neck (16.7%), temples (11.1%), nose (10.8%) or lips (7.1%). Incomplete excision of SCC was associated with the setting of the operation in the hospital as compared to ambulatory settings (p = 0.046) and was inversely associated with the specimen thickness (p = 0.002). There was no statistically significant association between incomplete excision of SCC and gender, age, clinical appearance of the lesion (suspected SCC vs other diagnoses), differentiation pattern, diameter of the tumor, length or width of the excised specimen, solar changes or ulceration. Conclusion: We recommend that in patients with SCCs located in the forehead, temples, periauricular region, ears, cheeks, nose, lips or neck surgeons should commence particular surgical measures to avoid inadequate excisions of the tumors. In particular, surgeons should use wider excisional margins in tumors located in the embryonic fusion planes (e.g. eyelids and naso‐labial folds).

Blast injury caused by a booby-trapped cellular phone

Terrorists are recently using cellular phones to remotely detonate bombs. A patient was injured while assembling a bomb connected to a cellular phone. The patient sustained combined injury to the head and to the dominant hand which held the phone. Amputation of the hand was required, the facial injuries were reconstructed. The characteristics of this unusual type of injury are described and compared to injuries caused by other bombs and explosive devices.

Accreditation of skin from a methanol-poisoned victim for banking and grafting

Background. Acute poisoning is a contraindication for organ and tissue donation. In this study the suitability of skin from a methanol-poisoned (MP) donor for future grafting and keratinocytes culturing was investigated. Methods. A patient was admitted with a methanol blood level of 2.7 mg/mL, which became undetectable after 4 days of treatment with 4-methylpyrazole (fomepizole). Upon declared brain death and family consent, organs and skin were harvested. For approving MP skin for grafting, the following parameters were studied: viability and plating efficiency of MP keratinocytes, integrity of MP skin after cryopreservation, and its performance as xenografts on wounds in a pig model. Nonpoisoned (NP) controls included skin of matching age, cryopreservation period, and NP keratinocytes. Results. No significant differences were observed for any parameter between NP and MP samples. Furthermore, in vitro exposure of NP keratinocytes and fibroblasts to <10 mg/mL methanol inhibited their growth by <20%, with an extrapolated LD50 of 100 mg/mL. A parallel exposure to formaldehyde, a spontaneous metabolite of methanol, yielded LD50 of 20 &mgr;g/mL and eradication of viability at 300 &mgr;g/mL. Conclusions. These results indicate that skin from a carefully monitored MP donor is suitable for banking toward massive burns and skin losses. This methodology may be applied to approve skin harvested from other types of poisoned donors for banking and future grafting.

Pericardial effusion: a rare complication of thermal burn.

Sir: Sepsis in the early period following a major burn is a very common complication. The heart is among the less frequently injured organs following thermal injury (2.1 %) [1]. Pericardial effusion is a rare complication of major burn (0.1%) [1, 2, 3, 4]. We present the case of a 28-year-old woman who was brought to the Emergency Room with 30% TBSA 2nd and 3rd degree flame burns of her face, neck, chest, arms, hands, abdomen and thighs. There were signs of char around her ala nasi. Since the accident took place in a closed space, smoke inhalation was also suspected. She was highly excited, pale, tachypneic (40 b/min), shivering and with shallow breathing. Her vital signs were stable: blood pressure: 140/90, pulse: 110/min, respiration: 35/min and hemoglobin level was nine. Blood gases and electrolytes were within normal levels. There were no signs of burn in her nasopharynx. Chest X-ray and ECG were normal. Mechanical ventilation was started and intravenous fluid administration with Ringers lactate solution at 4 cc/kg per h was begun. During the following days she developed acute respiratory distress syndrome (ARDS) and mechanical ventilation was therefore continued. In the second week blood cultures were positive for Acinetobacter and enterococci, common and notorious inhabitants of the hospital, and i. v. antibiotics were begun. The patient gradually developed respiratory distress. Her blood gases deteriorated and chest X-ray revealed disseminated pulmonary infiltrates and cardiomegaly. Central venous pressure (CVP) levels rose to near 30 cmH2O and paradoxical pulse appeared. Her daily intake included 3.5 l of 1/3 standard plus 2500 cc of Pulmocare. Fluid balance was 10 l positive, and she was oliguric (50 cc/h) and needed furosemide to maintain adequate urine output. The clinical picture was compatible with tamponade and echocardiography was performed. A large amount of pericardial fluid and a mild collapse of the left atrial walls were found. It was decided not to drain the pericardium, but rather continue the conservative treatment with Aspirin, antibiotics and respiratory support. A slow but continued improvement followed over the next few days. CVP levels dropped gradually, urine output increased, blood gases improved and the respiratory distress subsided. Mechanical ventilation was terminated. Repeated echocardiography showed only a residual amount of pericardial fluid. On follow-up several months later, she was free of complaints. The elevation of CVP, cardiomegaly, the development of tachypnea, the appearance of disseminated pulmonary infiltrates, a positive fluid balance of nearly 10 l and acute heart failure led us to consider three possible causes: (1) over-hydration induced heart failure, (2) respiratory failure due to ARDS and septicemia, and (3) heart failure as a result of pericardial effusion, considering the high CVP levels. The subsequent echocardiography showed, indeed, that there was pericardial involvement. The burns on her chest had no awindowo of unburned skin and the decision not to drain the pericardium was based on the assumption that bacteria from the infected burned chest surface might contaminate the otherwise non-infected reactive pericardial effusion and actually complicate the situation. The conservative treatment with antibiotics, Aspirin and respiratory support proved to be beneficial. Had the clinical course deteriorated, we would have considered pericardial drainage through the burned area. Our conclusion is that the option of conservative treatment should be taken full advantage of in thermally injured patients whose condition is complicated by pericardial effusion before pericardial drainage is carried out.

A thermal burn to a prolapsed uterus

Burns to the concealed area of the perineum, are relatively rare and usually associated with massive burns and a high mortality rate. A rare case of a thermal burn to a prolapsed uterus is described. The victim was a 72-year-old Bedouin woman, with a 70 per cent total body surface area deep burn from an open fire. In addition to the conventional treatment dictated by such a burn, two unique problems must be considered: (1) the common pathogens of the uterus, Neisseria gonorrhoeae, Chlamydia trachomatis and mycoplasma, are different from those of the skin; (2) the lymphatics of the uterus drain directly into the abdominal cavity and the risk of peritonitis and generalized infection is potentially higher. Intravenous, prophylactic, broad-spectrum antibiotics were therefore initiated immediately following admission. These included: cefoxitin, gentamicin and metronidazole a combination that covers both the potential pathogens of the uterus and the common pathogens of the skin. In addition, and for the same reason, Betadine substituted Flamazine for the local treatment of the exposed uterus. Our patient did not survive the burn, but in a similar, unusual case, the local and systematic remedies must protect against uterine pathogens that are not commonly seen in a burn victim.

An improved design for vacuum tube drains.

Mini vacuum drains can be helpful in reconstructive surgery. The drains may be assembled using a scalp needle and a vacuum tube. The addition of the adapter that is used with the vacuum tubes for blood sampling improves the ease of use and practicality of these drains and increases their safety.