Awareness of residents' technical ability can affect margin status in breast conserving operations.

PURPOSE: The current study was performed to determine if awareness of the potential affect of residents could affect margin status. METHODS: Retrospective review of all patients who underwent lumpectomy from July 2006 to May 2017 was evaluated. The effect of surgical residents' participation and their technical ability was evaluated to determine the effect on margin status. Logistic regression analysis was performed to determined factors which affect margin status. RESULTS: Of 444 patients, 14% of patients had positive margins. The positive margin rate was lower during the second time period after the effect of technical ability of the residents was known 12% versus 19% (p = 0.10). Greater participation by the attending surgeon (32% vs. 21%) occurred in the second time period. In multivariate logistic regression analysis, operations done by residents with satisfactory technical skills or attending surgeon were less likely to have positive margins than those done by residents with unsatisfactory technical skills (OR 0.19, 95% CI 0.10-0.38; p = 0.0001). With mean follow-up of 48 months, 1.4% had local recurrences as a first event. CONCLUSIONS: Technically ability of residents appears to affect margin status after lumpectomy. Increased intervention by the attending surgeon can improve this outcome.

Lemons in the Arizona Sunshine: The Effects of Furocoumarins Leading to Phytophotodermatitis and Burn-like Injuries.

INTRODUCTION: Phytophototoxic dermatitis is a strong phototoxic reaction to ultraviolet A (UV-A) radiation exposure after cutaneous contact with citrus fruit containing furocoumarins, leading to skin injury. At the Arizona Burn Center (Phoenix, AZ), the majority of these injuries are managed in the outpatient setting. CASE REPORT: The authors present a pediatric admission for burn-like injuries following prolonged cutaneous exposure to lemons while playing in the Arizona sunshine. A 7-year-old girl playing in her backyard squeezed lemon juice onto her skin while in the hot Arizona sunshine; within 24 hours, the child experienced pain, erythema, and blistering to multiple areas of her skin. She was admitted to the authors' burn center for wound care and pain control. She had scattered first-degree and second-degree burn-like lesions to her face, neck, and chest as well as bilateral forearms, hands, lower extremities, and feet. After blister debridement, appropriate dressing care, and pain medication, the patient was discharged home after 4 days of hospitalization with appropriate clinical follow-up. CONCLUSIONS: Burn-like lesions caused by furocoumarins after cutaneous absorption and UV-A exposure are known clinical entities in Arizona. The sequential progression from erythema to blisters equivalent to second-degree burn-like lesions to cutaneous hyperpigmentation is a well-described clinical triad. Meticulous wound care and pain control for the treatment of these burn-like lesions are essential as is the need for the wound care specialist to be well versed on this topic to quickly identify the etiology of the injury, thereby avoiding misdiagnosing the patient with nonaccidental traumatic injuries.

Antenna coupling explains unintended thermal injury caused by common operating room monitoring devices.

INTRODUCTION: Unintended thermal injury from patient monitoring devices (eg, electrocardiogram pads, neuromonitoring leads) results in third-degree burns. A mechanism for these injuries is not clear. The monopolar "bovie" emits radiofrequency energy that transfers to nearby, nonelectrically active cables or wires without direct contact by capacitive and antenna coupling. The purpose of this study was to determine if, and to what extent, radiofrequency energy couples to common patient monitoring devices. MATERIALS AND METHODS: In an ex vivo porcine model, monopolar radiofrequency energy was delivered to a handheld "bovie" pencil. Nonelectrically active neuromonitoring and cardiac-monitoring leads were placed in proximity to the monopolar pencil and its cord. Temperature changes of tissue touched by the monitoring lead were measured using a thermal camera immediately after a 5-second activation. The energy-device cords were then separated by 15 cm, the power was reduced from 30 W coag to 15 W coag and different cord angulation was tested. An advanced bipolar device, a plasma-based device, and an ultrasonic device were also tested at standard settings. RESULTS: The neuromonitoring lead increased tissue temperature at the insertion site by 39 ± 13°C (P<0.001) creating visible char at the skin. The electrocardiogram lead raised tissue temperature by 1.3 ± 0.5°C (P<0.001). Decreasing generator power from 30 W to 15 W and separating the bovie cord from the neuromonitoring cord by 15 cm significantly reduced the temperature change (39 ± 13°C vs. 26±5°C; P<0.001 and 39 ± 13°C vs. 10 ± 5°C; P<0.001, respectively). Lastly, monopolar energy increased tissue temperatures significantly more than argon beam energy (34 ± 15°C), advanced bipolar energy (0.2 ± 0.4°C), and ultrasonic energy (0 ± 0.3°C) (all P<0.001). CONCLUSIONS: Stray energy couples to commonly used patient monitoring devices resulting in potentially significant thermal injury. The handheld bovie cord transfers energy via antenna coupling to neuromonitoring leads that can raise tissue temperatures over 100°F (39°C) using standard settings. The most effective ways to decrease this energy coupling is to reduce generator power, increase the separation between wires, or utilize lower voltage energy devices such as ultrasonic or bipolar energy.