Sun protection counseling for children: primary care practice patterns and effect of an intervention on clinicians.

OBJECTIVES: To describe current primary care sun protection advice for children and assess the effect on clinicians of an intervention to enhance their sun protection advocacy. SETTING: Primary care practices caring for children in New Hampshire with special attention to clinicians serving 10 towns that were involved in a randomized controlled trial of the multicomponent SunSafe intervention involving schools, recreation areas, and primary care practices. DESIGN/INTERVENTION: A statewide survey of all primary care clinicians serving children addressed their self-reported sun protection advocacy practices. Clinicians in 10 systematically selected rural towns were involved in the subsequent intervention study. The primary care intervention provided assistance to practices in establishing an office system that promoted sun protection advice to children and their parents during office visits. MAIN OUTCOME MEASURES: Sun protection promotion activities of primary care clinicians as determined by their self report, research assistant observation, and parent interviews. RESULTS: Of 261 eligible clinicians responding to the statewide survey, about half provide sun protection counseling "most of the time" or "almost always" during summer well care visits. Pediatricians do so more often than family physicians. Clinicians involved in the intervention increased their use of handouts, waiting room educational materials, and sunscreen samples. Compared with control town parents, parents in intervention towns reported an increase in clinician sun protection advice. CONCLUSIONS: The SunSafe primary care intervention increased sun protection counseling activities of participating clinicians. A single-focus preventive service office system is feasible to include in community interventions to promote sun protection.

A community-based randomized trial encouraging sun protection for children.

OBJECTIVE: We evaluated the impact of an intervention promoting sun protection behavior among children 2 to 11 years of age through schools and day care centers, primary care practices, and recreation areas. METHODS: Ten towns in New Hampshire were paired, then assigned randomly to intervention or control status. The multicomponent SunSafe intervention was provided to children and caregivers through primary care practices, day care centers, schools, and beach recreation areas. Training support and materials were provided by the SunSafe project, but project staff had no direct contact with children or parents in providing the intervention. All intervention components promoted the same message: avoid the sun between 11 AM and 3 PM, cover up using hats and protective clothing, use sun block with a sun protection factor >/=15, and encourage sun protection among family and friends. The impact of the intervention was determined by observing children's sun protection behavior at the beach during baseline compared with 1 year later. The primary outcomes of interest were changes in the proportion of children per town using at least some sun protection and changes in the proportion of children fully protected. Children were clustered by town, with the town thus being the unit of analysis. The primary care practice component included one practice meeting for clinicians and staff at which project staff presented background on skin cancer and how to promote its prevention; a sun protection office system manual based on our previous work, which provided specific direction on how to share responsibility among office staff and clinicians in carrying out routines that promote sun protection; and educational posters, pamphlets, and self-adhesive reminder notes designed to enhance sun protection counseling. SunSafe removable tattoos and stickers were offered to children at well-child and illness visits during the summer months. Schools each received three project staff visits: a brief visit with the principal to describe the intervention and to answer questions; an in-service program to educate teachers about skin cancer and to introduce curricular materials; and help with one parent outreach program. Larger day care centers each received one project staff visit. An additional six smaller day care centers received curricular materials through the mail but no visits. Two similar sets of curricular materials were used, one for grade schools and the other for preschools and day care centers. Both emphasized the importance of sun protection rather than the danger of skin cancer. Materials emphasized dynamic activities modeled after the "Slip, Slop, Slap" and "SunSmart" programs and included new material developed to suit regional needs. Both manuals offered structured plans but also provided a variety of activities from which teachers could choose. Teachers agreed to devote a minimum of two class periods to these materials. For recreation areas, lifeguards in each of the intervention communities attended an in-service meeting, during which background about skin cancer prevention was presented by project staff. The project also provided displays about the ultraviolet (UV) light index and about sun protection to be posted at each beach. Subsequently, project staff called beach staff in each community each morning with the predicted UV index for the day to post on the display. Educational pamphlets about the UV index and free sun-block samples were available to beachgoers through the lifeguards. One brief follow-up visit by project staff was made to each beach area to provide reinforcement. RESULTS: We observed 1930 children. Use of some sunscreen on at least one body area increased in all 5 intervention towns compared with paired control towns. In intervention towns, this mean proportion increased from 0.56 of those observed at baseline to 0.76 of those observed postintervention, with a minimal increase among control town children. (ABSTRACT TRUNCATED

Perichondrial cutaneous grafts for reconstruction of skin cancer excision defects.

BACKGROUND: Perichondrial cutaneous grafts (PCCGs) are composite grafts comprised of skin and subjacent perichondrium. Animal models and preliminary clinical reports have shown that PCCGs are thicker, survive better and contract less than full-thickness skin grafts, and are simpler to perform that alternative reconstructive methods such as two-stage flaps. OBJECTIVE: The applicability of PCCGs to surgical defects following Mohs surgery was investigated. METHODS: PCCGs were used to reconstruct patients with surgical defects following Mohs excision of skin cancers from facial sites near free anatomic margins and in defects with exposed cartilage. RESULTS: A series of cases is described, all with good to excellent cosmesis and function. CONCLUSION: PCCGs are useful in reconstruction of defects following Mohs excision of skin cancers.

Matricectomy.

Removal of the nail matrix is indicated in a variety of recalcitrant conditions in which the growth of the nail plate causes mechanical problems such as recurrent onychocryptosis or pain due to pinching or pressure. Before performing a matricectomy, the physician must consider the use of nonsurgical methods and the possible contraindications to surgery. Once the decision for matricectomy is made, the physician should then utilize the modality with the least morbidity and greatest convenience for the patient. A wide repertoire of methods of matricectomy is available for use; all methods, when performed properly, have similar high rates of cure.

Successful embolization of multiple AV foot lesions--a case history.

A 39-year-old white female with multiple arteriovenous malformations of the left foot had had surgical ligation on her left dorsalis pedis artery at age 12 with no clinical improvement. She was placed into a leotard at age 16 and was able to function but would tire very easily and her left foot was twice the size of her right one. In May 1988, she had four large feeder vessels off the posterior tibial artery and two off the anterior tibial artery embolized by use of 1,000 microns PVA particles, occlusive spring coils, and detachable balloons. Her foot shrunk and is now smaller than her normal right foot; she does not tire, and she now wears a knee length stocking to help prevent other channels from opening.

Split-thickness skin grafting in extensive ulcerative sarcoidosis.

A 64-year-old white male had extensive ulcerative cutaneous sarcoidosis of the lower extremities. After stabilization with methotrexate and prednisone therapy, the ulcers were debrided and covered with split-thickness skin grafts. An 80% graft acceptance was maintained 2 months later. Successful grafting of ulcerative sarcoidosis has not been reported previously.

Letterer-Siwe disease in adults.

Histiocytosis X (HX) is a rare disorder of histiocytic proliferation characterized by a broad spectrum of clinicopathologic disease. An unusual case of Letterer-Siwe disease (LSD) or subacute disseminated HX in a 71-year-old woman is presented. The patient had a 3-year history of splenomegaly before skin lesions developed. She presented to our clinic at 1.5 years later and the diagnosis of HX was made by skin biopsy. Topical nitrogen mustard (NM) therapy resulted in complete clearing of cutaneous lesions. Her condition was stable over the next 10 months. However, she subsequently suffered a rapid and fatal dissemination of her disease. Systemic treatment with prednisone, vinblastine sulphate, and suppressin A (SA) (a calf thymus derived hormone preparation that specifically induces suppressor T-cells) was ineffective. Characteristic histopathologic, immunohistochemical, and electron microscopic findings of HX are illustrated. A review of the adult cases of LSD and treatment options for HX are presented and discussed.

Evaluation of a method for measuring the sustainable rate of sebaceous wax ester secretion.

Sebaceous wax ester secretion rates were measured in six subjects on six occasions each, using absorption into bentonite clay and analysis of the collected lipid by quantitative thin-layer chromatography. On each occasion eight samples were collected, four from the left and four from the right side of the forehead in four successive intervals. The first two intervals, which totaled 14 h, were intended to deplete the follicular reservoir of sebum so that a constant rate of absorption could be obtained during the third and fourth intervals, which were 3 h each. Thin-layer analysis of each sample was done in triplicate. The data were examined using analysis of variance techniques to determine the reproducibility of the measurement method and to identify possible sources of variability. The intraclass correlation coefficient (rI) for all 432 post-depletion determinations was 0.80. The reproducibility was considerably better for three of the subjects (rI = 0.93) than for the other three (rI = 0.75). Variability within the latter three subjects did not seem to be attributable to lack of reproducibility in the thin-layer analysis. Real biological variability also seems unlikely considering the holocrine mechanism of sebum secretion. Therefore, the variability probably arises from non-representative collection of sebum into the bentonite absorbent.