Timing of surgery in acute deep partial-thickness burns: A study protocol

For deep partial-thickness burns no consensus on the optimal treatment has been reached due to conflicting study outcomes with low quality evidence. Treatment options in high- and middle-income countries include conservative treatment with delayed excision and grafting if needed; and early excision and grafting. The majority of timing of surgery studies focus on survival rather than on quality of life. This study protocol describes a study that aims to compare long-term scar quality, clinical outcomes, and patient-reported outcomes between the treatment options. A multicentre prospective study will be conducted in the three Dutch burn centres (Rotterdam, Beverwijk, and Groningen). All adult patients with acute deep-partial thickness burns, based on healing potential with Laser Doppler Imaging, are eligible for inclusion. During a nine-month baseline period, standard practice will be monitored. This includes conservative treatment with dressings and topical agents, and excision and grafting of residual defects if needed 14-21 days post-burn. The subsequent nine months, early surgery is advocated, involving excision and grafting in the first week to ten days post-burn. The primary outcome compared between the two groups is long-term scar quality assessed by the Patient and Observer Scar Assessment Scale 3.0 twelve months after discharge. Secondary outcomes include clinical outcomes and patient-reported outcomes like quality of life and return to work. The aim of the study is to assess long-term scar quality in deep partial-thickness burns after conservative treatment with delayed excision and grafting if needed, compared to early excision and grafting. Adding to the ongoing debate on the optimal treatment of these burns. The broad range of studied outcomes will be used for the development of a decision aid for deep partial-thickness burns, to fully inform patients at the point of consent to surgery and support optimal person-centred care.

Short-term and long-term increased mortality in elderly patients with burn injury: a national longitudinal cohort study

BACKGROUND

The population of elderly patients with burn injuries is growing. Insight into long-term mortality rates of elderly after burn injury and predictors affecting outcome is limited. This study aimed to provide this information.

METHODS

A multicentre observational retrospective cohort study was conducted in all three Dutch burn centres. Patients aged ≥65 years, admitted with burn injuries between 2009 and 2018, were included. Data were retrieved from electronic patient records and the Dutch Burn Repository R3. Mortality rates and standardized mortality ratios (SMRs) were calculated. Multivariable logistic regression was used to assess predictors for in-hospital mortality and mortality after discharge at 1 year and five-year. Survival analysis was used to assess predictors of five-year mortality.

RESULTS

In total, 682/771 admitted patients were discharged. One-year and five-year mortality rates were 8.1 and 23.4%. The SMRs were 1.9(95%CI 1.5-2.5) and 1.4(95%CI 1.2-1.6), respectively. The SMRs were highest in patients aged 75-80 years at 1 year (SMRs 2.7, 95%CI 1.82-3.87) and five-year in patients aged 65-74 years (SMRs 10.1, 95%CI 7.7-13.0). Independent predictors for mortality at 1 year after discharge were higher age (OR 1.1, 95%CI 1.0-1.1), severe comorbidity, (ASA-score ≥ 3) (OR 4.8, 95%CI 2.3-9.7), and a non-home discharge location (OR 2.0, 95%CI 1.1-3.8). The relative risk of dying up to five-year was increased by age (HR 1.1, 95%CI 1.0-1.1), severe comorbidity (HR 2.3, 95%CI 1.6-3.5), and non-home discharge location (HR 2.1, 95%CI 1.4-3.2).

CONCLUSION

Long-term mortality until five-year after burn injury was higher than the age and sex-matched general Dutch population, and predicted by higher age, severe comorbidity, and a non-home discharge destination. Next to pre-injury characteristics, potential long-lasting systemic consequences on biological mechanisms following burn injuries probably play a role in increased mortality. Decreased health status makes patients more prone to burn injuries, leading to early death.

Regrafting of the Split-Thickness Skin Graft Donor-Site: Is It Beneficial?

Split-thickness skin grafting remains a fundamental treatment for patients with deep burns and other traumatic injuries. Unfortunately, the donor site wound that remains after split skin graft (SSG) harvesting may also cause problems for the patient; they can lead to discomfort and scars with a poor cosmetic outcome. Regrafting of the donor site is one of the methods described to improve donor site healing and scarring. In this report, we describe a case of a 26-year-old woman with a self-inflicted chemical burn (0.5% TBSA) who underwent split skin grafting. During surgery, only part of the donor site was regrafted with split skin graft remnants. This part healed faster and had a better scar quality at 3 months postsurgery. Nevertheless, the appearance and patients' opinion on the regrafted part deteriorated after 12 months. With this case report, we aim to create awareness of the long-term consequences of regrafting, which may differ from short-time results. Patients expected to have poor reepithelialization potential may benefit from regrafting of the SSG on the donor site. But in healthy young individuals, timewise there would be no benefit since it can lead to an aesthetically displeasing result.

Diffusion Tensor Imaging and Fiber Tractography in Children with Craniosynostosis Syndromes

BACKGROUND AND PURPOSE

Patients with craniosynostosis syndromes caused by mutations in FGFR-2, FGFR-3, and TWIST1 genes are characterized by having prematurely fused skull sutures and skull base synchondroses, which result in a skull deformity and are accompanied by brain anomalies, including altered white matter microarchitecture. In this study, the reliability and reproducibility of DTI fiber tractography was investigated in these patients. The outcomes were compared with those of controls.

MATERIALS AND METHODS

DTI datasets were acquired with a 1.5T MR imaging system with 25 diffusion gradient orientations (voxel size = 1.8 × 1.8 × 3.0 mm(3), b-value = 1000 s/mm(2)). White matter tracts studied included the following: corpus callosum, cingulate gyrus, fornix, corticospinal tracts, and medial cerebellar peduncle. Tract pathways were reconstructed with ExploreDTI in 58 surgically treated patients with craniosynostosis syndromes and 7 controls (age range, 6-18 years).

RESULTS

Because of the brain deformity and abnormal ventricular shape and size, DTI fiber tractography was challenging to perform in patients with craniosynostosis syndromes. To provide reliable tracts, we adapted standard tracking protocols. Fractional anisotropy was equal to that in controls (0.44 versus 0.45 ± 0.02, P = .536), whereas mean, axial, and radial diffusivity parameters of the mean white matter were increased in patients with craniosynostosis syndromes (P < .001). No craniosynostosis syndrome-specific difference in DTI properties was seen for any of the fiber tracts studied in this work.

CONCLUSIONS

Performing DTI fiber tractography in patients with craniosynostosis syndromes was difficult due to partial volume effects caused by an anisotropic voxel size and deformed brain structures. Although these patients have a normal fiber organization, increased diffusivity parameters suggest abnormal microstructural tissue properties of the investigated white matter tracts.

Dynamics and fates of trace metals chronically input in a Mediterranean coastal zone impacted by a large urban area

Quantification and characterization of chronic inputs of trace metals and organic carbon in a coastal Mediterranean area (the city of Marseille) during the dry season was carried out. The 625 km(2) watershed includes two small coastal rivers whose waters are mixed with treated wastewater (TWW) just before their outlet into the sea. Dissolved and particulate Cu, Pb, Cd, Zn, Co, Ni and organic carbon concentrations in the rivers were comparable to those in other Mediterranean coastal areas, whereas at the outlet, 2- to 18-fold higher concentrations reflected the impact of the TWW. A non-conservative behavior observed for most of the studied metals in the mixing zone was validated by a remobilization experiment performed in the laboratory. The results showed that sorption/desorption processes could occur with slow kinetics with respect to the mixing time in the plume, indicating non-equilibrium in the dissolved/particulate metal distribution. Thus, a sample filtration immediately after sampling is strictly required.

Base flow and stormwater net fluxes of carbon and trace metals to the Mediterranean sea by an urbanized small river

Base flow and storm flow events from a small, urbanized Mediterranean river located in the South of France were studied to evaluate net fluxes from the continent to the coastal sea water. Considered variables were: pH, conductivity, redox potential, temperature, dissolved O(2), SPM (Suspended Particulate Matter), Cl(-), NO(3)(-), SO(4)(2-), Na(+), K(+), Mg(2+), Ca(2+), DOC (Dissolved Organic Carbon), Cu, Zn, Cd and Pb in the dissolved fraction and POC (Particulate Organic Carbon), Cr, Mn, Fe, Ni, Cu, Zn, Cd and Pb in the particulate fraction. If rainfall intensity and antecedent rainfall history were sufficient to explain many observed variations, the patterns of particles and solutes transport greatly varied from one storm event to another. SPM, POC, particulate Cu, Zn, Cd and Pb had similar behavior characterized by an immediate increase at the beginning of the storm flow and the highest values at the first high discharge peak. Among dissolved species, Cl(-), SO(4)(2-), Na(+), Ca(2+) and Mg(2+) had a behavior very similar one to the other. They exhibited high concentrations and enrichment factors at the beginning of the storm flow, due to fast leaching of highly labile species. Their concentrations decreased during posterior discharge peaks but positive enrichment factors indicated permanent sources for these ions. DOC, K(+) and NO(3)(-) had different behaviors which indicated sources positively correlated with rainfall intensity. A 3D-fluorescence study showed that the humified organic matter contribution to DOC increased during storm flow. Relationships between DOC and dissolved Cu and Pb indicated differences in organic-matter binding properties between dry and humid periods. Storm flow were responsible for more than 90% of the annual output to the sea of SPM, POC and particulate Cu, Zn, Cd and Pb and more than 70% for dissolved Pb, Cd, NO(3)(-) and DOC. For the other dissolved species, outputs were balanced between base flow and storm flow. Contrary to what was observed in large rivers, organic carbon was mainly transported in the POC fraction. The average specific fluxes of Cu and Pb to the sea were 3.8 and 3.4 kg km(-2) y(-1), respectively, of the same order of magnitude than specific fluxes of other North-Mediterranean rivers, but outputs were more intense during shorter durations. The extrapolation of the Eygoutier River data to the Mediterranean non-desert coastline showed that the order of magnitude of Cu and Pb annually brought to the sea by the whole of small anthropized coastal rivers can be similar to the annual input by the Rhône or the Po River.

The relation between biological activity of the rain forest and mineral composition of soils

In most soils of the humid tropics, kaolinitic topsoil horizons overlie more gibbsitic horizons. This arrangement cannot be produced simply by leaching. Quantitative measurement of the turnover of chemical elements in the litterfall in an Amazonian ecosystem indicates that the forest cycles a significant amount of elements, particularly silicon. As a result, fluids that percolate through topsoil horizons already contain dissolved silicon. This effect keeps silicon from being leached down and may account for the stability of kaolinite in the soil upper horizons. The soil mineral composition is thus maintained by biological activity.

3D modeling from uncalibrated color images for a complete wound assessment tool

This paper is concerned with the 3D modeling of skin wound using uncalibrated vision techniques for the volumetric assessment of the healing process. We have developed an original approach for matching two color images captured with a free-handled digital camera and generate a semi-dense 3D model. We evaluate the precision of the inferred 3D model by registration to a ground truth on artificial wounds. The method is then applied to volumetric measurements. The clinician requirements of a global 5% precision are overshot as 3% is obtained locally. The best configuration for taking photos lies between 1.2 and 1.5 for distance ratios and between 15 degrees and 30 degrees for vergence of the stereo pair. This work is part of the ESCALE project dedicated to the design of a complete 3D and color wound assessment tool using a simple free handled digital camera: a smart solution for massive diffusion in care centers as such very low cost system should be operated directly by nurses.

Tracing of dissolved organic matter from the Sepetiba Bay (Brazil) by PARAFAC analysis of total luminescence matrices

Fluorescent excitation-emission matrices (FEEM) of the fluorescent dissolved organic matter (FDOM) are widely used for DOM characterization and tracing. In this work, a set of FEEM from sampling campaigns in the Sepetiba Bay (Brazil) was decomposed into independent components using the parallel factor analysis (PARAFAC) algorithm. Four independent components were extracted describing the total fluorescence of the FDOM. The well described peaks A, C, M, B and T were found, and a new peak, A', linked to the C peak, was detected. Relative contribution of each of four components to the total fluorescence confirms that the coastal water has DOM of terrestrial origin, except for the 275Ex/400-500Em range (nm), which primarily occurs in marine waters.

Transfer of nutrients and labile metals from the continent to the sea by a small Mediterranean river

The contribution of small watersheds to coastal pollution in Mediterranean areas is still poorly known, and presents great variations along an hydrological year. This work deals with the characterization and quantification of Al, Fe, Zn, Cu, Pb, Si, NO(3)(-) and organic carbon transported from the continent to the sea by a small coastal river in the French Mediterranean area. Transported species were characterized both during rainy and dry periods. During non-rainy periods (base-flow), waters showed a low content of contaminants, whereas during heavy rain events, following dry periods, some metals and organic carbon reached concentrations that could affect biological populations. These contaminants were mainly found in the particulate fraction, originating from the runoff of surface waters, which represents the main process of pollution in urban areas.

Effects of UV-visible irradiation on natural organic matter from the Amazon basin

The aim of this work was to evaluate the effects of UV-visible irradiation on organic carbon concentration, fluorescence intensity and metal transport ability of the natural organic matter (NOM) at fixed pH values and under several types of atmosphere (air, N(2), O(2)). The water samples were obtained from various sampling sites along the Rio Negro (Amazon basin) and the NOM metal transport ability was determined with regard to Cu(2+). As a first step we measured the concentration of total organic carbon (TOC) and its fluorescence intensity before and after an irradiation for a given time. The results demonstrated that when photodegradation happened, the dominant reactions involved O(2) and the fluorescent sites were among the first to be altered. Then we determined by spectrofluorometry the complexing capacity (C(L)) before and after irradiation. Fluorescence and complexing site densities (C(L)/TOC ratio) increased after a short irradiation time (20 min, i.e. before the photodegradation happened) and decreased after longer irradiation times. Therefore, we conclude that a change of the macromolecular structure activates previously inactive fluorophores and complexing sites prior to photodegradation.

SYDESCO: a laser-video scanner for 3D scoliosis evaluations

SYDESCO is a new 3D vision system developed for trunk surface topography. This structured light surface scanner uses the principle of triangulation-based range sensing to infer 3D shape. The complete trunk acquisition is fast (2 seconds). The accuracy of the metric data is ensured by a subpixel image detection and a calibration process, which rectifies image deformations. A preliminary study presents results on 50 children in a gymnastics school. These children, aged between eight to sixteen years, are particularly exposed to spinal deformities. An asymmetry index is calculated from the 3D data to detect the pathologic cases. These results have been compared to an independent medical diagnosis. The system results have been confirmed for 72,1% of the patients.

Urinary iodine excretion during normal pregnancy in healthy women living in the southwest of France: correlation with maternal thyroid parameters

A prospective study was undertaken to evaluate urinary iodine excretion and changes of maternal thyroid function during pregnancy in healthy women living in the southwest of France. The cohort included a total of 347 pregnant women (mean age 28.0+/-0.5 years). Iodine concentration in a random urine sample and thyroid tests (free thyroxine [FT4], free triiodothyronine [FT3], thyrotropin (TSH), thyroxine-binding globulin [TBG], and thyroglobulin [Tg]) were measured at initial presentation (before 12 weeks of gestation), and during the ninth month of pregnancy. A thyroid ultrasound was performed 1 to 5 days after delivery in 246 mothers. Mean urinary iodine levels were low during the first trimester (6.9+/-0.4 microg/dL), as well as during the ninth month of pregnancy (8.6+/-0.6 microg/dL). During pregnancy, FT4 and T3 concentrations decreased (p < .001), and TSH and Tg concentrations increased (p < .001). Thyroid hypertrophy (thyroid volume greater than 18 mL) was present in 15.4% of women whose first trimester urinary iodine concentration was less than 5 microg/dL, but was present in only 3.5% of women whose urinary iodine concentration was greater than 10 microg/dL. A goiter (thyroid volume greater than 22 mL) was present in 11% of the mothers. In conclusion, this prospective study shows that urinary iodine excretion is low in pregnant women living in the southwest of France. This low iodine intake is associated with reduced circulating thyroid hormone levels and growth of the thyroid gland. These data point to the need of an increased iodine supply in these pregnant women to reduce the potential consequences of low iodine intake on maternal thyroid economy.

[The value of the C-reactive protein assay for the early diagnosis of neonatal infection at the maternity ward and pediatric service of a general hospital center]

Five hundred and ninety-four children hospitalized in the Maternity Ward and Pediatric Department of a General Hospital were enrolled in this retrospective study. Two CRP assays were performed with 24 hours of birth in 105 neonates at high risk for materno-fetal infection. Results suggested infection in 12 cases (2%). CRP kinetics were studied comparatively in these 105 patients and in 55 control neonates of identical gestational age. Differences between the two groups were evidenced and were already significant for the six to 12-hour age groups. Results indicated that the upper limit of normal is 6 mg at age 12 hours and 8 mg at age 24 hours, whereas levels above 12 mg at age 12 hours and 20 mg at age 24 hours are abnormal. This early marker for neonatal infection is especially valuable in general hospitals lacking sophisticated equipment for the management of neonates. The number of neonates referred from the maternity ward and unnecessarily treated by antimicrobial agents fell by 20% approximately, with no increase in risk. CRP assays proved sensitive in streptococcus B infections and were valuable for evaluating the effectiveness of antimicrobial therapy.