1
|
Kerr JR, Castro ALF, Melo NO, Daniels JA, Holgate A, Dolman LA, Silva LGM, Kemp PS. The effects of simulated hydropower turbine rapid decompression on two Neotropical fish species. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 903:166770. [PMID: 37660813 DOI: 10.1016/j.scitotenv.2023.166770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/17/2023] [Accepted: 08/31/2023] [Indexed: 09/05/2023]
Abstract
Barotrauma is a major cause of injury and mortality of fish as they pass through hydropower turbines. Current understanding of hydropower related barotrauma is biased towards northern temperate and southern subtropical species with single chambered swim bladders, specifically North American and Australian species, respectively. Today, unprecedented hydropower development is taking place in Neotropical regions where many species have complex multi-chambered swim bladder architecture. This study investigated barotrauma in two dual-chambered physostomous Neotropical fish (pacu, Piaractus mesopotamicus, and piracanjuba, Brycon orbignyanus) exposed to rapid (< 1 s) decompression at different Ratios of Pressure Change (RPC), using a hypo-hyperbaric chamber. The incidence and intensity (percentage surface area of organ affected) of injury and physiological and behavioural response (hereafter just response) of each species immediately after decompression was assessed. Twenty-two injury types (e.g. gill haemorrhage and exophthalmia) and eight response categories (e.g. rising to the surface and loss of orientation) were identified and the influence of: 1) species, 2) RPC, and 3) swim bladder rupture on each was quantified. There was considerable interspecific difference with emboli type injuries occurring more frequently in piracanjuba, but injury intensity tending to be higher in pacu. Both swim bladder chambers tended to rupture in piracanjuba but only the anterior chamber in pacu. RPC was positively correlated with response, incidence and intensity of several injury types for both species with some injuries occurring at very low RPC (e.g. 50 % probability of swim bladder rupture at 2.2 and 1.75 for piracanjuba and pacu, respectively). Multiple responses (e.g. loss of orientation) and injuries (e.g. eye haemorrhage) were correlated with swim bladder rupture suggesting gas venting into the body cavity likely causes secondary injury. When directly comparing our results with those available in the published literature, both pacu and piracanjuba appear to be more susceptible to barotrauma than previously studied subtropical and temperate species.
Collapse
Affiliation(s)
- J R Kerr
- International Centre for Ecohydraulics Research, Faculty of Engineering and Physical Sciences, University of Southampton, Boldrewood Campus, Southampton SO16 7QF, United Kingdom.
| | - A L F Castro
- Molecular Ecology & Ichthyology Lab, Department of Natural Sciences (DCNAT), Universidade Federal de São João del-Rei (UFSJ), Praça Frei Orlando 170, 36307-352 São João del-Rei, MG, Brazil
| | - N O Melo
- Molecular Ecology & Ichthyology Lab, Department of Natural Sciences (DCNAT), Universidade Federal de São João del-Rei (UFSJ), Praça Frei Orlando 170, 36307-352 São João del-Rei, MG, Brazil
| | - J A Daniels
- International Centre for Ecohydraulics Research, Faculty of Engineering and Physical Sciences, University of Southampton, Boldrewood Campus, Southampton SO16 7QF, United Kingdom
| | - A Holgate
- International Centre for Ecohydraulics Research, Faculty of Engineering and Physical Sciences, University of Southampton, Boldrewood Campus, Southampton SO16 7QF, United Kingdom
| | - L A Dolman
- International Centre for Ecohydraulics Research, Faculty of Engineering and Physical Sciences, University of Southampton, Boldrewood Campus, Southampton SO16 7QF, United Kingdom
| | - L G M Silva
- Stocker Lab, Institute for Environmental Engineering, Department of Civil, Environmental and Geomatic Engineering, ETH-Zurich, Zurich 8046, Switzerland
| | - P S Kemp
- International Centre for Ecohydraulics Research, Faculty of Engineering and Physical Sciences, University of Southampton, Boldrewood Campus, Southampton SO16 7QF, United Kingdom
| |
Collapse
|
2
|
Jiang M, Qian H, Li Q, Han Y, Hu K. Predictive value of lactate dehydrogenase combined with the abbreviated burn severity index for acute kidney injury and mortality in severe burn patients. Burns 2023; 49:1344-1355. [PMID: 36805837 DOI: 10.1016/j.burns.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 12/15/2022] [Accepted: 01/25/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND Extensive burns are devastating trauma. This study aimed to explore the predictive value of early lactate dehydrogenase (LDH) level, the abbreviated burn severity index (ABSI) and their combination on acute kidney injury (AKI) and mortality after severe burns. METHODS AND RESULTS 194 severe burn patients (TBSA ≥ 30%) were included. After multivariate analyses, early LDH value (first 24 h after admission) was an independent risk factor for early AKI (OR=1.095, CI,1.025-1.169,p = 0.007) and AKI (OR=1.452, CI,1.131-1.864, p = 0.003) in severe burn patients and was still a significant risk factor for mortality (OR=1.059, CI,1.006-1.115,p = 0.03). In ROC analysis, after combining LDH and ABSI, the AUC values were 0.925 for AKI, 0.926 for stage 3 AKI, and 0.904 for mortality. Based on cut-off values, patients were divided into different risk groups. The cumulative incidence of AKI (within 5 days, 30 days) and survival rate (within 60 days) were analyzed by the Kaplan-Meier method. The mortality, AKI incidence, and AKI staging showed a significant upward trend with the increasing risk level (P < 0.001). CONCLUSION Early LDH level is an independent risk factor for early AKI and AKI. LDH combined with ABSI can better predict mortality and AKI than single indicators.
Collapse
Affiliation(s)
- Ming Jiang
- Department of Burn and Plastic Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province 226001, People's Republic of China; Nantong University Medical School, Nantong, Jiangsu Province 226001, People's Republic of China.
| | - Hongyan Qian
- Cancer Research Centre Nantong, Tumor Hospital Affiliated to Nantong University, Nantong, Jiangsu Province 226300, People's Republic of China.
| | - Qiqi Li
- Department of Burn and Plastic Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province 226001, People's Republic of China; Nantong University Medical School, Nantong, Jiangsu Province 226001, People's Republic of China.
| | - Yingying Han
- Nantong Center for Disease Control and Prevention Institute of Chronic Non-communicable Diseases Prevention and Control, Nantong, Jiangsu Province 226001, People's Republic of China.
| | - Kesu Hu
- Department of Burn and Plastic Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province 226001, People's Republic of China.
| |
Collapse
|
3
|
Xiao K, Chen WX, Li XJ. Analysis of risk factors of prolonged mechanical ventilation in patients with severe burn injury. THE CLINICAL RESPIRATORY JOURNAL 2023; 17:791-798. [PMID: 37519126 PMCID: PMC10435940 DOI: 10.1111/crj.13673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 06/30/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Mechanical ventilation is an essential means of life support for patients with severe burns. However, prolonged mechanical ventilation (PMV) increases the incidence of complications and length of hospital stay. Therefore, studying the risk factors of mechanical ventilation duration is of great significance for reducing the duration of mechanical ventilation, reducing related complications, and improving the success rate of severe burn treatment. METHOD This study was a retrospective study of patients with burns ≥30% of the area admitted to the BICU of Guangzhou Red Cross Hospital affiliated with Jinan University from January 2016 to January 2023 who were mechanically ventilated. Patients were classified into the prolonged mechanical ventilation group if they were mechanically ventilated for ≥21 days. Then, independent risk factors for prolonged mechanical ventilation were determined by logistic regression analysis of the collected data. RESULT Of all the 112 enrolled patients, 79 had prolonged mechanical ventilation, with an incidence of 70.5%. Logistic regression analysis revealed that including abbreviated burn severity index (ABSI%) (P < 0.001), moderate and severe inhalation injury (P = 0.005, P = 0.044), albumin (P = 0.032), lactic acid (P < 0.001) were independent risk factors for prolonged mechanical ventilation. In addition, ventilator-related complications were 44% in the PMV group and 21% in the non-PMV group. CONCLUSION ABSI%, inhalation injury, albumin, and lactic acid on admission are the risk factors for PMV in severe burn patients. In addition, ventilator-related complications were higher in group PMV than in group non-PMV in our study.
Collapse
Affiliation(s)
- Kui Xiao
- Department of Burn and Plastic Surgery, Guangzhou Red Cross HospitalJinan UniversityGuangzhouChina
| | | | - Xiao Jian Li
- Department of Burn and Plastic Surgery, Guangzhou Red Cross HospitalJinan UniversityGuangzhouChina
| |
Collapse
|
4
|
Use of procalcitonin as a biomarker for sepsis in pediatric burns. Eur J Pediatr 2023; 182:1561-1567. [PMID: 36752894 DOI: 10.1007/s00431-023-04831-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 12/05/2022] [Accepted: 01/12/2023] [Indexed: 02/09/2023]
Abstract
UNLABELLED Infection and sepsis continue to be the leading cause of morbidity and death in burn injuries. Diagnosing sepsis in burns is challenging as signs and symptoms of sepsis are not specific and overlap with those related to the burn injury. While the use of procalcitonin (PCT) as a biomarker is recommended for diagnosing sepsis in burns, evidence for children with burns is scarce. In this study, we aimed to investigate the role of PCT in distinguishing sepsis in pediatric burns. A prospective observational study was conducted in a single pediatric burn unit. Children hospitalized with burns ≤ 30% of total body surface area were included while patients with chemical burn, inhalation injury, or concomitant chronic diseases were excluded. Patients were classified into three groups for sepsis, systemic inflammatory response syndrome (SIRS), or controls using the American Burn Association (ABA) criteria. The predictive role of C-reactive protein (CRP) and PCT was investigated for distinguishing sepsis. Seventy-two patients were included in the study. The median total body surface area (TBSA) size was 12% (2.0-28.5%), and the median abbreviated burn severity index (ABSI) score was 3 (2-7). The median length of burn unit stay was 9.5 days (1-59 days). Sepsis was diagnosed in 11 patients (15.2%), and SIRS was present in 23 patients (40.0%), whereas 38 patients (52.8%) had neither SIRS nor sepsis (control group). Receiver operating characteristic analysis revealed that CRP and PCT levels distinguished sepsis patients from non-sepsis patients while PCT had a higher positive predictive value (50.0% vs. 45.0%). Optimal cutoff values of CRP and PCT for distinguishing sepsis were 66.75 mg/L and 0.95 ng/mL. CONCLUSIONS PCT levels could distinguish sepsis in children with burn injuries, performing better than CRP levels. Confirmatory studies are needed to evaluate the development of sepsis and the role of PCT in diagnosing sepsis in pediatric burn patients. WHAT IS KNOWN • Even though there are excellent criteria for the diagnosis of infection and sepsis in children and several clinical parameters and biomarkers are being studied, it's difficult to diagnose burn wound sepsis in children. WHAT IS NEW • Data from this study showed that procalcitonin levels performed better than CRP levels as a biomarker for distinguishing sepsis from systemic inflammatory response syndrome (SIRS) in children with burn injuries.
Collapse
|
5
|
|
6
|
Factors Associated With Mechanical Ventilation Duration in Pediatric Burn Patients in a Regional Burn Center in the United States. Pediatr Crit Care Med 2022; 23:e536-e540. [PMID: 36040074 DOI: 10.1097/pcc.0000000000003068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Among burned children who arrive at a burn center and require invasive mechanical ventilation (IMV), some may have prolonged IMV needs. This has implications for patient-centered outcomes as well as triage and resource allocation decisions. Our objective was to identify factors associated with the duration of mechanical ventilation in pediatric patients with acute burn injury in this setting. DESIGN Single-center, retrospective cohort study. SETTING Registry data from a regional, pediatric burn center in the United States. PATIENTS Children less than or equal to 18 years old admitted with acute burn injury who received IMV between January 2005 and December 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Ventilator days were defined as any full or partial day having received IMV via an endotracheal tube or tracheostomy, not inclusive of time spent ventilated for procedures. Of 5,766 admissions for acute burn care, 4.3% ( n = 249) required IMV with a median duration of 10 days. A multivariable model for freedom from mechanical ventilation showed that the presence of inhalational injury (subhazard ratio [sHR], 0.62; 95% CI, 0.46-0.85) and burns to the head and neck region (sHR, 0.94; 95% CI, 0.90-0.98) were associated with increased risk of remaining mechanically ventilated at any time point. Older (sHR, 1.03; 95% CI, 1.01-1.04) and male children (sHR, 1.39; 95% CI, 1.05-1.84) were more likely to discontinue mechanical ventilation. A majority of children (94.8%) survived to hospital discharge. CONCLUSIONS The presence of inhalational injury and burns to the head and neck region were associated with a longer duration of mechanical ventilation. Older age and male gender were associated with a shorter duration of mechanical ventilation. These factors should help clinicians better estimate a burned child's expected trajectory and resource-intensive needs upon arrival to a burn center.
Collapse
|
7
|
Chiu YJ, Huang YC, Chen TW, King YA, Ma H. A Systematic Review and Meta-Analysis of Extracorporeal Membrane Oxygenation in Patients with Burns. Plast Reconstr Surg 2022; 149:1181e-1190e. [PMID: 35426867 PMCID: PMC9150852 DOI: 10.1097/prs.0000000000009149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 07/22/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Severely burned patients are at high risk for cardiopulmonary failure. Promising studies have stimulated interest in using extracorporeal membrane oxygenation as a potential therapy for burn patients with refractory cardiac and/or respiratory failure. However, the findings from previous studies vary. METHODS In this study, the authors conducted a systematic review and meta-analysis using standardized mortality ratios to elucidate the benefits associated with the use of extracorporeal membrane oxygenation in patients with burn and/or inhalation injuries. A literature search was performed, and clinical outcomes in the selected studies were compared. RESULTS The meta-analysis found that the observed mortality was significantly higher than the predicted mortality in patients receiving extracorporeal membrane oxygenation (standardized mortality ratio, 2.07; 95 percent CI, 1.04 to 4.14). However, the subgroup of burn patients with inhalation injuries had lower mortality rates compared to their predicted mortality rates (standardized mortality ratio, 0.95; 95 percent CI, 0.52 to 1.73). Other subgroup analyses reported no benefits from extracorporeal membrane oxygenation; however, these results were not statistically significant. Interestingly, the pooled standardized mortality ratio values decreased as the selected patients' revised Baux scores increased (R = -0.92), indicating that the potential benefits from the treatment increased as the severity of patients with burns increased. CONCLUSIONS The authors' meta-analysis revealed that burn patients receiving extracorporeal membrane oxygenation treatment were at a higher risk of death. However, select patients, including those with inhalation injuries and those with revised Baux scores over 90, would benefit from the treatment. The authors suggest that burn patients with inhalation injuries or with revised Baux scores exceeding 90 should be considered for the treatment and early transfer to an extracorporeal membrane oxygenation center.
Collapse
Affiliation(s)
- Yu-Jen Chiu
- From the Divisions of Plastic and Reconstructive Surgery and Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital; Department of Surgery, School of Medicine, and Institute of Clinical Medicine, National Yang Ming Chiao Tung University; Department of Dermatology and Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, and Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University; Department of Dermatology, Taipei Medical University-Shuang Ho Hospital; and Department of Surgery, National Defense Medical Center
| | - Yu-Chen Huang
- From the Divisions of Plastic and Reconstructive Surgery and Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital; Department of Surgery, School of Medicine, and Institute of Clinical Medicine, National Yang Ming Chiao Tung University; Department of Dermatology and Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, and Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University; Department of Dermatology, Taipei Medical University-Shuang Ho Hospital; and Department of Surgery, National Defense Medical Center
| | - Tai-Wei Chen
- From the Divisions of Plastic and Reconstructive Surgery and Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital; Department of Surgery, School of Medicine, and Institute of Clinical Medicine, National Yang Ming Chiao Tung University; Department of Dermatology and Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, and Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University; Department of Dermatology, Taipei Medical University-Shuang Ho Hospital; and Department of Surgery, National Defense Medical Center
| | - Yih-An King
- From the Divisions of Plastic and Reconstructive Surgery and Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital; Department of Surgery, School of Medicine, and Institute of Clinical Medicine, National Yang Ming Chiao Tung University; Department of Dermatology and Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, and Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University; Department of Dermatology, Taipei Medical University-Shuang Ho Hospital; and Department of Surgery, National Defense Medical Center
| | - Hsu Ma
- From the Divisions of Plastic and Reconstructive Surgery and Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital; Department of Surgery, School of Medicine, and Institute of Clinical Medicine, National Yang Ming Chiao Tung University; Department of Dermatology and Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, and Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University; Department of Dermatology, Taipei Medical University-Shuang Ho Hospital; and Department of Surgery, National Defense Medical Center
| |
Collapse
|
8
|
Zhang JX, Ahmed SN, Pangli H, Papp A. Predicting and Estimating Burn Outcomes: An Institutional Analysis of 4622 cases. J Burn Care Res 2022; 43:1426-1433. [PMID: 35481479 DOI: 10.1093/jbcr/irac051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Advances in burn care have improved patient outcomes, and independently validated indices and predictors of burn outcomes warrant re-evaluation. The purpose of this study is to consolidate predictors of burn outcomes and determine the factors that significantly contribute to length-of-stay (LOS) and mortality. A retrospective review was conducted of all burn patients (n=5778) admitted to a quaternary provincial burn unit from 1973 to 2017. Our inclusion criteria yielded 4622 independent cases. Multivariate linear and logistic regression models were generated, and area-under-receiver-operator-curve (AUROC) analysis was performed. Burn predictors included %TBSA, Baux (classic and revised) index, Abbreviated Burn Severity Index (ABSI), and Ryan score. Primary outcomes were mortality and LOS. Multivariate logistic regression for mortality showed the Baux index to be the best predictor for mortality (OR=1.11, p<0.001). The AUROC for Baux index was 0.95. With regards to LOS, ABSI was the best predictor for LOS (p<0.001). ICU stay, ventilator use, alcoholism, age, significantly associated with increased LOS. Interestingly, hypertension had a protective effect for LOS (p<0.01) and trended towards a protective effect in mortality. Lethal score 50% (LS50) improved over the study period. The regressions show that burn mortality and LOS are best predicted with the Baux index and ABSI, respectively. Hypertension may have a protective effect on burn outcomes and may be attributed to increased perfusion to the periphery. These predictive scores are useful in determining institutional outcomes in burn surgery. Objective benchmarking of improvement in burn care outcomes can be established using LS50 trends.
Collapse
Affiliation(s)
- Jacques X Zhang
- Division of Plastic Surgery, Department of Surgery, University of British Columbia
| | - S Nafeel Ahmed
- Faculty of Medicine, Department of Surgery, University of British Columbia
| | - Harpreet Pangli
- Division of Plastic Surgery, Department of Surgery, University of British Columbia
| | - Anthony Papp
- Division of Plastic Surgery, Department of Surgery, University of British Columbia
| |
Collapse
|
9
|
Pediatric major burns: a monocentric retrospective review of etiology and outcomes (2008–2020). EUROPEAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.1007/s00238-022-01957-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Abstract
Background
Burns are one of the most common causes of mortality and morbidity among children. This study aims to assess the epidemiology of pediatric major burns in a third level hospital in Spain to evaluate demographics, etiology, and outcomes.
Methods
A retrospective study was held by the Plastic, Reconstructive and Burn Surgery department of the hospital. We included 147 patients under 18 admitted to hospital between January 2008 and December 2020 who meet the inclusion criteria: partial thickness burns > 10% total body surface area (TBSA) in patients < 18 years old. Clinical data extracted included age, gender, date of admission, %TBSA, burn types, severity and sites of burn, length of stay, length of ventilator support, intensive care admission, blood transfusion, surgical interventions, and complications.
Results
Three groups of age were analyzed. The average %TBSA was 18.7 (SE 0.9). Scalds were the main mechanism of injury (70.1%) and upper extremity was the most frequent location affected (68%). The 28.6% of patients suffered some complication, but the mortality rate was low (0.7%). In our series, the group aged 13–18 showed significantly higher %TBSA, more number of surgeries and blood transfusions.
Conclusions
Scald burns are the most frequent mechanism of injury in pediatric burns. However, teenagers suffer more severe burns and complications, usually caused by flame. Despite the low mortality rates, more measures of prevention should be taken to increase children security.
Level of evidence: Level IV, Risk/Prognostic.
Collapse
|
10
|
Moiemen N, Schiestl C, Hartmann-Fritsch F, Neuhaus K, Reichmann E, Löw A, Stenger C, Böttcher-Haberzeth S, Meuli M. First time compassionate use of laboratory engineered autologous Zurich skin in a massively burned child. BURNS OPEN 2021. [DOI: 10.1016/j.burnso.2021.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
11
|
Chen L, He X, Xian J, Liao J, Chen X, Luo Y, Wang Z, Li N. Development of a framework for managing severe burns through a 17-year retrospective analysis of burn epidemiology and outcomes. Sci Rep 2021; 11:9374. [PMID: 33931691 PMCID: PMC8087787 DOI: 10.1038/s41598-021-88507-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/07/2021] [Indexed: 11/09/2022] Open
Abstract
Burns are one of the most common injuries in daily life for all ages of population. This study was to investigate the epidemiology and outcomes among burn patients in one of the largest burn centers in the southwest of China. The study was performed at the Institute of Burn Research in the first affiliated with the Army Medical University (AMU). A total of 17,939 burn patients were included in this retrospective study. Information regarding burn epidemiology and outcomes in 17 years were collected, calculated and compared. The age ranged from 257 days to 95 years old. Scalding and flame were the two most common causes to burn injuries, comprising of 91.96% in total. Limbs, head/face/neck, and trunk were the most frequently occurred burn sites, with the number and the percent of 12,324 (68.70%), 7989 (44.53%), and 7771 (43.32%), respectively. The average total body surface area (TBSA) was 13.64 ± 16.83% (median 8%) with a range of 0.1–100%. A total of 874 (4.9%) patients had TBSA > 50%. The presence of a burn with an inhalation injury was confirmed in 543 patients (3.03%). The average LOS was 32.11 ± 65.72 days (median: 17 days). Eventually, the retrospective analysis resulted in the development of a burn management continuum used for developing strategies to prevent and manage severe burns. The annual number of burn injuries has kept decreasing, which was partially attributed to the increased awareness and education of burn prevention and the improved burn-preventative circumstances. However, the burn severity and the economic burden were still in a high level. And the gender difference and age difference should be considered when making individualized interventions and rehabilitative treatments.
Collapse
Affiliation(s)
- Ling Chen
- Department of Emergency, The 958th Hospital of PLA, The Affiliated Hospital of Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400020, People's Republic of China
| | - Xiaochong He
- School of Nursing, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China
| | - Jishu Xian
- Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China
| | - Jianmei Liao
- Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China
| | - Xuanji Chen
- School of Public Health and Management, Chongqing Medical University, Chongqing, 400016, People's Republic of China
| | - Yue Luo
- Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), Gaotanyan Street No.30, Shapingba District, Chongqing, 400038, People's Republic of China
| | - Zonghua Wang
- School of Nursing, Third Military Medical University (Army Medical University), Chongqing, 400038, People's Republic of China.
| | - Ning Li
- Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), Gaotanyan Street No.30, Shapingba District, Chongqing, 400038, People's Republic of China.
| |
Collapse
|
12
|
Navarro-Delgadillo CI, Garcia-Espinoza JA, Arámbula-Sánchez BY, Marquez-Miranda V, Avalos-Gómez VH, De Luna-Gallardo D, Márquez-Espriella C. Use of the abbreviated burn severity index (ABSI) as a severity scale in a burn unit in Mexico: a 2-year experience. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-020-01724-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
13
|
Yoshimura Y, Saitoh D, Yamada K, Nakamura T, Terayama T, Ikeuchi H, Sasaki J, Nemoto M. Comparison of prognostic models for burn patients: A retrospective nationwide registry study. Burns 2020; 46:1746-1755. [PMID: 33148486 DOI: 10.1016/j.burns.2020.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/03/2020] [Accepted: 10/08/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Prognostic burn index (PBI) is a unique model utilized to predict mortality of burn patients in Japan. In contrast, other prediction models are rarely used in Japan, and their accuracy and predictive value are unknown. The present study aimed to compare commonly used burn prediction models and determine the appropriate model for mortality prediction in Japanese burn patients. METHODS Japanese burn patients registered in the nationwide burn registry of Japanese Society for Burn Injury between April 1, 2011 and March 31, 2019 were reviewed retrospectively. The prognostic performance of PBI was compared with Baux score, revised Baux score, abbreviated burn severity index (ABSI), Ryan score and Belgian outcome in burn injury score (BOBI). The primary outcome was in-hospital mortality. RESULTS The study included 7911 acute burn patients. The overall mortality rate was 10.7%, the median age was 52 (interquartile range, 26-72) years, and the median % total body surface area was 7% (interquartile range, 3%-17%). The areas under the receiver operating characteristic curve for PBI, Baux score, ABSI, revised Baux score, Ryan score, and BOBI were 0.940 (95% confidence interval [CI]: 0.931-0.948), 0.943 (95% CI: 0.934-0.951; p=0.002), 0.945 (95% CI: 0.937-0.953; p=0.058), 0.946 (95% CI: 0.937-0.953; p=0.002), 0.859 (95% CI: 0.846-0.870; p<0.001), and 0.896 (95% CI: 0.885-0.905; p<0.001), respectively. CONCLUSION Although the performance of PBI was good, it was not superior to the Baux score, revised Baux score, and ABSI. These three scores have a high prognostic accuracy. Hence, they are considered as alternative burn prognostic scores in Japan. The Baux score was an optimal prognostic model for patients with burns in Japan.
Collapse
Affiliation(s)
- Yuya Yoshimura
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan; Department of Emergency and Acute Medicine, Saitama Medical University International Medical Center, Saitama, Japan.
| | - Daizoh Saitoh
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan; Division of Traumatology, Research Institute, National Defense Medical College, Saitama, Japan
| | - Kohei Yamada
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan
| | - Takahiro Nakamura
- Department of Mathematics, National Defense Medical College, Saitama, Japan
| | - Takero Terayama
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan
| | - Hisashi Ikeuchi
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Manabu Nemoto
- Department of Emergency and Acute Medicine, Saitama Medical University International Medical Center, Saitama, Japan
| |
Collapse
|
14
|
Bartels P, Thamm OC, Elrod J, Fuchs P, Reinshagen K, German Burn Registry, Koenigs I. The ABSI is dead, long live the ABSI - reliable prediction of survival in burns with a modified Abbreviated Burn Severity Index. Burns 2020; 46:1272-1279. [DOI: 10.1016/j.burns.2020.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/15/2020] [Accepted: 05/11/2020] [Indexed: 01/23/2023]
|
15
|
Evaluating Mortality Risk Adjustment Among Children Receiving Extracorporeal Support for Respiratory Failure. ASAIO J 2020; 65:277-284. [PMID: 29746311 DOI: 10.1097/mat.0000000000000813] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study evaluates whether three commonly used pediatric intensive care unit (PICU) severity of illness scores, pediatric risk of mortality score (PRISM) III, pediatric index of mortality (PIM) 2, and pediatric logistic organ dysfunction (PELOD), are the appropriate tools to discriminate mortality risk in children receiving extracorporeal membrane oxygenation (ECMO) support for respiratory failure. This study also evaluates the ability of the Pediatric Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS) to discriminate mortality risk in the same population, and whether Ped-RESCUERS' discrimination of mortality is improved by additional clinical and laboratory measures of renal, hepatic, neurologic, and hematologic dysfunction. A multi-institutional retrospective cohort study was conducted on children aged 29 days to 17 years with respiratory failure requiring respiratory ECMO support. Discrimination of mortality was evaluated with the area under the receiver operating curve (AUC); model calibration was measured by the Hosmer-Lemeshow goodness of fit test and Brier score. Admission PRISM-III, PIM-2, and PELOD were found to have poor ability to discriminate mortality with an AUC of 0.56 [0.46-0.66], 0.53 [0.43-0.62], and 0.57 [0.47-0.67], respectively. Alternatively, Ped-RESCUERS performed better with an AUC of 0.68 [0.59-0.77]. Higher alanine aminotransferase, ratio of the arterial partial pressure of oxygen the fraction of inspired oxygen, and lactic acidosis were independently associated with mortality and, when added to Ped-RESCUERS, resulted in an AUC of 0.75 [0.66-0.82]. Admission PRISM-III, PIM-2, and PELOD should not be used for pre-ECMO risk adjustment because they do not discriminate death. Extracorporeal membrane oxygenation population-derived scores should be used to risk adjust ECMO populations as opposed to general PICU population-derived scores.
Collapse
|
16
|
Noor DM, Wicaksana A, Fauzi AR, Seswandhana R. Comparison between revised Baux score and abbreviated burn severity index as a predictor of mortality in burn patients at a tertiary care center in Yogyakarta, Indonesia. EUROPEAN JOURNAL OF PLASTIC SURGERY 2019. [DOI: 10.1007/s00238-019-01578-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
17
|
Li J, Xu J, Zhang X. Dataset on acute hyperglycemia in extensively burned patients and mice. Data Brief 2018; 21:2316-2322. [PMID: 30555869 PMCID: PMC6280553 DOI: 10.1016/j.dib.2018.11.089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 11/16/2018] [Accepted: 11/16/2018] [Indexed: 11/25/2022] Open
Abstract
A single center, prospective cohort study recruiting 107 burn patients and 62 control patients was conducted to characterize the early phase of acute hyperglycemia in patients with burns. A total of 1643 blood samples were collected, and blood glucose and serum proinflammatory cytokines were detected and analyzed. A mouse severe burn model was used to study the underlying mechanisms of acute hyperglycemia postburn. An expression profile of IL-1 receptor, serum IL-1β and pancreatic islet function were detected in both control mice and burned mice. The data in this article is associated with the research article published in Biochim Biophys Acta “Acute pancreatic beta cell apoptosis by IL-1β is responsible for postburn hyperglycemia: evidence from humans and mice” [1].
Collapse
Affiliation(s)
- Jun Li
- Department of Aerospace Medicine, Fourth Military Medical University, Xi'an 710032, China.,Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Jie Xu
- Department of Aerospace Medicine, Fourth Military Medical University, Xi'an 710032, China
| | - Xing Zhang
- Department of Aerospace Medicine, Fourth Military Medical University, Xi'an 710032, China
| |
Collapse
|
18
|
Li J, Xu J, Qin X, Yang H, Han J, Jia Y, Zhu H, Zhu L, Li J, Xie W, Hu D, Zhang X, Gao F. Acute pancreatic beta cell apoptosis by IL-1β is responsible for postburn hyperglycemia: Evidence from humans and mice. Biochim Biophys Acta Mol Basis Dis 2018; 1865:275-284. [PMID: 30419339 DOI: 10.1016/j.bbadis.2018.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/15/2018] [Accepted: 11/07/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute hyperglycemia is regarded as a risk factor for critically ill patients; however, insufficient understanding of its nature and underlying mechanisms hinders widespread adoption of glycemic control in critical care units. METHODS A single center, prospective cohort study recruiting 107 burn patients and 62 controls was conducted to characterize the early phase of acute hyperglycemia in burn patients. A total of 1643 blood samples were collected and analyzed over the entire postburn 200 h. A mouse severe burn model was used to study the underlying mechanisms of acute hyperglycemia postburn. RESULTS The dynamic change of postburn blood glucose represented a distinctive pattern in amplitude and duration that was in parallel with the degree of burn injury. Multiple linear regressions revealed that serum insulin, glucagon and glucocorticoid were the major factors affecting blood glucose postburn. Particularly, extensive burns impaired capacity and responsiveness of pancreatic insulin secretion, which was associated with increased serum IL-1β in burn patients. Mechanistically, acute IL-1β elevation specifically induced pancreatic beta cell apoptosis and dampened capacity of insulin secretion, leading to postburn hyperglycemia in burned mice. More importantly, inhibition of IL-1β not only alleviated pancreatic beta cell apoptosis, but also attenuated hyperglycemia and improved survival of burned mice. CONCLUSIONS Our findings reveal a novel mechanism of acute hyperglycemia postburn in which impaired insulin secretory capacity mediated by IL-1β leads to acute hyperglycemia. These data suggest that targeting IL-1β to restore endogenous insulin secretory function may be a novel glycemic control strategy to improve outcomes for burn patients.
Collapse
Affiliation(s)
- Jun Li
- Department of Aerospace Medicine, Fourth Military Medical University, Xi'an 710032, China; Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Jie Xu
- Department of Aerospace Medicine, Fourth Military Medical University, Xi'an 710032, China
| | - Xinghua Qin
- School of Life Sciences, Northwestern Polytechnical University, Xi'an 710072, China.
| | - Hongyan Yang
- Department of Aerospace Medicine, Fourth Military Medical University, Xi'an 710032, China.
| | - Juntao Han
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Yanhui Jia
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Huayu Zhu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Liang Zhu
- Department of Medical Education, Fourth Military Medical University, Xi'an 710032, China
| | - Jia Li
- Department of Aerospace Medicine, Fourth Military Medical University, Xi'an 710032, China.
| | - Wenjun Xie
- School of Life Science and Technology, Xi'an Jiaotong University, Xi'an 710049, China.
| | - Dahai Hu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Xing Zhang
- Department of Aerospace Medicine, Fourth Military Medical University, Xi'an 710032, China.
| | - Feng Gao
- Department of Aerospace Medicine, Fourth Military Medical University, Xi'an 710032, China.
| |
Collapse
|
19
|
Hardwicke J. The influence of outcomes on the provision and practice of burn care. Burns 2016; 42:307-15. [DOI: 10.1016/j.burns.2015.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 07/06/2015] [Indexed: 01/10/2023]
|
20
|
Epidemiology and outcomes of pediatric burns over 35 years at Parkland Hospital. Burns 2016; 42:202-208. [DOI: 10.1016/j.burns.2015.10.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/27/2015] [Accepted: 10/07/2015] [Indexed: 11/21/2022]
|
21
|
Queiroz LFT, Anami EHT, Zampar EF, Tanita MT, Cardoso LTQ, Grion CMC. Epidemiology and outcome analysis of burn patients admitted to an Intensive Care Unit in a University Hospital. Burns 2016; 42:655-62. [PMID: 26762620 DOI: 10.1016/j.burns.2015.08.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 08/01/2015] [Accepted: 08/06/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To describe the epidemiologic aspects of burn victims who were hospitalized in the Intensive Care Unit (ICU) at the Burn Center in the University Hospital of the State University of Londrina (UEL). METHODS A longitudinal retrospective study was conducted, involving patients admitted to the Intensive Care Unit of the Burn Center from January 2010 to December 2012. Demographic and diagnostic data including the diagnosis of the extent and causes of the burns, complications resulting from the burns and the need for specific surgical interventions were collected, together with data for the calculation of the Acute Physiology and Chronic Health Evaluation (APACHE II), Sequential Organ Failure Assessment (SOFA), Therapeutic Intervention Scoring System (TISS-28) and Abbreviated Burn Severity Index (ABSI). Data were collected at admission and daily until discharge from the burn Intensive Care Unit. Risk factors for death and the prognostic performance of scores to predict mortality were analyzed. The level of significance was set at 5%. RESULTS Two hundred ninety-three patients were analyzed in the study; 68.30% were men, with a median age of 38 years (interquartile range: 28-52). The mean total body surface area burned was 26.60±18.05%. Home incidents were the most frequent cause, occurring in 53.90% of the cases. Fire was the most common cause, found in 77.10% of patients. Liquid alcohol was the most common agent and was associated with 51.50% of the cases. The ABSI presented a median of 7, and the area under the ROC curve was 0.890. In multivariate analysis, age (p<0.001), female gender (p=0.02), total body surface area burned (p<0.001), mechanical ventilation (p<0.001) and acute renal failure (p<0.001) were all associated with mortality. ICU mortality was 32.80%, and hospital mortality was 34.10%. CONCLUSION Burns most often occurred in young adult men in our study. The most common cause was a direct flame. Liquid alcohol was the most frequent accelerating agent. Patients were considered to be severely burned. Most of the samples had a high mean total body surface area burned. The ABSI score showed the best performance in discriminating non-survivors. Hospital mortality rate was high.
Collapse
Affiliation(s)
- Luiz Fernando Tibery Queiroz
- Londrina State University, Hospital Universitário - Universidade Estadual de Londrina, Rua Robert Koch 60, Vila Operária, Londrina, Paraná 86038-440, Brazil
| | - Elza H T Anami
- Londrina State University, Hospital Universitário - Universidade Estadual de Londrina, Rua Robert Koch 60, Vila Operária, Londrina, Paraná 86038-440, Brazil
| | - Elisangela F Zampar
- Londrina State University, Hospital Universitário - Universidade Estadual de Londrina, Rua Robert Koch 60, Vila Operária, Londrina, Paraná 86038-440, Brazil
| | - Marcos T Tanita
- Londrina State University, Hospital Universitário - Universidade Estadual de Londrina, Rua Robert Koch 60, Vila Operária, Londrina, Paraná 86038-440, Brazil
| | - Lucienne T Q Cardoso
- Department of Internal Medicine, Londrina State University, Hospital Universitário - Universidade Estadual de Londrina, Rua Robert Koch 60, Vila Operária, Londrina, Paraná 86038-440, Brazil
| | - Cintia Magalhaes C Grion
- Department of Internal Medicine, Londrina State University, Hospital Universitário - Universidade Estadual de Londrina, Rua Robert Koch 60, Vila Operária, Londrina, Paraná 86038-440, Brazil.
| |
Collapse
|
22
|
Tsurumi A, Que YA, Yan S, Tompkins RG, Rahme LG, Ryan CM. Do standard burn mortality formulae work on a population of severely burned children and adults? Burns 2015; 41:935-45. [PMID: 25922299 DOI: 10.1016/j.burns.2015.03.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 02/24/2015] [Accepted: 03/28/2015] [Indexed: 10/23/2022]
Abstract
Accurate prediction of mortality following burns is useful as an audit tool, and for providing treatment plan and resource allocation criteria. Common burn formulae (Ryan Score, Abbreviated Burn Severity Index (ABSI), classic and revised Baux) have not been compared with the standard Acute Physiology and Chronic Health Evaluation II (APACHEII) or re-validated in a severely (≥20% total burn surface area) burned population. Furthermore, the revised Baux (R-Baux) has been externally validated thoroughly only once and the pediatric Baux (P-Baux) has yet to be. Using 522 severely burned patients, we show that burn formulae (ABSI, Baux, revised Baux) outperform APACHEII among adults (AUROC increase p<0.001 adults; p>0.5 children). The Ryan Score performs well especially among the most at-risk populations (estimated mortality [90% CI] original versus current study: 33% [26-41%] versus 30.18% [24.25-36.86%] for Ryan Score 2; 87% [78-93%] versus 66.48% [51.31-78.87%] for Ryan Score 3). The R-Baux shows accurate discrimination (AUROC 0.908 [0.869-0.947]) and is well-calibrated. However, the ABSI and P-Baux, although showing high measures of discrimination (AUROC 0.826 [0.737-0.916] and 0.848 [0.758-0.938]) in children), exceedingly overestimates mortality, indicating poor calibration. We highlight challenges in designing and employing scores that are applicable to a wide range of populations.
Collapse
Affiliation(s)
- Amy Tsurumi
- Department of Surgery, Massachusetts General Hospital, Bigelow 1302, 55 Fruit Street, Boston, MA 02114, USA; Department of Microbiology and Immunobiology, Harvard Medical School, 77 Ave. Louis Pasteur, Boston, MA, USA; Shriners Hospitals for Children-Boston®, 51 Blossom St., Boston, MA, USA.
| | - Yok-Ai Que
- Department of Intensive Care Medicine, Lausanne University Hospital, BH 08-624, CH-1011 Lausanne, Switzerland.
| | - Shuangchun Yan
- Department of Surgery, Massachusetts General Hospital, Bigelow 1302, 55 Fruit Street, Boston, MA 02114, USA; Department of Microbiology and Immunobiology, Harvard Medical School, 77 Ave. Louis Pasteur, Boston, MA, USA; Shriners Hospitals for Children-Boston®, 51 Blossom St., Boston, MA, USA.
| | - Ronald G Tompkins
- Department of Surgery, Massachusetts General Hospital, Bigelow 1302, 55 Fruit Street, Boston, MA 02114, USA.
| | - Laurence G Rahme
- Department of Surgery, Massachusetts General Hospital, Bigelow 1302, 55 Fruit Street, Boston, MA 02114, USA; Department of Microbiology and Immunobiology, Harvard Medical School, 77 Ave. Louis Pasteur, Boston, MA, USA; Shriners Hospitals for Children-Boston®, 51 Blossom St., Boston, MA, USA.
| | - Colleen M Ryan
- Department of Surgery, Massachusetts General Hospital, Bigelow 1302, 55 Fruit Street, Boston, MA 02114, USA; Shriners Hospitals for Children-Boston®, 51 Blossom St., Boston, MA, USA.
| |
Collapse
|
23
|
|
24
|
|