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Our study aimed to provide a description of the early childhood development of pediatric burn patients relative to Dutch reference values, using both pre- and post-burn data from the Dutch Development Instrument and the D-score. Data from the Dutch Development Instrument were used to calculate the D-score and age-standardized D-score. Similar to a growth chart, the D-score was used to plot pediatric burn patients’ development relative to Dutch reference values for their age. Pediatric burn patients’ (n = 38) median age at the time of injury was 1.0 (1.0–2.0) years old. Burn size ranged from 1.0% to 36.0% of the total body surface area. Ninety-five percent (± 6.0%) of pediatric burn patients passed each of the age-appropriate developmental milestones at the target age. The mean age-standardized D-score was just above the Dutch average (+0.49 SD [0.18, 0.80]) and did not vary depending on sex (p = 0.06) or burn size (p = 0.41). In conclusion, among pediatric patients aged up to two-and-a-half years old, with non-full thickness burns, development was on track relative to the Dutch reference values. Our findings offer valuable first insights into the early childhood development of pediatric burn patients and may alleviate some parental concerns.

Keloids are differentiated from hypertrophic scars by their invasive lateral growth vs. the expansive growth of hypertrophic scars. This case report demonstrates the dynamic nature of keloids and the importance of clinical follow-up on its natural progression over time, especially when differentiation from hypertrophic scars is difficult. Serial photographic documentation is an invaluable aid for follow-up evaluation.

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.

IntroductionBurns are characterized by a massive and prolonged acute inflammation, which persists for up to months after the initial trauma. Due to the complexity of the inflammatory process, Predicting the dynamics of wound healing process can be challenging for burn injuries. The aim of this study was to develop simulation models for the post-burn immune response based on (pre)clinical data.MethodsThe simulation domain was separated into blood and tissue compartments. Each of these compartments contained solutes and cell agents. Solutes comprise pro-inflammatory cytokines, anti-inflammatory cytokines and inflammation triggering factors. The solutes diffuse around the domain based on their concentration profiles. The cells include mast cells, neutrophils, and macrophages, and were modeled as independent agents. The cells are motile and exhibit chemotaxis based on concentrations gradients of the solutes. In addition, the cells secrete various solutes that in turn alter the dynamics and responses of the burn wound system.ResultsWe developed an Glazier-Graner-Hogeweg method-based model (GGH) to capture the complexities associated with the dynamics of inflammation after burn injuries, including changes in cell counts and cytokine levels. Through simulations from day 0 – 4 post-burn, we successfully identified key factors influencing the acute inflammatory response, i.e., the initial number of endothelial cells, the chemotaxis threshold, and the level of chemoattractants.ConclusionOur findings highlight the pivotal role of the initial endothelial cell count as a key parameter for intensity of inflammation and progression of acute inflammation, 0 – 4 days post-burn.

Abstracts of the plenary and special interest sessions, workshops, and oral and poster presentations of the 20th EBA Congress in Nantes, France from 6–9 September 2023.

Background: Implementing innovations emerging from clinical research can be challenging. Thermal imagers provide an accessible diagnostic tool to increase the accuracy of burn wound depth assessment. This mixed-methods implementation study aimed to assess the barriers and facilitators, design implementation strategies, and guide the implementation process of thermal imaging in the outpatient clinic of a burn centre. Methods: This study was conducted between September 2022 and February 2023 in Beverwijk, The Netherlands. Semi-structured interviews with burn physicians guided by the Consolidated Framework for Implementation Research (CFIR) were conducted to identify barriers and facilitators. Based on the barriers, implementation strategies were developed with the CFIR-ERIC Matching Tool, and disseminated to support the uptake of the thermal imager. Subsequently, thermal imaging was implemented in daily practice, and an iterative RE-AIM approach was used to evaluate the implementation process. Results: Common facilitators for the implementation of the thermal imager were the low complexity, the relative advantage above other diagnostic tools, and benefits for patients. Common barriers were physicians’ attitude towards and perceived value of the intervention, the low compatibility with the current workflow, and a lack of knowledge about existing evidence. Six implementation strategies were developed: creating a formal implementation blueprint, promoting adaptability, developing educational materials, facilitation, conducting ongoing training, and identifying early adopters. These strategies resulted in the effective implementation of the thermal imager, reflected by a >70% reach among eligible patients, and >80% effectiveness and adoption. Throughout the implementation process, compatibility, and available resources remained barriers, resulting in low ratings on RE-AIM dimensions. Conclusions: This study developed implementation strategies based on the identified CFIR constructs that impacted the implementation of a thermal imager for burn wound assessment in our outpatient clinic. The experiences and findings of this study could be leveraged to guide the implementation of thermal imaging and other innovations in burn care.

The International Tundra Experiment (ITEX) was established to understand how environmental change impacts Arctic and alpine ecosystems. The success of the ITEX network has allowed for several important across-site syntheses, and for some ITEX sites enough data have now been collected to perform within-site syntheses on the effects of environmental change across ecological scales. In this study, we analyze climate data and synthesize three decades of research on the ecological effects of environmental change at the ITEX site at Finse, southern Norway. We found a modest warming rate of +0.36 °C per decade and minor effects on growing season length. Maximum winter snow depth was highest in winters with a positive North Atlantic Oscillation. Our synthesis included 80 ecological studies from Finse, biased towards primary producers with few studies on ecological processes. Species distributions depended on microtopography and microclimate. Experimental warming had contrasting effects on abundance and traits of individual species and only modest effects at the community level above and below ground. In contrast, nutrient addition experiments caused strong responses in primary producer and arthropod communities. This within-site synthesis enabled us to conclude how different environmental changes (experimental and ambient warming, nutrient addition, and environmental gradients) impact across ecological scales, which is challenging to achieve with across-site approaches.

Background Intralesional corticosteroid administration (ICA) is a first-line therapy in keloid treatment. However, its clinical results are still highly variable and often suboptimal. Treatment results may strongly be influenced by various ways of ICA. Objective To explore the prevailing practice of ICA in keloid treatment among dermatologists and plastic surgeons in the Netherlands. Methods The survey was constructed based on a scoping review on ICA in keloid treatment. Members of the Dutch Society for Plastic surgery and the Dutch Society for Dermatology and Venereology were asked to participate. Results One hundred and thirty-six responses were obtained. One hundred and thirty (95.6%) participants used triamcinolone acetonide. The majority (54.7%) did not use local anesthesia for pain reduction. Reported corticosteroid dosing that one would inject in one specific keloid differed by a factor of 40. Treatment intervals varied from 1 week to more than 8 weeks. The keloid center was most often injected (46.9%), followed by subepidermal (18.0%). Conclusions A wide variety in ICA for keloids is noted among dermatologists and plastic surgeons, even in a limited geographic region and when evidence points toward an optimal way of treatment. Future studies and better implementation of existing evidence may reduce variation in ICA and optimize its treatment results.

Over the past decades, long-term sequelae of burns have gained increasing attention. Women of childbearing age, who sustained abdominal burns earlier in life, may have unmet information needs on scar-related complications they can expect during pregnancy. We performed a review of the literature to identify abdominal, foetal, and potential other complications during pregnancy in women with abdominal burn scars. PubMed, Embase, and Scopus were searched from inception to 1 July 2020 and updated once on 23 April 2021 (PROSPERO CRD42022187883). Main search terms included pregnancy, scar, burns, and abdominal. Studies on burns obtained during pregnancy have been excluded. Screening, data extraction and bias assessment were conducted by two investigators. We included 22 studies comprising 217 patients. The time between burn injury and first pregnancy varied between 7 and 32 years. Most of the women had normal pregnancies regarding delivery mode and duration of pregnancy. The most reported abdominal burn scar complications were an increased feeling of tightness, itch, pain, and scar breakdown. In some cases, scar release surgery was performed during or prior to pregnancy. Some cases of foetal complications were described. Complications during pregnancy after abdominal burn scars may be limited. More quantitative and qualitative research is needed to assess the maternal and foetal outcomes and complications. The results may be used to inform women and contribute to personalised obstetric management.

Background: Efforts to identify therapies to treat hospitalised patients with COVID-19 are being continued. Alkaline phosphatase (AP) dephosphorylates pro-inflammatory adenosine triphosphate (ATP) into anti-inflammatory adenosine. Methods: In a randomised controlled trial, we investigated the safety and efficacy of AP in patients with SARS-CoV-2 infection admitted to the ICU. AP or a placebo was administered for four days following admission to the ICU. The primary outcome was the duration of mechanical ventilation. Mortality in 28 days, acute kidney injury, need for reintubation, safety, and inflammatory markers relevant to the described high cytokine release associated with SARS-CoV-2 infection were the secondary outcomes. Results: Between December 2020 and March 2022, 97 patients (of the intended 132) were included, of which 51 were randomised to AP. The trial was terminated prematurely based on meeting the threshold for futility. Compared to the placebo, AP did not affect the duration of mechanical ventilation (9.0 days vs. 9.3 days, p = 1.0). No safety issues were observed. After 28 days, mortality was 9 (18%) in the AP group versus 6 (13%) in the placebo group (p = 0.531). Additionally, no statistically significant differences between the AP and the placebo were observed for the other secondary outcomes. Conclusions: Alkaline phosphatase (AP) therapy in COVID-19 ICU patients showed no significant benefits in this trial.

The past few decades have witnessed a growing popularity in Eulerian–Lagrangian solvers due to their significant potential for simulating aerodynamic flows, particularly in cases involving strong body–vortex interactions. In this hybrid approach, the two component solvers are mutually coupled in a two-way fashion. Initially, the Lagrangian solver can supply boundary conditions to the Eulerian solver, while the Eulerian solver functions as a corrector for the Lagrangian solution in regions where the latter cannot achieve high accuracy. To utilize such tools effectively, it is vital for them to be capable of handling dynamic mesh movements. This study builds upon the previous research conducted by our team and extends the capabilities of the hybrid solver to handle dynamic meshes. While OpenFOAM, the Eulerian component of this hybrid code, incorporates built-in dynamic mesh properties, certain modifications are necessary to ensure its compatibility with the Lagrangian solver. More specifically, the evolution algorithm of the pimpleFOAM solver needs to be divided into two discrete steps: first, updating the mesh, and later, evolving the solution. This division enables a proper coupling between pimpleFOAM and the Lagrangian solver as an intermediate step. Therefore, the primary objective of this specific paper is to adapt the OpenFOAM solver to meet the demands of the hybrid solver and subsequently validate that the hybrid solver can effectively address dynamic mesh challenges using this approach. This approach introduces a pioneering method for conducting dynamic mesh simulations within the OpenFOAM framework, showcasing its potential for broader applications. To validate the approach, various test cases involving dynamic mesh movements are employed. Specifically, all these cases employ the Lamb–Oseen diffusing vortex, but each case incorporates different types of mesh movements, including translational, rotational, oscillational, and combinations thereof. The results from these cases demonstrate the effectiveness of the proposed OpenFOAM algorithm, with the maximum relative errors —when compared to the analytical solution across all presented cases—capped at 2.0% for the worst-case scenario. This affirms the algorithm’s capability to successfully handle dynamic mesh simulations with the proposed solver.

The relative contribution of bryophytes to plant diversity, primary productivity, and ecosystem functioning increases towards colder climates. Bryophytes respond to environmental changes at the species level, but because bryophyte species are relatively difficult to identify, they are often lumped into one functional group. Consequently, bryophyte function remains poorly resolved. Here, we explore how higher resolution of bryophyte functional diversity can be encouraged and implemented in tundra ecological studies. We briefly review previous bryophyte functional classifications and the roles of bryophytes in tundra ecosystems and their susceptibility to environmental change. Based on shoot morphology and colony organization, we then propose twelve easily distinguishable bryophyte functional groups. To illustrate how bryophyte functional groups can help elucidate variation in bryophyte effects and responses, we compiled existing data on water holding capacity, a key bryophyte trait. Although plant functional groups can mask potentially high interspecific and intraspecific variability, we found better separation of bryophyte functional group means compared with previous grouping systems regarding water holding capacity. This suggests that our bryophyte functional groups truly represent variation in the functional roles of bryophytes in tundra ecosystems. Lastly, we provide recommendations to improve the monitoring of bryophyte community changes in tundra study sites.

Abstract Background In the last decades, autologous fat grafting has been used to treat adherent dermal scars. The observed regenerative and scar-reducing properties have been mainly ascribed to the tissue-derived stromal vascular fraction (tSVF) in adipose tissue. Adipose tissue’s components augment local angiogenesis and mitosis in resident tissue cells. Moreover, it promotes collagen remodeling. We hypothesize that tSVF potentiates fat grafting-based treatment of adherent scars. Therefore, this study aims to investigate the effect of tSVF-enriched fat grafting on scar pliability over a 12-month period. Methods and design A clinical multicenter non-randomized early phase trial will be conducted in two dedicated Dutch Burn Centers (Red Cross Hospital, Beverwijk, and Martini Hospital, Groningen). After informed consent, 46 patients (≥18 years) with adherent scars caused by burns, necrotic fasciitis, or degloving injury who have an indication for fat grafting will receive a sub-cicatricic tSVF-enriched fat graft. The primary outcome is the change in scar pliability measured by the Cutometer between pre- and 12 months post-grafting. Secondary outcomes are scar pliability (after 3 months), scar erythema, and melanin measured by the DSM II Colormeter; scar quality assessed by the patient and observer scales of the Patient and Observer Scar Assessment Scale (POSAS) 2.0; and histological analysis of scar biopsies (voluntary) and tSVF quality and composition. This study has been approved by the Dutch Central Committee for Clinical Research (CCMO), NL72094.000.20. Conclusion This study will test the clinical efficacy of tSVF-enriched fat grafting to treat dermal scars while the underlying working mechanism will be probed into too. Trial registration Dutch Trial Register NL 8461. Registered on 16 March 2020

In vitro research in the field of mechanotransducive regulation of dermal fibroblasts is characterized by highly variable methodology and contradictory results. The primary objective of this systematic review was to establish how in vitro mechanical stretch affects human dermal fibroblast function, by means of a quantitative synthesis of all available evidence. The secondary objectives were to examine the effects of covariates related to donor age, fibroblast origin, experimental treatments, and mechanical stimulation parameters on dermal fibroblast responsiveness to mechanical strain. Summary outcomes for fibroblast proliferation and collagen production were combined using a fixed-effects meta-analytical model. Subgroup analysis and meta-regression were used to investigate the effects of different conditions on the summary outcomes. Mechanical strain was found to not affect fibroblast proliferation in neonatal fibroblasts, while adult fibroblasts proliferation was significantly increased. Collagen production was significantly increased in response to mechanical stimulation, with Vitamin C stimulation as the most important covariate. Stretching frequency emerged as positively associated with fibroblast proliferation and negatively associated with collagen production. We conclude from this study that distinct differences exist in the effects of mechanical stretching between dermal fibroblasts from neonatal and adult donors, which will help to further elucidate the pathophysiological mechanism behind tension-induced scarring.

IntroductionAutologous split thickness skin grafting is the standard-of-care for most deep dermal and full thickness skin defects. Historically, mesh grafting is used to expand skin grafts for smaller defects and other techniques such as Meek micrografting is used to enable expansion for larger skin defects. Yet, Meek micrografting is increasingly used for smaller skin defects as well. Both techniques are frequently used, especially in burn centers, but evidence on which one is preferable for relative smaller skin defects is lacking. Therefore, an intra-patient randomized controlled trial was designed to adequately compare multiple outcomes of the Meek micrografting and mesh grafting techniques.Materials and methodsA multicenter intra-patient controlled randomized trial is being performed in two burn centers (the Netherlands and Belgium) to compare multiple outcomes of Meek micrografting and mesh grafting burns or skin defects. Study registration number (NL74274.029.20). Adult patients with a (burn) wound and an indication for surgical excision and skin grafting were screened for inclusion. In total 70 patients will be included and the primary outcome is scar quality twelve months post-surgery assessed by the Patient and Observer Scar Assessment Scale. Moreover, graft take, re-epithelialization, infection rate, donor site size and patients' preference are also measured within hospital admission, on 3 months and 12 months post-surgery.DiscussionThis is the first randomized trial that is intra-patient controlled, which enables a proper comparison between both skin expansion techniques. The results of this study will contribute to the clarification of the indications of both techniques and ample attention is paid for the patients' opinion on the surgical treatment options.

Severe burn injuries often lead to skin contraction, leading to stresses in and around the damaged skin region. If this contraction leads to impaired joint mobility, one speaks of contracture. To optimize treatment, a mathematical model, that is based on finite element methods, is developed. Since the finite element-based simulation of skin contraction can be expensive from a computational point of view, we use machine learning to replace these simulations such that we have a cheap alternative. The current study deals with a feed-forward neural network that we trained with 2D finite element simulations based on morphoelasticity. We focus on the evolution of the scar shape, wound area, and total strain energy, a measure of discomfort, over time. The results show average goodness of fit (R2) of 0.9979 and a tremendous speedup of 1815000X. Further, we illustrate the applicability of the neural network in an online medical app that takes the patient's age into account.

The systemic and local immune response in burn patients is often extreme and derailed. As excessive inflammation can damage healthy tissues and slow down the healing process, modulation of inflammatory responses could limit complications and improve recovery. Due to its complexity, more detailed information on the immune effects of thermal injury is needed to improve patient outcomes. We therefore characterized and quantified subsets of immune cells and mediators present in human burn wound tissue (eschar), sampled at various time points. This study shows that after burn injury, the number of immune cells were persistently increased, unlike the normal wound healing process. There was an immediate, strong increase in neutrophils and a moderate increase in monocytes/macrophages and lymphocytes, especially in the second and third week post burn. The percentage of classical (CD14highCD16-) monocytes/macrophages demonstrated a steady decrease over time, whereas the proportion of intermediate (CD14highCD16+) monocytes/macrophages slowly increased. The absolute numbers of T cells, NK cells and B cells increased up to week 3, while the fraction of γδ T cells was increased only in week 1. Secretome profiling revealed high levels of chemokines and an overall pro-inflammatory cytokine milieu in burn tissue. The local burn immune response shows similarities to the systemic immune reaction, but differs in neutrophil maturity and lymphocyte composition. Altogether, the neutrophil surges, high levels of pro-inflammatory cytokines and limited immunosuppression might be key factors that prolong the inflammation phase and delay the wound healing process in burns.

Background: Outcome assessment is essential to understand the impact and recovery of burns of the hand and tailor treatment. There is however, a large variety of measures and outcome assessment is often incomplete. The aim was therefore to initiate a set of outcome assessments for use in a clinical setting. Method: A concept set was drafted, based on the framework of the International Classification of Functioning, which distinguished two phases, three patient states and included both patient reported and clinical outcomes. Subsequently, potential assessments were allocated to the various outcomes. This concept was discussed during the European Burns Association congress in 2013 and revised. The revision was sent to 65 colleagues from 28 institutions, accompanied by a survey. Results: Eleven surveys were returned from 16 persons representing 9 institutions from 6 countries. Based on the feedback, final revisions were made. Points raised were time investment and translations of not all assessments already available. Conclusions: With multidisciplinary and international input, a multidimensional set of outcome assessments for burns of the hand has been established, covering almost all domains of functioning. This first step towards more uniform clinical evaluation, will contribute to knowledge on outcome and effectiveness of treatment of hand burns.

Burn injury induces a complex inflammatory response, both locally and systemically, and is not yet completely unravelled and understood. In order to enable the development of accurate treatment options, it is of paramount importance to fully understand post-burn immunology. Research in the last decades describes insights into the prolonged and excessive inflammatory response that could exist after both severe and milder burn trauma and that this response differs from that of none-burn acute trauma. Persistent activity of complement, acute phase proteins and pro- and anti-inflammatory mediators, changes in lymphocyte activity, activation of the stress response and infiltration of immune cells have all been related to post-burn local and systemic pathology. This “narrative” review explores the current state of knowledge, focusing on both the local and systemic immunology post-burn, and further questions how it is linked to the clinical outcome. Moreover, it illustrates the complexity of post-burn immunology and the existing gaps in knowledge on underlying mechanisms of burn pathology.

In nuclear fuel rod bundles, turbulence-induced pressure fluctuations caused by an axial flow can create small but significant vibrations in the fuel rods, which in turn can cause structural effects such as material fatigue and fretting wear. Fluid-structure interaction simulations can be used to model these vibrations, but for affordable simulations based on the URANS approach, a model for the pressure fluctuations must be utilised. Driven by the goal to improve the current state-of-the-art pressure fluctuation model, AniPFM (Anisotropic Pressure Fluctuation Model) was developed. AniPFM can model velocity fluctuations based on anisotropic Reynolds stress tensors, with temporal correlation through the convection and decorrelation of turbulence. From these velocity fluctuations and the mean flow properties, the pressure fluctuations are calculated. The model was applied to several test cases and shows promising results in terms of reproducing qualitatively similar flow structures, as well as predicting the root-mean-squared pressure fluctuations. While further validation is being performed, the AniPFM has already demonstrated its potential for affordable simulations of turbulence-induced vibrations in industrial nuclear applications.