Contact Burns Research Articles

NLRP12 suppresses host innate immune signaling to limit inflammation during emergency hematopoiesis (INM6P.404)

Abstract The hematopoietic system is capable of rapidly increasing myeloid cell production in response to tissue damage. NLRP12 is expressed in peripheral leukocytes and by osteoclasts and marrow progenitor cells. This NLR family member has been controversial but has been implicated in regulation of innate immune responses. We hypothesized that NLRP12 is a central regulator of innate immune reconstitution following an emergency hematopoietic event. To test this, wild type and Nlrp12-/- C57BL/6 female mice underwent a radiation-thermal combined injury (RCI) consisting of a 20% total body surface area, full thickness contact burn in addition to receiving a single whole body dose of 5 Gy γ-radiation. Following RCI, NLRP12-deficient mice display a lack of peripheral innate immune cell reconstitution as seen in wild type mice; specifically a ten-fold decrease in total numbers of splenic and pulmonary neutrophils and immature monocytes compared to wild type, and a three-fold increase in apoptosis of bone marrow granulocyte/monocyte progenitor cells resulting in a three-fold reduction of total bone marrow cells. Lack of NLRP12 results in a sustained increase in inflammation after injury, with significant increase in serum levels of TNFα, IL-6, IL-12, and type I interferons compared to injured, wild type mice that is inflammasome-independent. These data suggest that NLRP12 acts as an important regulator of inflammation during events that trigger immune hematopoeisis and reconstitution.

G167(P) Paediatric burn injury presentations to a UK District General Hospital Paediatric Emergency Department: provisions and interventions to reduce risk of attendance

BackgroundMost burns in children are scalds. The prevalence of abuse-related burns admitted to burns units is 10 to 14%. Provided local burns data is available a burns injury prevention programme...

Contact burn due to a heated-wire breathing circuit

To the Editor: A 23-year-old female with no underlying disease underwent septorhinoplasty, which lasted about 3 h and 40 min. A heated-wire breathing circuit was used, and it was fastened at the patient’s right thigh to the patient’s pants with a Kelly forceps to prevent movement. After 1 h postoperation, a second-degree burn about 13 cm long with a vesicle 1 9 1 cm in size was found on her right thigh (Fig. 1). The direction and shape of the skin lesion matched the heated circuit. It is highly likely that the burn was due to the heated circuit. The temperature of the material and the duration of contact are important determinants of contact burns [1, 2]. To determine the temperature of the circuit, the heated circuit was wrapped with a skin towel and fastened tightly with a Kelly forceps to create a situation similar to this case. The temperature of the heated wire and the circuit surface reached about 65 and 47 C, respectively after 1 h at the 42 C set point. According to a report by Yarmolenko et al. [1] cumulative equivalent minutes at 43 C (CEM43) between 480 and 960 min caused immediate superficial burns. Assuming that this patient was exposed to 45 C continuously over a period of 3 h, CEM43 is 720 min. This is enough heat to cause superficial burns. In conclusion, it is important to recognize that accidental burns can occur due to a heated-wire breathing circuit. To prevent accidental burns, direct contact of the heated circuit with the patient’s skin should be avoided and the heated circuit must not put pressure on the patient’s skin.

Patterns of burns and scalds in children

ObjectiveTo describe the characteristics of childhood burns and scalds, mechanisms and agents to inform prevention.MethodsProspective multicentred cross-sectional study of children (<16 years) with unintentional burns/scalds from five Emergency Departments (ED),...

The Effects of Topical Agent (Kelo-Cote or Contractubex) Massage on the Thickness of Post-Burn Scar Tissue Formed in Rats

BackgroundWe conducted an experimental study to compare the effect of massage using topical agents (Kelo-cote or Contractubex) on scar formation by massaging the healed burn wound on the dorsal area of Sprague-Dawley (SD) rats.MethodsFour areas of second degree contact burn were made on the dorsal area of each of 15 SD rats, using a soldering iron 15 mm in diameter. After gross epithelialization in the defect, 15 SD rats were randomly divided into four groups: the Kelo-cote group, Contractubex group, Vaseline group, and control group. Rats in three of the groups (all but the Control group) were massaged twice per day for 5 minutes each day, while those in the Control group were left unattended. For histologic analysis, we performed a biopsy and evaluated the thickness of scar tissue.ResultsIn the Kelo-cote and Contractubex groups, scar tissue thicknesses showed a significant decrease, compared with the Vaseline and control groups. However, no significant differences were observed between the Kelo-cote and Contractubex groups. In the Vaseline group, scar tissue thicknesses showed a significant decrease, compared with the control groups.ConclusionsThe findings of this study suggest that massage using a topical agent is helpful in the prevention of scar formation and that massage only with lubricant (no use of a topical agent) also has a considerable effect, although not as much as the use of a topical agent. Thus, we recommend massage with a topical agent on the post-burn scar as an effective method for decreasing the scar thickness.

Implications of Immediate Autologous Fat Grafting and Expanded Adipose-Derived Progenitor Cells on Hypertrophic Scar Maturation in a Swine Model

INTRODUCTION: Hypertrophic scar formation is unpredictable and poorly understood, afflicting both the pediatric and adult populations. Treatment methods with conservative and invasive approaches have low rates of compliance and high rates of morbidity. The purpose of this study is to develop a reproducible scar model and investigate a new technique of scar modification through the use of adipose-derived progenitor stromal cells (ASCs). METHODS: 20 thermal deep-partial thickness contact burns were created on the dorsum of three 8-week old domestic swine and allowed to mature for 10 weeks. Scars were then injected with 2 cc saline, expanded autologous ASCs, or 2 cc fresh lipoaspirate and sampled at 2 week intervals up to 10 weeks post injection. Volumetric analysis with a 3-D scanner, mechanical elasticity testing through negative pressure transduction, and standardized photography evaluation with Image J was performed. Biopsies were taken at 2 week intervals and histologically analyzed for collagen deposition and vascularity. RNA sequencing was performed on scar tissue samples, cultured cells, and fresh lipoaspirate. RESULTS: Volumetric analysis demonstrates a reduction in average scar thickness at 6 weeks when injected with ASCs (-1.601 cc³) and autologous fat (-1.965 cc³) relative to controls (-0.121 cc³, p<0.05). A decrease in overall tissue compliance is observed with fat or ASC injection when compared to unburned skin at 8 weeks (35.99/ 37.94 vs 49.36 mmHg*mm, p<0.01). Scars treated with fat or ASCs increase the rate at which erythema resolves. RNA sequencing suggests regulation of fibroblast gene expression and a decreased inflammatory profile when scars are injected with fat cells. CONCLUSION: Early results suggest that autologous fat and/or ASCs may improve healing of hypertrophic scarring by altering the cellular and structural components during wound remodeling up to 14 weeks after injury. This may have beneficial applications in early treatment of large or cosmetically sensitive immature burn scars (Figures 1 and 2).Figure 1: 3-D volumetric analysis of hypertrophic scars. Scans at 2 and 4 weeks were superimposed (top left, top middle, top right) and thickness differences (arrow) calculated between time points (bottom).Figure 2: Biochemical evaluation through negative pressure transduction demonstrates a decrease in overall elasticity in all injected wounds (saline, cells, fat) up to 4 weeks. Elasticity increases in each wound starting around week 6.

Outpatient treated burns in infants younger than 1 year in Helsinki during 2005–2009

In general, voluminous data exists concerning burns in children, but the data focusing specially on children less than 1 year of age is sporadic. We therefore focused on examining the special features of burns in children less than 1 year of age.A retrospective study of all outpatient treated burn patients <1 year old at the Hospital for Children and Adolescents, Helsinki, Finland, from January 2005 to December 2009 was performed. During the 5-year period we identified 106 outpatient treated infants with burns, representing 15% of all pediatric burns during the study period.The majority was male and aged 9–12 months. Most of the burns occurred at home, and in most cases a caregiver was present in the injury room. Scalds were the most common type of injury followed by contact burns. The most common source of scald was from cups containing hot drink, and the most common source of contact burn was hot stoves or oven doors.Special attention needs to be targeted toward the prevention of burns in children less than 1 year of age. The majority of the injuries could have been prevented with more vigilance.

Electrothermal Ring Burn From a Car Battery

Despite prevention efforts, burn injuries among auto mechanics are described in the literature. Electrothermal ring burns from car batteries occur by short-circuiting through the ring when it touches the open terminal or metal housing. This article describes a 34-year-old male auto mechanic who was holding a wrench when his gold ring touched the positive terminal of a 12-volt car battery and the wrench touched both his ring and the negative terminal. He felt instant pain and had a deep partial-thickness circumferential burn at the base of his ring finger. No other soft tissues were injured. He was initially managed conservatively, but after minimal healing at 3 weeks, he underwent a full-thickness skin graft. The graft incorporated well and healed by 4 weeks postoperatively. He had full range of motion. The cause of ring burns has been controversial, but based on reports similar to the current patient's mechanism, they are most likely electrothermal burns. Gold, a metal with high thermal conductivity, can heat up to its melting point in a matter of seconds. Many treatments have been described, including local wound care to split- and full-thickness skin grafts. Because most burns are preventable, staff should be warned and trained about the potential risks of contact burns. All jewelry should be removed, and the live battery terminal should be covered while working in the vicinity of the battery.

The use of diverting colostomies in paediatric peri-anal burns: Experience in 45 patients

Peri-anal burns are common in children. Continual exposure to enteric organisms may lead to a contaminated burn wound, invasive sepsis, graft loss, scar contracture, anal and urinary malfunction, and delayed discharge from hospital. Use of a temporary diverting colostomy has been advocated to reduce complications. To review the incidence, indications, methods, bacteriology, therapeutic effects and outcomes of colostomy for perianal burns. A prospective study of children with peri-anal burns and stomas over a 17-year period. Prophylactic or therapeutic faecal diversion was achieved by temporary, divided sigmoid end-colostomy with Hartmann's closure of the distal end. Between 1995 and 2012, 45 children with peri-anal burns received a colostomy. The mean total body surface area burned was 35% (range 3 - 80%). There were 28 flame burns, 16 fluid burns and 1 contact burn. Prophylactic colostomies were performed in 29 children, on average on day 6 after admission, and therapeutic colostomies to counteract deep wound infection and septicaemia in 16 patients, on average on day 24. In all but 2 cases there was a marked improvement in clinical appearance, graft take and healing. The bacterial profile changed from gut-derived organisms to Pseudomonas aeruginosa or no pathogens. Complications occurred in 5 patients (11.1%). Three stomas required manual reduction. Two children died of established septic shock, compounded by stomal dehiscence in 1 case. Reversal of the colostomy was performed on average at 4 months. Diverting colostomy has therapeutic advantages in a select group of paediatric burns patients in whom continual faecal soiling poses a threat to both graft and life.

Contact, Cigarette and Flame Burns in Physical Abuse: A Systematic Review

This systematic review identifies features of intentional non‐scald burns in physical abuse. Fifteen bibliographic databases of international literature (1950–2011) were searched to identify potential studies that were critically appraised using standardised methods. Primary studies with confirmed intentional non‐scald burns in children aged &lt; 18 years were included to provide a descriptive analysis of the causation, appearance and distribution of burns.‘This systematic review identifies features of intentional non‐scald burns in physical abuse’Twenty studies were included: one cross‐sectional, one case control and 18 case studies/small case series representing 73 children with intentional non‐scald burns. The majority were contact burns from household items: the agents included cigarettes (18), irons (9), electric fires/heaters/radiators (10), cigarette lighters (2), hairdryers (7), curling tongs (3), chemicals (3), microwaves (2) flame burns (7), miscellaneous (7) and burns of unknown cause (5). The burns occurred throughout childhood. The majority of children were older than three years. The characteristic features were of clearly demarcated contact burns or scars in shapes that mirrored the agent. They were predominantly recorded on the limbs, trunks and the backs of hands; they were frequently multiple and co‐existed with additional signs of abuse. These features should raise concerns of suspected physical abuse. Copyright © 2013 John Wiley &amp; Sons, Ltd.Key Practitioner MessagesIntentional Non‐scald Burns The commonest reported cause of intentional non‐scald burns are contact burns: cigarettes, irons, hairdryers or domestic heaters. Burns are often clearly demarcated in the shape of the causative agent. Burns are found on the limbs, back or trunk, in locations other than the palms of the hands. Burns are often multiple and may co‐exist with other injuries suspicious of abuse. Single or multiple circular, deep‐cratered burns are consistent with cigarette burns.‘The commonest reported cause of intentional non‐scald burns are contact burns’

Laser Doppler Line Scan Burn Imager (LDLS-BI): Sideways move or a step ahead?

ObjectiveTo assess the accuracy of a Laser Doppler Line Scanner (LDLS) in predicting burn wound healing in children compared to conventional Laser Doppler Imaging (LDI). MethodsA prospective study comparing a LDLS with a conventional LDI to assess burn wound Healing Potential (HP) was performed in 50 paediatric patients presenting to our institution between February 2010 and March 2011, as part of a multi-centre, international trial. Inclusion criteria were superficial to deep dermal burns that were able to be scanned between 42h and 5 days of the burn. ResultsOf the 50 patients enrolled, one was excluded from subsequent analysis as they were unable to present for wound reviews at 14 and 21 days. Ninety scans were performed of 59 burn wounds in the remaining 49 patients. The mean age was 4 years and 9 months (range 8 months to 16 years) and the mean Total Body Surface Area burnt was 8.3% (range 0.1–15%). The most common mechanism of injury was a scald, followed by contact and flame burns. A limb was the most common site of injury. Overall accuracy of the scanners was 94.5% (LDI) and 95% (LDLS), with accuracy lowest for indeterminate burns that healed within 14–21 days. ConclusionThe LDLS was found to be as accurate as the LDI in predicting burn wound HP in children. Whilst the LDLS scan resolution was lower, with more scans of larger burns required, its smaller size and greater scan speed proved valuable in children.

Outpatient burn data: An untapped resource

IntroductionThe National Burn Repository (NBR) currently only contains inpatient data from participating United States burn centres. However, the majority of the patients treated in burn centres are managed as outpatients. Unfortunately, this significant demographic is not represented in the NBR annual report. The purpose of this study is to compare the difference in aetiology and demographics between inpatient and outpatient burn patients. In addition, the workload demands for data entry of inpatient and outpatient records in the burn registry will be compared. MethodsOutpatient and inpatient burn data at an American Burn Association-Verified Burn Center were prospectively collected during fiscal year 2008. Data collected included age, burn size and aetiology of burn. Aetiology was also stratified by age group. Inpatient data were compared with outpatient data with Fisher's exact test. The amount of time taken to enter inpatients’ and outpatients’ data parameters in the TRACS v5.0 database was also recorded. ResultsData were collected for 241 inpatients and for 543 outpatients during fiscal year 2008. No significant differences in gender or race were found between the two groups. When comparing demographics, outpatients tended to be younger (26±19years vs. 32±22years, p=0.01) with a smaller burn size (2.5±7% vs. 6.8±12%, p<0.001) and a lower frequency of full-thickness burns (17% vs. 41%, p<0.001).Of the patients managed as an outpatient, a total 29.7% were eventually admitted to the hospital. Just over half of those (16.7%) initially managed in the outpatient setting were admitted for a planned surgical procedure. The other 13% were admitted for pain control and wound-care issues.Injury was more likely to be caused by flame in inpatients (p<0.001). Scald injuries were more common in the outpatient setting (34% vs. 27%), but this difference did not reach statistical significance (p=0.079). Outpatients were more likely to be injured with a contact burn (p<0.0001). Outpatient injury was more likely to be work-related than inpatient injury (p=0.0497), but less likely to be related to recreational activity (p=0.006) or arson/abuse/assault (p=0.0158). An experienced TRACSv5.0 user required 11±0.6min to enter an inpatient record and 6±0.6min to enter an outpatient record in the system (p=0.002). ConclusionsInpatient injury is more likely to be caused by flame, whereas outpatient injury is more likely to be caused by scald and contact burns. Work-related burn is more likely to be treated in the outpatient setting. Outpatient burn data also take less time to enter. Since significant differences in aetiology exist, outpatient data should be reported separately from inpatient data in order to understand the full spectrum of burn aetiology. The NBR and other registries should be modified to track outpatient burn data and outcomes.

Fibrin biomatrix-conjugated platelet-derived growth factor AB accelerates wound healing in severe thermal injury

Controlled delivery of growth factors from biodegradable biomatrices could accelerate and improve impaired wound healing. The study aim was to determine whether platelet-derived growth factor AB (PDGF.AB) with a transglutaminase (TG) crosslinking substrate site released from a fibrin biomatrix improves wound healing in severe thermal injury. The binding and release kinetics of TG-PDGF.AB were determined in vitro. Third-degree contact burns (dorsum of Yorkshire pigs) underwent epifascial necrosectomy 24 h post-burn. Wound sites were covered with autologous meshed (3:1) split-thickness skin autografts and either secured with staples or attached with sprayed fibrin sealant (FS; n = 8/group). TG-PDGF.AB binds to the fibrin biomatrix using the TG activity of factor XIIIa, and is subsequently released through enzymatic cleavage. Three doses of TG-PDGF.AB in FS (100 ng, 1 µg and 11 µg/ml FS) were tested. TG-PDGF.AB was bound to the fibrin biomatrix as evidenced by western blot analysis and subsequently released by enzymatic cleavage. A significantly accelerated and improved wound healing was achieved using sprayed FS containing TG-PDGF.AB compared to staples alone. Low concentrations (100 ng-1 µg TG-PDGF.AB/ml final FS clot) demonstrated to be sufficient to attain a nearly complete closure of mesh interstices 14 days after grafting. TG-PDGF.AB incorporated in FS via a specific binding technology was shown to be effective in grafted third-degree burn wounds. The adhesive properties of the fibrin matrix in conjunction with the prolonged growth factor stimulus enabled by this binding technology could be favourable in many pathological situations associated with wound-healing disturbances. Copyright © 2013 John Wiley & Sons, Ltd.

Reliability performance of 25 Gbit s−1 850 nm vertical-cavity surface-emitting lasers

Multimode 850 nm vertical cavity surface-emitting lasers (VCSELs) suitable for high bit rate operation are studied. VCSELs with oxide aperture diameters of 5–7 µm show a high −3 dB modulation bandwidth (∼20 GHz) and D-factor (∼ 8 GHz mA−1/2). To allow low capacitance a multiple layer oxide-confined aperture design was applied. Eye diagrams are clearly open up to 35 Gbit s−1 at the temperature of 25 °C. Using 35 µm diameter PIN photodiodes and 6 µm oxide aperture diameter VCSELs error-free 25 Gbit s−1 (defined as a bit error ration of ≤1 × 10−12) optical fiber communication links were tested over 100 m of standard OM3 multimode optical fibers at 25 °C and 85 °C. The received optical power for error-free operation was below −4 dBm at both temperatures. A VCSEL reliability study at 95 °C was performed at the high current densities (∼18 kA cm−2) needed for error-free 25 Gbit s−1 operation at elevated temperatures. After 6000 h a slight increase (less than 5%) of the output optical power at a constant current was observed and most likely due to an ohmic contact burn in effect within the first 2000 h of the study. The results clearly indicate that 25 Gbit s−1 850 nm oxide-confined VCSELs with a complex AlGaO multilayer aperture design and with step-graded Al-compositions have the potential for reliable operation.

Combined radiation and thermal injury induces a non-suppressive myeloid CD11b+ Gr1+ cell population (P4025)

Abstract Increasing sophistication of terrorist attacks and recent nuclear energy crises have amplified the interest in the immunobiology of combined radiation and burn injury (RCI). Burn is associated with immunosuppression and increased mortality with lower doses of ionizing radiation. Following trauma, putative myeloid derived suppressor cells (MDSCs; CD11b+Gr1+) have been described. We hypothesized that RCI-MDSCs display a suppressive phenotype and RCI will result in increased susceptibility to bacterial infection. C57BL/6 female mice underwent either a 20% total body surface area full thickness contact burn or sham procedure. All mice then received a single whole body dose of 5Gy γ-radiation. Mice were infected 14 days post injury with Pseudomonas aeruginosa intratracheally. Immune cells underwent apoptosis following RCI and infection, with CD11b+Gr1(Ly6C)+ cells being the predominant surviving cell type, which we isolated and cocultured 1:1 with untouched T cells. Surprisingly, T cells incubated with CD11b+Gr1(Ly6C)+ cells from RCI mice displayed greater proliferation, increased IFN-γ and decreased IL-10 production compared to MDSC from radiation-only mice. RCI mice were able to clear the P. aeruginosa infection significantly better than radiation-only mice. These data suggest that while RCI depletes immune cells, resistant CD11b+Gr1(Ly6C)+ cells represent a target population for modulation of bacterial clearance after injury.

Determinants of burn first aid knowledge: Cross-sectional study

IntroductionThis study investigated demographic factors, experience of burn/care and first aid course attendance as factors influencing burn first aid knowledge. MethodsA cross-sectional study was undertaken using convenience sampling of members of sporting and recreation clubs. The main outcome measure was the proportion of correct responses to multiple-choice questions relating to four burn scenarios: (1) scald, (2) contact burn, (3) ignited clothing, and (4) chemical burn. ResultsA total of 2602 responses were obtained. Large gaps (30–50% incorrect answers) were identified in burn first aid knowledge across all scenarios. 15% more individuals gave correct answers if they had attended a first aid course compared to those who had not (p<0.0001); this proportion increased if the course was undertaken within the previous five years (p<0.0001) or contained a burns-specific component (p<0.0001). Males and younger (≤25 years) and older (≥65 years) age-groups had relatively lower levels of burn first aid knowledge. Gender and age were significant predictors of first aid course attendance, with males and younger (≤25 years) and older (≥65 years) age-groups less likely to have attended a first aid course. ConclusionIn this sample, first aid training undertaken within the last 5 years with a specific burns component was associated with enhanced burn first aid knowledge.

Salvage of the Lower Limb after a Full Thickness Burn with Loss of the Knee Extensor Mechanism: A Case Report

We report on a 79-year-old woman who underwent salvage of the knee and lower leg using a Whichita Fusion Nail for knee arthrodesis, combined with a medial gastrocnemius muscle flap for a 3% contact burn that resulted in loss of the extensor mechanism. This provided an alternative to above-knee amputation when extensor mechanism reconstruction was not feasible.

Progression of Wound pH During the Course of Healing in Burns

The aim of this study was to measure the pH on the wound surface of 30 burn patients and test the hypothesis that wound surface pH is correlated to healing time and burn depth. Inclusion criteria were any adult outpatient with burn injury. Patient age was 17 to 75 years (mean, 44), burn depth ranged from superficial to full thickness with a TBSA of 0.4 to 4%. Cause of burn included scalds, flame burn, and contact burns. On admission, and at each dressing change, the pH on the wound surface was measured. The pH in both healing and nonhealing wounds was found to decrease with each dressing change. At the second dressing change, wounds that went on to heal were found to have a significantly lower pH of 7.32 in comparison with pH 7.73 in wounds that failed to heal and therefore required subsequent grafting (P = .004). Wound pH was also correlated to depth at the second dressing change (superficial = pH 6.05, full thickness = pH 8.0). The correlation between pH and wound outcome could be used as an additional diagnostic tool to predict poor healing in wounds. Early identification of a nonhealing wound may allow a more aggressive treatment regimen, including skin grafting, to bring about rapid wound healing.

Radiation Combined With Thermal Injury Induces Immature Myeloid Cells

The continued development of nuclear weapons and the potential for thermonuclear injury necessitates the further understanding of the immune consequences after radiation combined with injury (RCI). We hypothesized that sublethal ionization radiation exposure combined with a full-thickness thermal injury would result in the production of immature myeloid cells. Mice underwent either a full-thickness contact burn of 20% total body surface area or sham procedure followed by a single whole-body dose of 5-Gy radiation. Serum, spleen, and peripheral lymph nodes were harvested at 3 and 14 days after injury. Flow cytometry was performed to identify and characterize adaptive and innate cell compartments. Elevated proinflammatory and anti-inflammatory serum cytokines and profound leukopenia were observed after RCI. A population of cells with dual expression of the cell surface markers Gr-1 and CD11b were identified in all experimental groups, but were significantly elevated after burn alone and RCI at 14 days after injury. In contrast to the T-cell-suppressive nature of myeloid-derived suppressor cells found after trauma and sepsis, myeloid cells after RCI augmented T-cell proliferation and were associated with a weak but significant increase in interferon γ and a decrease in interleukin 10. This is consistent with previous work in burn injury indicating that a myeloid-derived suppressor cell-like population increases innate immunity. Radiation combined injury results in the increase in distinct populations of Gr-1CD11b cells within the secondary lymphoid organs, and we propose these immature inflammatory myeloid cells provide innate immunity to the severely injured and immunocompromised host.

Risk factors for burns at home in Kurdish preschool children: a case-control study

BackgroundIt is globally reported that young children are at a higher risk of burns but little is known about the individual risk factors. This study was undertaken in 2008 to...