European Psychiatric Association (EPA) guidance on post-graduate psychiatric training in Europe.

The European Union Free Movement Directive gives professionals the opportunity to work and live within the European Union, but does not give specific requirements regarding how the specialists in medicine have to be trained, with the exception of a required minimum of 4 years of education. Efforts have been undertaken to harmonize post-graduate training in psychiatry in Europe since the Treaty of Rome 1957, with the founding of the European Union of Medical Specialists (UEMS) and establishment of a charter outlining how psychiatrists should be trained. However, the different curricula for post-graduate training were only compared by surveys, never through a systematic review of the official national requirements. The published survey data still shows great differences between European countries and unlike other UEMS Boards, the Board of Psychiatry did not introduce a certification for specialists willing to practice in a foreign country within Europe. Such a European certification could help to keep a high qualification level for post-graduate training in psychiatry all over Europe. Moreover, it would make it easier for employers to assess the educational level of European psychiatrists applying for a job in their field.

Human middle longitudinal fascicle: segregation and behavioral-clinical implications of two distinct fiber connections linking temporal pole and superior temporal gyrus with the angular gyrus or superior parietal lobule using multi-tensor tractography.

The middle longitudinal fascicle (MdLF) is a major fiber connection running principally between the superior temporal gyrus and the parietal lobe, neocortical regions of great biological and clinical interest. Although one of the most prominent cerebral association fiber tracts, it has only recently been discovered in humans. In this high angular resolution diffusion imaging (HARDI) MRI study, we delineated the two major fiber connections of the human MdLF, by examining morphology, topography, cortical connections, biophysical measures, volume and length in seventy-four brains. These two fiber connections course together through the dorsal temporal pole and the superior temporal gyrus maintaining a characteristic topographic relationship in the mediolateral and ventrodorsal dimensions. As these pathways course towards the parietal lobe, they split to form separate fiber pathways, one following a ventrolateral trajectory and connecting with the angular gyrus and the other following a dorsomedial route and connecting with the superior parietal lobule. Based on the functions of their cortical affiliations, we suggest that the superior temporal-angular connection of the MdLF, i.e., STG(MdLF)AG plays a role in language and attention, whereas the superior temporal-superior parietal connection of the MdLF, i.e., STG(MdLF)SPL is involved in visuospatial and integrative audiovisual functions. Furthermore, the MdLF may have clinical implications in neurodegenerative disorders such as primary progressive aphasia, frontotemporal dementia, posterior cortical atrophy, corticobulbar degeneration and Alzheimer's disease as well as attention-deficit/hyperactivity disorder and schizophrenia.

DIFFEOMORPHIC POINT SET REGISTRATION USING NON-STATIONARY MIXTURE MODELS.

This paper investigates a diffeomorphic point-set registration based on non-stationary mixture models. The goal is to improve the non-linear registration of anatomical structures by representing each point as a general non-stationary kernel that provides information about the shape of that point. Our framework generalizes work done by others that use stationary models. We achieve this by integrating the shape at each point when calculating the point-set similarity and transforming it according to the calculated deformation. We also restrict the non-rigid transform to the space of symmetric diffeomorphisms. Our algorithm is validated in synthetic and human datasets in two different applications: fiber bundle and lung airways registration. Our results shows that non-stationary mixture models are superior to Gaussian mixture models and methods that do not take into account the shape of each point.

Unsupervised white matter fiber clustering and tract probability map generation: applications of a Gaussian process framework for white matter fibers.

With the increasing importance of fiber tracking in diffusion tensor images for clinical needs, there has been a growing demand for an objective mathematical framework to perform quantitative analysis of white matter fiber bundles incorporating their underlying physical significance. This article presents such a novel mathematical framework that facilitates mathematical operations between tracts using an inner product between fibres. Such inner product operation, based on Gaussian processes, spans a metric space. This metric facilitates combination of fiber tracts, rendering operations like tract membership to a bundle or bundle similarity simple. Based on this framework, we have designed an automated unsupervised atlas-based clustering method that does not require manual initialization nor an a priori knowledge of the number of clusters. Quantitative analysis can now be performed on the clustered tract volumes across subjects, thereby avoiding the need for point parameterization of these fibers, or the use of medial or envelope representations as in previous work. Experiments on synthetic data demonstrate the mathematical operations. Subsequently, the applicability of the unsupervised clustering framework has been demonstrated on a 21-subject dataset.

Effects of candidaemia on outcome of burns.

AIM: To evaluate the diversity and antifungal susceptibilities of Candida isolates from wounds and blood of burn victims, and the associated mortality rates compared with those of controls without candidaemia. METHODS: We performed a nested case-control study within a database of clinical data for all patients admitted to our burn unit from January 2001 to December 2005. Each candidaemic patient was compared with two matched controls. Bloodstream cultures were performed if the core temperature was >39 degrees C, and three sites were cultured weekly for fungal identification (burn wound, pharynx, urinary tract). RESULTS: At least one episode of candidaemia was diagnosed among 20 of 851 persons admitted during the study period. Isolates in bloodstream infection were Candida albicans (65%), C. parapsilosis (25%) and C. tropicalis (10%). The median time between admission and onset of candidaemia was greater with C. albicans infection (42.6+/-31 days) than with infection by other yeasts (18+/-12 days). Candidaemia was associated with more extensive burn and longer duration of hospital stay but with similar mortality, compared with controls. CONCLUSION: Candidaemia in burn cases is mostly due to fluconazole-susceptible C. albicans and is not associated with increased mortality.

Mathematical methods for diffusion MRI processing.

In this article, we review recent mathematical models and computational methods for the processing of diffusion Magnetic Resonance Images, including state-of-the-art reconstruction of diffusion models, cerebral white matter connectivity analysis, and segmentation techniques. We focus on Diffusion Tensor Images (DTI) and Q-Ball Images (QBI).

Case report: cytomegalovirus primoinfection may be associated with severe outcome in burns.

We report two cases of severe cytomegalovirus (CMV) primoinfection in seriously burned patients. The infection may have contributed to both patients' fatal outcome. This underlines the importance of research in viral aetiology, especially with regard to CMV, when immunodeficient patients - as burn patients are - develop unexplained fever. We propose a monitoring and a prevention strategy for CMV in the most severely burned patients. The prevention strategy involves the use of skin allografts and blood products in seronegative patients. CMV infection should not be underestimated in severely burned patients.

A silver sulphadiazine-impregnated lipidocolloid wound dressing to treat second-degree burns.

OBJECTIVE: To evaluate the efficacy and tolerance of Urgotul SSD dressing (Laboratoires Urgo) in the treatment of second-degree burns. METHOD: This was a national multicentre phase III non-comparative open-label prospective study involving 10 burns units. The 41 subjects were non-immunosuppressed adults with second-degree thermal burn(s), which were clinically non-infected, less than 24 hours old, had a surface area less than 500 cm2 and warranted the local use of silver sulphadiazine. For four weeks, subjects were followed up weekly with a clinical assessment, bacteriological swabs and photographic recording. RESULTS: Of the 41 patients, 24 healed within a mean of 10.8 days and 13 had a skin graft on the study burn within a mean of 11.5 days. There were four premature study withdrawals. The total number of cumulative treatment days was 445, and 298 treatments were performed (including 257 dressing changes). Mean dressing wear time was 1.73 days. None of the subjects acquired a secondary infection. Researchers took 121 bacteriological samples, and wound colonisation with Staphylococcus aureus was found in only one patient. At follow-up nursing staff reported that dressing acceptability was good. CONCLUSION: Use of Urgotul SSD led to a good wound outcome--wounds healed or were grafted.

[Criteria for burn severity. Epidemiology. prevention, organization of management]. / Critères de gravité des brûlures. Epidémiologie, prévention, organisation de la prise en charge.

Total body surface area burned and deep of the skin injury are the main determinants of the burn severity. Other factors like age of the patient, pathological conditions, pulmonary injury by smoke inhalation, wound localizations play also a major role. 500,000 cases of burn injuries occurred each year in France. Ten hundred are hospitalized among witch 3,000 are hospitalized in burn units. Burns by flames are the most common in adult severely burned patients. In children, for all type of injuries, and in adult patients suffering of light or medium injuries, hot liquids are the most frequent encountered agents. Obviously, prevention programs should markedly decrease the occurrence of burn injuries. Regulation modifications are probably more potent than information campaigns. There is 25 burn units in France. Unfortunately, these units take care of less than one third of all the burned hospitalized patients. The organization of a national network binding regional burn centers and local specialized units would probably improve the efficiency of burn therapy in our country.

[Systemic complications of extended burns]. / Les répercussions générales des brûlures étendues.

Burns covering more than 10% of the total body surface area (TBSA) are responsible for systemic perturbations which, in very severe cases, can represent a vital risk and, in all cases, affect the wound evolution. Among these general perturbations, fluid volume and electrolyte changes, leading eventually to burn shock, have the most dramatic consequences. Burn shock is, still to day, a vital risk and can also, in case of inadequate early fluid resuscitation, results in secondary morbidity and mortality. Fluid replacement during the very first hours after injury represents certainly a key point of the management of severe burn cases. Estimation of resuscitation fluid needs during this period is frequently underestimated. For adult, we recommend, during the first hour, a minimum of one liter for all severe injuries and two liters if the injury exceeds 50% of TBSA. Pulmonary injuries due to smoke inhalation are frequent, about 25% of patients hospitalized in burn units, and responsible for numerous death at site of house fires. In burn units, about 25% of hospitalized patients have pulmonary injuries in relation with smoke inhalation. This population has a high mortality rate increasing with the area of the skin injury and with age. Patients with inhalation injury need more resuscitation fluids, are subject to pneumonia and necessitate frequently mechanical ventilation. Parameters of the mechanical ventilation have to be choice to avoid barotrauma. Severe burn patients are submitted to a very high metabolic level. This can leads to a deep nutritional deficit responsible for an immunological suppression. It is then of major importance to provide an adequate nutritional support. It is also necessary to fight against the stress and to put the patient in a warm environment. Finally, infection is the most frequent and the most severe complication of burn injuries. Everything have to be done to avoid bacteriological contamination including architecture, equipment's, care procedure, nutritional support, types of wound dressing and most importantly surgery. Surgical procedures have to be done as earliest as possible to excise necrosis and cover the wound.

Differences between burns in rural and in urban areas: implications for prevention.

This study aimed to identify typical features of burns in rural areas and to improve their prevention by comparing the characteristics of burnt patients and their burns in rural and urban areas. A cross-sectional survey was conducted in 19 of the 23 French burns units over one year, using a structured questionnaire. We analysed the resulting database. Of the 1422 patients, excluding 188 burnt in unclassified areas, 420 (34%) were burnt in rural areas. Burns were more frequent in rural than in urban areas. Occupational burns were more frequent in rural than in urban areas. The characteristics of patients and burns did not differ between the areas. Patients burnt during everyday activities were older and more frequently had predisposing factors in rural than in urban areas. Burns occurred outdoors more often in rural than in urban areas and were frequently due to flames or explosions or to the use of barbecues or open fires. The hands and perineum were burnt more frequently in rural than in urban areas. Rural burns were more severe than urban burns: they were deeper, involved a larger body surface area and caused more deaths. Preventive measures in rural areas should take into account occupation and everyday activities. They should be specifically adapted to the profiles of burnt patients.

Inhibiteur de rejet de greffe alpha2-macroglobulin in burn injury: a suppressive activity on complement.

A subform of alpha2-macroglobulin, (inhibiteur de rejet de greffe (IRG), present at a low rate in healthy rat, increased with rate-related suppressive activity on complement during inflammatory processes. In human serum, a molecule with such properties was described. Serum and blister IRG from burn patients belonging to a selected population was purified under gentle conditions. Serum IRG increased quickly within the first day after hospitalization and continued to increase until day 6. Although absent in whole serum, the rate-related activity of IRG varied according to the surface area and the degree of burns. A rate-related activity was also revealed in whole blister fluid and in purified blister IRG. We report a new site and a new suppressive activity of IRG in its native form from serum and blister fluid during inflammatory processes of burned patients. The suppressive activity of IRG on complement is discussed, and it appears to play a role in the development of inflammatory processes.

A decade of change in clinical waste treatment and disposal in Scotland.

Ten years ago there were over 150 small incinerators located on hospital premises throughout Scotland. The majority were operated by portering staff, had poor combustion and no gas cleaning equipment. At that time alternatives to incineration were in their infancy and relatively expensive. Funding for major capital projects lay with the Government, and a strategic study suggested the installation of 12 centralised modern incinerators on the mainland and three on the islands: one per Scottish Health Board. Some health boards proceeded with new installations well ahead of dead-lines for closure of old plant. Others adopted a 'wait and see' policy and were overtaken by political changes. These resulted in a cutback in government-funded capital investment and a shift of non-core services to the private sector. Clinical waste disposal was contracted out as a service contract and some private sector companies offered alternative low-temperature technologies for clinical waste treatment. As a result there is now the opportunity to compare the advantages and disadvantages of incineration, sterilization, dry heat disinfection and other techniques. Technological change has also required revised waste segregation methods within the hospitals. In parallel with this there has been an overall reduction in waste quantities. The remaining incinerator operators are now faced with more stringent emission limits to be implemented by June 2000. This is resulting in closures of incinerators that have been operating for a few years. The situation continues to change.

Use of random amplified polymorphic DNA as a typing method for Candida albicans in epidemiological surveillance of a burn unit.

Burn patients are particularly exposed to deep-seated nosocomial infections caused by Candida species. Superficial carriage of C. albicans is a potential source of infection and dissemination, and typing methods could be useful to trace the different isolates. We report the use of random amplified polymorphic DNA to type isolates of C. albicans in the Hôpital Cochin burn unit. This molecular typing method, which is based on PCR with arbitrary short primers, was evaluated on a panel of 32 C. albicans strains isolated from various anatomical sites of unrelated patients, and the strains showed 22 different patterns. Random amplified polymorphic DNA was then used in the epidemiological surveillance of the patients in the burn unit over a 9-month period. Seven patterns were identified among 84 isolates from 18 patients. One pattern (pattern A) corresponding to isolates from 7 of the 18 patients (68% of isolates) predominated throughout the 9-month study, while some strains with other profiles were isolated only once. Some profiles appeared to show a particular geographic pattern within the unit, suggesting transmission from room to room. These results underline the importance of fungal surveillance in such patients and the need to inform nursing staff of measures to prevent the spread of Candida spp. from patient to patient.

[Child victims of house fires in France. Mortality, morbidity, prevention]. / Enfants, victimes d'incendies d'habitations en France. Mortalité, morbidité, prévention.

Children injuries by house fires in France are the cause of a severe mortality (sixty deaths in average each year) and of a morbidity for the survival due to smoke toxicity (oxygen deprivation and inhalation of toxic gases--CO and HCN) and to thermal burns. Epidemiological studies show that young children (0 to 4) are specially concerned by this threat and that the deaths occurred more often in some part of France (Nord-Pas-de-Calais Region). A special strategy for this prevention should be applied in France, the same available in USA, Sweden and UK, including information on the behavior one should have with children: never leave them alone and escape with them as soon as possible out of the smoke. The usefulness of smoke detectors should be confirmed by French administration and recommended to the public, since they have had effective results in other countries.