Dermal substitute: a safe and effective way in surgical management of adults post-burn dorsal foot contractures.

OBJECTIVE: Neglected dorsal foοt burns may result in typical fοrefοοt defοrmities characterised by cοntractures leading tο hyperextensiοn οf the tοes and gait disturbance. These defοrmities usually cause a significant impairment in daily activities and difficulty in wearing shοes. This article presents a recοnstructiοn series οf severe fοrefοοt defοrmities by means of dermal regeneratiοn templates (also known as dermal substitutes) and split thickness skin grafts. PATIENTS AND METHODS: We retrοspectively reviewed οur institutiοnal burn database from 2010 to 2020 focusing on all those dοrsal fοοt cοntractures treated with the use οf a dermal regeneratiοn template. The patients' demοgraphics, burn injury mechanisms, depth, lοcalizatiοn, surface, treatments and fοllοw-up were described. RESULTS: Twelve patients underwent this prοcedure and the mean affected area was 75 cm2. The mean time between the dermal regeneratiοn template applicatiοn and the split thickness skin graft was 19.6 days. Just fοr one patient, an additiοnal skin grafting prοcedure was required. The mean fοllοw-up was 4.6 years. We did not register specific cοmplicatiοns at bοth the recipient (forefoot) and dοnοr sites (scalp). All patients were able tο wear shοes and walk after the procedure. Nο recurrence οf cοntractures were οbserved. All patients were satisfied with cοsmetic results, and they did not request any additiοnal prοcedure οf cοsmetic imprοvement. CONCLUSIONS: The use οf the dermal regeneratiοn template can be cοnsidered as an extremely safe and efficient treatment οf severe post-burn fοrefοοt defοrmities.

Repair Of Palm Burns Of The Hand: A Contralateral Inner Arm Bag-Shaped Flap.

Hands are one of the most often burnt parts of the body. Deep palmar burns are often the result of an electrical burn or a thermal burn from grasping a hot item. With a deep burn, joints, vasculo-nervous pedicles, tendons or bones can become exposed and lead to amputation. Different surgical repair methods are used depending on the area of the hand that is burnt. Most of the publications to date have described surgical techniques for dorsal hand burns. The abdominal bag-shaped flap is one of the main surgical techniques to cover dorsal deep tissue exposure. Bag-shaped flaps need time to achieve the vascular autonomy of the flap without any movement. Abdominal bagshaped flaps are particularly suitable for dorsal soft-tissue defects, while for palmar defects, it is an uncomfortable position to maintain for three weeks. A contralateral arm bag-shaped flap for palmar burns allows a comfortable position to be achieved as the upper burnt limb is positioned as if the patient has their arms crossed. Furthermore, as stated above, the contralateral arm bag-shaped flap has the advantage of allowing a flap to be used that is thinner than an abdominal bag-shaped flap. At the Saint Louis Burns Center, we recently treated two patients with deep palmar burns and deep tissue exposure. We performed a contralateral arm bag-shaped flap for both of these patients. In our experience, the use of the contralateral arm bag-shaped flap technique to cover palmar lesions resulted in favorable postoperative progression, with complete closure of the lesions, good functional outcomes, as well as other advantages such as a hidden scar at the donor site. This technique allows amputation of fingers to be avoided when pedicles, joints, or tendons are exposed and when the burnt area of the palm is extensive and no other flaps can be used.

Les brûlures surviennent fréquemment au niveau des mains. Les brûlures profondes de la face palmaire des mains sont souvent secondaires à des brûlures électriques ou à des contacts sur des solides chauds. À la suite d'une brûlure profonde, les articulations, les pédicules vasculonerveux, les tendons ou les os peuvent être exposés, conduisant à des indications d'amputation. Différentes techniques de chirurgie réparatrice peuvent être utilisées, en fonction de la zone anatomique brûlée. La plupart des publications décrivent des techniques de couverture des brûlures de la face dorsale de la main. Le lambeau d'empochement abdominal est l'une des principales techniques décrites pour la couverture des pertes de substance profondes de la face dorsale de la main. Ces lambeaux d'empochement nécessitent une immobilisation stricte pour permettre une revascularisation anatomique du lambeau. Si ces lambeaux d'empochement abdominaux sont une très bonne indication pour les pertes de substance de la face dorsale de la main, la position est particulièrement inconfortable à maintenir trois semaines pour les faces palmaires. Un lambeau d'empochement à la face interne du bras controlatéral pour les brûlures palmaires de la main permet de maintenir une position confortable, comme si le patient avait les bras croisés. De plus, le lambeau d'empochement sur la face interne du bras controlatéral a l'avantage de fournir un lambeau plus fin que le lambeau d'empochement abdominal. Au centre de brûlés de Saint-Louis, nous avons récemment traité deux patients présentant des brûlures profondes de la face palmaire de la main et avec exposition de tissus nobles. Nous avons réalisé un lambeau d'empochement du bras controlatéral pour chacun de ces patients. Dans notre expérience, cette technique d'empochement des lésions palmaires a permis une couverture complète, de bons résultats fonctionnels et, a l'avantage que la cicatrice du site donneur est peu visible. Cette technique permet d'éviter des amputations digitales en cas d'exposition articulaire, tendineuse ou pédiculaire lorsque la surface palmaire brûlée ne permet pas l'utilisation d'autres lambeaux.

Reconstruction strategies after rupture of the extensor pollicis longus tendon: A systematic review.

Ruptures of the extensor pollicis longus (EPL) tendon result in a major loss of function. The most practiced reconstruction surgery appears to be extensor indicis proprius (EIP) transfer, which is contraindicated in certain cases. The objective of this review was to present the various reconstruction methods for the EPL tendon. A systematic review was conducted of the literature from 2010 to 2020 on strategies for reconstructing the EPL tendon. A search of the PubMed database was done using the following keywords: 'extensor', 'pollicis', 'longus', and 'thumb'. Data analyzed were the type of study, the number of patients, surgery, follow-up, and results. Of the 142 articles selected from PubMed, only 18 (12.7%) were included in the analysis. Follow-up ranged from 6 months to 6 years, with an average of 28 months, and the total number of patients was 515. Numerous strategies exist for reconstruction following rupture of the EPL tendon. The preferred modality seems to be a transfer of the EIP tendon with intraoperative testing of applied tension with the interphalangeal joint in extension, hand flat, forearm in pronation, and neutral wrist position. When the EIP is not available, other transfers should be considered if the patient has significant tendon attrition, or a graft should be considered if an isolated defect is present.

Head and neck skin expansion: assessment of efficiency for the treatment of lesions in the lower half of the face.

The treatment of sequelae for burns or other loss of perioral tissues is complex due to the site where they occur, its functional importance, and social and esthetic aspects. Functional consequences of burns to this area are cutaneous retraction and a lack of skin that can lead to an inability to close the oral aperture, compromising the provision of dental hygiene and intubation procedures. The aim of the present publication was to evaluate the efficacy of chin, labial and jugal cutaneous expansions for the treatment of perioral lesions and lesions of the lower half of the face in our retrospective series of patients. We collected data and photography from digital files for each patient. Proportion of scarred skin that could be treated by one or several expansion procedures was evaluated. The main outcome was the resection of 50% or more initial lesions. Side effects were assessed. Out of a total of 33 expanders, 28 were at the jugal level, 5 were chin expanders, and none were labial expanders. This equated to the inclusion of fourteen patients. The average percentage of the lesion that was removed after the perioral expansion protocol was 68.9% (40%-100%). 85% of patients had a positive outcome. 12% of procedures were complicated by hematoma, infection or prosthesis exposure. Each time that the lesional area could be fully (i.e. 100%) treated, only a single expansion was used. Head and neck expansion is the technique of choice for reconstruction of the lower half of the face and the horizontal part of the neck in terms of efficiency and safety.

Le traitement des séquelles de brûlures ou d'autres pertes de substances tissulaires de la région péri buccale est complexe du fait de l'importance fonctionnelle de cette région et des conséquences esthétiques et sociales. Les conséquences des brûlures de cette région sont les rétractions ou la rigidité cutanées entrainant une limitation de la fermeture buccale et de ce fait compromettant l'état dentaire et les procédures d'intubation. Le but de ce travail est d'évaluer l'efficacité de l'expansion cutanée du menton, des lèvres et des joues dans le traitement des lésions de la région péribuccale ou de la face basse par une étude rétrospective de notre série. Nous avons repris les données cliniques et les photographies à partir des dossiers informatisés pour chaque patient. Nous avons évalué la quantité de peau cicatricielle traitée en un ou plusieurs temps. Le résultat principal est que plus de 50% de la lésion initiale a été traitée. Les effets secondaires ont été évalués. 14 patients ont été inclus. 33 expandeurs ont été posés, 28 étaient au niveau de la joue, 5 sur le menton et aucun sur les lèvres. Le pourcentage moyen de lésion excisée après expansion cutanée de la région péribuccale était de 68,9% (40%-100%). 85% des patients ont eu un résultat satisfaisant. 12% des procédures d'expansion se sont compliquées d'hématome, d'infection ou d'exposition de la prothèse. A chaque fois que la lésion pouvait être traitée totalement, une seule procédure a été réalisée. L'expansion cutanée de la tête et du cou est la technique de choix pour la reconstruction de la face basse et de la portion horizontale du cou en termes de résultats et de complications.

[Quick screening for Body Dysmorphic Disorder in a plastic surgery population in France]. / Dépistage rapide du Body Dysmorphic Disorder en consultation de chirurgie plastique en France.

INTRODUCTION: All plastic surgeons are frequently faced with patients with Body Dysmorphic Disorder (BDD). However, no screening test exists in French to help the plastic surgeons to diagnose this disease. The Body Dysmorphic Disorder Questionnaire (BDDQ) is the Gold Standard to easily detect BDD in consultation with any non-psychiatric physician. The aim of this study was to translate and validate the BDDQ into French to help plastic surgeons to detect BDD before the surgery. This way, plastic surgeons will be able to provide an optimal medical care and to reduce the risk of psychiatric collapse. METHODS: We asked Katherine Philipps for her approval to use her BDDQ for our study, and thereafter we translated it respecting the criteria of the World Health Organization. We first evaluated the psychometric qualities of the BDDQ in French and then its reproducibility and its sensitivity to change. RESULTS: A French version of the BDDQ appeared to be reliable and comprehensible. The questionnaire has been tested on a sample of patients in plastic surgery consultation, at a T moment and a T plus one month to certify its reproducibility and its sensitivity to change. CONCLUSION: These results permit to claim that the French version of the BDDQ is now validated to detect patients with a BDD in a plastic surgery consultation.

Reconstruction Of The Burnt Nose Using A Carved Flap In Four Cases.

Techniques for reconstructing nasal defects in burns are very limited because the surrounding scar tissue makes it difficult to use local flaps. The authors report their experience using the Converse scalping flap harvested from scarred skin, placed as a mass on the nasal area, then secondarily carved to shape the nose and covered by a skin graft. This is a retrospective study of 4 patients, 3 men and 1 woman, with an average age of 45 years, who were operated on between 1994 and 2013 using this technique for postburn nasal reconstruction. Patients had 45% burns on average. The flap was weaned from its donor site at the third week and the frontalis donor area grafted. Several months later, the flap was sculpted from the outside to the inside in the three dimensions, removing the scarred epidermal areas to restore the aesthetic units of the nose, which were grafted using a full thickness skin graft. The final aesthetic result of the nasal reconstruction was evaluated by the patient and the surgical team. The four nasal reconstructions were carried out to completion. Three were rated as 'very good' (75%) and one was rated as 'good' (25%). The Converse flap modification, referred to as the "carved flap", to reconstruct the burned nose is a reliable technique, possible on a scarred forehead with no additional donor site morbidity.

Les techniques de reconstruction nasale après brûlure sont limitées. En effet, la peau cicatricielle environnante rend difficile l'utilisation de lambeaux locaux. Les auteurs rapportent leur expérience avec le lambeau scalpant de Converse prélevé en peau cicatricielle, placé en bloc sur la région nasale puis secondairement sculpté pour donner sa forme au nez et greffé. Il s'agit d'une étude rétrospective sur quatre cas, 3 hommes et 1 femme, d'un âge moyen de 45 ans, opéré entre 1994 et 2013, en utilisant cette technique de reconstruction nasale après brûlure. Les patients étaient brûlés en moyenne à 45% de la surface corporelle. Le lambeau a été sevré du site donneur à trois semaines et la perte de substance au niveau du front a été greffée. Plusieurs mois plus tard, le lambeau a été sculpté de dehors en dedans dans les trois dimensions, la peau cicatricielle a été désépidermisée sur l'unité esthétique du nez qui a été greffée en peau totale. Le résultat esthétique final de cette reconstruction nasale a été évaluée à la fois par le patient et par l'équipe chirurgicale. Les quatre reconstructions nasales ont été menées à terme. Elles ont été cotées comme très bon résultat dans 75% des cas et comme bon résultat dans 25% des cas. Ce lambeau de Converse modifié, appelé « lambeau sculpté ¼, est une technique fiable pour reconstruire un nez, possible sur un front cicatriciel et sans morbidité additionnelle au site donneur.

Electrical Burns and Late Spontaneous Artery Ruptures: About Three Cases.

Electrical burns are responsible for arterial and venous thrombosis, as well as weakening of the arteries. Immediate or delayed arterial occlusions, secondary to the aggression of the intima, or aneurysms, secondary to the aggression of the media, sometimes lead to artery ruptures without any warning signs. Such ruptures may trigger a hemorrhagic shock whose period of onset is variable and unpredictable. We are presenting here three cases treated in our department for electrical burns, whose complications were marked by hemorrhagic shock, secondary to late artery ruptures, sometimes occurring several months following the event. These case reports required performance of emergency hemostasis in order to control sudden bleeding, with first approach being placement of a tourniquet at the base of the limb and/or a compression point. Through these cases, we thought it is crucial to closely monitor for a few weeks all patients who were victims of electrical injury, even more so if it was associated with a compartment syndrome of one or more limbs and high rhabdomyolysis, which seem to be predictive factors of late artery ruptures in our case reports.

Brûlures chimiques: notre série sur 25 ans.

Chemical burns raise diagnostic and treatment issues because they have specific appearances and evolution. Our objective was to study the characteristics of chemical burns and to assess the quality of our treatment. This retrospective observational study examined the records of all patients admitted for chemical burns to the burn treatment center of Saint Louis Hospital in Paris from January 1, 1990, through December 31, 2015. During this period, 162 patients came to our center for chemical burn treatment. Most of them were men (67%). The majority of the burns were caused by alkalis (27%) and resulted from workplace accidents (29%). The average time before consultation was 5.36 days. The areas mainly damaged were the hands (36%) and the burn areas averaged 1.2% of the total body surface area (TBSA). Forty-eight patients had at least one deep patch. In total, 59 patients (36.4%) were hospitalized for an average duration of 4.18 days. Thirty-eight of them underwent surgery. Lastly, 92% of the operations had been anticipated from the first consultation. In our center, the population affected, the circumstances and the topography of our patients' burns were similar to the data from the literature. It appears that the principal specificity of our series is a very low body surface burned. This can be attributed to the prevention measures we have in France and underlines their importance. Only 8% of the patients who had surgery were underestimated or their burns became deeper secondarily. This number is lower than the data from other series.

[Complications with surgical treatment of basal cell carcinomas in individuals over 75 years of age: A retrospective study of prognostic factors in 158 cases]. / Complications du traitement chirurgical des carcinomes basocellulaires après 75 ans. Étude rétrospective des facteurs pronostiques sur 158 cas.

INTRODUCTION: Basal cell carcinoma (BCC) is a pathology that evolves locally and it is common in elderly subjects whose frailty could restrict the indications for the reference treatment, which is based on surgery. The aim of this study was to investigate the morbidity and the mortality associated with surgical treatment of BCC in patients over 75 years of age, so as to identify possible prognostic factors for postoperative complications. MATERIALS AND METHODS: This was a retrospective study carried out with patients over 75 years of age who were treated surgically for one or several BCC between 2010 and 2015 in the reconstructive and cosmetic plastic surgery unit of the Saint-Louis Hospital in Paris (France). We collated the demographic characteristics, the characteristics of the treatment, as well as the rate of major postoperative complications. We performed a univariate and then a multivariate analysis of the various risk factors that were identified. RESULTS: A total of 158 patients were analyzed and they exhibited a rate of major complications of 12%. The statistical analysis identified five significant risk factors: being over 85 years of age (P=0.006), long-term use of anticoagulant treatment (P=0.02), the presence of at least one comorbidity (P=0.018), a conventional hospitalization (P=0.002), and the use of general anesthesia (P=1.2e-10). CONCLUSION: Five risk factors for major postoperative complications with the surgical treatment of BCC in patients over 75 years of age were identified. These factors may provide direction to medico-surgical teams in regard to the optimal treatment of BCC in elderly patients.

Interleukin-32 promotes detachment and activation of human Langerhans cells in a human skin explant model.

BACKGROUND: Cross-talk between skin keratinocytes (KCs) and Langerhans cells (LCs) plays a fundamental role in the body's first line of immunological defences. However, the mechanism behind the interaction between these two major epidermal cells is unknown. Interleukin (IL)-32 is produced in inflammatory skin disorders. We questioned the role of IL-32 in the epidermis. OBJECTIVES: We aimed to determine the role of IL-32 produced by KCs on surrounding LCs. METHODS: We used an ex vivo human explant model from healthy donors and investigated the role of IL-32 on LC activation using imaging, flow cytometry, reverse transcriptase quantitative polymerase chain reaction and small interfering (si)RNA treatment. RESULTS: Modified vaccinia virus ankara (MVA) infection induced KC death alongside the early production of the proinflammatory cytokine IL-32. We demonstrated that IL-32 produced by MVA-infected KCs induced modest but significant morphological changes in LCs and downregulation of adhesion molecules, such as epithelial cell adhesion molecule and very late antigen-4, and CXCL10 production. The treatment of KCs with IL-32-specific siRNA, and anti-IL-32 blocking antibody significantly inhibited LC activation, demonstrating the role of IL-32 in LC activation. We also found that some Toll-like receptor ligands induced a very high level of IL-32 production by KCs, which initiated LC activation. CONCLUSIONS: We propose, for the first time, that IL-32 is a molecular link between KCs and LCs in healthy skin, provoking LC migration from the epidermis to the dermis prior to their migration to the draining lymph nodes.

[Greater omentum flap: Treatment of chronic wounds and seroma: About a case]. / Le lambeau de grand épiploon : traitement des plaies et lymphorrhees chroniques : à propos d'un cas.

INTRODUCTION: Cicatricial complications after abdominal or pelvic surgery are more frequent in obese patients. In this case, infection, seroma and delays in scarring can be extremely difficult to treat. The objective of this technical note is to present an original case of an obese patient operated nine years ago of a hysterectomy by laparotomy and chronically presenting a non-resolving septic seroma despite multiple surgical procedures whose healing could be obtained by a flap of greater omentum. SURGICAL TECHNIQUE: The ideal is to carry out this intervention in a double team with a digestive surgeon in case of intra-abdominal visceral or vascular wound during dissection. The greater omentum flap was raised in a conventional manner over the gastroepiploic artery. A sufficiently wide orifice should be left at the level of the abdominal aponeurosis in order to avoid any compression of the pedicle. Finally, the flap must be spread over the whole surface of the detachment and fixed to the anterior aponeurosis. CONCLUSION: Reliability and vascular and lymphatic richness make the greater omentum flap a very effective method in chronic wound cases associated with important seroma. The scarring obtained in the clinical case presented thus highlights the specific qualities of this flap.

Our 35 years' experience on postburn heterotopic ossification: A three-step treatment.

Our retrospective study of burn patients presents a three-step treatment of heterotopic ossification: excision surgery, early rehabilitation, and analgesia. We included patients admitted to the department for treatment of postburn heterotopic ossification between January 1, 1979, and September 30, 2015. The mean age at the time of the burn was 43.3 years. Men accounted for the majority of burn patients who developed an osteoma (70.8%). The mean total skin area burned was 38.4%. No osteoma justifying surgery was found for any patient with a total burned skin area less than 19%. The burned zones were related to the osteoma development in 94.3% of cases. On average, the surgery took place 10.8 months after the burn. The osteotomy was accompanied by surgical treatment of a contracture in 37.1% of patients. Most of the osteomata were found at the elbows (30), followed by the shoulders (3), and finally the knees (2). Rehabilitation began on D0 after the surgery, except if a flap or a thin-skin graft was used. Regarding analgesia, opiates were prescribed systematically during the immediate postoperative period. Elbow range of motion on flexion improved by a mean of 84.1°. During the postoperative period, we found 2 recurrences of osteoma and 1 elbow hematoma in two separate patients. There were no postoperative infections or neurological sequelae. Our retrospective French study confirmed results found in the international literature. The three-step treatment - excision surgery, early rehabilitation, and antalgia - seems to be the best means of treating osteoma with satisfactory results. Surgery is indicated only in the case of functional impairment and not simply based on imaging.

Three-dimensional imaging, an important factor of decision in breast augmentation.

INTRODUCTION: Since the beginning of the 21st century, three-dimensional imaging systems have been used more often in plastic surgery, especially during preoperative planning for breast surgery and to simulate the postoperative appearance of the implant in the patient's body. The main objective of this study is to assess the patients' attitudes regarding 3D simulation for breast augmentation. METHOD: A study was conducted, which included women who were operated on for primary breast augmentation. During the consultation, a three-dimensional simulation with Crisalix was done and different sized implants were fitted in the bra. RESULTS: Thirty-eight women were included. The median age was 29.4, and the median prosthesis volume was 310mL. The median rank given regarding the final result was 9 (IQR: 8-9). Ninety percent of patients agreed (66% absolutely agreed, and 24% partially agreed) that the final product after breast augmentations was similar to the Crisalix simulation. Ninety-three percent of the patients believed that the three-dimensional simulation helped them choose their prosthesis (61% a lot and 32% a little). After envisaging a breast enlargement, patients estimated that the Crisalix system was absolutely necessary (21%), very useful (32%), useful (45%), or unnecessary (3%). Regarding prosthesis choice, an equal number of women preferred the 3D simulation (19 patients) as preferred using different sizes of implants in the bra (19 patients). CONCLUSION: The present study demonstrated that 3D simulation is actually useful for patients in order to envisage a breast augmentation. But it should be used as a complement to the classic method of trying different sized breast implants in the bra.

[Self-inflicted burns in our burns center between 2011 and 2016]. / Immolation dans notre centre de traitement des brûlés de 2011 à 2016.

The prevalence of immolation by fire in France is uncertain. We carried out a retrospective epidemiological study on immolations between 2011 and 2016 at the burn treatment centre at the hôpital Saint-Louis in Paris. We studied the prevalence and characteristics of patients entering hospital for this reason. Between 2011 and 2016, a total of 1098 patients were hospitalized in the centre, of which 50 were admitted for immolation, i.e. five percent of the hospitalized population. The average age at entry was 46 years, and they were mostly men (62%). All but one was a suicide attempt. The average total burn area was 34.5%, and the average length of stay in the centre was 53 days. The products used for the immolation were mostly white spirit, alcohol or gasoline. Nine (18%) out of the 50 patients died, burned at 62.5% on average. A psychiatric history was reported in 35 patients and 21 had previously attempted suicide; nine patients were chronic alcoholics and four were drug addicts. The most frequently reported reasons for the suicide attempt were sentimental breakdown, death of a relative or financial problem. The prevalence of immolation in our study is very low compared to that found in developing countries. The majority of our cohort is composed of patients with a history of psychiatric disorders. The history of attempted suicide is also a major risk factor for committing suicidal acts by immolation. Prevention measures should be implemented to reduce this risk.

Burns caused by electronic vaping devices (e-cigarettes): A new classification proposal based on mechanisms.

Introduction With more than 10 million of daily users, e-cigarettes encountered a great success. But in the past few years, the number of medical reports of injuries caused by the explosion of e-cigarettes has significantly increased. This article aims at reporting our series and reviewing the literature to propose a new classification based on the mechanisms of injuries related to e-cigarettes that can guide non-specialists and specialists in the management of these patients. Method We performed a retrospective review of our institutional burn database from June 2016 to July 2017 for injuries caused by or in the context of using an e-cigarette. The patients' demographics (age, gender), burn injury mechanisms, depth, localization, surface and interventions were described. Results Ten patients suffered from burns related to the use of e-cigarettes. The burns were located at the thigh (80%) and the hand (50%) with a mean surface of 3% of TBSA. Four different mechanisms could be described: Type A: thermal burns with flames due to the phenomenon of "thermal runaway", Type B: blasts lesions secondary to the explosion, Type C: chemical alkali burns caused by spreading of the electrolyte solution and Type D: thermal burns without flames due to overheating. These different mechanisms suggest specific surgical and non-surgical management. Conclusion Management of injuries sustained from e-cigarettes' explosions should be approached from the standpoint of mechanisms. Different mechanisms could be associated and should be considered in specific management.