One-stage reconstruction of the massive overlying skin and Achilles tendon defects using a free chimeric anterolateral thigh flap with fascia lata.

BACKGROUND: Treatment for large defects in the non-weight-bearing Achilles tendon and soft tissues remains a reconstructive challenge. The free composite anterolateral thigh flap (ALT) with fascia lata (FL) has been indicated in the single-stage reconstruction of the Achilles tendon and soft tissue defect and this technique remain some disadvantages, such as the inability to perform primary flap thinning, requiring secondary flap thinning, and the delayed normalization of the range of motion of the ankle joint. The free chimeric ALT flap with FL was introduced as a novel alternative with many advantages in reconstructing the Achilles tendon and soft tissue defects. This paper reports the reconstruction of the massive Achilles tendon and overlying skin defects using free chimeric ALT flaps with FL. METHODS: From June 2017 to October 2020, we performed on a series of 5 patients receiving free chimeric ALT flaps with FL to reconstruct the Achilles tendon and soft tissue defects. The age of patients ranged from 43 to 62 years old. All five patients had full-layer defects of the Achilles tendon with infection. The sizes of the skin defects ranged from 6 × 4 cm to 12 × 10 cm. The perforators from the descending branch of the lateral circumflex femoral arteries are located using a handheld Doppler. The perforators help to design the outline of the ALT flap and fascia flap. The skin flap was thinned under microscopy if the flap was too thick. The anastomosis was accomplished before insetting the flaps into the defect. RESULTS: The size of the ALT flap ranged from 10 × 5 cm to 15 × 12 cm, and the size of the FL flap ranged from 7 × 4 cm to 10 × 8 cm. The mean perforator length for the skin flap and fascia lata was 3.3 cm (range, 2.5-5.0 cm) and 5.3 cm (range, 3.5-7.0 cm), respectively. Four patients received skin flap thinning up to 57%-79% of the flap thickness, while one patient did not need to debulk. The thickness of the ALT flap ranged from 6 to 13 mm. All the flaps survived completely and postoperative courses were uneventful without any complications. The follow-up time ranged from 12 to 51 months. All patients were able to stand and ambulate, and they were satisfied with the reconstructive results. CONCLUSIONS: The free thin chimeric ALT with FL flap is appeared to be an appropriate treatment for the massive Achilles tendon and overlying skin defects. This may be a practical approach to improve the functional outcomes of patients with infected massive Achilles tendon and overlying skin defects.

Plasma cell-free DNA: a potential biomarker for early prediction of severe dengue.

BACKGROUND: Considerable progress has been made in dengue management, however the lack of appropriate predictors of severity has led to huge number of unwanted admissions mostly decided on the grounds of warning signs. Apoptosis related mediators, among others, are known to correlate with severe dengue (SD) although no predictive validity is established. The objective of this study was to investigate the association of plasma cell-free DNA (cfDNA) with SD, and evaluate its prognostic value in SD prediction at acute phase. METHODS: This was a hospital-based prospective cohort study conducted in Vietnam. All the recruited patients were required to be admitted to the hospital and were strictly monitored for various laboratory and clinical parameters (including progression to SD) until discharged. Plasma samples collected during acute phase (6-48 h before defervescence) were used to estimate the level of cfDNA. RESULTS: Of the 61 dengue patients, SD patients (n = 8) developed shock syndrome in 4.8 days (95% CI 3.7-5.4) after the fever onset. Plasma cfDNA levels before the defervescence of SD patients were significantly higher than the non-SD group (p = 0.0493). From the receiver operating characteristic (ROC) curve analysis, a cut-off of > 36.9 ng/mL was able to predict SD with a good sensitivity (87.5%), specificity (54.7%), and area under the curve (AUC) (0.72, 95% CI 0.55-0.88; p = 0.0493). CONCLUSIONS: Taken together, these findings suggest that cfDNA could serve as a potential prognostic biomarker of SD. Studies with cfDNA kinetics and its combination with other biomarkers and clinical parameters would further improve the diagnostic ability for SD.

Association between dengue severity and plasma levels of dengue-specific IgE and chymase.

There is no definitive predictor of dengue severity, and this has led to a very large number of unnecessary hospitalizations worldwide. Although mast cell mediators are believed to a play role in dengue severity, the lack of precise kinetic data demands further research on early predictors. We enrolled 111 patients with confirmed dengue and 85 with "other febrile illness" (OFI) in a hospital-based prospective study in Vietnam. Dengue patients were classified as level 1, 2, or 3 based on the clinical intervention received. Blood samples were collected from each patient every day (pre- and post-defervescence) and after discharge. Plasma chymase, total IgE, and dengue-specific IgE were measured. Dengue-specific IgE levels showed an increasing trend during the course of illness and remained high even at post-discharge, although no significant difference was observed among severity levels. Total IgE showed no such trend. The specific IgE/total IgE ratio (S/T ratio) remained constantly higher in level 3 patients compared to other levels, with a significant difference at some time points. The S/T ratio of acute phase samples (before defervescence) tended to increase with increasing severity (level 1 < 2 < 3), and was significantly higher in level 3 patients than in level 1 and OFI patients. As an early predictor of severity allowing level 3 patients to be distinguished from other dengue patients, the S/T ratio achieved a sensitivity of 75% and specificity of 68%. We describe the kinetic profiles of IgEs, their ratio, and chymase levels at different severity levels. The S/T ratio was found to be associated with dengue severity, suggesting that it could potentially be used as an early predictor of severity.

Characteristics of Ag-incorporated bioactive glasses prepared by a modified sol-gel method with a shortened synthesis time and without the use of catalysts.

This work presents the preparation of bioactive glasses 70SiO2-(26 - x)CaO-4P2O5-xAg2O (with x = 0, 1, 3, 10 mol%) by a modified sol-gel method with reduced synthesis time based on hydrothermal reaction in a medium without acid or base catalysts. The synthetic materials were characterized by several physical-chemical techniques such as TG-DSC, XRD, SEM, TEM, and N2 adsorption/desorption measurement. The analysis data confirmed that the glass sample not containing Ag has a completely amorphous structure, while glass samples containing Ag exhibited a pure phase of metallic nano-silver in the glass amorphous phase. All the synthetic glasses have mesoporous structures with particle sizes of less than 30 nm. The addition of silver to the bioactive glass structure in general did not drastically reduce the specific surface areas and pore volumes of glasses as in previous studies. The bioactivity of the silver-incorporated glasses did not reduce, and even increased in the cases of bioactive glass containing 3, and 10 mol% of Ag2O. The biocompatibility of synthetic glasses with fibroblast cells (L-929) was confirmed, even with glass containing high amounts of Ag. Representatively, Ag-incorporated glass samples (sample x = 3, and x = 10) were selected to check the antibacterial ability using bacterial strain Pseudomonas aeruginosa ATCC 27853 (Pa). The obtained results indicated that these glasses exhibited good antibacterial ability to Pseudomonas aeruginosa. Thus, the synthetic method in this study proved to be a fast, environmentally friendly technique for synthesizing Ag-incorporated glass systems. The synthesized glasses show good bioactive, biocompatible, and antibacterial properties.

Kinetics of CD4+ T Helper and CD8+ Effector T Cell Responses in Acute Dengue Patients.

Background: The protective or pathogenic role of T lymphocytes during the acute phase of dengue virus (DENV) infection has not been fully understood despite its importance in immunity and vaccine development. Objectives: This study aimed to clarify the kinetics of T lymphocyte subsets during the clinical course of acute dengue patients. Study design: In this hospital-based cohort study, 59 eligible Vietnamese dengue patients were recruited and admitted. They were investigated and monitored for T cell subsets and a panel of clinical and laboratory parameters every day until discharged and at post-discharge from the hospital. Results: We described for the first time the kinetics of T cell response during the clinical course of DENV infection. Severe cases showed significantly lower levels of effector CD8+ T cells compared to mild cases at day -1 (p = 0.017) and day 0 (p = 0.033) of defervescence. After defervescence, these cell counts in severe cases increased rapidly to equalize with the levels of mild cases. Our results also showed a decline in total CD4+ T, Th1, Th1/17 cells during febrile phase of dengue patients compared to normal controls or convalescent phase. On the other hand, Th2 cells increased during DENV infection until convalescent phase. Cytokines such as interferon-γ, IL-12p70, IL-5, IL-23, IL-17A showed tendency to decrease on day 0 and 1 compared with convalescence and only IL-5 showed significance indicating the production during acute phase was not systemic. Conclusion: With a rigorous study design, we uncovered the kinetics of T cells in natural DENV infection. Decreased number of effector CD8+ T cells in the early phase of infection and subsequent increment after defervescence day probably associated with the T cell migration in DENV infection.

Criteria of "persistent vomiting" in the WHO 2009 warning signs for dengue case classification.

INTRODUCTION: Dengue is a viral disease that spreads rapidly in the tropic and subtropic regions of the world and causes 22,000 deaths annually. In 2009, the World Health Organization (WHO) released a new classification of dengue infections, which divided them into three categories: dengue without warning sign (D), dengue with warning sign (DWS), and severe dengue (SD). However, researchers have been using different criteria to define persistent vomiting; therefore, we aimed to evaluate the ability of the number of vomiting times in early prediction of SD development among D/DWS patients. METHOD: A hospital-based cohort study was conducted in Ben Tre-south of Vietnam. We enrolled confirmed dengue patients with D and DWS at admission. The final classification was determined on the discharged day for every patient based on the classification of WHO 2009 without using vomiting symptom, using the receiver operating characteristic (ROC) curve to evaluate the ability of the number of vomiting times in early prediction of SD development among D/DWS patients. RESULT: The prevalence of vomiting symptom was higher in SD group than D/DWS group (92 versus 46 %, p = 0.006), and the median of the number of vomiting times was higher in SD group than D/DWS group (2.5 versus 0, p = 0.001). To distinguish SD from D/DWS, the ROC curve of the number of vomiting episodes showed that the area under the curve was 0.77; with the cut point of two, the sensitivity and specificity were 92 and 52 %, respectively. DISCUSSION: The number of vomiting times could be a good clinical sign which can early predict SD from the group of D/DWS. We suggest the definition of persistent vomiting should be vomiting two times or more per day.

A Proteomic Approach Identifies Candidate Early Biomarkers to Predict Severe Dengue in Children.

BACKGROUND: Severe dengue with severe plasma leakage (SD-SPL) is the most frequent of dengue severe form. Plasma biomarkers for early predictive diagnosis of SD-SPL are required in the primary clinics for the prevention of dengue death. METHODOLOGY: Among 63 confirmed dengue pediatric patients recruited, hospital based longitudinal study detected six SD-SPL and ten dengue with warning sign (DWS). To identify the specific proteins increased or decreased in the SD-SPL plasma obtained 6-48 hours before the shock compared with the DWS, the isobaric tags for relative and absolute quantification (iTRAQ) technology was performed using four patients each group. Validation was undertaken in 6 SD-SPL and 10 DWS patients. PRINCIPAL FINDINGS: Nineteen plasma proteins exhibited significantly different relative concentrations (p<0.05), with five over-expressed and fourteen under-expressed in SD-SPL compared with DWS. The individual protein was classified to either blood coagulation, vascular regulation, cellular transport-related processes or immune response. The immunoblot quantification showed angiotensinogen and antithrombin III significantly increased in SD-SPL whole plasma of early stage compared with DWS subjects. Even using this small number of samples, antithrombin III predicted SD-SPL before shock occurrence with accuracy. CONCLUSION: Proteins identified here may serve as candidate predictive markers to diagnose SD-SPL for timely clinical management. Since the number of subjects are small, so further studies are needed to confirm all these biomarkers.