RESUMO
COVID-19 is a disease caused by the novel Coronavirus SARS-CoV-2 causing an acute respiratory disease that can eventually lead to severe acute respiratory syndrome (SARS). An exacerbated inflammatory response is characteristic of SARS-CoV-2 infection, which leads to a cytokine release syndrome also known as cytokine storm associated with the severity of the disease. Considering the importance of this event in the immunopathology of COVID-19, this study analyses cytokine levels of hospitalized patients to identify cytokine profiles associated with severity and mortality. Using a machine learning approach, 3 clusters of COVID-19 hospitalized patients were created based on their cytokine profile. Significant differences in the mortality rate were found among the clusters, associated to different CXCL10/IL-38 ratio. The balance of a CXCL10 induced inflammation with an appropriate immune regulation mediated by the anti-inflammatory cytokine IL-38 appears to generate the adequate immune context to overrule SARS-CoV-2 infection without creating a harmful inflammatory reaction. This study supports the concept that analyzing a single cytokine is insufficient to determine the outcome of a complex disease such as COVID-19, and different strategies incorporating bioinformatic analyses considering a broader immune profile represent a more robust alternative to predict the outcome of hospitalized patients with SARS-CoV-2 infection.
RESUMO
INTRODUCCIÓN Y OBJETIVO: Los colgajos de perforantes son una técnica de la Cirugía Reconstructiva que utiliza una porción de piel y/o grasa subcutánea vascularizada por uno o varios vasos que perforan un plano profundo (músculo, fascia o tabique), tomada de una zona distante o adyacente, para cerrar y restaurar un área de defecto corporal. Permiten realizar reconstrucciones utilizando estructuras adecuadas sin desvitalizar las áreas donantes. El objetivo de este artículo es describir la experiencia en el cierre y la reconstrucción de heridas traumáticas de antebrazo y mano mediante el uso de colgajos pediculados de vasos perforantes intercostales, específicamente de arterias laterales, dorsolaterales y/o anteriores, como una opción reconstructiva accesible, funcional y estéticamente viable, en países con ingresos medios y bajos en los que se cuenta con un acceso limitado al uso de la Microcirugía en casos de emergencia. MATERIAL Y MÉTODO: Presentamos 3 casos clínicos representativos que ejemplifican el uso de distintos tipos de colgajos de perforantes intercostales como alternativa a la amputación quirúrgica en lesiones extensas de miembro superior, que por su complejidad, comprometen la viabilidad del mismo. Los 3 casos fueron atendidos en uno de los 3 hospitales de referencia de adultos de la Seguridad Social de un país de ingresos medios, Costa Rica, donde no se dispone de acesso habitual a la Microcirugía. RESULTADOS: Los 3 pacientes son varones. Caso 1: de 19 años de edad; fractura expuesta y lesión en antebrazo con compromiso de piel y tejidos blandos a consecuencia de accidente automovilístico; reconstrucción con colgajo LICAP de 32 X 12 cm. Caso 2: de 21 años de edad; trauma importante en codo y mano a consecuencia de accidente de tránsito; reconstrucción con colgajo AICAP izquierdo de 8 X 10 cm y LICAP derecho de 20 X 12 cm. Caso 3: de 32 años de edad; pérdida de la cara anterior del antebrazo derecho por accidente con cristal; intervención vascular y después colgajo LICAP de 30 X 10 cm. En todos los casos se utilizaron colgajos con 2 perforantes y la autonomización se realizó a las 3 semanas de la intervención. Cierre adecuado de las heridas y evolución de los colgajos sin complicaciones con recuperación de funcionalidad. CONCLUSIONES: En realidades donde los recursos sanitarios son limitados y no siempre están disponibles alternativas terapéuticas novedosas, nuestra experiencia, apoyada en los 3 casos descritos, muestra como los colgajos de perforantes intercostales son una alternativa viable en la reconstrucción postraumática de miembros superiores
BACKGROUND AND OBJECTIVE: Perforator flaps are a reconstructive surgery technique that uses a portion of skin and/or subcutaneous fat tissue vascularized by one or more vessels that perforate a deep plane (muscle, fascia or septum), which is removed from a distant or adjacent part to close and restore the excised section. This procedure allows reconstruction using appropriate structures without devitalizing the donor area. The aim of this report is to describe the experience in the closure and reconstruction of traumatic forearm and hand wounds using pedicled flaps of perforating intercostal arteries from lateral, dorsolateral and/or anterior vessels, as an accessible, functional and aesthetically viable option, in low- and middle-income countries where other alternatives such as Microsurgery are not frequently accessible. METHODS: We describe 3 procedures to exemplify reconstruction by using different types of intercostal perforator flaps as an alternative to surgical amputation of extensive traumatic upper limb injuries that, due to complexity, compromise their viability. The selection of cases corresponds to patients attended in one of the 3 referral hospitals of Social Security of a middle-income country, Costa Rica, where Microsurgery is not usually available. RESULTS: All cases corresponded to male patients. Case 1: 19-year-old patient who, after a car accident, presented an exposed fracture and an extensive forearm injury that compromised skin and soft tissue; reconstruction with a 32 X 12 cm LICAP flap. Case 2: 21-year-old patient who, after a traffic accident, presented significant trauma to the elbow and hand; reconstruction with a left 8 X 10 cm AICAP flap and a right 20 X 12 cm LICAP flap. Case 3: 32-year-old patient presenting loss of the anterior aspect of the right forearm after an accident with a glass window; he required prior vascular intervention and was subsequently treated with a 30 X 10 cm LICAP flap. In all cases, flaps with 2 perforators were used and autonomization was performed 3 weeks after the intervention. Likewise, adequate wound closure, flap evolution without complications, and recovery of functionality were recorded. CONCLUSIONS: In scenarios where healthcare resources are limited and the newest therapeutic alternatives are not always available, our experience, supported by the 3 cases described, shows how the use of intercostal perforating flaps constitutes a viable alternative in the reconstruction of upper limbs after trauma, especially in low- and middle-income countries
