Evaluation of Clinical and Biomechanical Features of Scars Resulting from the Treatment of Burn Contractures Comparing Acellular Dermal Matrices: A Randomized Clinical Trial.

OBJECTIVE: The aim of this study was to compare clinical and biomechanical features of scars resulting from the treatment of burn contractures using different acellular dermal matrices (ADM). SUMMARY BACKGROUND DATA: Extensive burns often lead to severe sequelae, such as skin contractures, that can be treated using ADM to improve the quality of these scars. METHODS: A prospective, randomized and controlled clinical trial was performed including patients with burn contractures at least 1-year post-burn, treated using split-thickness skin graft (STSG). These patients were randomized into 4 groups: control (received only STSG without ADM), Integra (ADM + STSG), Matriderm (ADM + STSG), and Pelnac (ADM + STSG). Exclusion criteria were loss of follow-up and graft integration failure. The evaluation was performed using the Vancouver Scar Scale (VSS), the durom-eter, and the cutometer in areas of normal skin, hypertrophic scar, and surgical scar, at least 1 year after the surgery. RESULTS: In the VSS, durometer, and cutometer evaluation, there was no difference in the comparison of surgical scars among groups. Analyzing each group, with an intraindividual evaluation comparing areas of normal skin with surgical scars, the results suggested a possibility of a surgical scar hardness closer to normal skin for Integra and Matriderm groups measured with the durometer. In the cutometer evaluation, surgical scars were not comparable to areas of normal skin. CONCLUSIONS: This study suggests that there is no difference in the quality of scar assessed through the analysis of clinical and biomechanical features comparing acellular dermal matrices (Integra, Matriderm, and Pelnac) and only split-thickness skin graft without a dermal matrix.

Polar mutagenesis of polycistronic bacterial transcriptional units using Cas12a.

BACKGROUND: Functionally related genes in bacteria are often organized and transcribed as polycistronic transcriptional units. Examples are the fim operon, which codes for biogenesis of type 1 fimbriae in Escherichia coli, and the atp operon, which codes for the FoF1 ATP synthase. We tested the hypothesis that markerless polar mutations could be efficiently engineered using CRISPR/Cas12a in these loci. RESULTS: Cas12a-mediated engineering of a terminator sequence inside the fimA gene occurred with efficiencies between 10 and 80% and depended on the terminator's sequence, whilst other types of mutations, such as a 97 bp deletion, occurred with 100% efficiency. Polar mutations using a terminator sequence were also engineered in the atp locus, which induced its transcriptional shutdown and produced identical phenotypes as a deletion of the whole atp locus (ΔatpIBEFHAGDC). Measuring the expression levels in the fim and atp loci showed that many supposedly non-polar mutants induced a significant polar effect on downstream genes. Finally, we also showed that transcriptional shutdown or deletion of the atp locus induces elevated levels of intracellular ATP during the exponential growth phase. CONCLUSIONS: We conclude that Cas12a-mediated mutagenesis is an efficient simple system to generate polar mutants in E. coli. Different mutations were induced with varying degrees of efficiency, and we confirmed that all these mutations abolished the functions encoded in the fim and atp loci. We also conclude that it is difficult to predict which mutagenesis strategy will induce a polar effect in genes downstream of the mutation site. Furthermore the strategies described here can be used to manipulate the metabolism of E. coli as showcased by the increase in intracellular ATP in the markerless ΔatpIBEFHAGDC mutant.

Evaluation of contraction of the split-thickness skin graft using three dermal matrices in the treatment of burn contractures: A randomised clinical trial.

Burn injuries commonly result in serious sequelae (such as skin contractures) in surviving patients, for which no single optimal solution is known. The goal of this study was to compare the late contraction of autologous skin grafts with or without dermal matrices used in the treatment of patients with burn contractures. This parallel design prospective, randomised and controlled clinical trial included patients with burn contracture treated using autologous skin grafts and dermal matrix. Patients were randomly assigned to one of the four groups: Integra® matrix (n = 10), Pelnac® matrix (n = 10), Matriderm® matrix (n = 9) or a Control Group (n = 10, without dermal matrix, only skin graft). The boundaries of skin defect were marked and transferred to a flat sterile surface for area measurement. The current area of the skin grafts was measured during surgery and compared with those obtained at 1, 3, 6 and 12 months postoperatively. Twelve months after surgery, the Control Group presented lower rates of skin graft contraction than Integra® (p < 0.01), Matriderm® (p = 0.01) and Pelnac® (p < 0.01) groups. Pelnac® resulted in larger skin graft contraction than Matriderm® (p < 0.01) and Integra® (p = 0.02), while differences between Integra® and Matriderm® were not significant (p = 0.16). The comparison between intraoperative and 12 months after surgery showed that the worst mean rates of skin graft contraction were from the Pelnac® (51.79%) and Matriderm® (59.17%). In patients with burn contractures, the use of these three dermal matrices did not reduce or avoid the occurrence of late contraction of the skin graft, so their use for this purpose should be carefully evaluated.

Heart transplantation at the Peruvian National Heart Institute: One-decade single-center experience.

BACKGROUND: Heart transplantations are ideal for most patients with end-stage heart failure refractory to medical treatment. The transplantation program at the Peruvian National Heart Institute started with a 10-year continuity in 2010. OBJECTIVE: To compare our 10-year heart transplantation experience results with international standards and reflect on our Transplant Program. METHODS: We studied 83 patients who underwent orthotopic heart transplantation at a single center between January 2010 and December 2019. The recipients' profiles and survival rates were analyzed according to sex and age group, ensuring the information's confidentiality. RESULTS: The recipients' mean age was 41.2 ± 17 years, 88% were adults, and 68.7% were male. The main indications for transplantation were idiopathic dilated cardiomyopathy. 85.5% of recipients were clinically categorized as INTERMACS profiles 1-3 before transplantation. There was a significant difference between sexes regarding the preoperative left ventricular ejection fraction and between age groups regarding the waiting time. The average ischemia time was 3.1 h, operating time was 6.1 h, cardiopulmonary bypass time was 3 h, and aortic cross-clamp time was 1.7 h. The principal early postoperative complications were hematological disorders and acute kidney failure. The principal late ones were kidney failure and severe anemia. The postoperative mortality was 15.9%, and the principal causes were infection and then acute rejection. The survival at 1, 5, and 10 years was 87.5%, 79.8%, and 79.8%, respectively. The survival results were not influenced by sex or age group. CONCLUSION: Our patients' postoperative complications, mortality, and survival rates coincided with those reported by the ISHLT registry.

Critical Analysis of Hypothesis Tests in Federal Information Processing Standard (140-2).

This work presents an analysis of the existing dependencies between the tests of the FIPS 140-2 battery. Two main analytical approaches are utilized, the first being a study of correlations through the Pearson's correlation coefficient that detects linear dependencies, and the second one being a novel application of the mutual information measure that allows detecting possible non-linear relationships. In order to carry out this study, the FIPS 140-2 battery is reimplemented to allow the user to obtain p-values and statistics that are essential for more rigorous end-user analysis of random number generators (RNG).

Analysis of biofilm formation by Sporothrix schenckii.

The development of mature biofilms is an aid in numerous aspects of the life cycle of fungi. It is well known that Sporothrix schenckii complex causes a benign subcutaneous mycosis, but recent studies have suggestedthat biofilm formation may be one of the important factors involved in its virulence. Here we report the study of the biomass organization and a model of the stages of S. schenckii biofilm development: adsorption, active adhesion, microcolony formation, maturation, and dispersal of biofilm fragments. During the development, the biofilm is surrounded by extracellular matrix, which contains glycoprotein (mannose rich), carbohydrates, lipids, and nucleic acid. In addition, the extracellular DNA increases in extracellular matrix as a key component to structural integrity and antifungal resistance. The study of S. schenckii biofilm contributes to a better understanding of growth biofilm and physiology, adding new insights into the mechanisms of virulence and persistence of pathogenic microorganisms.

Treating complex palmar-plantar wounds using a bilaminar 'trapdoor' technique: a case series.

OBJECTIVE: Due to the similarities of glabrous skin, the plantar region is an excellent donor area for covering complex palmar-plantar wounds. However, taking grafts from the plantar area often results in significant morbidity at the donor site or non-integration of the graft due to the greater thickness of the plantar corneal layer. METHOD: This is a prospective case series including patients with burns or wounds who have been treated with a dermal graft using the bilaminar 'trapdoor' technique. This procedure is used to remove a thin graft from the deep plantar dermis after the partial elevation of the first layer including the entire epidermis and superficial part of the dermis. RESULTS: At the donor area in the four patients in this case series, we observed healing at around 10 days, and absence of hypertrophic scar in all patients. There was complete re-epithelialisation between two and three weeks from the periphery to the centre of the deep dermal graft, and from the glandular epithelium transferred with the graft. During the follow-up, patients presented aesthetic and functional features of glabrous and amelanotic skin, with similar resistance to those of the adjacent areas of the wound in the palmar-plantar region. CONCLUSION: This technique has some advantages, such as less surgical time, minimal morbidity in the plantar donor area, easy integration of the grafts, and maintenance of the functional and aesthetic properties of glabrous skin both in the plantar donor area and in the palmar-plantar recipient region. DECLARATION OF INTEREST: The authors have no conflicts of interest to declare.

Venezuela's public health crisis: a regional emergency.

The economic crisis in Venezuela has eroded the country's health-care infrastructure and threatened the public health of its people. Shortages in medications, health supplies, interruptions of basic utilities at health-care facilities, and the emigration of health-care workers have led to a progressive decline in the operational capacity of health care. The effect of the crisis on public health has been difficult to quantify since the Venezuelan Ministry of Health stopped publishing crucial public health statistics in 2016. We prepared a synthesis of health information, beyond what is available from other sources, and scholarly discussion of engagement strategies for the international community. Data were identified through searches in MEDLINE, PubMed, and the grey literature, through references from relevant articles, and governmental and non-governmental reports, and publicly available databases. Articles published in English and Spanish until Dec 1, 2018, were included. Over the past decade, public health measures in Venezuela have substantially declined. From 2012 to 2016, infant deaths increased by 63% and maternal mortality more than doubled. Since 2016, outbreaks of the vaccine-preventable diseases measles and diphtheria have spread throughout the region. From 2016 to 2017, Venezuela had the largest rate of increase of malaria in the world, and in 2015, tuberculosis rates were the highest in the country in 40 years. Between 2017 and 2018, most patients who were infected with HIV interrupted therapy because of a lack of medications. The Venezuelan economic crisis has shattered the health-care system and resulted in rising morbidity and mortality. Outbreaks and expanding epidemics of infectious diseases associated with declines in basic public health services are threatening the health of the country and the region.

Investigating the utility of Google trends for Zika and Chikungunya surveillance in Venezuela.

INTRODUCTION: Chikungunya and Zika Virus are vector-borne diseases responsible for a substantial disease burden in the Americas. Between 2013 and 2016, no cases of Chikungunya or Zika Virus were reported by the Venezuelan Ministry of Health. However, peaks of undiagnosed fever cases have been observed during the same period. In the context of scarce data, alternative surveillance methods are needed. Assuming that unusual peaks of acute fever cases correspond to the incidences of both diseases, this study aims to evaluate the use of Google Trends as an indicator of the epidemic behavior of Chikungunya and Zika. METHODS: Time-series cross-correlations of acute fever cases reported by the Venezuelan Ministry of Health and data on Google search queries related to Chikungunya and Zika were calculated. RESULTS: A temporal distinction has been made so that acute febrile cases occurring between 25th of June 2014 and 23rd of April 2015 were attributed to the Chikungunya virus, while cases occurring between 30th of April 2015 and 29th of April 2016 were ascribed to the Zika virus. The highest cross-correlations for each disease were shown at a lag of 0 (r = 0.784) for Chikungunya and at + 1 (r = 0.754) for Zika. CONCLUSION: The strong positive correlation between Google search queries and official data on acute febrile cases suggests that this resource can be used as an indicator of endemic urban arboviruses activity. In the Venezuelan context, Internet search queries might help to overcome some of the gaps that exist in the national surveillance system.

Resurgence of Vaccine-Preventable Diseases in Venezuela as a Regional Public Health Threat in the Americas.

Venezuela's tumbling economy and authoritarian rule have precipitated an unprecedented humanitarian crisis. Hyperinflation rates now exceed 45,000%, and Venezuela's health system is in free fall. The country is experiencing a massive exodus of biomedical scientists and qualified healthcare professionals. Reemergence of arthropod-borne and vaccine-preventable diseases has sparked serious epidemics that also affect neighboring countries. In this article, we discuss the ongoing epidemics of measles and diphtheria in Venezuela and their disproportionate impact on indigenous populations. We also discuss the potential for reemergence of poliomyelitis and conclude that action to halt the spread of vaccine-preventable diseases within Venezuela is a matter of urgency for the country and the region. We further provide specific recommendations for addressing this crisis.

Role of Arf-like proteins (Arl1 and Arl2) of Mucor circinelloides in virulence and antifungal susceptibility.

Mucor circinelloides is an etiologic agent of mucormycosis, a fungal infection produced by Mucorales often associated with mortality due to unavailability of antifungal drugs. Arl proteins belong to the Arf family and are involved in vesicle trafficking and tubulin assembly. This study identified two Arl (Arf-like)-encoding genes, arl1 and arl2, in M. circinelloides and explored their function in morphogenesis, virulence, and antifungal susceptibility. Although Arl1 and Arl2 proteins shared 55% amino acid sequence identity, arl1 and arl2 genes showed distinct transcriptional expression patterns. arl1 was expressed at higher levels than arl2 and induced in mycelia, suggesting a role in morphological transitions. Disruption of the arl1 and arl2 genes led to heterokaryon (Δarl1(+)(-)) and homokaryon (Δarl2) genotypes, respectively. The incapacity to generate homokaryon mutants for arl1 suggested that it is essential for growth of M. circinelloides. Deletion of each gene reduced the expression of the other, suggesting the existence of a positive cross-regulation between them. Thus, deletion of arl2 resulted in a ~60% reduction of arl1 expression, whereas the Δarl1(+)(-) showed ∼90% reduction of arl1 expression. Mutation of arl2 showed no phenotype or a mild phenotype between Δarl1(+)(-) and wild-type (WT), suggesting that all observed phenotypes in both mutant strains corresponded to arl1 low expression. The Δarl1(+)(-) produced a small amount of spores that showed increased sensitivity to dodecyl-sulfate and azoles, suggesting a defect in the cell wall that was further supported by decrease in saccharide content. These defects in the cell wall were possibly originated by abnormal vesicle trafficking since FM4-64 staining of both mutants Δarl1(+)(-) and Δarl2 revealed less well-localized endosomes compared to the WT. Moreover, aberrant vesicle trafficking may be responsible for the secretion of specific virulence-related proteins since cell-free medium from Δarl1(+)(-) were found to increase killing of Caenorhabditis elegans compared to WT.

Acute otitis externa because of negative pressure wound therapy applied over the head and ear canal for scalping treatment.

Scalping is considered a complex wound with difficult treatment, requiring early surgical intervention, reconstructive plastic surgery, and a multidisciplinary team. The reconstruction of the scalp frequently requires a combination of therapies, including temporary coverage, such as negative pressure wound therapy (NPWT). Complications of NPWT, such as bleeding, infection, and pain, have been described. However, there is no report of acute otitis externa (AOE) because of NPWT. In this article, we present an unprecedented clinical case - a female patient who developed AOE after scalping treatment with NPWT applied over the head and ear canal. We consider that it may be a result of the direct physical action of subatmospheric pressure, the presence of dressing covering the external meatus, and alteration of the bacterial population.

Digital Image Tamper Detection Technique Based on Spectrum Analysis of CFA Artifacts.

Existence of mobile devices with high performance cameras and powerful image processing applications eases the alteration of digital images for malicious purposes. This work presents a new approach to detect digital image tamper detection technique based on CFA artifacts arising from the differences in the distribution of acquired and interpolated pixels. The experimental evidence supports the capabilities of the proposed method for detecting a broad range of manipulations, e.g., copy-move, resizing, rotation, filtering and colorization. This technique exhibits tampered areas by computing the probability of each pixel of being interpolated and then applying the DCT on small blocks of the probability map. The value of the coefficient for the highest frequency on each block is used to decide whether the analyzed region has been tampered or not. The results shown here were obtained from tests made on a publicly available dataset of tampered images for forensic analysis. Affected zones are clearly highlighted if the method detects CFA inconsistencies. The analysis can be considered successful if the modified zone, or an important part of it, is accurately detected. By analizing a publicly available dataset with images modified with different methods we reach an 86% of accuracy, which provides a good result for a method that does not require previous training.

Digital Images Authentication Technique Based on DWT, DCT and Local Binary Patterns.

In the last few years, the world has witnessed a ground-breaking growth in the use of digital images and their applications in the modern society. In addition, image editing applications have downplayed the modification of digital photos and this compromises the authenticity and veracity of a digital image. These applications allow for tampering the content of the image without leaving visible traces. In addition to this, the easiness of distributing information through the Internet has caused society to accept everything it sees as true without questioning its integrity. This paper proposes a digital image authentication technique that combines the analysis of local texture patterns with the discrete wavelet transform and the discrete cosine transform to extract features from each of the blocks of an image. Subsequently, it uses a vector support machine to create a model that allows verification of the authenticity of the image. Experiments were performed with falsified images from public databases widely used in the literature that demonstrate the efficiency of the proposed method.

Nasal Skin Necrosis: An Unexpected New Finding in Severe Chikungunya Fever.

Three adult Venezuelan patients with virologically confirmed Chikungunya fever, who developed extensive acute nasal skin necrosis early in the course of a life-threatening illness characterized by shock and multiple organ dysfunction syndrome, are discussed. One patient survived and fully recovered. Nasal necrosis has not previously been associated with the disease.

Assessing the extent and nature of wildlife trade on the dark web.

Use of the internet as a trade platform has resulted in a shift in the illegal wildlife trade. Increased scrutiny of illegal wildlife trade has led to concerns that online trade of wildlife will move onto the dark web. To provide a baseline of illegal wildlife trade on the dark web, we downloaded and archived 9852 items (individual posts) from the dark web, then searched these based on a list of 121 keywords associated with illegal online wildlife trade, including 30 keywords associated with illegally traded elephant ivory on the surface web. Results were compared with items known to be illegally traded on the dark web, specifically cannabis, cocaine, and heroin, to compare the extent of the trade. Of these 121 keywords, 4 resulted in hits, of which only one was potentially linked to illegal wildlife trade. This sole case was the sale and discussion of Echinopsis pachanoi (San Pedro cactus), which has hallucinogenic properties. This negligible level of activity related to the illegal trade of wildlife on the dark web relative to the open and increasing trade on the surface web may indicate a lack of successful enforcement against illegal wildlife trade on the surface web.

Isolation of the GFA1 gene encoding glucosamine-6-phosphate synthase of Sporothrix schenckii and its expression in Saccharomyces cerevisiae.

Glucosamine-6-phosphate synthase (GlcN-6-P synthase) is an essential enzyme involved in cell wall biogenesis that has been proposed as a strategic target for antifungal chemotherapy. Here we describe the cloning and functional characterization of Sporothrix schenckii GFA1 gene which was isolated from a genomic library of the fungus. The gene encodes a predicted protein of 708 amino acids that is homologous to GlcN-6-P synthases from other sources. The recombinant enzyme restored glucosamine prototrophy of the Saccharomyces cerevisiae gfa1 null mutant. Purification and biochemical analysis of the recombinant enzyme revealed some differences from the wild type enzyme, such as improved stability and less sensitivity to UDP-GlcNAc. The sensitivity of the recombinant enzyme to the selective inhibitor FMDP [N(3)-(4-methoxyfumaroyl)-l-2,3-diaminopropanoic acid] and other properties were similar to those previously reported for the wild type enzyme.

Amniotic fluid pulmonary embolism and COVID-19: Case report.

Amniotic fluid embolism is a rare complication of peripartum. It is caused by the entry of fetal components into the maternal systemic circulation. There are 2 main types: typical; it presents with the triad of hemodynamic collapse, respiratory distress and disseminated intravascular coagulation type coagulopathy, while atypical; disseminated intravascular coagulation does not occur. SARS CoV-2 infection causes coagulopathy due to the alteration of Virchow's triad and coagulation factors. We present the case of a 21-year-old pregnant woman who consulted for premature rupture of membranes, with an indication for cesarean section, and during surgery presented bradycardia, hypotension, and desaturation until cardiorespiratory arrest. An angiotomography showed amniotic fluid embolism associated with pulmonary edema, ruling out differential diagnoses associated with the disease, leaving as the only cause of the infection confirmed by COVID-19, which, it was inferred, was closely related to the immunological disorder suffered by the patient.

Ten years follow-up of the largest oral Chagas disease outbreak: Cardiological prospective cohort study.

BACKGROUND: Chagas disease (ChD) is the most important endemy in Latin America. Some patients, develop chronic Chagasic cardiopathy (CCC) years after the acute phase. It is unknown if patients infected by the oral route have higher risk of developing early CCC. METHODS AND FINDINGS: A prospective cohort study was conducted to assess morbidity and mortality during 10 years observation in 106 people simultaneously infected and treated in the largest known orally transmitted ChD outbreak in 2007. A preschooler died during the acute phase, but thereafter was no mortality associated to ChD. All acute phase findings improved in the first-year post-treatment. Each person was evaluated 8.7 times clinically, 6.4 by electrocardiogram (ECG)/Holter, and 1.7 by echocardiogram. Based on prevalence, the number of people who had any abnormalities (excluding repolarization abnormalities and atrial tachycardia which decreased) was higher than 2007, since they were found at least once between 2008-2017. However, when we evaluated incidence, except for clinical bradycardia and dizziness, it was observed that the number of new cases of all clinical and ECG findings decreased at the end of the follow-up. Between 2008-2017 there was not incidence of low voltage complex, 2nd degree AV block, long QT interval, left bundle branch block or left ventricular dysfunction that allowed the diagnosis of CCC. Total improvement prevailed over the persistence of all clinical and ECG/Holter findings, except for sinus bradycardia. Incomplete right bundle branch block, sinus bradycardia and/or T-wave inversion were diagnosed persistently in 9 children. The second treatment did not have significant influence on the incidence of clinical or ECG/Holter findings. CONCLUSIONS: At the end of the 10-year follow-up, there were not clinical or ECG/Holter criteria for classifying patients with CCC. The incidence of arrhythmias and repolarization abnormalities decreased. However, special attention should be paid on findings that not revert as sinus bradycardia, or those diagnosed persistently in all ECG as sinus bradycardia, incomplete right bundle branch block or T-wave inversion. Early diagnosis and treatment may have contributed to the rapid improvement of these patients. In ChD follow-up studies prevalence overestimates the real dimension of abnormalities, the incidence looks as a better indicator.