PRECISE Scale: a quantitative classification for androgenetic alopecia and its application to hair transplantation.

BACKGROUND: Androgenetic alopecia (AGA) is a prevalent genetic condition that can affect both male and female, and is considered the most frequent form of hair loss. Traditional scales and methods of classifying AGA are basically qualitative. OBJECTIVE: This work aims to propose a quantitative scale to classify AGA in order to assist hair transplantation surgery. METHODS: Based on whole hairless and thinning areas that needs to receive follicular units in a hair transplantation procedure, basic equations to support the scale are proposed. Additionally, the study involves simulations that apply the classification system and compare its results with those of qualitative methods. RESULTS: The PRECISE scale utilizes a range of 0-10, using 30 cm2 as the measured standard of a bald area. For hair transplantation, 1500 follicular units (FU) are recommended for each score in the PRECISE scale. Technological and manual methods to measure the hairless and thinning areas are presented and discussed. This new quantitative classification, combined with different and complementary methods of measurement of hairless and thinning areas endorse the understanding of the clinical condition by the patient and the planning of a surgery procedure. CONCLUSION: The developed PRECISE scale brings a different way of classifying Androgenetic alopecia (AGA), through an essentially quantitative evaluation. It can be used to elaborate the best strategy for the hair transplantation surgery and to improve the outcomes. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

CD154-expressing CMV-specific T cells associate with freedom from DNAemia and may be protective in seronegative recipients after liver or intestine transplantation.

Cell-mediated immunity to CMV, if known, could improve antiviral drug therapy in at-risk children and young adults with LT and IT. Host immunity has been measured with CMV-specific T cells, which express IFNγ, but not those which express CD154, a possible substitute for IFNγ. CMV-specific CD154+ T cells and their subsets were measured with flow cytometry after stimulating PBL from recipient blood samples with an overlapping peptide mix of CMV-pp65 antigen for up to 6 hours. CMV-specific CD154+ T cells co-expressed IFNγ in PBL from three healthy adults and averaged 3.8% (95% CI 3.2%-4.4%) in 40 healthy adults. CMV-specific T cells were significantly lower in 19 CMV DNAemic LT or IT recipients, compared with 126 non-DNAemic recipients, 1.3% (95% CI 0.8-1.7) vs 4.1 (95% CI 3.6-4.6, P < .001). All T-cell subsets demonstrated similar between-group differences. In logistic regression analysis of 46 training set samples, 12 with DNAemia, all obtained between days 0 and 60 from transplant, CMV-specific T-cell frequencies ≥1.7% predicted freedom from DNAemia with NPV of 93%. Sensitivity, specificity, and PPV were 83%, 74%, and 53%, respectively. Test performance was replicated in 99 validation samples. In 32 of 46 training set samples, all from seronegative recipients, one of 19 recipients with CMV-specific T-cell frequencies ≥1.7% experienced DNAemia, compared with 8 of 13 recipients with frequencies <1.7% (P = .001). CMV-specific CD154+ T cells are associated with freedom from DNAemia after LT and IT. Among seronegative recipients, CMV-specific T cells may protect against the development of CMV DNAemia.

Impaired Cellular and Antibody immunity after COVID-19 in Chronically Immunosuppressed Transplant Recipients.

Assessment of cellular immunity to the SARS-CoV-2 coronavirus is of great interest in chronically immunosuppressed transplant recipients (Tr), who are predisposed to infections and vaccination failures. We evaluated CD154-expressing T-cells induced by spike (S) antigenic peptides in 204 subjects-103 COVID-19 patients and 101 healthy unexposed subjects. S-reactive CD154+T-cell frequencies were a) higher in 42 healthy unexposed Tr who were sampled pre-pandemic, compared with healthy NT (p=0.02), b) lower in Tr COVID-19 patients compared with healthy Tr (p<0.0001) and were accompanied by lower S-reactive B-cell frequencies (p<0.05), c) lower in Tr with severe COVID-19 (p<0.0001), or COVID-19 requiring hospitalization (p<0.05), compared with healthy Tr. Among Tr with COVID-19, cytomegalovirus co-infection occurred in 34%; further, incidence of anti-receptor-binding-domain IgG (p=0.011) was lower compared with NT COVID-19 patients. Healthy unexposed Tr exhibit pre-existing T-cell immunity to SARS-CoV-2. COVID-19 impairs anti-S T-cell and antibody and predisposes to CMV co-infection in transplant recipients.

Impaired T-cell and antibody immunity after COVID-19 infection in chronically immunosuppressed transplant recipients.

Assessment of T-cell immunity to the COVID-19 coronavirus requires reliable assays and is of great interest, given the uncertain longevity of the antibody response. Some recent reports have used immunodominant spike (S) antigenic peptides and anti-CD28 co-stimulation in varying combinations to assess T-cell immunity to SARS-CoV-2. These assays may cause T-cell hyperstimulation and could overestimate antiviral immunity in chronically immunosuppressed transplant recipients, who are predisposed to infections and vaccination failures. Here, we evaluate CD154-expressing T-cells induced by unselected S antigenic peptides in 204 subjects-103 COVID-19 patients and 101 healthy unexposed subjects. Subjects included 72 transplanted and 130 non-transplanted subjects. S-reactive CD154+T-cells co-express and can thus substitute for IFNγ (n=3). Assay reproducibility in a variety of conditions was acceptable with coefficient of variation of 2-10.6%. S-reactive CD154+T-cell frequencies were a) higher in 42 healthy unexposed transplant recipients who were sampled pre-pandemic, compared with 59 healthy non-transplanted subjects (p=0.02), b) lower in Tr COVID-19 patients compared with healthy transplant patients (p<0.0001), c) lower in Tr patients with severe COVID-19 (p<0.0001), or COVID-19 requiring hospitalization (p<0.05), compared with healthy Tr recipients. S-reactive T-cells were not significantly different between the various COVID-19 disease categories in NT recipients. Among transplant recipients with COVID-19, cytomegalovirus co-infection occurred in 34%; further, CMV-specific T-cells (p<0.001) and incidence of anti-receptor-binding-domain IgG (p=0.011) were lower compared with non-transplanted COVID-19 patients. Healthy unexposed transplant recipients exhibit pre-existing T-cell immunity to SARS-CoV-2. COVID-19 infection leads to impaired T-cell and antibody responses to SARS-CoV-2 and increased risk of CMV co-infection in transplant recipients.

Use of Implanters in Premade Recipient Sites for Hair Transplantation.

BACKGROUND: Techniques of hair transplantation are evolving with time both in terms of use of better methods of graft harvestment and implantation. The result of the procedure ultimately depends on the tenderness with which grafts are handled. AIMS: The aim of this study was to evaluate efficacy and feasibility of using implanter in premade slits for implantation of the graft. MATERIALS AND METHODS: This technique was used in 104 patients who were willing to undergo hair transplantation by follicular unit extraction. After administration of local anesthesia, the recipient sites were created. Thereafter, the processes of scoring the skin with a motorized punch, graft extraction, and implantation using implanter into the premade slits were performed simultaneously. These patients were followed up to look for the time period of initiation of hair growth. Improvement was assessed by comparing basic and specific classification (BASP) at the baseline and during subsequent follow-up. RESULTS: Of 104 patients, 103 (99%) were men and one (1%) was woman. According to pretransplant BASP score, 98 (94.2%) patients were having severe type and 6 (5.8%) were having mild type. As per the posttransplant BASP score, patients having severe and mild type were 24 and 80, respectively. Improvement in the BASP score (from severe to mild type) was seen in 74 (71%) patients and no change was seen in 30 (29%) patients. Hair growth started becoming visible after two to five months and "good" results were obtained in all except two patients after a follow-up period varying from 8 to 18 months. CONCLUSION: Placement of the grafts into premade slits using implanter will help in improved results because of minimal graft handling, more graft placement in less time, and thereby reducing body out of time. LIMITATION: No objective assessment was carried out to document regrowth of hair in our study.

Direct hair transplantation: a modified follicular unit extraction technique.

BACKGROUND: In hair transplantation, the survival rate of harvested grafts depends upon many factors like maintenance of hydration, cold temperature, reduced mechanical handling and asepsis. All these factors are favourably improved if time out of body is reduced significantly. We have tried a modification called direct hair transplantation in the existing follicular unit extraction technique, in which the follicular unit grafts are implanted as soon as they are harvested. In this article, we have described the detailed methodology and a series of 29 patients who underwent direct hair transplantation. AIM: To evaluate the efficacy and feasibility of direct hair transplantation. SUBJECTS AND METHODS: The patients willing to undergo hair transplantation by the technique of follicular unit extraction were enrolled for the surgery. After administration of local anaesthesia, the recipient sites were created. Thereafter, the processes of scoring the skin with a motorized punch, graft extraction and implantation were performed simultaneously. These patients were followed up to look for the time period of initiation of hair growth, the growth achieved at the end of 6-8 months and any adverse events. The results of patients with noticeable improvement in the photographs and reduction in baldness grade were taken as 'good', whereas, in other patients, it was classified as 'poor'. RESULTS: All patients were males with age ranging from 21 to 66 years (median 30 years). Twenty-six patients had androgenetic alopecia, 1 patient had traction alopecia and 2 patients had scarring alopecia. Twenty-seven patients showed 'good' results, whereas 2 patients showed 'poor' results. CONCLUSION: Direct hair transplantation is a simple and feasible modification in the follicular unit extraction technique. It is an efficacious surgical treatment modality for baldness.