Hybrid immunity and protection against infection during the Omicron wave in Malta

By December 2021, administration of the third dose of COVID-19 vaccinations coincided with the spread of the Omicron variant in Europe. Questions had been raised on protection against infection conferred by previous vaccination and/or infection. Our study population included 252,433 participants from the COVID-19 vaccination registry in Malta. Data were then matched with the national testing database. We collected vaccination status, vaccine brand, vaccination date, infection history, and age. Using logistic regression, we examined different combinations of vaccine dose, prior infection status and time, and the odds of infection during the period when the Omicron variant was the dominant variant in Malta. Participants infected with Sars-Cov-2 prior to the Omicron wave had a significantly lower odds of being infected with the Omicron variant. Additionally, the more recent the infection and the more recent the vaccination, the lower the odds of infection. Receiving a third dose within 20 weeks of the start of the Omicron wave in Malta offered similar odds of infection as receiving a second dose within the same period. Time since vaccination was a strong determinant against infection, as was previous infection status and the number of doses taken. This finding reinforces the importance of future booster dose provision especially to vulnerable populations.

Approaches, challenges, and opportunities to strengthen the epidemic intelligence workforce: a scoping review

BACKGROUND

Weak surveillance systems have limited countries' ability to adequately respond to public health emergencies. Strengthening the human workforce in this field is considered an important opportunity to ensure the future response to infectious diseases outbreaks globally. A scoping review of the academic literature and relevant documents was conducted to identify approaches, challenges, and opportunities to strengthen the epidemic intelligence (EI) workforce.

METHODS

Five peer-reviewed databases were systematically searched, as well as Google as a grey literature source. English language articles and documents published between 2014 and 2022 were included. No geographical restrictions were set.

RESULTS

37 articles and 20 documents were included in the review. Professional training, the acknowledgement of including a broad variety of disciplines into the workforce, the inclusion of communities, the pursuit of a One Health approach and the use of digital tools were identified as impeding and/or facilitating the EI workforce. The review shows that the field epidemiology training programme is a prominent approach for strengthening the EI workforce and that little evidence exists on how non-traditional disciplines (e.g., disciplines besides medicine, laboratory science, or epidemiology) contributing to surveillance may support the future EI workforce.

CONCLUSION

The identification of approaches, challenges, and opportunities of EI can inform future policy and practice on strengthening the EI workforce. The conduct of more high-quality studies is needed to guide this process. The potential benefits of integrating a wider range of disciplines than currently found in the surveillance workforce and of involving communities in disease surveillance needs to be further researched.

Vaccine effectiveness against COVID-19 hospitalisation in adults (≥ 20 years) during Omicron-dominant circulation: I-MOVE-COVID-19 and VEBIS SARI VE networks, Europe, 2021 to 2022

IntroductionThe I-MOVE-COVID-19 and VEBIS hospital networks have been measuring COVID-19 vaccine effectiveness (VE) in participating European countries since early 2021.AimWe aimed to measure VE against PCR-confirmed SARS-CoV-2 in patients ≥ 20 years hospitalised with severe acute respiratory infection (SARI) from December 2021 to July 2022 (Omicron-dominant period).MethodsIn both networks, 46 hospitals (13 countries) follow a similar test-negative case-control protocol. We defined complete primary series vaccination (PSV) and first booster dose vaccination as last dose of either vaccine received ≥ 14 days before symptom onset (stratifying first booster into received < 150 and ≥ 150 days after last PSV dose). We measured VE overall, by vaccine category/product, age group and time since first mRNA booster dose, adjusting by site as a fixed effect, and by swab date, age, sex, and presence/absence of at least one commonly collected chronic condition.ResultsWe included 2,779 cases and 2,362 controls. The VE of all vaccine products combined against hospitalisation for laboratory-confirmed SARS-CoV-2 was 43% (95% CI: 29-54) for complete PSV (with last dose received ≥ 150 days before onset), while it was 59% (95% CI: 51-66) after addition of one booster dose. The VE was 85% (95% CI: 78-89), 70% (95% CI: 61-77) and 36% (95% CI: 17-51) for those with onset 14-59 days, 60-119 days and 120-179 days after booster vaccination, respectively.ConclusionsOur results suggest that, during the Omicron period, observed VE against SARI hospitalisation improved with first mRNA booster dose, particularly for those having symptom onset < 120 days after first booster dose.

Vaccine effectiveness against COVID-19 hospitalisation in adults (≥ 20 years) during Alpha- and Delta-dominant circulation: I-MOVE-COVID-19 and VEBIS SARI VE networks, Europe, 2021

IntroductionTwo large multicentre European hospital networks have estimated vaccine effectiveness (VE) against COVID-19 since 2021.AimWe aimed to measure VE against PCR-confirmed SARS-CoV-2 in hospitalised severe acute respiratory illness (SARI) patients ≥ 20 years, combining data from these networks during Alpha (March-June)- and Delta (June-December)-dominant periods, 2021.MethodsForty-six participating hospitals across 14 countries follow a similar generic protocol using the test-negative case-control design. We defined complete primary series vaccination (PSV) as two doses of a two-dose or one of a single-dose vaccine ≥ 14 days before onset.ResultsWe included 1,087 cases (538 controls) and 1,669 cases (1,442 controls) in the Alpha- and Delta-dominant periods, respectively. During the Alpha period, VE against hospitalisation with SARS-CoV2 for complete Comirnaty PSV was 85% (95% CI: 69-92) overall and 75% (95% CI: 42-90) in those aged ≥ 80 years. During the Delta period, among SARI patients ≥ 20 years with symptom onset ≥ 150 days from last PSV dose, VE for complete Comirnaty PSV was 54% (95% CI: 18-74). Among those receiving Comirnaty PSV and mRNA booster (any product) ≥ 150 days after last PSV dose, VE was 91% (95% CI: 57-98). In time-since-vaccination analysis, complete all-product PSV VE was > 90% in those with their last dose < 90 days before onset; ≥ 70% in those 90-179 days before onset.ConclusionsOur results from this EU multi-country hospital setting showed that VE for complete PSV alone was higher in the Alpha- than the Delta-dominant period, and addition of a first booster dose during the latter period increased VE to over 90%.

Liver injury in hospitalized patients with COVID-19: An International observational cohort study

BACKGROUND

Using a large dataset, we evaluated prevalence and severity of alterations in liver enzymes in COVID-19 and association with patient-centred outcomes.

METHODS

We included hospitalized patients with confirmed or suspected SARS-CoV-2 infection from the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) database. Key exposure was baseline liver enzymes (AST, ALT, bilirubin). Patients were assigned Liver Injury Classification score based on 3 components of enzymes at admission: Normal; Stage I) Liver injury: any component between 1-3x upper limit of normal (ULN); Stage II) Severe liver injury: any component ≥3x ULN. Outcomes were hospital mortality, utilization of selected resources, complications, and durations of hospital and ICU stay. Analyses used logistic regression with associations expressed as adjusted odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Of 17,531 included patients, 46.2% (8099) and 8.2% (1430) of patients had stage 1 and 2 liver injury respectively. Compared to normal, stages 1 and 2 were associated with higher odds of mortality (OR 1.53 [1.37-1.71]; OR 2.50 [2.10-2.96]), ICU admission (OR 1.63 [1.48-1.79]; OR 1.90 [1.62-2.23]), and invasive mechanical ventilation (OR 1.43 [1.27-1.70]; OR 1.95 (1.55-2.45). Stages 1 and 2 were also associated with higher odds of developing sepsis (OR 1.38 [1.27-1.50]; OR 1.46 [1.25-1.70]), acute kidney injury (OR 1.13 [1.00-1.27]; OR 1.59 [1.32-1.91]), and acute respiratory distress syndrome (OR 1.38 [1.22-1.55]; OR 1.80 [1.49-2.17]).

CONCLUSIONS

Liver enzyme abnormalities are common among COVID-19 patients and associated with worse outcomes.

Digitalizing and Upgrading Severe Acute Respiratory Infections Surveillance in Malta: System Development

BACKGROUND

In late 2020, the European Centre for Disease Prevention and Control and Epiconcept started implementing a surveillance system for severe acute respiratory infections (SARI) across Europe.

OBJECTIVE

We sought to describe the process of digitizing and upgrading SARI surveillance in Malta, an island country with a centralized health system, during the COVID-19 pandemic from February to November 2021. We described the characteristics of people included in the surveillance system and compared different SARI case definitions, including their advantages and disadvantages. This study also discusses the process, output, and future for SARI and other public health surveillance opportunities.

METHODS

Malta has one main public hospital where, on admission, patient data are entered into electronic records as free text. Symptoms and comorbidities are manually extracted from these records, whereas other data are collected from registers. Collected data are formatted to produce weekly and monthly reports to inform public health actions. From October 2020 to February 2021, we established an analogue incidence-based system for SARI surveillance. From February 2021 onward, we mapped key stakeholders and digitized most surveillance processes.

RESULTS

By November 30, 2021, 903 SARI cases were reported, with 380 (42.1%) positive for SARS-CoV-2. Of all SARI hospitalizations, 69 (7.6%) were admitted to the intensive care unit, 769 (85.2%) were discharged, 27 (3%) are still being treated, and 107 (11.8%) died. Among the 107 patients who died, 96 (89.7%) had more than one underlying condition, the most common of which were hypertension (n=57, 53.3%) and chronic heart disease (n=49, 45.8%).

CONCLUSIONS

The implementation of enhanced SARI surveillance in Malta was completed by the end of May 2021, allowing the monitoring of SARI incidence and patient characteristics. A future shift to register-based surveillance should improve SARI detection through automated processes.

National long COVID impact and risk factors

OBJECTIVE

Our objective was to estimate the prevalence and risk factors for long COVID symptoms among polymerase chain reaction-confirmed COVID-19 patients (hospitalised and community) in Malta.

STUDY DESIGN

This was a national cross-sectional survey among COVID-19 patients in Malta during 2020.

METHODS

Patients were sent a questionnaire 3-6 months after testing positive. Data were analysed descriptively to estimate symptom prevalence, and multivariable logistic regressions were used to determine the risk factors for long COVID symptoms. Age, sex, initial symptoms, hospitalisation, and healthcare worker status were used as risk factors and symptoms (cough, shortness of breath, fatigue, anxiety, sadness, and memory loss) 2.5 months or more after COVID-19 onset were used as outcomes.

RESULTS

Of 8446 eligible participants, 2665 (31.55%) responded with a median age of 37 years. Initial symptoms were reported in 82% of responders, and 7.73% were hospitalised. Among the long COVID symptoms, fatigue persisted among most non-hospitalised responders, whereas anxiety, shortness of breath, and sadness were the most common symptoms. Female sex, hospitalisation, and initial symptoms were associated with higher odds of fatigue, shortness of breath, cough, anxiety, sadness, and memory loss as long COVID symptoms.

CONCLUSIONS

Our study is the first to highlight long COVID symptoms and risk factors in Malta, showing that long COVID is common among hospitalised and non-hospitalised patients. These data should increase awareness of long COVID and facilitate support to those affected nationally.

Symptom-based case definitions for COVID-19: Time and geographical variations for detection at hospital admission among 260,000 patients

Introduction

Case definitions are used to guide clinical practice, surveillance and research protocols. However, how they identify COVID-19-hospitalised patients is not fully understood. We analysed the proportion of hospitalised patients with laboratory-confirmed COVID-19, in the ISARIC prospective cohort study database, meeting widely used case definitions.

Methods

Patients were assessed using the Centers for Disease Control (CDC), European Centre for Disease Prevention and Control (ECDC), World Health Organization (WHO) and UK Health Security Agency (UKHSA) case definitions by age, region and time. Case fatality ratios (CFRs) and symptoms of those who did and who did not meet the case definitions were evaluated. Patients with incomplete data and non-laboratory-confirmed test result were excluded.

Results

A total of 263,218 of the patients (42%) in the ISARIC database were included. Most patients (90.4%) were from Europe and Central Asia. The proportions of patients meeting the case definitions were 56.8% (WHO), 74.4% (UKHSA), 81.6% (ECDC) and 82.3% (CDC). For each case definition, patients at the extremes of age distribution met the criteria less frequently than those aged 30 to 70 years; geographical and time variations were also observed. Estimated CFRs were similar for the patients who met the case definitions. However, when more patients did not meet the case definition, the CFR increased.

Conclusions

The performance of case definitions might be different in different regions and may change over time. Similarly concerning is the fact that older patients often did not meet case definitions, risking delayed medical care. While epidemiologists must balance their analytics with field applicability, ongoing revision of case definitions is necessary to improve patient care through early diagnosis and limit potential nosocomial spread.

ISARIC-COVID-19 dataset: A Prospective, Standardized, Global Dataset of Patients Hospitalized with COVID-19

The International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) COVID-19 dataset is one of the largest international databases of prospectively collected clinical data on people hospitalized with COVID-19. This dataset was compiled during the COVID-19 pandemic by a network of hospitals that collect data using the ISARIC-World Health Organization Clinical Characterization Protocol and data tools. The database includes data from more than 705,000 patients, collected in more than 60 countries and 1,500 centres worldwide. Patient data are available from acute hospital admissions with COVID-19 and outpatient follow-ups. The data include signs and symptoms, pre-existing comorbidities, vital signs, chronic and acute treatments, complications, dates of hospitalization and discharge, mortality, viral strains, vaccination status, and other data. Here, we present the dataset characteristics, explain its architecture and how to gain access, and provide tools to facilitate its use.

Assessment of bovine respiratory disease progression in calves challenged with bovine herpesvirus 1 and Mannheimia haemolytica using point-of-care and laboratory-based blood leukocyte differential assays

Blood leukocyte differentials can be useful for understanding changes associated with bovine respiratory disease (BRD) progression. By improving turnaround time, point-of-care leukocyte differential assays (PCLD) may provide logistical advantages to laboratory-based assays. Our objective was to assess BRD progression in steers challenged with bovine herpesvirus 1 and Mannheimia haemolytica using point-of-care and laboratory-based blood leukocyte differentials. Thirty Holstein steers (average body weight of 211 kg + 2.4 kg) were inoculated intranasally on day 0 with bovine herpesvirus 1 and intrabronchially on day 6 with Mannheimia haemolytica. Blood leukocytes differentials were measured using both assays from study days 0 to 13. Linear mixed models were fitted to evaluate the associations between: (1) the type of assay (laboratory-based or PCLD) with respect to leukocyte, lymphocyte, and neutrophil concentrations; (2) study day with cell concentrations; and (3) cell concentrations with lung consolidation measured at necropsy. Point-of-care leukocyte, lymphocyte, and neutrophil concentrations were significantly associated (P < 0.05) with the respective cell concentrations obtained from the laboratory-based leukocyte differential. Cell concentrations reported by both assays differed significantly (P < 0.05) over time, indicating shifts from healthy to viral and bacterial disease states. Lymphocyte concentrations, lymphocyte/neutrophil ratios obtained from both assays, and band neutrophil concentrations from the laboratory-based assay were significantly associated (P < 0.05) with lung consolidation, enhancing assessments of disease severity. The PCLD may be a useful alternative to assess BRD progression when laboratory-based leukocyte differentials are impractical.

Policy Perspectives of Dog-Mediated Rabies Control in Resource-Limited Countries: The Ethiopian Situation

One Health disease-control programs are believed to be most effective when implemented within the population transmitting the disease. The World Health Organization (WHO) and partners have targeted the elimination of dog-mediated human rabies by 2030 primarily through mass dog vaccination. Mass vaccination, however, has been constrained by financial resource limitations. The current owner-charged dog vaccination strategy, used in most resource-limited countries like Ethiopia, has not reached the minimum coverage required to build population immunity. Dog vaccination is non-existing in most rural areas of Ethiopia, and coverage is <20% in urban areas. Although the health and economic benefits of rabies elimination outweigh the costs, the direct beneficiaries (public in general) and those who bear the costs (dog owners) are not necessarily the same. In this perspective paper, we aggregate evidence on the socioeconomic burden of rabies in Ethiopia as well as the implications for potential opportunities to control the disease and possibilities to obtain the required funding sources for evidence-based interventions in the control of rabies in Ethiopia.

Analytic Sensitivity of an ELISA Test on Pooled Sera Samples for Detection of Bovine Brucellosis in Eradication Stages in Uruguay

Bovine brucellosis has been under eradication in Uruguay since 1998. The eradication program includes, among other interventions, individual sera sampling of beef animals at slaughter, and annual serum testing of all dairy cows—accounting for two million samples annually. At a herd prevalence of 0.8%, a pooled-sera sample approach could reduce the economic burden of the surveillance system by reducing the testing and operational costs. Our objective was to evaluate the analytic sensitivity of an indirect ELISA test for Brucella abortus in serum pools. Sixty-two Brucella abortus-positive bovine sera samples (based upon rose bengal and fluorescent polarization assay) were used as the positive control samples. Rose bengal-negative sera from negative farms were used to dilute the positive samples to the desired concentrations. Positive samples were diluted by using 1 ml of positive sera and 1 ml of negative sera (1/2 dilution) up to 1/1,024. Data were analyzed using generalized linear mixed models with a binary outcome (positive or negative), dilution number as a fixed effect, and a random effect for sample ID. Analytic sensitivity was 99.0% [95% confidence interval (CI): 96.3–99.7], 98.3% (95% CI: 93.1–99.6), 97.3% (95% CI: 87.4–99.4) for dilutions 1/2, 1/4, and 1/8, respectively. The analytical sensitivity, however, decreased when diluted to greater proportions. Given the current herd prevalence in Uruguay, it seems plausible that the use of a pooled sample approach could be adopted by policymakers to reduce the cost of the surveillance program and increase the number of samples being tested.

Performance of multiple diagnostic methods in assessing the progression of bovine respiratory disease in calves challenged with infectious bovine rhinotracheitis virus and Mannheimia haemolytica1

The objective of this study was to evaluate the diagnostic performance of chute-side diagnostic methods for detecting physiological and pathological changes as indicators of early bovine respiratory disease (BRD) in calves experimentally inoculated with infectious bovine rhinotracheitis virus (IBR) and Mannheimia haemolytica (Mh). A challenge study was performed over 14 d in 30 Holstein steers [average weight (±SEM) = 211 kilograms (kg) ± 2.4 kg] inoculated on day 0 with IBR and on day 6 with Mh. Diagnostic methods included clinical illness scores (CIS), lung auscultation using a computer-aided stethoscope (CAS), rectal temperature, facial thermography, pulse oximetry, and bilateral thoracic ultrasonography. Animals were randomized into 1 of 5 necropsy days (days 6, 7, 9, 11, and 13) when the percentage of lung consolidation was estimated. The effect of study day on the results of the diagnostic methods and associations between each diagnostic method's values with lung consolidation measured at necropsy were determined with mixed models. Values for all diagnostic methods differed significantly (P < 0.01) by day. During the IBR phase (days 0 to 6) calves had "normal" to "moderate" CIS, whereas during the Mh phase (days 6.5 to 13) scores were predominantly "severe" to "moribund." Similarly, CAS scores were "normal" and "mild acute" during the IBR phase and "mild acute" to "moderate acute" after the Mh challenge. Oxygen saturation did not differ significantly between days 0, 1, 2, 4, and 6; however, significantly decreased 12 h after inoculation with Mh (P < 0.05). Mean lung consolidation between animal's right and left side recorded by ultrasound was 0.13% (±0.07) before the inoculation with Mh. However, during the Mh phase, mean consolidation increased significantly over time (P < 0.05). The percentage of lung consolidation at necropsy ranged from 1.7% (±0.82) on day 6 to 55.4% (±7.49) on day 10. Clinical illness scores, rectal temperature, facial thermography, oxygen saturation, and ultrasonography were significantly associated (P < 0.05) with lung consolidation at necropsy. In addition, there was a significant trend (P = 0.07) between CAS and lung consolidation scores at necropsy. These chute-side diagnostic methods are useful for detecting disease progression on animals with early stages of BRD.

Immediate breast reconstruction using a laparoscopically harvested omental flap

Use of an omental flap to reconstruct the breast after cancer surgery was first reported by Kiricuta in 1963. Since then, the omentum has been widely used in cancer surgery to cover extensive thoracic defects associated with radionecrosis. In contrast, for breast reconstruction or augmentation mammaplasty, rectus abdominis and latissimus dorsi flaps have been used far more often than omental flaps. This article describes a new technique for immediate breast reconstruction using laparoscopically harvested omentum and reports the results obtained in 10 patients. Nine patients underwent immediate breast reconstruction after subcutaneous mastectomy. In the other patient, omentum was used in combination with skin grafting to cover a postmastectomy defect. Follow-up exceeded 16 months in the first patients. The results suggest that breast reconstruction using a laparoscopically harvested omental flap may be extremely dependable in terms of vascular supply (there was one case of partial necrosis, which healed with local management alone). The postoperative course of all patients was uneventful, and the use of laparoscopy reduced the hospital stay to less than 7 days. Donor-site scars were minimal. There was no residual loss of function, and there were no cases of incisional ventral hernia. Cosmetic results were satisfactory, with a soft breast that was both natural in appearance and stable in volume. However, in two patients the amount of omentum was found to be inadequate during the procedure; consequently, an implant was inserted under the omental flap. Breast reconstruction using a laparoscopically harvested omental flap is a new technique that allows autogenous reconstruction without disfigurement of the do-nor site and that results in a soft, natural-looking breast.

Syncytial giant-cell hepatitis due to autoimmune hepatitis type II (LKM1+) presenting as subfulminant hepatitis

Giant cell hepatitis (GCH) in adults is a rare event. The diagnosis of GCH is based on findings of syncytial giant hepatocytes. It is commonly associated with either viral infection or autoimmune hepatitis type I. A patient with GCH due to autoimmune hepatitis type II (LKM1+) is described, a combination that has not been previously reported. Corticosteroid therapy was effective in decreasing serum liver enzymes; however, the patient deteriorated rapidly and developed subfulminant hepatic failure. Although an emergency orthotopic liver transplantation was performed, the patient died because of reperfusion injury. Interestingly, only a few giant hepatocytes were noted in the explanted liver. This case stresses the association of GCH with autoimmune disorders, the possible immune mechanism involved in the formation of giant cell hepatocytes, and illustrates the rapidly progressive course and unfavorable prognosis that these patients can develop.

Advantage of the presence of living dermal fibroblasts within in vitro reconstructed skin for grafting in humans

Methods for serial cultivation of human keratinocytes can provide large quantities of epidermal cells, which have the potential of restoring the vital barrier function of the epidermis in extensive skin defects such as burns. To investigate the value of combining an epidermis with a dermal component, fibroblasts originated from the superficial dermis were used to seed a collagen lattice as described by E. Bell (dermal equivalent). Beginning in 1981, we grafted 18 patients (burns and giant nevi) using 35 grafts 10 x 10 cm in size. In the course of this work, the original technique was modified and improved as experience was gained. We began by using small skin biopsy samples as a source of keratinocytes cultured on a dermal equivalent before grafting in a one-step procedure, but this gave poor cosmetic results, because of a nonhomogeneous epidermalization. We then chose to cover the graft bed using a two-step procedure. The first step consisted of grafting a dermal equivalent to provide a dermal fibroblast-seeded substrate for subsequent in vivo epidermalization by cultured epidermal sheets. Whatever the epidermalization technique used, a living dermal equivalent applied to the graft bed was found to reduce pain, to provide good hemostasis, and to improve the mechanical and cosmetic properties of the graft. A normal undulating dermal-epidermal junction reappeared by 3 to 4 months after grafting and elastic fibers were detectable 6 to 9 months after grafting. As a result of the biosynthesis of these products, the suppleness (e.g., elasticity) of the grafts was closer to that of normal skin than the cicatricial skin usually obtained with epidermal sheets grafted without the presence of living dermal cells. This rapid improvement of the mechanical properties of the graft could be attributed to the presence of fibroblasts cultured from the dermis and seeded into the collagen matrix.

[Skin sensitivity before and after reduction mammaplasty. Report of 44 cases]

The main aim of reductive surgery for breast hypertrophy has often been the aesthetic result without considering on the cutaneous sensitivity. This retrospective analysis studied the subjective and objective sensitivity after mammoplasty reduction 44 patients. The preoperative results showed a reduction of sensitivity directly proportional to the ptosis. After surgery the patients described an improvement of the sensibility, especially in the case of moderate resection. This study shows the good restoration of nerve fibers after chronic stretching due to hypertrophy. Nerve fibres were restored when areolar graft was used.

Obtaining maximal use of expanded scalp rotation flaps via an experimental model

The relative inelasticity of scalp skin and the irregular convexity of the cranial vault necessitate careful planning in the design and mobilization of scalp flaps. Rotation flaps adapt particularly well to the curves of the cranial vault. An experimental model has enabled us to study the design and mobilization of expanded scalp rotation flaps and to obtain maximal efficiency from the tissue expansion process. The use of a round tissue expander situated immediately adjacent to a scalp defect is an excellent method for the creation of a rotation flap. To optimize the use of the expanded tissues, the flap should be designed so that its border passes along the periphery of these expanded tissues. In cases in which it is advisable to separate the expander from the defect, such as when the defect is highly contaminated, efficient use of the expanded tissues can still be obtained by placing the expander at the site of a rotation flap backcut. Furthermore, although this study focuses on rotation flaps only, this same model can be used to examine and compare different closure methods using other types of flaps as well.

[Preservation of the muscle in the use of rectus abdominis free flap in breast reconstruction: from TRAM to DIEP (Deep inferior epigastric perforator) flap. Technical notes and results]

The advantages of TRAM (Transverse Rectus Abdominus Muscle) flap for breast reconstruction is now well recognised. This technique allows a cosmetic reconstruction with a more natural shape than with conventional reconstruction with prosthesis. However the disadvantage is the need of removal of part or all rectus abdominis muscle. If the techniques of free flap are now recognised to be more reliable than pedicle TRAM they have not demonstrate a superiority in term of parietal sequellae. To avoid such problem some teams have progressively developed the DIEP (Deep Inferior Epigastric Peforator Flap). This flap is harvested only on the transmuscular perforators. We are presenting here our expertise which progressively has leed us from free partial TRAM to DIEP. From december 1995 to january 1997 we have practice 18 breast reconstructions with free flap. On 13 DIEP we had only one parietal complication due to incomplete closing of the aponeurosis at the lowest part of the surgical approach. This complication was easily corrected as the muscle was still tonic. On 5 TRAM, clinical examination finds parietal weakness on 3 cases. We believe that this technique is full of promises as it brings autologous tissue with no complication on donor site.

[Value of reduction mammoplasty in the conservative treatment of breast neoplasms. Apropos of 70 cases]

Breast cancer surgery is on the increase. Until now conservative treatment has been limited to tumors less than 3 cm; it is now extending to surgery on reduced tumors after chemotherapy or radiotherapy. Some cancers still require mastectomy because a carcinologic satisfactory tumorectomy would create a major deformity not compatible with conservative treatment. It is technically possible to perform major tumor resection with good cosmetic results using the reduction mammoplasty technique well known in plastic surgery. Between 1983 and 1991, 70 patients were treated at Henri Mondor Hospital for breast cancer with breast reduction mammoplasty and irradiation. We present the result with an average five years follow-up in terms of the cosmetic results relapses and survival rate. The actuarial local relapse was less than 10%, the survival with local relapse was 86% after 5 years, cosmetic results were good in 81% of cases. The association of reduction mammoplasty and radiotherapy seems to be a good extension of conservative treatment in some large breast tumors.

[Mammary silicone granuloma. Apropos of 3 cases]

Since the beginning of the sixties, plastic surgeons now use silicone gel prostheses, in aesthetic or reconstruction surgery, for augmentation mammaplasty. Organic complications occurring after the insertion of these implants are reported in the literature, due to the large number of women now treated. Out of the purely local complications, and the general complications related to silicone biocompatibility, some regional complications are described, such as silicone granuloma. Authors describe three cases of sicilone granuloma they have observed and cured. After a short review of the literature, they underline problems raised by silicone granuloma, such as those related to diagnostic and therapeutic approaches.

bcl-2 expression in normal breast tissue during the menstrual cycle

bcl-2 is a proto-oncogene discovered through the t(14;18) translocation occurring in most human follicular lymphomas. The function so far attributed to bcl-2 is to counteract the occurrence of apoptosis and to prolong cell survival without affecting the cycling cells. Apoptosis has been described in normal breast tissue epithelial cells, and it peaks at the end of the luteal phase. We have studied bcl-2 expression by an immunohistochemical method in 50 samples of normal breast tissue distributed throughout the menstrual cycle. bcl-2 staining predominated in the lobular epithelial cells. It displayed a striking cyclic variation, with maximal expression at the mid-cycle period and a sharp decrease at the end of the cycle. These results strongly suggest that the regulation of bcl-2 expression in breast tissue is hormone-dependent. This could be of significance in tumorigenesis.

[Pathology of autografts of the nipple in mammaplasty. Apropos of 2 original cases]

Autologous nipple graft is a classical technique in nipple reconstruction. The authors present two cases of deferred development of specific lesions in the grafted nipple, including one historical case of Paget's disease. After reviewing the current state of knowledge concerning Paget's disease of the nipple and in the light of these two cases, the authors discuss the histogenesis of this disease and the pathology of the grafted nipple in reconstructive surgery.

[Plastic surgery and conservative treatment of breast cancer. Indications and results]

After conservative treatment for breast cancer, 75% of patients have good cosmetic results, but 20 to 25% of patients have a fair or a bad result. The tumor itself is responsible for some of these bad results (tumor volume, location in the inferior quadrants of the breast) but more often, failures are related to surgery and/or radiotherapy. Some patients will then ask for reconstructive surgery. It should always be preceded by a careful examination of the breast, both with an oncologic and a reconstructive approach. The techniques used are numerous, ranging from simple reexcision of the lumpectomy scar to mastectomy with immediate TRAM flap reconstruction. We believe that plastic surgery techniques should be used as soon as the initial lumpectomy, as they help to fill in the defect. In the case of a tumor located in the inferior quadrants, bad cosmetic results are twice as frequent as in the upper quadrants: we treated 16 of these patients with immediate bilateral breast reduction, reshaping the breast at the same time as the lumpectomy, and achieving symmetry of the contralateral breast. This technique did not interfere with radiotherapy or chemotherapy. When radiotherapy followed surgery, cosmetic results were good. Local and distant recurrences were not modified by the adjunction of a breast reduction to the lumpectomy. In 49 cases, we also proposed a bilateral breast reduction for larger tumors (T > 3 cm, bifocal cancer). 4-year local recurrence rate was less than 10%: this technique could help to extend the indications for conservative treatment for breast cancer. More cases and longer follow-up are necessary.

[Effect of inadequate filling of deflation of inflatable breast prostheses. Statistical study of 535 inflatable prostheses]

This study was based on a series of 535 inflatable prostheses used for breast reconstruction or augmentation with a mean follow-up of 5.15 years. The authors specifically analysed the statistical correlation between underinflation and deflation due to late rupture. They demonstrated a statistically significant difference between the initial filling of the prostheses which subsequently deflated and the initial filling of all prostheses of the series. The mean filling of prostheses which subsequently deflated was 89% while the mean filling of all prosthesis in the series was 100%. The various pathologies are analysed according to the cosmetic or reconstructive indications. The two series, cosmetic and reconstructive, were homogeneous in terms of filling volume and deflation; the only difference concerned the age distribution. Patients undergoing breast reconstruction with a prosthesis were older than patients undergoing augmentation surgery for small breasts. The authors discuss the advantages and disadvantages of this type of prosthesis.

[Surgical injury of the temporo-frontal branch of the facial nerve. Anatomical study and clinical consequences]

The frequency of frontal paralysis due to surgical trauma of the temporo-frontal nerve seems to be increasing due to the growing number of operations in the temporo-frontal area and the complexity of surgical techniques. A series of 20 anatomical dissections demonstrates the course of the temporo-frontal nerve. Frontal myomectomy of the healthy side to allow facial equilibration seems to us to be the best technique of reconstructive surgery for definitive frontal paralysis.

[Can tumors of the breast larger than 3 centimeters be treated conservatively?]

Unlike small breast cancers, which are now treated conservatively by primary tumorectomy, the most important lesions (T2 and T3) as usually treated tumorectomy, the most important lesions (T2 and T3) as usually treated by mastectomy. However, in patients with these large lesions attempts may be made at conserving the breast with reliable oncological safety and good cosmetic results. Depending on clinical presentation, one or the other of two therapeutic approaches may be considered. The most common treatment is preoperative radiotherapy of 45 Gy which, in more than 50 p. 100 of the cases results in a tumoral regression that is sufficient for secondary tumorectomy to be performed. In some patients, the first-line treatment consists of wide tumoral excision as part of a reductive mammaplasty, followed by radiation.

Ethnic differences in the incidence of postnecrotic cirrhosis in Israel: correlation with hepatitis B virus serological markers

While immigrants from Morocco and Romania make up 7 and 6%, respectively, of the Israeli population, one-third of all postnecrotic cirrhosis patients come from Morocco and another third from Romania. The rate of hepatitis B virus (HBV) infection, as expressed by serum hepatitis B surface antigen, anti-HBs, and anti-HBc, was compared in immigrant patients with postnecrotic cirrhosis and in age and sex matched controls from the same countries. Among 19 Moroccan immigrants with postnecrotic cirrhosis 74% showed evidence of HBV infection. This was not significantly different from the prevalence of HBV infection (64%) in a matched control group of 61 Moroccan individuals. In the 26 Romanian cirrhotics, however, a significantly higher prevalance of HBV infection than in the 60 matched controls was observed (54 and 23%, respectively, p less than 0.01). The difference was detected only when anti-HBc was looked for in addition to hepatitis B surface antigen and anti-HBs. These results indicate that: 1) HBV infection and postnecrotic cirrhosis are associated in Romanian immigrants to Israel. 2) Association between HBV infection and cirrhosis in Moroccan immigrants cannot be shown because of the high infection rate in the control population. 3) Anti-HBc is often the only marker of HBV infection in cirrhotic patients, and should be examined in addition to hepatitis B surface antigen and anti-HBs in order to get meaningful results.