A Useful Technique for Templating the Reverse Radial Forearm Flap (RFF) for Thumb Degloving Injuries.

Degloving injuries of the thumb pose a significant challenge as replantation is usually unsuccessful. A 60-year-old man was transferred to "Queen Victoria Hospital NHS Trust" four hours after having his left thumb completely avulsed at metacarpophalangeal level. The anastomosis repeatedly failed during urgent replantation and a distally based pedicled RFF was utilized. To achieve accurate flap design, we used the amputated part as a template for the missing tissue. After a longitudinal cut exposing the inner surface, the thumb was placed flat on top of a clean gauze package which was used as a paper template for the skin paddle; the flap was subsequently sutured without tension. Since the circumferential soft tissue envelope is three-dimensional, accurate designing of the flap on the forearm is vital. We propose a useful technique using the amputated part to enable a precise estimation of the tissue requirements to reduce potential complications related to flap inset.

Les lésions de dégantage du pouce posent un défi significatif dans la mesure où la réimplantation échoue habituellement. Un homme âgé de 60 ans a été transféré à « Queen Victoria Hospital NHS Trust ¼ quatre heures après l'arrachement complet de son pouce au niveau métacarpophalangien. L'anastomose a échoué de manière répétée au cours de la réimplantation en urgence et un RFF pédiculé à base distale a été utilisé. Pour obtenir une forme exacte du lambeau, nous avons utilisé la partie amputée comme modèle pour le tissu manquant. Après une incision longitudinale exposant la surface interne, le pouce a été mis à plat sur un paquet de compresses propres qui a servi de modèle papier pour la palette de peau; le lambeau a ensuite été suturé sans tension. Considérant que l'enveloppe de tissu souple circonférentielle est tridimensionnelle, une détermination précise du lambeau sur l'avant-bras est vitale. Nous proposons une technique utile consistant à utiliser la partie amputée pour avoir une estimation précise des besoins en tissu afin de réduire les complications potentielles liées à l'insertion du lambeau.

Environmental relationships and anthrax epidemiology: field experiences of host resistance as opposed to dose-dependent experiments.

Even though anthrax is a disease of antiquity that has been studied for centuries, serious concerns have been raised about our understanding of its epidemiology. Since the 1960s, we have based the epidemiology of anthrax on the results of dose-dependent experiments, especially those involving cattle at that time. In this species the experiments demonstrated that the severity of infection was dependent upon the numbers of Bacillus anthracis spores ingested. The opinion was that ingesting only a few spores would be insufficient to cause an apparent infection; any infection that resulted would be latent (i.e., unrecognized). Based on the results of these experiments, it was accepted that the ingestion of large numbers of spores was the source of infection for hundreds of anthrax outbreaks. However, many investigations of both human and animal anthrax outbreaks have failed to identify sources of large numbers of spores, suggesting that these outbreaks are only rarely a consequence of ingestion or inhalation of large quantities of spores. This opinion piece builds upon the indirect evidence previously presented in an article focused on the existence of latent infections. Much of the evidence for the existence of latent infections was predicated upon a reduction of host resistance, which revealed how latent infections could be a source of more severe forms of the infection. That is, a latent infection can be the source of a severe infection, but the cause of the severe infection is the reduced host resistance. That first article concentrated on the arguments for latent infections, while this article concentrates on the arguments for host resistance. Host resistance is virtually impossible to measure objectively in the field. To provide a subjective measure of host resistance during anthrax outbreaks, we suggest the use of the opinions of livestock owners and or their veterinary practitioners and or field workers during investigations of anthrax outbreaks. When veterinary personal work in the field they are much like field biologists. In some ways field biologists better appreciate environmental factors, population ecology and other perspectives that are of use to epidemiologists. The more diverse the information the better the epidemiology is understood. To this effect we present our personal anecdotal and theoretical ideas from our experiences as well as a collection of bibliographic observations from others'. Our conclusions are that a combination of latent infections and reduced host resistance based on the host's relationship with its environment would better explain the epidemiology of severe infections in anthrax outbreaks for which large quantities of spores have not been located. This applies especially if the area has a history of the disease and/or if necropsies have shown the presence of latent infections in otherwise normal animals in the area and/or if environmental conditions are considered stressful and include intense insect activity.

Bilateral Transverse Upper Gracilis Flaps for Unilateral Breast Reconstruction: A 4-Year Retrospective Study of the "2-in-1" Technique and a Systematic Review With Meta-analysis.

INTRODUCTION: The transverse upper gracilis (TUG) flap is a reliable alternative to abdominally based breast reconstruction because of its advantageous anatomy. However, the limited tissue volume prevents reconstruction of large breasts. The bilateral TUG flaps for unilateral breast reconstruction can overcome this problem. METHODS: A retrospective analysis was performed regarding unilateral breast reconstruction with bilateral TUGs at the Queen Victoria Hospital from 2015 to 2019. Associations between categorical variables were examined with Fisher exact test, and any differences in continuous variables by complication status were evaluated with Mann-Whitney-Wilcoxon test for independent samples. A relevant systematic review was conducted with a meta-analysis of proportions using the Freeman-Tukey arcsine transformation for the estimation of the overall survival rates. RESULTS: Ten cases were identified with 6 having a delayed reconstruction. Median age and body mass index were 50.8 years and 23.9 kg/m 2 , respectively, and average flap weight was 268.3 g. One flap was placed superiorly with its pedicle anastomosed to the retrograde internal mammary vessels, except of half of the cases where a second anterograde vein was used. The mean follow-up was 21.4 months, and all flaps survived. Two patients returned to theater, and 4 experienced donor-site problems. The presence of complications was not associated with age, ever smoking, body mass index, TUG weight, or anastomosis to retrograde internal mammary vein. The systematic review resulted in 8 eligible articles with a total sample of 156 flaps. The overall survival rate was 96.8%. In 6 cases, the indication was Poland syndrome (7.7%), and in 48.7%, axillary vessels were also used as recipient vessels. The estimated overall flap survival rate was 100% (95% confidence interval, 99%-100%), and no significant heterogeneity was noted ( I2 = 0%, P = 0.71). CONCLUSIONS: The "2-in-1" technique can lead to symmetrical aesthetically pleasant results for both recipient and donor sites. Our case series and the conducted systematic review reiterate the reliability of this approach.

A Review of Arguments for the Existence of Latent Infections of Bacillus anthracis, and Research Needed to Understand their Role in the Outbreaks of Anthrax.

Hugh-Jones and Blackburn and Turnbull's collective World Health Organization (WHO) report did literature reviews of the theories and the bases for causes of anthrax outbreaks. Both comment on an often-mentioned suspicion that, even though unproven, latent infections are likely involved. Hugh-Jones suggested Gainer do an updated review of our present-day knowledge of latent infections, which was the basis for Gainer's talk at the Biology of Anthrax Conference in Bari, Italy 2019. At the Conference Gainer met Vergnaud who presented anthrax genome studies that implied that the disease might have spread throughout Asia and from Europe to North America in a short time span of three or four centuries. Vergnaud wondered if latent infections might have played a role in the process. Several other presenters at the Conference also mentioned results that might suggest the existence of latent infections. Vergnaud subsequently looked into some of the old French literature about related observations, results, and discussions of early Pasteur vaccine usage (late 1800's) and found mentions of suspected latent infections. The first part of the paper is a focused summary and interpretation of Hugh-Jones and Blackburn's and Turnbull's reviews specifically looking for suggestions of latent infections, a few additional studies with slightly different approaches, and several mentions made of presentations and posters at the Conference in Italy. In general, many different investigators in different areas and aspects of the anthrax study at the Conference found reasons to suspect the existence of latent infections. The authors conclude that the affected species most studied, including Homo sapiens, provide circumstantial evidence of latent infections and modified host resistance. The last part of the review explores the research needed to prove or disprove the existence of latent infections.

Parkinson's Disease in Louisiana, 1999-2012: Based on Hospital Primary Discharge Diagnoses, Incidence, and Risk in Relation to Local Agricultural Crops, Pesticides, and Aquifer Recharge.

The two major causes of Parkinson's disease (PD) are genetic susceptibility and exposure to agricultural pesticides. Access to 23,224 individuals' hospital primary discharge diagnoses of PD allowed the mapping of cases against known crop distributions and pesticides. Our main objective was to map PD risks (cases per 10,000 people) against crops and their pesticides. The ZIP Code address locations, and the 2000 and 2010 census data, were used to map the risks of PD throughout Louisiana and in relation to United States Department of Agriculture (USDA)-recorded crops. The introduction of glyphosate-resistant crops appears to have initiated the PD disappearance from northeastern parishes on the west bank of the Mississippi river. Rice and sugar cane are seemingly unassociated with PD, as is the Mississippi itself, except for Jefferson and St. Charles Parishes, which are essentially urban or industrial. The present major PD-affected areas are associated with commercial forests, woodlands, and pastures, and thus with certain arbor-pastoral pesticides, 2,4-D, chlorpyrifos, and paraquat. Human populations at maximum risk are those living in areas of moderate and high aquifer-recharge potential. The levels of estimated pesticide exposure in these recharge areas we were able to access were of variable use, but significant amounts of 2,4-D were being used.

The global distribution of Bacillus anthracis and associated anthrax risk to humans, livestock and wildlife.

Bacillus anthracis is a spore-forming, Gram-positive bacterium responsible for anthrax, an acute infection that most significantly affects grazing livestock and wild ungulates, but also poses a threat to human health. The geographic extent of B. anthracis is poorly understood, despite multi-decade research on anthrax epizootic and epidemic dynamics; many countries have limited or inadequate surveillance systems, even within known endemic regions. Here, we compile a global occurrence dataset of human, livestock and wildlife anthrax outbreaks. With these records, we use boosted regression trees to produce a map of the global distribution of B. anthracis as a proxy for anthrax risk. We estimate that 1.83 billion people (95% credible interval (CI): 0.59-4.16 billion) live within regions of anthrax risk, but most of that population faces little occupational exposure. More informatively, a global total of 63.8 million poor livestock keepers (95% CI: 17.5-168.6 million) and 1.1 billion livestock (95% CI: 0.4-2.3 billion) live within vulnerable regions. Human and livestock vulnerability are both concentrated in rural rainfed systems throughout arid and temperate land across Eurasia, Africa and North America. We conclude by mapping where anthrax risk could disrupt sensitive conservation efforts for wild ungulates that coincide with anthrax-prone landscapes.

Spatio-temporal patterns of an anthrax outbreak in white-tailed deer, Odocoileus virginanus, and associated genetic diversity of Bacillus anthracis.

BACKGROUND: Anthrax, a soil-borne zoonosis caused by the bacterium Bacillus anthracis, is enzootic in areas of North America with frequent outbreaks in west Texas. Despite a long history of study, pathogen transmission during natural outbreaks remains poorly understood. Here we combined case-level spatio-temporal analysis and high resolution genotyping to investigate anthrax transmission dynamics. Carcass locations from a single white-tailed deer, Odocoileus virginanus, outbreak were analyzed for spatial clustering using K-function analysis and directionality with trend surface analysis and the direction test. RESULTS: The directionalities were compared to results of high resolution genotyping. The results of the spatial clustering analyses, combined with deer movement data, suggest anthrax transmission events occur within limited spatial areas, with carcass locations occurring within the activity space of adjacent cases. The directionality of the outbreak paralleled adjacent dry river beds. Isolates from the outbreak were represented by a single genotype based on multiple locus variable number tandem repeat analysis (MLVA); four sub-genotypes were identified using single nucleotide repeat (SNR) analysis. CONCLUSIONS: Areas of high transmission agreed spatially with areas of higher SNR genetic diversity; however, SNRs did not provide clear evidence of linear transmission. Overlap of case home ranges provides spatial and temporal support for localized transmission, which may include the role of necrophagous or hematophagous flies in outbreaks in this region. These results emphasize the need for active surveillance and prompt cleanup of anthrax carcasses to control anthrax both during outbreaks and between seasons.

The necrophagous fly anthrax transmission pathway: empirical and genetic evidence from wildlife epizootics.

Early studies confirmed Bacillus anthracis in emesis and feces of flies under laboratory conditions, but there is little empirical field evidence supporting the roles of flies in anthrax transmission. We collected samples during outbreaks of anthrax affecting livestock and native and exotic wildlife on two ranches in West Texas (2009-2010). Sampling included animal carcasses, maggots, adult flies feeding on or within several meters of carcasses, and leaves from surrounding vegetation. Microbiology and PCR were used to detect B. anthracis in the samples. Viable B. anthracis and/or PCR-positive results were obtained from all represented sample types. Genetic analysis of B. anthracis samples using multilocus variable number tandem repeat analysis (MLVA) confirmed that each ranch represented a distinct genetic lineage. Within each ranch, we detected the same genotype of B. anthracis from carcasses, maggots, and adult flies. The results of this study provide evidence supporting a transmission cycle in which blowflies contaminate vegetation near carcasses that may then infect additional browsing animals during anthrax outbreaks in the shrubland environment of West Texas.

Successful delayed nose replantation following a dogbite: arterial and venous microanastomosis using interpositional vein grafts.

The nose is one of the most important aesthetic units of the face. Following traumatic amputation, although technically very challenging, replantation is undoubtedly the procedure of choice. We present the first successful replantation of a partially amputated nose subjected to an ischaemic time of over 12 h. The injury was sustained following a dog-bite and inter-positional vein grafts were used to re-establish both arterial and venous blood flow.

Ecological niche modeling of Bacillus anthracis on three continents: evidence for genetic-ecological divergence?

We modeled the ecological niche of a globally successful Bacillus anthracis sublineage in the United States, Italy and Kazakhstan to better understand the geographic distribution of anthrax and potential associations between regional populations and ecology. Country-specific ecological-niche models were developed and reciprocally transferred to the other countries to determine if pathogen presence could be accurately predicted on novel landscapes. Native models accurately predicted endemic areas within each country, but transferred models failed to predict known occurrences in the outside countries. While the effects of variable selection and limitations of the genetic data should be considered, results suggest differing ecological associations for the B. anthracis populations within each country and may reflect niche specialization within the sublineage. Our findings provide guidance for developing accurate ecological niche models for this pathogen; models should be developed regionally, on the native landscape, and with consideration to population genetics. Further genomic analysis will improve our understanding of the genetic-ecological dynamics of B. anthracis across these countries and may lead to more refined predictive models for surveillance and proactive vaccination programs. Further studies should evaluate the impact of variable selection of native and transferred models.

Analysing the spatial patterns of livestock anthrax in Kazakhstan in relation to environmental factors: a comparison of local (Gi*) and morphology cluster statistics.

We compared a local clustering and a cluster morphology statistic using anthrax outbreaks in large (cattle) and small (sheep and goats) domestic ruminants across Kazakhstan. The Getis-Ord (Gi*) statistic and a multidirectional optimal ecotope algorithm (AMOEBA) were compared using 1st, 2nd and 3rd order Rook contiguity matrices. Multivariate statistical tests were used to evaluate the environmental signatures between clusters and non-clusters from the AMOEBA and Gi* tests. A logistic regression was used to define a risk surface for anthrax outbreaks and to compare agreement between clustering methodologies. Tests revealed differences in the spatial distribution of clusters as well as the total number of clusters in large ruminants for AMOEBA (n = 149) and for small ruminants (n = 9). In contrast, Gi* revealed fewer large ruminant clusters (n = 122) and more small ruminant clusters (n = 61). Significant environmental differences were found between groups using the Kruskall-Wallis and Mann-Whitney U tests. Logistic regression was used to model the presence/absence of anthrax outbreaks and define a risk surface for large ruminants to compare with cluster analyses. The model predicted 32.2% of the landscape as high risk. Approximately 75% of AMOEBA clusters corresponded to predicted high risk, compared with ~64% of Gi* clusters. In general, AMOEBA predicted more irregularly shaped clusters of outbreaks in both livestock groups, while Gi* tended to predict larger, circular clusters. Here we provide an evaluation of both tests and a discussion of the use of each to detect environmental conditions associated with anthrax outbreak clusters in domestic livestock. These findings illustrate important differences in spatial statistical methods for defining local clusters and highlight the importance of selecting appropriate levels of data aggregation.

Metachronous melanoma in breast reconstruction patients.

The incidence and mortality due to malignant melanoma has increased three- to four-fold across males and females in England and Wales over the past thirty years. Ninety percent of patients with primary melanoma have no clinical evidence of lymphadenopathy at presentation. In this paper we describe our management of impalpable axillary melanoma deposits in a patient with a pedicled latissimus dorsi (LD) flap reconstruction to the ipsilateral breast. No such case has been previously described in the literature.

Confirmation of Bacillus anthracis from flesh-eating flies collected during a West Texas anthrax season.

This case study confirms the interaction between necrophilic flies and white-tailed deer, Odocoileus virginianus, during an anthrax outbreak in West Texas (summer 2005). Bacillus anthracis was identified by culture and PCR from one of eight pooled fly collections from deer carcasses on a deer ranch with a well-documented history of anthrax. These results provide the first known isolation of B. anthracis from flesh-eating flies associated with a wildlife anthrax outbreak in North America and are discussed in the context of wildlife ecology and anthrax epizootics.

Modeling the potential distribution of Bacillus anthracis under multiple climate change scenarios for Kazakhstan.

Anthrax, caused by the bacterium Bacillus anthracis, is a zoonotic disease that persists throughout much of the world in livestock, wildlife, and secondarily infects humans. This is true across much of Central Asia, and particularly the Steppe region, including Kazakhstan. This study employed the Genetic Algorithm for Rule-set Prediction (GARP) to model the current and future geographic distribution of Bacillus anthracis in Kazakhstan based on the A2 and B2 IPCC SRES climate change scenarios using a 5-variable data set at 55 km(2) and 8 km(2) and a 6-variable BioClim data set at 8 km(2). Future models suggest large areas predicted under current conditions may be reduced by 2050 with the A2 model predicting approximately 14-16% loss across the three spatial resolutions. There was greater variability in the B2 models across scenarios predicting approximately 15% loss at 55 km(2), approximately 34% loss at 8 km(2), and approximately 30% loss with the BioClim variables. Only very small areas of habitat expansion into new areas were predicted by either A2 or B2 in any models. Greater areas of habitat loss are predicted in the southern regions of Kazakhstan by A2 and B2 models, while moderate habitat loss is also predicted in the northern regions by either B2 model at 8 km(2). Anthrax disease control relies mainly on livestock vaccination and proper carcass disposal, both of which require adequate surveillance. In many situations, including that of Kazakhstan, vaccine resources are limited, and understanding the geographic distribution of the organism, in tandem with current data on livestock population dynamics, can aid in properly allocating doses. While speculative, contemplating future changes in livestock distributions and B. anthracis spore promoting environments can be useful for establishing future surveillance priorities. This study may also have broader applications to global public health surveillance relating to other diseases in addition to B. anthracis.

Incidence of 'Incidentalomas' in over 100 consecutive CT angiograms for preoperative DIEP flap planning.

The gold standard in breast reconstruction is the deep inferior epigastric perforator (DIEP) flaps, although muscle-sparing tranverse rectus abdominis myocutaneous (TRAM) flaps are still being performed due to variations in the abdominal vasculature and to reduce flap complications. Recently, there has been a rise in interest in preoperative imaging, in particular, by means of computer tomography angiogram (CTA). CTA has been shown to delineate the vascular anatomy, improve preoperative decision making and possibly reduce operating time and constitutes a routine preoperative investigation in our unit. Of the 104 consecutive patients who had undergone CTA prior to breast reconstruction, we have found a 13% incidence of unexpected findings or 'incidentalomas' in otherwise asymptomatic women. None were malignant, but changes to the initial operative plan included deferring immediate breast reconstruction, further surgery and further investigations for these incidentalomas. We recommend that all women are counselled of the possibilities of incidentalomas prior to CTA. Furthermore, clinicians need to be receptive to the possibility of a delayed or alternative reconstruction, and closely liaise with other specialties to avoid damage to the deep inferior epigastric vasculature.

Evaluation of immune response to orally administered Sterne strain 34F2 anthrax vaccine.

Present animal vaccines against Bacillus anthracis infection are capable of inducing protective immunity. However, due to the route of administration, the vaccine has limited or no use in wildlife especially in rural areas of the world. Hence, an oral vaccine is needed for controlling this disease. For proof of concept we used the commercially available Sterne strain 34F2 vaccine mixed with oral scarifying agents. Although the immunological response as measured by ELISA in this group was not equal to the parenterally inoculated animals, the results indicate that the oral administration of this vaccine with oropharyngeal mucosa scarifying agents mixed with feed can induce immune responses in goats.

Global genetic population structure of Bacillus anthracis.

Anthrax, caused by the bacterium Bacillus anthracis, is a disease of historical and current importance that is found throughout the world. The basis of its historical transmission is anecdotal and its true global population structure has remained largely cryptic. Seven diverse B. anthracis strains were whole-genome sequenced to identify rare single nucleotide polymorphisms (SNPs), followed by phylogenetic reconstruction of these characters onto an evolutionary model. This analysis identified SNPs that define the major clonal lineages within the species. These SNPs, in concert with 15 variable number tandem repeat (VNTR) markers, were used to subtype a collection of 1,033 B. anthracis isolates from 42 countries to create an extensive genotype data set. These analyses subdivided the isolates into three previously recognized major lineages (A, B, and C), with further subdivision into 12 clonal sub-lineages or sub-groups and, finally, 221 unique MLVA15 genotypes. This rare genomic variation was used to document the evolutionary progression of B. anthracis and to establish global patterns of diversity. Isolates in the A lineage are widely dispersed globally, whereas the B and C lineages occur on more restricted spatial scales. Molecular clock models based upon genome-wide synonymous substitutions indicate there was a massive radiation of the A lineage that occurred in the mid-Holocene (3,064-6,127 ybp). On more recent temporal scales, the global population structure of B. anthracis reflects colonial-era importation of specific genotypes from the Old World into the New World, as well as the repeated industrial importation of diverse genotypes into developed countries via spore-contaminated animal products. These findings indicate humans have played an important role in the evolution of anthrax by increasing the proliferation and dispersal of this now global disease. Finally, the value of global genotypic analysis for investigating bioterrorist-mediated outbreaks of anthrax is demonstrated.