Reconstruction of a Large Anterior Ear Defect after Mohs Micrographic Surgery with a Cartilage Graft and Postauricular Revolving Door Flap

A novel postauricular revolving door island flap and cartilage graft combination was employed to correct a large defect on the anterior ear of an 84-year-old man who underwent Mohs micrographic surgery for an antihelical squamous cell carcinoma. The defect measured 4.6 × 2.4 cm and spanned the antihelix, scapha, a small portion of the helix, and a large segment of underlying cartilage, with loss of structural integrity and anterior folding of the ear. The repair involved harvesting 1.5 cm2 of exposed cartilage from the scaphoid fossa and then sculpting and suturing it to the remnant of the antihelical cartilage in order to recreate the antihelical crura. The skin of the posterior auricle was then incised just below the helical rim and folded anteriorly to cover the cartilage graft. The flap remained attached by a central subcutaneous pedicle, and an island designed using the full-thickness defect as a stencil template was pulled through the cartilage window anteriorly to resurface the anterior ear. This case demonstrates the use of the revolving door flap for coverage of large central ear defects with loss of cartilaginous support and illustrates how cartilage grafts may be used in combination with the flap to improve ear contour after resection

Novel polymorphisms influencing transcription of the human CHRM2 gene in airway smooth muscle

Muscarinic receptors are a functionally important family of G-protein-coupled receptors. Using a combination of rapid amplification of 5′ cDNA ends and reporter gene assays, we characterized the 5′ untranslated region of the CHRM2 gene as expressed in human airway smooth muscle (HASM) cells. A splice site is present 46 bp upstream from the ATG start codon. Five exons with alternative splicing patterns are present upstream of this splice site, separated by introns ranging from 87 bp to > 145 kb. There is evidence for the gene being under the control of a TATA-less promoter with Sp1, GATA, and activator protein-2 binding sites. Multiple transcription start sites (TSSs) were identified. We identified a novel 0.5-kb hypervariable region located 648 bp upstream of the most 5′ TSS, a multiallelic (CA) tandem repeat 96 bp downstream of the most 5′ TSS, and a common C→A SNP located 136 bp upstream of the most 5′ TSS. Functional studies in primary HASM cells and the BEAS-2B cell line demonstrated highest promoter activity to be upstream of the most 3′ TSS, with potential repressor elements operating in a cell type-dependent manner, located upstream of the most 5′ TSS. We present functional data to show that the CA repeat may influence the transcription of the gene in HASM and BEAS-2B cells.peer-reviewe

Transcriptional regulation of the human muscarinic M2 receptor gene

Muscarinic M2 receptors are important regulators of airway smooth muscle tone and alteration in M2 receptor function has been described in asthmatic patients. Information regarding transcriptional regulatory control of muscarinic M2 receptor expression in human airway smooth muscle cells is not available in the scientific literature. This project aimed to study the transcriptional regulation of human muscarinic M2 receptors and identify potential polymorphic variation, which may contribute to alteration in receptor expression. Total mRNA was extracted from a human airway smooth muscle (HASM) primary cell culture and used as a template for analysis. A 5’ RACE (Rapid Amplification of cDNA Ends) approach was used to identify and characterize the promoter region of the M2 receptor. The promoter activity of pGL3E deletion constructs was subsequently investigated using a luciferase-based reporter gene assay approach in transiently transfected HASM and BEAS-2B cells. Three different regions of transcriptional initiation were identified, with multiple transcription start sites (TSSs) clustered within each region. The distance separating the most 5’ TSS from the coding region exceeds 146kb, and includes multiple exons, some of which are alternatively spliced. Sequencing of genomic DNA revealed the presence of a novel 0.5kb hypervariable region located 648bp upstream of the most 5’ TSS, a CÆA SNP located 136bp upstream of the most 5’ TSS and a multiallelic CA tandem repeat 96bp downstream of the most 5’ TSS. The CA repeat has been shown to influence reporter gene transcriptional activity in transient cell transfectants. This study has elucidated the arrangement of the muscarinic M2 5’ untranslated region, and has defined the key regions likely to be important in transcriptional regulation of the gene in HASM cells. Studies to define potential linkage between the functional tandem CA repeat and asthma are currently underway. This work was funded by the University of Malta and the National Asthma Campaign (UK).peer-reviewe

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Reconstruction of a Large Anterior Ear Defect after Mohs Micrographic Surgery with a Cartilage Graft and Postauricular Revolving Door Flap

A novel postauricular revolving door island flap and cartilage graft combination was employed to correct a large defect on the anterior ear of an 84-year-old man who underwent Mohs micrographic surgery for an antihelical squamous cell carcinoma. The defect measured 4.6 × 2.4 cm and spanned the antihelix, scapha, a small portion of the helix, and a large segment of underlying cartilage, with loss of structural integrity and anterior folding of the ear. The repair involved harvesting 1.5 cm2 of exposed cartilage from the scaphoid fossa and then sculpting and suturing it to the remnant of the antihelical cartilage in order to recreate the antihelical crura. The skin of the posterior auricle was then incised just below the helical rim and folded anteriorly to cover the cartilage graft. The flap remained attached by a central subcutaneous pedicle, and an island designed using the full-thickness defect as a stencil template was pulled through the cartilage window anteriorly to resurface the anterior ear. This case demonstrates the use of the revolving door flap for coverage of large central ear defects with loss of cartilaginous support and illustrates how cartilage grafts may be used in combination with the flap to improve ear contour after resection

Mycobacterium fortuitum infection arising in a new tattoo

We report an uncommon case of a cutaneous infection with Mycobacterium fortuitum arising in a new tattoo. A 29-year-old man presented with a several month history of a non-pruritic papular eruption within a tattoo; the papules developed 1-to-2 weeks after the tattoo procedure. He denied similar symptoms with previous tattoos. He had been treated unsuccessfully with cephalexin. Histopathologic examination revealed perifollicular chronic and granulomatous inflammation, consistent with chronic folliculitis. Acid-fast bacilli culture identified Mycobacterium fortuitum complex. The patient was treated with a 2-month course of oral trimethoprim-sulfamethoxazole (160mg/800mg twice daily) and ciprofloxacin (250 mg twice daily), with clinical improvement at follow up after three weeks of the antibiotic regimen. Rapidly growing mycobacteria have emerged as a cause of tattoo-associated cutaneous infection in recent years. Diagnosis and treatment can be difficult without clinical suspicion. M. fortuitum and other rapidly growing mycobacteria should be considered in the differential diagnosis of tattoo-associated dermatologic complications

Bioinformatics pipelines for targeted resequencing and whole-exome sequencing of human and mouse genomes: A virtual appliance approach for instant deployment

Targeted resequencing by massively parallel sequencing has become an effective and affordable way to survey small to large portions of the genome for genetic variation. Despite the rapid development in open source software for analysis of such data, the practical implementation of these tools through construction of sequencing analysis pipelines still remains a challenging and laborious activity, and a major hurdle for many small research and clinical laboratories. We developed TREVA (Targeted REsequencing Virtual Appliance), making pre-built pipelines immediately available as a virtual appliance. Based on virtual machine technologies, TREVA is a solution for rapid and efficient deployment of complex bioinformatics pipelines to laboratories of all sizes, enabling reproducible results. The analyses that are supported in TREVA include: somatic and germline single-nucleotide and insertion/deletion variant calling, copy number analysis, and cohort-based analyses such as pathway and significantly mutated genes analyses. TREVA is flexible and easy to use, and can be customised by Linux-based extensions if required. TREVA can also be deployed on the cloud (cloud computing), enabling instant access without investment overheads for additional hardware. TREVA is available at http://bioinformatics.petermac.org/treva/

The TREVA workflow: execution of primary and secondary pipelines for variant calling on individual and related groups of samples.

<p>The TREVA workflow: execution of primary and secondary pipelines for variant calling on individual and related groups of samples.</p