Transient DNMT1 suppression reveals hidden heritable marks in the genome.

Genome-wide demethylation and remethylation of DNA during early embryogenesis is essential for development. Imprinted germline differentially methylated domains (gDMDs) established by sex-specific methylation in either male or female germ cells, must escape these dynamic changes and sustain precise inheritance of both methylated and unmethylated parental alleles. To identify other, gDMD-like sequences with the same epigenetic inheritance properties, we used a modified embryonic stem (ES) cell line that emulates the early embryonic demethylation and remethylation waves. Transient DNMT1 suppression revealed gDMD-like sequences requiring continuous DNMT1 activity to sustain a highly methylated state. Remethylation of these sequences was also compromised in vivo in a mouse model of transient DNMT1 loss in the preimplantation embryo. These novel regions, possessing heritable epigenetic features similar to imprinted-gDMDs are required for normal physiological and developmental processes and when disrupted are associated with disorders such as cancer and autism spectrum disorders. This study presents new perspectives on DNA methylation heritability during early embryo development that extend beyond conventional imprinted-gDMDs.

Digital Necrosis After Lidocaine and Epinephrine Injection in the Flexor Tendon Sheath Without Phentolamine Rescue.

The literature generally supports the safety of epinephrine injection in the digits, but recent case reports describe ischemic adverse events associated with the use of lidocaine and epinephrine in which phentolamine rescue was not performed. We present a case of finger necrosis and subsequent amputation in a patient after 1% lidocaine with 1:100,000 epinephrine was injected in the fat and flexor sheaths in the palm for a 3-finger trigger release. Phentolamine rescue was not performed. All surgeons who use epinephrine in the finger should be prepared to reverse vasoconstriction with phentolamine rescue if there is persistently inadequate perfusion of the fingertip.

Predicting and Estimating Burn Outcomes: An Institutional Analysis of 4622 Cases.

Advances in burn care have improved patient outcomes, and independently validated indices and predictors of burn outcomes warrant re-evaluation. The purpose of this study is to consolidate predictors of burn outcomes and determine the factors that significantly contribute to length-of-stay (LOS) and mortality. A retrospective review was conducted of all burn patients (n = 5778) admitted to a quaternary provincial burn unit from 1973 to 2017. Our inclusion criteria yielded 4622 independent cases. Multivariate linear and logistic regression models were generated, and area-under-receiver-operator-curve (AUROC) analysis was performed. Burn predictors included %TBSA, Baux (classic and revised) index, Abbreviated Burn Severity Index (ABSI), and Ryan score. Primary outcomes were mortality and LOS. Multivariate logistic regression for mortality showed the Baux index to be the best predictor for mortality (OR = 1.11, P < 0.001). The AUROC for Baux index was 0.95. With regard to LOS, ABSI was the best predictor for LOS (P < 0.001). ICU stay, ventilator use, alcoholism, and age are significantly associated with increased LOS. Interestingly, hypertension had a protective effect for LOS (P < 0.01) and trended towards a protective effect in mortality. Lethal score 50% (LS50) improved over the study period. The regressions show that burn mortality and LOS are best predicted with the Baux index and ABSI, respectively. Hypertension may have a protective effect on burn outcomes and may be attributed to increased perfusion to the periphery. These predictive scores are useful in determining institutional outcomes in burn surgery. Objective benchmarking of improvement in burn care outcomes can be established using LS50 trends.

Nosocomial transmission of necrotising fasciitis organisms from prepartum patient to healthcare worker.

Necrotising fasciitis is an aggressive skin and soft tissue infection requiring urgent surgical treatment, resuscitative efforts and intensive care management. We herein present a case of necrotising fasciitis with nosocomial transmission of causative organisms from patient to healthcare worker. Bacterial transmission from human to human despite personal protective equipment is quite rare, and with limited reports in the literature. The patient was also prepartum, representing to our knowledge, one of only a handful of cases of prepartum necrotising fasciitis. Recommendations to avoid healthcare worker transmission include wearing Association of the Advancement of Medical Instrumentation level 4 gowns during debridement, as well as eye protection and changing scrubs and showering between cases.

Do Microsurgical Outcomes Differ Based on Which Specialty Does the Operation? A NSQIP Analysis.

BACKGROUND: Because plastic surgeons do not "own" a specific anatomic region, other surgical specialties have increasingly assumed procedures historically performed by plastic surgery. Decreased case volume is postulated to be associated with higher complication rates. Herein, we investigate whether volume and surgical specialty have an impact on microsurgical complications, specifically surgical site infection (SSI) and reoperation rates. METHODS: The 2005-2015 National Surgical Quality Improvement Program participant use file was queried by Current Procedural Terminology code for breast and head/neck microsurgeries. Multivariate logistic regression was performed to compare the outcomes between surgical specialties. A cumulative frequency variable was introduced to investigate the effect of case volume on complication rates. RESULTS: We captured 6,617 microsurgical cases. Multivariate logistic regression revealed that although the rate of SSI was lower in plastic surgery compared with otolaryngology for head and neck reconstructions (13.3% versus 10.5%) and compared with general surgery for breast reconstructions (5.4% versus 4.7%), there was no significant difference between specialties (P = 0.13; P = 0.96). Increased case volume is negatively correlated with complications. CONCLUSIONS: Plastic surgery is at risk given case cannibalization by other specialties. We conclude that surgical specialty does not affect the rates of SSI and reoperation. We demonstrate a correlation between lower volumes and increased complications, implying that, once a specialty has amassed critical case experience, complication rates may decrease, and outcomes can be equivalent or superior. Case breadth and volumes should be maintained to preserve skills, optimize outcomes, and maintain the specialty as it currently exists.

High-Risk Plastic Surgery: An Analysis of 108,303 Cases From the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).

BACKGROUND: There is a lack of large-scale data that examine complications in plastic surgery. A description of baseline rates and patient outcomes allows better understanding of ways to improve patient care and cost-savings for health systems. Herein, we determine the most frequent complications in plastic surgery, identify procedures with high complication rates, and examine predictive risk factors. METHODS: A retrospective analysis of the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Program plastic surgery data set was conducted. Complication rates were calculated for the entire cohort and each procedure therein. Microsurgical procedures were analyzed as a subgroup, where multivariate logistic regression models determined the risk factors for surgical site infection (SSI) and related reoperation. RESULTS: We identified 108 303 patients undergoing a plastic surgery procedure of which 6 264 (5.78%) experienced ≥1 complication. The outcome with the highest incidence was related reoperation (3.31%), followed by SSI (3.11%). Microsurgical cases comprised 6 148 (5.68%) of all cases, and 1211 (19.33%) experienced ≥1 complication. Similar to the entire cohort, the related reoperation (12.83%) and SSI (5.66%) were common complications. Increased operative time was a common independent risk factor predictive of a related reoperation or development of an SSI (P < 001). Of all microsurgeries, 23.3% had an operative time larger than 10 hours which lead to faster increase in reoperation likelihood. CONCLUSIONS: The complication rate in plastic surgery remains relatively low but is significantly increased for microsurgery. Increased operative time is a common risk factor. Two-team approaches and staged operations could be explored, as a large portion of microsurgeries are vulnerable to increased complications.

HISTORIQUE: Les données à grande échelle sur les complications de la chirurgie plastique font défaut. Une description des taux de référence et des résultats cliniques des patients permettrait de mieux déterminer comment améliorer les soins aux patients et réaliser des économies dans les systèmes de santé. Dans le présent article, les chercheurs recensent les complications les plus fréquentes en chirurgie plastique, dégagent les interventions aux taux de complication élevés et examinent les facteurs de risque prédictifs. MÉTHODOLOGIE: Les chercheurs ont réalisé une analyse rétrospective des données de chirurgie plastique tirées du programme national d'amélioration de la qualité chirurgicale de l'American College of Surgeons entre 2012 et 2016. Ils ont calculé les taux de complications de toute la cohorte et de chaque intervention recensée. Ils ont analysé les interventions microchirurgicales en sous-groupe, où ils ont utilisé des modèles de régression logistique multivariée pour déterminer les facteurs de risque d'infection des plaies opératoires (IPO) et de réopérations s'y rapportant. RÉSULTATS: Les chercheurs ont dénombré 108 303 patients qui avaient subi une intervention en chirurgie plastique, dont 6 264 (5,78 %) avaient souffert d'au moins une complication. Les réopérations (3,31 %), suivies des IPO (3,11 %) étaient les résultats à la plus forte incidence. Les cas de microchirurgie représentaient 6 148 (5,68 %) de toutes les occurrences, et 1211 (19,33 %) ont souffert d'au moins une complication. Tout comme dans l'ensemble de la cohorte, les réopérations (12,83 %) et les IPO (5,66 %) étaient des complications courantes. La plus longue durée de l'opération était un facteur de risque indépendant fréquent, prédicteur d'une réopération ou d'une IPO (p<0,001). Ainsi, 23,3 % des microchirurgies duraient plus de dix heures, ce qui s'associait à une plus forte augmentation du risque de réopération. CONCLUSIONS: Le taux de complications demeure relativement faible en chirurgie plastique, mais est significativement plus élevé en microchirurgie. La longue durée des opérations représente un facteur de risque courant. On pourrait explorer les approches à deux équipes et les opérations échelonnées, car une forte proportion des microchirurgies sont vulnérables à un accroissement des complications.

Evidence-Based Medicine: The Bilateral Cleft Lip Repair.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Understand the epidemiology, abnormal embryology, anatomy, and etiopathogenesis of cleft lip. 2. Be able to classify and describe bilateral cleft lip. 3. Recognize the importance of preoperative management of bilateral cleft lip. 4. Recognize the large breadth of differing management options. 5. Describe key steps and tenets of the surgical repair. SUMMARY: This fourth Maintenance of Certification/Continuing Medical Education article on cleft lip focuses on the topic of bilateral cleft lip. Previous articles placed an emphasis on the unilateral cleft lip, velopharyngeal insufficiency, or cleft lip and palate management. The authors focus on summarizing key points from previous articles and describing the importance of preoperative management and surgical repair of the bilateral cleft lip.

Processes of Health Care Delivery, Education, and Provider Satisfaction in Acute Care Surgery: A Systematic Review.

In recent years, significant workload, high acuity, and complexity of emergency general surgery conditions have led hospitals to replace the traditional on-call model with dedicated acute care surgery (ACS) service models. A systematic search of Ovid, EMBASE, and MEDLINE was undertaken to examine the impact of ACS services on health-care delivery processes and cost, education, and provider satisfaction. From 1827 papers, reviewers identified 22 studies that met inclusion criteria and subsequently used The Evidence-Based Practice for Improving Quality method and Newcastle-Ottawa Scale to score quality and level of evidence. Most studies found an increase in daytime operating, improved patient transit from emergency department to operating room to home, and decreased length of stay. Higher and more diverse case volumes improved resident education and operative experience. ACS services enhanced the educational experience of residents on subspecialty services by offloading emergency work from those services. Finally, surgeons generally felt that ACS services improved job satisfaction, productivity, and billing. The ACS model has demonstrated improvement in timeliness of care, diversified case mix, decreased costs, improved trainee learning, and increased surgeon job satisfaction.

The Unilateral Cleft Lip Repair and Primary Cleft Rhinoplasty.

Supplemental Digital Content is available in the text.

What Is the Best Way to Measure Surgical Quality? Comparing the American College of Surgeons National Surgical Quality Improvement Program versus Traditional Morbidity and Mortality Conferences.

BACKGROUND: Morbidity and mortality conferences have played a traditional role in tracking complications. Recently, the American College of Surgeons National Surgical Quality Improvement Program Pediatrics (ACS NSQIP-P) has gained popularity as a risk-adjusted means of addressing quality assurance. The purpose of this article is to report an analysis of the two methodologies used within pediatric plastic surgery to determine the best way to manage quality. METHODS: ACS NSQIP-P and morbidity and mortality data were extracted for 2012 and 2013 at a quaternary care institution. Overall complication rates were compared statistically, segregated by type and severity, followed by a subset comparison of ACS NSQIP-P-eligible cases only. Concordance and discordance rates between the two methodologies were determined. RESULTS: One thousand two hundred sixty-one operations were performed in the study period. Only 51.4 percent of cases were ACS NSQIP-P eligible. The overall complication rates of ACS NSQIP-P (6.62 percent) and morbidity and mortality conferences (6.11 percent) were similar (p = 0.662). Comparing for only ACS NSQIP-P-eligible cases also yielded a similar rate (6.62 percent versus 5.71 percent; p = 0.503). Although different complications are tracked, the concordance rate for morbidity and mortality and ACS NSQIP-P was 35.1 percent and 32.5 percent, respectively. CONCLUSIONS: The ACS NSQIP-P database is able to accurately track complication rates similarly to morbidity and mortality conferences, although it samples only half of all procedures. Although both systems offer value, limitations exist, such as differences in definitions and purpose. Because of the rigor of the ACS NSQIP-P, we recommend that it be expanded to include currently excluded cases and an extension of the study interval.