Enhanced Recovery After Surgery Protocol Allows Safe Same-Day Discharge in Expander Based and Oncoplastic Breast Reconstruction.

PURPOSE: Data after enhanced recovery after surgery (ERAS) with same-day discharge in breast reconstruction is limited. This study evaluates early postoperative outcomes after same-day discharge in tissue-expander immediate breast reconstruction (TE-IBR) and oncoplastic breast reconstruction. METHODS: A single-institution retrospective review of TE-IBR patients from 2017 to 2022 and oncoplastic breast reconstruction patients from 2014 to 2022 was performed. Patients were divided by procedure and recovery pathway: group 1 (TE-IBR, overnight admission), group 2 (TE-IBR, ERAS), group 3 (oncoplastic, overnight admission), and group 4 (oncoplastic, ERAS). Groups 1 and 2 were subdivided by implant location: groups 1a (prepectoral) and 1b (subpectoral), and groups 2a (prepectoral) and 2b (subpectoral). Demographics, comorbidities, complications, and reoperations were analyzed. RESULTS: A total of 160 TE-IBR patients (group 1, 91; group 2, 69) and 60 oncoplastic breast reconstruction patients (group 3, 8; group 4, 52) were included. Of the 160 TE-IBR patients, 73 underwent prepectoral reconstruction (group 1a, 25; group 2a, 48), and 87 underwent subpectoral reconstruction (group 1b, 66; group 2b, 21). There were no differences in demographics and comorbidities between groups 1 and 2. Group 3 had a higher average body mass index than group 4 (37.6 vs 32.2, P = 0.022). There was no significant difference between groups 1a and 2a or between groups 1b and 2b in rates of for rates of infection, hematoma, skin necrosis, wound dehiscence, fat necrosis, implant loss, or reoperations. Group 3 and group 4 showed no significant difference in any complications or in reoperations. Notably, no patients in same-day discharge groups required unplanned hospital admission. CONCLUSIONS: Many surgical subspecialities have successfully adopted ERAS protocols into their patient care and have shown both its safety and feasibility. Our research shows that same-day discharge in both TE-IBR and oncoplastic breast reconstruction does not increase risk for major complications or reoperations.

The conserved transmembrane RING finger protein PLR-1 downregulates Wnt signaling by reducing Frizzled, Ror and Ryk cell-surface levels in C. elegans.

Wnts control a wide range of essential developmental processes, including cell fate specification, axon guidance and anteroposterior neuronal polarization. We identified a conserved transmembrane RING finger protein, PLR-1, that governs the response to Wnts by lowering cell-surface levels of the Frizzled family of Wnt receptors in Caenorhabditis elegans. Loss of PLR-1 activity in the neuron AVG causes its anteroposterior polarity to be symmetric or reversed because signaling by the Wnts CWN-1 and CWN-2 are inappropriately activated, whereas ectopic PLR-1 expression blocks Wnt signaling and target gene expression. Frizzleds are enriched at the cell surface; however, when PLR-1 and Frizzled are co-expressed, Frizzled is not detected at the surface but instead is colocalized with PLR-1 in endosomes. The Frizzled cysteine-rich domain (CRD) and invariant second intracellular loop lysine are crucial for PLR-1 downregulation. The PLR-1 RING finger and protease-associated (PA) domain are essential for activity. In a Frizzled-dependent manner, PLR-1 reduces surface levels of the Wnt receptors CAM-1/Ror and LIN-18/Ryk. PLR-1 is a homolog of the mammalian transmembrane E3 ubiquitin ligases RNF43 and ZNRF3, which control Frizzled surface levels in an R-spondin-sensitive manner. We propose that PLR-1 downregulates Wnt receptor surface levels via lysine ubiquitylation of Frizzled to coordinate spatial and temporal responses to Wnts during neuronal development.

Premonition of death in trauma: a survey of healthcare providers.

Prognostication in western medicine has traditionally been based on objective scientific criteria, yet providers often rely on a feeling or "sense" based on experience to provide prognoses. In trauma, some providers believe that patients who express a feeling of death are more likely to die. We randomly surveyed 302 members of the Eastern Association for the Surgery of Trauma regarding patient's premonitions of death (POD). Ninety-five per cent of respondents reported encountering patients who expressed POD. Fifty per cent agreed patients expressing POD had a higher mortality rate. Fifty-seven per cent believe patient willpower affects outcome. Forty-four per cent agreed patients have an innate ability to sense their ultimate outcome after injury; 85 per cent believe patient's POD do not cause deviations from protocols. Most trauma providers have encountered patients expressing POD. Whereas most believe that a patient's willpower affects outcome, they do not believe that expressing a desire to live decreases mortality with seemingly fatal injuries. Providers who have witnessed negative POD believe these patients are more likely to die, however, they do not deviate from treatment protocols. This survey represents the first attempt to understand the magnitude of premonition of death in trauma and the need for future research.