Patient and operative factors influence delayed discharge following bariatric surgery in an enhanced recovery setting

BACKGROUND

Enhanced Recovery After Surgery (ERAS) programs have been widely adopted in bariatric surgery. However, not all patients are successfully managed in the ERAS setting and there is currently little way of predicting the patients who will deviate from the program. Early identification of these patients could allow for more tailored protocols to be implemented preoperatively to address the issues, thereby improving patient outcomes.

OBJECTIVES

The aim of this study was to elucidate the factors which preclude discharge by comparing patients who were successfully discharged by the end of the first postoperative day (POD 0/1) to those who stayed longer, including revisional surgery in this analysis.

SETTING

A tertiary, high-volume Bariatric Centre, United Kingdom.

METHODS

A retrospective analysis was performed of all patients undergoing bariatric surgery in a single centre in 1 year. Multivariate analyses compared patient and operative variables between patients who were discharged on POD 0/1 and those who stayed longer.

RESULTS

A total of 288 bariatric operations were performed: 78% of operations performed were laparoscopic Roux-en-Y gastric bypass; 22% laparoscopic sleeve gastrectomy. Of these cases, 13% were revisional operations. Four patients returned to theatre on the index admission. 81% of patients were discharged by POD 0/1. A re-presentation within 30 days was seen in 6% of patients. There was no significant difference in length of stay for the type of operation performed (P = .86). Patients who had a revisional procedure were not more likely to stay longer. Length of stay was also independent of age, BMI, and comorbidities. Caucasian patients were more likely to be discharged on POD 0/1 than those of other ethnicities (90% versus 78%; P = .02). Operations performed by trainee surgeons, under consultant supervision, were significantly more likely to be discharged on POD 0/1 (P = .03). However, a logistic regression analysis was unable to predict patients who had a prolonged stay.

CONCLUSIONS

Patient length of stay is independent of BMI, operation, and comorbidities and these factors do not need special consideration in ERAS pathways. Patients undergoing revisional procedures can be managed in the same way as those having primary procedures, with a routine POD 0/1 discharge. However, the impact of individual patient factors, and their interaction, is complex and cannot predict overstay.

Formin 3 directs dendritic architecture via microtubule regulation and is required for somatosensory nociceptive behavior

Dendrite shape impacts functional connectivity and is mediated by organization and dynamics of cytoskeletal fibers. Identifying the molecular factors that regulate dendritic cytoskeletal architecture is therefore important in understanding the mechanistic links between cytoskeletal organization and neuronal function. We identified Formin 3 (Form3) as an essential regulator of cytoskeletal architecture in nociceptive sensory neurons in Drosophila larvae. Time course analyses reveal that Form3 is cell-autonomously required to promote dendritic arbor complexity. We show that form3 is required for the maintenance of a population of stable dendritic microtubules (MTs), and mutants exhibit defects in the localization of dendritic mitochondria, satellite Golgi, and the TRPA channel Painless. Form3 directly interacts with MTs via FH1-FH2 domains. Mutations in human inverted formin 2 (INF2; ortholog of form3) have been causally linked to Charcot-Marie-Tooth (CMT) disease. CMT sensory neuropathies lead to impaired peripheral sensitivity. Defects in form3 function in nociceptive neurons result in severe impairment of noxious heat-evoked behaviors. Expression of the INF2 FH1-FH2 domains partially recovers form3 defects in MTs and nocifensive behavior, suggesting conserved functions, thereby providing putative mechanistic insights into potential etiologies of CMT sensory neuropathies.

Toll and Toll-like receptor signalling in development

The membrane receptor Toll and the related Toll-like receptors (TLRs) are best known for their universal function in innate immunity. However, Toll/TLRs were initially discovered in a developmental context, and recent studies have revealed that Toll/TLRs carry out previously unanticipated functions in development, regulating cell fate, cell number, neural circuit connectivity and synaptogenesis. Furthermore, knowledge of their molecular mechanisms of action is expanding and has highlighted that Toll/TLRs function beyond the canonical NF-κB pathway to regulate cell-to-cell communication and signalling at the synapse. Here, we provide an overview of Toll/TLR signalling and discuss how this signalling pathway regulates various aspects of development across species.

Kek-6: A truncated-Trk-like receptor for Drosophila neurotrophin 2 regulates structural synaptic plasticity

Neurotrophism, structural plasticity, learning and long-term memory in mammals critically depend on neurotrophins binding Trk receptors to activate tyrosine kinase (TyrK) signaling, but Drosophila lacks full-length Trks, raising the question of how these processes occur in the fly. Paradoxically, truncated Trk isoforms lacking the TyrK predominate in the adult human brain, but whether they have neuronal functions independently of full-length Trks is unknown. Drosophila has TyrK-less Trk-family receptors, encoded by the kekkon (kek) genes, suggesting that evolutionarily conserved functions for this receptor class may exist. Here, we asked whether Keks function together with Drosophila neurotrophins (DNTs) at the larval glutamatergic neuromuscular junction (NMJ). We tested the eleven LRR and Ig-containing (LIG) proteins encoded in the Drosophila genome for expression in the central nervous system (CNS) and potential interaction with DNTs. Kek-6 is expressed in the CNS, interacts genetically with DNTs and can bind DNT2 in signaling assays and co-immunoprecipitations. Ligand binding is promiscuous, as Kek-6 can also bind DNT1, and Kek-2 and Kek-5 can also bind DNT2. In vivo, Kek-6 is found presynaptically in motoneurons, and DNT2 is produced by the muscle to function as a retrograde factor at the NMJ. Kek-6 and DNT2 regulate NMJ growth and synaptic structure. Evidence indicates that Kek-6 does not antagonise the alternative DNT2 receptor Toll-6. Instead, Kek-6 and Toll-6 interact physically, and together regulate structural synaptic plasticity and homeostasis. Using pull-down assays, we identified and validated CaMKII and VAP33A as intracellular partners of Kek-6, and show that they regulate NMJ growth and active zone formation downstream of DNT2 and Kek-6. The synaptic functions of Kek-6 could be evolutionarily conserved. This raises the intriguing possibility that a novel mechanism of structural synaptic plasticity involving truncated Trk-family receptors independently of TyrK signaling may also operate in the human brain.

A long-standing paradox had been to explain how brain structural plasticity, learning and long-term memory might occur in Drosophila in the absence of canonical Trk receptors for neurotrophin (NT) ligands. NTs link structure and function in the brain enabling adjustments in cell number, dendritic, axonal and synaptic patterns, in response to neuronal activity. These events are essential for brain development, learning and long-term memory, and are thought to depend on the tyrosine-kinase function of the NT Trk receptors. However, paradoxically, the most abundant Trk isoforms in the adult human brain lack the tyrosine kinase, and their neuronal function is unknown. Remarkably, Drosophila has kinase-less receptors of the Trk family encoded by the kekkon (kek) genes, suggesting that deep evolutionary functional conservation for this receptor class could be unveiled. Here, we show that Kek-6 is a receptor for Drosophila neurotrophin 2 (DNT2) that regulates structural synaptic plasticity via CaMKII and VAP33A. The latter are well-known factors regulating synaptic structure and plasticity and vesicle release. Furthemore, Kek-6 cooperates with the alternative DNT2 receptor Toll-6, and their concerted functions are required to regulate structural homeostasis at the NMJ. Our findings suggest that in mammals truncated Trk-family receptors could also have synaptic functions in neurons independently of Tyrosine kinase signaling. This might reveal a novel mechanism of brain plasticity, with important implications for understanding also the human brain, in health and disease.

Three-tier regulation of cell number plasticity by neurotrophins and Tolls in Drosophila

A three-tier mechanism involving distinct neurotrophin family ligand forms, different Toll receptors, and different adaptors regulates both cell survival and death. This rich mechanism confers cell number plasticity and could underlie structural plasticity in the nervous system and structural integrity, homeostasis, and regeneration in wider contexts.

Cell number plasticity is coupled to circuitry in the nervous system, adjusting cell mass to functional requirements. In mammals, this is achieved by neurotrophin (NT) ligands, which promote cell survival via their Trk and p75^NTR receptors and cell death via p75^NTR and Sortilin. Drosophila NTs (DNTs) bind Toll receptors instead to promote neuronal survival, but whether they can also regulate cell death is unknown. In this study, we show that DNTs and Tolls can switch from promoting cell survival to death in the central nervous system (CNS) via a three-tier mechanism. First, DNT cleavage patterns result in alternative signaling outcomes. Second, different Tolls can preferentially promote cell survival or death. Third, distinct adaptors downstream of Tolls can drive either apoptosis or cell survival. Toll-6 promotes cell survival via MyD88–NF-κB and cell death via Wek-Sarm-JNK. The distribution of adaptors changes in space and time and may segregate to distinct neural circuits. This novel mechanism for CNS cell plasticity may operate in wider contexts.

Review of the Neotropical scale insects formerly assigned to Coelostomidiidae and here transferred to a new tribe within the Monophlebidae (Hemiptera: Sternorrhyncha: Coccoidea)

This study reviews the status of all Neotropical genera and species of Coelostomidiidae (Hemiptera: Coccoidea) and transfers them to the family Monophlebidae in the Cryptokermesini Foldi & Gullan tribe n. (the tribe Cryptokermini Tao & Hao is recognised here as a nomen nudum). This change of family placement for Neotropical taxa is based on the morphology of adult males, as supported by the phylogenetic study of Hodgson & Hardy (2013), and by unpublished DNA data. New diagnoses are provided for each of the four recognised genera of Cryptokermesini: Cryptokermes Hempel, Mimosicerya Cockerell, Neocoelostoma Hempel and Paracoelostoma Morrison. The genus Nautococcus Vayssière is considered here to be a junior synonym (syn. n.) of Mimosicerya and the type species of Nautococcus, N. schraderae Vayssière, thus becomes M. schraderae (Vayssière) comb. n. Cryptokermes mexicanus Morrison is transferred to Mimosicerya as M. mexicana (Morrison) comb. n. Also Cryptokermes mimosae Foldi does not fit the morphological concept of Cryptokermes and is excluded from this genus and revision, and from the new tribe; its taxonomic position is uncertain and requires further study. All type species of the Cryptokermesini, including N. schraderae (as M. schraderae), are redescribed and illustrated based on most female instars and available adult males, examined using optical and scanning electron microscopes. Adult males are described and illustrated only for M. schraderae and N. xerophila. Keys are provided to distinguish the Neotropical monophlebid tribes Cryptokermesini and Llaveiini and to recognise each cryptokermesine genus based on female instars and first-instar nymphs. The included species of Cryptokermesini and their known distributions are: Cryptokermes brasiliensis Hempel from Brazil and C. oaxaensis Foldi from Mexico; Mimosicerya hempeli (Cockerell) from Brazil, M. mexicana from Mexico, M. schraderae from Panama and M. williamsi Foldi from Venezuela; Neocoelostoma xerophila Hempel from Argentina, Bolivia, Brazil, Paraguay and Uruguay; and Paracoelostoma peruvianum Morrison from Peru. All these insects live exposed on their host plant, either inside a secreted test (as for female and immature male instars of Cryptokermes, Neocoelostoma and Paracoelostoma) or the strongly sclerotised derm of the preadult female protects the adult (as for all species of Mimosicerya). Adult females of Mimosicerya are pupillarial, remaining within the exuviae of the previous instar, whereas adult females of the other three genera either remain within their test (and some species may be pupillarial) or escape the test to oviposit. The morphology of the adult female and often the preadult female is strongly modified, with reduction of antennae and legs, and with legs lacking in some species. 

Toll-6 and Toll-7 function as neurotrophin receptors in the Drosophila melanogaster CNS

Neurotrophin receptors corresponding to vertebrate Trk, p75^NTR or Sortilin have not been identified in Drosophila, thus it is unknown how neurotrophism may be implemented in insects. Two Drosophila neurotrophins, DNT1 and DNT2, have nervous system functions, but their receptors are unknown. The Toll receptor superfamily has ancient evolutionary origins and a universal function in innate immunity. Here we show that Toll paralogues unrelated to the mammalian neurotrophin receptors function as neurotrophin receptors in fruit-flies. Toll-6 and Toll-7 are expressed in the central nervous system throughout development, and regulate locomotion, motoraxon targeting and neuronal survival. DNT1 and 2 interact genetically with Toll-6 and 7, bind to Toll-7 and 6 promiscuously, and are distributed in vivo in complementary or overlapping domains. We conclude that in fruit-flies, Tolls are not only involved in development and immunity but also in neurotrophism, revealing an unforeseen relationship between the neurotrophin and Toll protein families.

Fine structure of the tegumentary glands secreting the protective "shield" in a sessile insect (Homoptera, Diaspiddae)

The tegumentary pygidial glands of Aonidiella aurantii (Homoptera, Diaspididae) produce a secretion forming the shield of these fixed parasites of plants. They are formed of seven cells: a principal unpaired secretory cell which produces an abundant glycoproteinaceous secretion; a small associated cell with a secondary reservoir for this secretion; two accessory secretory cells which have very abundant tubular extensions coming from the plasma membrane, and a flocculent secretion gathered in a large sub-cuticular space; two cells forming an enlarged part of the excretory canal, functioning like a spinneret; and finally a single cell forming the tubular duct of this complex gland. The cuticle of the secretory cells has a very special porous structure, through which the secretion passes. The final product is a ribbon formed by two hollow strands stuck together. The exact nature of this secretion is not clear. It is comparable to a silk secretion though it has its own particular characteristics.