The Upstate New York Surgical Quality Improvement Opioid Reduction Project.

Over 5 million Americans currently abuse prescription opioids. Patients' first exposure to opioids is often after surgery. Few opioid guidelines account for the challenges to health care institutions that serve wide catchment areas. We standardized postoperative opioid prescribing recommendations amongst surgical providers at our institutions and analyzed postoperative prescribing habits. The Upstate New York Surgical Quality Improvement (UNYSQI) collaborative met with surgical champions from 16 hospitals to standardize opioid prescribing for 21 surgical procedures. The guidelines were distributed to all surgical care providers at participating institutions. 581,465 pills were dispensed for 12,672 surgeries (average of 45.9 pills per procedure) before implementation. Post-implementation, 1,097,849 pills were dispensed for 28,772 surgeries (average of 38.2 pills per surgery) with over 222,000 fewer pills being prescribed. Our project suggests opioid prescribing guidelines for institutions that serve diverse communities.

Mesenteric Vascular Injury in Trauma: An NTDB Study.

BACKGROUND: Although abdominal trauma remains a major cause of morbidity and mortality, there has not been a large-scale multicenter study regarding outcomes in patients who incur mesenteric vascular injuries. The goal of this retrospective analysis was to investigate the factors associated with outcomes in patients with trauma diagnosed with mesenteric vascular injuries. METHODS: A retrospective database analysis was performed on patients who sustained a mesenteric vascular injury (MVI, ICD-9 902.20-902.29) identified by the 2012 National Trauma Data Bank. Data were analyzed to identify differences in hospital length of stay, emergency room (ER) and final hospital disposition, and mortality based on patient age, gender, race, Injury Severity Score (ISS), and injury type (blunt or penetrating). RESULTS: Of the 1,133 total patients included, blunt trauma accounted for 740 (65%) of the injuries, whereas penetrating trauma accounted for 364 of the injuries (32%). Patients with penetrating injuries were 1.43 times more likely to die from their injuries than those suffering from blunt trauma (95% CI 1.04-1.98, P < 0.05). Patients with a higher ISS (>16) were 5.39 times more likely to die from their injuries than those with a lower ISS (95% CI 1.89-15.4, P = 0.002); if ISS was >25, the patient was 15.1 times more likely to die (95% CI 5.5-41.7, P < 0.001). Men were more likely to suffer from penetrating injuries than women (37% vs. 13%, P < 0.001), and African Americans were nearly 4 times more likely to present with penetrating injuries (69% vs 17%, P < 0.001). Age was also associated with mortality as patients >65 years and between 21 and 44 years were more likely to die from their injuries than patients in other age categories. Of the 740 patients with blunt MVIs, 326 (44%) were taken directly from the ER to the operating room (OR) and 306 (41%) to the intensive care unit (ICU), whereas with penetrating MVIs, 311 (85%) were taken to the OR from the emergency department and 18 (5%) to the intensive care unit. Of the 740 blunt MVIs, 115 died (16%), compared with 76 (21%) of the penetrating MVIs (P < 0.001). Injuries to the hepatic and superior mesenteric arteries were associated with higher mortality, with OR 2.03 and 3.03, respectively (P < 0.001). CONCLUSIONS: The presence of mesenteric arterial injury warrants rapid identification and management as these injuries are associated with significant morbidity and mortality, with penetrating mechanism, injury to large mesenteric vessels, and increased ISS associated with increased mortality.

Abdominal and Pelvic Vascular Injury: A National Trauma Data Bank Study.

The aim of this study was to characterize the outcomes of traumatic abdominal and pelvic vascular injuries. Using the 2012 National Trauma Data Bank, we identified 5858 patients with major abdominal and/or pelvic vascular injury. Patients were stratified by age group, gender, race, Injury Severity Score (ISS), and mechanism of injury. We evaluated the percentage of patients with blunt and penetrating trauma by demographic and correlated the mechanism of injury to the ISS score, emergency room disposition, and hospital disposition. We performed a logistic regression analysis to calculate predictors of death. In the final cohort, 1458 patients (25%) with abdominal/pelvic vascular injury died of trauma. In total, 3368 patients (57%) had a blunt mechanism of injury, whereas 2353 (40%) were victims of a penetrating trauma. Patients with penetrating injuries were 1.72 times more likely to die from their injuries than those with blunt traumas. Patients with higher ISS scores (>16) were more likely to die from their injuries than patients with lower ISS scores. Men were more likely to experience a penetrating vascular injury than women (48% vs 17%). Similarly, 77 per cent of black patients had a penetrating mechanism of injury compared with 20 per cent of white patients. There were 1910 patients with penetrating injuries (81%) that went immediately from the emergency room to the OR, compared with 1287 patients with blunt injuries (38%). Of the patients with blunt injuries, 695 (21%) died, whereas 727 (31%) patients with penetrating injuries died. Abdominal and pelvic traumatic vascular injuries carry a high mortality rate. Penetrating mechanism of injury, ISS score, and race are independent predictors of mortality.

Loss of catalytically inactive lipid phosphatase myotubularin-related protein 12 impairs myotubularin stability and promotes centronuclear myopathy in zebrafish.

X-linked myotubular myopathy (XLMTM) is a congenital disorder caused by mutations of the myotubularin gene, MTM1. Myotubularin belongs to a large family of conserved lipid phosphatases that include both catalytically active and inactive myotubularin-related proteins (i.e., "MTMRs"). Biochemically, catalytically inactive MTMRs have been shown to form heteroligomers with active members within the myotubularin family through protein-protein interactions. However, the pathophysiological significance of catalytically inactive MTMRs remains unknown in muscle. By in vitro as well as in vivo studies, we have identified that catalytically inactive myotubularin-related protein 12 (MTMR12) binds to myotubularin in skeletal muscle. Knockdown of the mtmr12 gene in zebrafish resulted in skeletal muscle defects and impaired motor function. Analysis of mtmr12 morphant fish showed pathological changes with central nucleation, disorganized Triads, myofiber hypotrophy and whorled membrane structures similar to those seen in X-linked myotubular myopathy. Biochemical studies showed that deficiency of MTMR12 results in reduced levels of myotubularin protein in zebrafish and mammalian C2C12 cells. Loss of myotubularin also resulted in reduction of MTMR12 protein in C2C12 cells, mice and humans. Moreover, XLMTM mutations within the myotubularin interaction domain disrupted binding to MTMR12 in cell culture. Analysis of human XLMTM patient myotubes showed that mutations that disrupt the interaction between myotubularin and MTMR12 proteins result in reduction of both myotubularin and MTMR12. These studies strongly support the concept that interactions between myotubularin and MTMR12 are required for the stability of their functional protein complex in normal skeletal muscles. This work highlights an important physiological function of catalytically inactive phosphatases in the pathophysiology of myotubular myopathy and suggests a novel therapeutic approach through identification of drugs that could stabilize the myotubularin-MTMR12 complex and hence ameliorate this disorder.