RESUMO
OBJECTIVES: Physical examination and computed tomography (CT) are useful to rule out cervical spine injury (CSI). Computed tomography scans increase lifetime cancer risk in children from radiation exposure. Most CSI in children occur between the occiput and C4. We developed a cervical spine (C-spine) clearance guideline to reduce unnecessary CTs and radiation exposure in pediatric trauma patients. METHODS: A pediatric C-spine clearance guideline was implemented in September 2018 at our Level 2 Pediatric Trauma Center. Guidance included CT of C1 to C4 to scan only high-yield regions versus the entire C-spine and decrease radiation dose. A retrospective cohort study was conducted comparing preguideline and postguideline of all pediatric trauma patients younger than 8 years screened for CSI from July 2017 to December 2020. Primary endpoints included the following: number of full C-spine and C1 to C4 CT scans and radiation dose. Secondary endpoints were CSI rate and missed CSI. Results were compared using χ 2 and Wilcoxon rank-sum test with P < 0.05 significant. RESULTS: The review identified 726 patients: 273 preguideline and 453 postguideline. A similar rate of total C-spine CTs were done in both groups (23.1% vs 23.4%, P = 0.92). Full C-spine CTs were more common preguideline (22.7% vs 11.9%, P < 0.001), whereas C1 to C4 CT scans were more common post-guideline (11.5% vs 0.4%, P < 0.001). Magnetic resonance imaging utilization and CSIs identified were similar in both groups. The average radiation dose was lower postguideline (114 vs 265 mGy·cm -1 ; P < 0.001). There were no missed CSI. CONCLUSIONS: A pediatric C-spine clearance guideline led to increasing CT of C1 to C4 over full C-spine imaging, reducing the radiation dose in children. LEVEL OF EVIDENCE: Level IV, therapeutic.
Assuntos
Lesões do Pescoço , Exposição à Radiação , Traumatismos da Coluna Vertebral , Ferimentos não Penetrantes , Criança , Humanos , Estudos Retrospectivos , Exposição à Radiação/prevenção & controle , Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/lesões , Tomografia Computadorizada por Raios X/efeitos adversos , Tomografia Computadorizada por Raios X/métodos , Traumatismos da Coluna Vertebral/diagnóstico , Lesões do Pescoço/complicações , Ferimentos não Penetrantes/complicaçõesRESUMO
The use of robotic technology in general surgery continues to increase, though its utility for emergency general surgery remains under-studied. This study explores the current trends in patient outcomes and cost of robotic emergency general surgery (REGS). The Florida Agency for Healthcare Administration database (2018-2020) was queried for adult patients undergoing intra-abdominal emergency general surgery within 24 h of admission and linked to CMS Cost Reports/Hospital Compare, American Hospital Association, and Rand Corporation Hospital datasets. Patients from the four most common REGS procedures were propensity matched to laparoscopic equivalents for hospital cost analysis. A telephone survey was performed with the top 10 REGS hospitals to identify key qualities for successful REGS programs. 181 hospitals (119 REGS, 62 non-REGS) performed 60,733 emergency surgeries. Six-percent were REGS. The most common REGS were cholecystectomy, appendectomy, inguinal and ventral hernia repairs. Before and after propensity matching, total cost for these four procedures were significantly higher than their laparoscopic equivalents, which was due to higher surgical cost as the non-operative costs did not differ. There were no differences in mortality, individual complications, or length of stay for most of the four procedures. REGS volume significantly increased each year. The survey found that 8/10 hospitals have robotic-trained staff available 24/7. Although REGS volume is increasing in Florida, cost remains significantly higher than laparoscopy. Given higher costs and lack of significantly improved outcomes, further study should be undertaken to better inform which specific patient populations would benefit from REGS.
Assuntos
Hérnia Ventral , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Adulto , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Colecistectomia/métodos , Custos Hospitalares , Estudos Retrospectivos , Herniorrafia/métodosRESUMO
We assessed the ability of cryptophycin 52 (LY355703), a novel antimicrotubule, to induce growth arrest and apoptosis in prostate cancer cell lines and investigated potential molecular mechanisms of death. LNCaP (androgen-dependent) and DU-145 (androgen-independent) cells accumulated in G(2)-M phase of the cell cycle and progressively acquired sub-G(0)-G(1) DNA content after 48 h of exposure to cryptophycin 52 (1-10 pM). Induction of apoptosis was confirmed by DNA ladder formation and detection of cytoplasmic nucleosomes. PC-3 (androgen-independent) cells were less responsive to cryptophycin 52-induced death. Apoptosis was associated with proteolytic processing and activation of the caspase-3-like subfamily proteins caspase-3 and caspase-7 and cleavage of the caspase substrate poly(ADP-ribose) polymerase. The pan-caspase inhibitor BOC-Asp(OMe)-fluoromethylketone effectively reduced cryptophycin 52-induced caspase-3-like protease activity and apoptosis in DU-145 cells. In contrast, BOC-Asp(OMe)-fluoromethylketone did not inhibit apoptosis induction in LNCaP cells by cryptophycin 52, even though both cryptophycin 52-induced caspase-3-like activity and staurosporine-induced death were blocked under identical conditions. Cryptophycin 52 induced phosphorylation of c-raf1 and bcl-2 and/or bcl-x(L) to comparable levels in all cell lines studied, and LNCaP cells overexpressing bcl-2 were more resistant to cryptophycin 52-induced apoptosis. Up-regulation of p53, bax, and p21 expression was induced in wild-type p53-expressing LNCaP cells only after cryptophycin 52 exposure. A sustained increase in c-Jun NH(2)-terminal kinase phosphorylation was also observed, the levels of which strongly correlated with apoptosis. We conclude that apoptosis induced by cryptophycin 52 in prostate cancer cells is androgen status independent, cell type specific for caspase requirement, modulated by the bcl-2 family, linked to but not dependent on p53, and strongly correlated with c-Jun NH(2)-terminal kinase phosphorylation. Cryptophycin 52-induced apoptosis in prostate cancer cells is therefore associated with multiple cell line-specific alterations in apoptosis-associated proteins and pathways.