Molecular Insights into the Architecture of the Human SMC5/6 Complex.

A family of Structural Maintenance of Chromosome (SMC) complexes is essential for key cellular processes ensuring proper cohesion, condensation and replication. They share a common SMC-kleisin architecture allowing them to embrace DNA. In SMC5/6, the NSE1 and NSE3 KITE and NSE4 kleisin subunits form a stable subcomplex that binds DNA and regulates essential processes. In addition, NSE5 and NSE6 subunits associate with the core SMC5/6 complex and recruit it to DNA repair sites. The architecture of the SMC5/6 complex is crucial for its proper functioning, and mutations within the human SMC5/6 subunits result in severe syndromes. Therefore, we aimed to analyze interactions within the human SMC5/6 complex and determine its detailed architecture. Firstly, we analyzed different parts of SMC5/6 by crosslinking and MS/MS analysis. Our data suggested domain arrangements of hNSE1-hNSE3 and orientation of hNSE4 within the hNSE1-hNSE3-hNSE4 subcomplex. The crosslinking and electron microscopic analysis of the SMC5/6 core complex showed its rod-like architecture with juxtaposed hSMC5-hSMC6 arms. Additionally, we observed fully or partially opened hSMC5-hSMC6 shapes with the hNSE1-hNSE3-hNSE4 trimer localized in the SMC head domains. To complete mapping of the human SMC5/6 complex architecture, we analyzed positions of hNSE5-hNSE6 at the hSMC5-hSMC6 arms. We showed that hNSE6 binding to hNSE5 and the coiled-coil arm of hSMC6 is mediated by a conserved FAM178 domain, which we therefore renamed CANIN (Coiled-coil SMC6 And NSE5 INteracting) domain. Interestingly, hNSE6 bound both hSMC5 and hSMC6 arms, suggesting that hNSE6 may lock the arms and regulate the dynamics of the human SMC5/6 complex.

Rocuronium versus suxamethonium for rapid sequence induction of general anaesthesia for caesarean section: influence on neonatal outcomes.

BACKGROUND: In a previous study we compared rocuronium and suxamethonium for rapid-sequence induction of general anaesthesia for caesarean section and found no difference in maternal outcome. There was however, a significant difference in Apgar scores. As this was a secondary outcome, we extended the study to explore this finding on a larger sample. METHODS: We included 488 parturients of whom 240 were women from the original study. Women were randomly assigned to receive either rocuronium 1mg/kg (ROC n=245) or suxamethonium 1mg/kg (SUX n=243) after propofol 2mg/kg. Anaesthesia was maintained with up to 50% nitrous oxide and up to one minimum alveolar concentration of sevoflurane until the umbilical cord was clamped. We compared neonatal outcome using Apgar scores and umbilical cord blood gases. RESULTS: Data were analysed for 525 newborns (ROC n=263vs. SUX n=262). There was a statistically significant difference in the proportion of Apgar scores <7 at 1min (ROC 17.5% vs. SUX 10.3%, P=0.023) but no difference at 5min (ROC 8% vs. SUX 4.2%, P=0.1) or 10min (ROC 3.0% vs. SUX 1.9%, P=0.58). There was no difference between groups in other measured outcomes. CONCLUSION: The use of rocuronium was associated with lower Apgar scores at 1min compared with suxamethonium. The clinical significance of this is unclear and warrants further investigation.

Detection of the etiological agents of hospital-acquired pneumonia - validity and comparison of different types of biological sample collection: a prospective, observational study in intensive care patients.

BACKGROUND: There is still a lack of evidence as to which method of biological sample collection is optimal for identifying bacterial pathogens causing hospital-acquired pneumonia (HAP). Much effort has been made to find an easy and valid approach to be used in clinical practice. METHODS: The primary endpoint of this prospective, observational study was to determine the predictive value of oropharyngeal swab (OS) and gastric aspiration (GA) as simple and non-invasive methods for diagnosing HAP. Their efficacy was compared to endotracheal aspiration (ETA) and protected specimen brushing (PSB), the standard methods approved for HAP diagnosis. RESULTS: Initially, 56 patients were enrolled. Significant amounts of bacterial pathogens were detected in 48 patients (79 isolates) in Round A and in 39 patients (45 isolates) in Round B (after 72 hours). The sensitivity rates were: ETA 98%, PSB 31%, OS 64% and GA 67% in Round A and ETA 87%, PSB 32%, OS 74% and GA 42% in Round B. Strains of 12 bacterial species were identified in the samples. The three most common etiological agents (both rounds together) were Klebsiella pneumoniae (23.7%), Burkholderia multivorans (21.1%) and Pseudomonas aeruginosa (15.8%). CONCLUSIONS: Blind ETA is an optimum method for obtaining biological samples for identification of etiological agents causing HAP in intubated patients. Microbial etiological agents were more frequently detected in ETA samples than in those collected by PSB. If ETA/PSB results are negative, samples may be collected by OS and/or GA as these techniques followed ETA in terms of the frequency of pathogen detection.

[Surgery for degenerative spondylolisthesis of the lumbar spine using intra-articular fusion. A prospective study]. / Operace degenerativní spondylolistézy bederní pátere metodou intraartikulární fúze: prospektivní studie.

PURPOSE OF THE STUDY: The aim of the study is to present our surgical method of treating degenerative spondylolisthesis, which includes radical bilateral laminectomy to relieve compression on the spinal cord, transpedicular fixation of the segment and arthrodesis by bilateral intra-articular fusion. MATERIAL AND METHODS: This surgery was indicated in patients with grade I or grade II of degenerative sponylolisthesis with a 4-mm or more slippage. Our prospectively studied group consisted of 46 patients (17 men, 29 women; average age, 64.2 years; range, 39-84 years). Before surgery and at 1 year after the procedure, the intensity of axial pain and that of radicular pain were each assessed using the visual Analogue Scale (VAS). Difficulty in performing daily living activities was measured by the Oswestry Disability Index (ODI). The surgical procedure included laminectomy, partial medial facetectomy, foraminotomy to relieve pressure on the spinal nerve roots and transpedicular fixation to provide stability. Using a cutter, cartilage was separated off the cortical bone and, in order to facilitate fusion, bone cavities thus produced were filed with corticospongious grafts harvested from the removed vertebral arch with Kerrison forceps. At 1-year follow-up, dynamic X-ray was used to evaluate spine alignment and, on a CT scan, the degree of intra-articular fusion was assessed. Fusion was achieved when bone density measurement showed more than 350 Hounsfield Units (HU). For the measurements, the authors used their own modified method by means of a Region of Interest (ROI) analysis. The clinical and radiographic results were statistically evaluated. RESULTS: At 1 year after surgery, lumbar flexion-extension bending X-ray films revealed stability of the treated segments in all patients (100%). CT examination showed bone density higher than 350 HU at both joints, i.e., complete bone fusion, also in all 46 patients. The mean post-operative ODI score was significantly lower than its mean pre-operative value (23.6 vs 55.4), which was improvement by 57.4%. The differences in pre- and post-operative VAS scores were also statistically significant. The mean VAS score for low back pain decreased from 7.61 to 1.74, i.e., improvement by 77.1%, and the mean vAS score for radicular pain dropped from 6.98 to 1.24, i.e., improvement by 82.2%. Assessed by Odom's outcome criteria, the results were excellent in 26 patients and very good in 20 patients, and they were not related to age, gender or the spinal level treated. Any complications associated with the operative procedure or wound healing and requiring repeated surgical treatment were not recorded. DISCUSSION: The surgical technique described here has advantages over other methods in reliable achieving nerve decompression, joint fusion and spinal stability at low costs and short operative time. In addition, it avoids the necessity of harvesting bone from the iliac crest. CONCLUSIONS: At 1-year follow-up all patients showed better health conditions, with improvement in average scores for the ODI by 57%, for low back pain by 77% and for radicular and claudication pain by 82%. The technique of intra-articular fusion for treatment of degenerative spondylolisthesis resulted in solid bone fusion and spinal stability in all patients.

[Use of artifiial bone in lateral interbody fusion of the lumbar spine: a prospective radiographic study]. / Pouzití umelé kostní náhrady pri laterální mezitelové fúzi na bederní páteri: prospektivní radiologická studie.

PURPOSE OF THE STUDY: The aim of the study was to evaluate the extent of fusion using synthetic ß-tricalcium phosphate as a bone substitute in extreme lateral interbody fusion (XLIF). MATERIAL AND METHODS: In this prospective study, patients undergoing XLIF with an Oracle cage filed with the artifiial bone ChronOs Strip (Synthes, USA) were evaluated. The group consisted of 61 patients, 33 women and 28 men, with an average age of 50.9 years (range, 21 to 73 years). A total of 64 segments were operated on. Stand-alone interbody fusion was performed in 14 segments, lateral plate fiation in 19, transpedicular (TP) fiation before XLIF was carried out in 14 and TP fiation after XLIF in 17 segments. At one-year follow-up, dynamic X-rays to exclude instability, and CT images were obtained in order to evaluate the extent of bone fusion outside the implant (complete fusion, partial fusion, no fusion) and inside it (% of the bone fusion surface area). In addition, bone mineral density following fusion mass bone quality (expressed in Hounsfild units [HU]) was assessed inside the implant at the site of ChronOs Strip placement, using a region of interest (ROI) analysis. For the evaluation of fusion bone quality inside the implant on CT scans with HU qualifiation, the authors propose the following scale: 1. no fusion (0-99 HU) 2. Uncertain fusion (100-190 HU) 3. Probable fusion (200-299 HU) 4. Reliable fusion (300 and more HU) All results were statistically evaluated in relation to the gender, age, treated segment, surgical diagnosis, method of fiation, implant height and intervertebral space reduction at one-year follow-up. RESULTS: Fusion outside the implant was complete in 18 segments (28%) and partial in 27 (42%); in 19 segments (30%) it was not detected. The bone fusion surface area inside the implant was 54.5% (0-100%) on the average. It was related to age and implant height; the surface area increased with increasing age and with increasing implant height. Solid bone fusion inside the implant, as assessed on CT images using HU, was reliable in 36 segments (56%), probable in 11 (17%), uncertain in 10 (16%) and was not detected in seven segments (11%). A signifiant relationship was found between the quality of bone fusion and the type of fiation. Of the segments treated by stand-alone XLIF, 29% showed no fusion while the segments managed by lateral plate fiation had 32% of them with probable fusion. Correlations were also found with the height of an implant (the higher the implant, the more reliable its fusion), with age (the higher age, the higher bone density) and with the spinal level (the lower level, the lower bone density). In 45 (70%) segments, bone mineral density inside the implant was higher than the density of surrounding spongious bone. The average density inside the implant was 333.7 HU (14-1075) and that of the surrounding bone was 244.6 HU (66-500). The intervertebral space was reduced by an average of 1.1 mm (0-6.2). All treated segments were found stable on dynamic X-rays. DISCUSSION: The use of a tricortical bone graft collected from the iliac crest is associated with pain at the harvest donor site in 2.8% to 39% of the cases, and this has been an impetus for many surgeons to use bone substitutes. In terms of the final outcome, i.e., solid bone fusion, the difference between the resorption rates of allogenous graft/artificial bone and ingrowth of autologous bone (from vertebral bodies) plays the most decisive role. CONCLUSIONS: The change of (3-tricalcium phosphate to bone tissue is not always reliable and this can largely be expected when the resorption rate of ChronOs strip is low, i.e., at higher patient age and with a higher height of the implant.The authors recommend increasing the probability of solid fusion in XLIF by using lateral plate fixation.The method of assessing bone fusion by measuring bone density on CT scans proved to be useful because of its objectivity, and it can replace the current assessments based only on subjective judgement.

[Serious sepsis treatment in intensive care departments in the Czech Republic -  EPOSS Project pilot results]. / Lécba tezké sepse na pracovistích intenzivní péce v Ceské republice -  pilotní výsledky projektu EPOSS.

INTRODUCTION: Severe sepsis is still associated with significant morbidity and mortality, which is however different, as well as its management, depending on the region. What is the situation in the Czech Republic and what is the character of patients with severe sepsis is currently not known. The aim of the project is to describe the processes of care, outcome and characteristics of patients with severe sepsis admitted to the intensive care department of the Czech Republic. METHODS: This is a multicentre and observational project with retrospective enrollment of patients who meet the criteria for severe sepsis before or within 24 hours after admission to selected intensive care units (ICU EPOSS). RESULTS: 394 patients were analyzed. Median age at admission was 66 (56- 76) years, males predominated (58.9%) and the median APACHE II score on admission was 25 (19- 32). Patients were predominantly medical (56.9%) and most were secondary admitted from other ICU (53.6%). Meeting the criteria of severe sepsis was most frequently within the period (± 4 hours) of admission the EPOSS ICU (77.6%). Median total fluid intake during the first 24 hours was 6,680 (4,840- 9,450) ml. Most patients required mechanical ventilation (58.4%). Compliance with the resuscitation bundle of severe sepsis in our group was very good and was associated with lower mortality of patients. Most frequently, the EPOSS ICU length of stay (LOS) was 7 (3- 15) days and median hospital LOS was 13 (8- 28) days. Hospital mortality in our cohort was 35.8%. CONCLUSION: Introducing the project, which in its first stage obtained valuable and internationally comparable data about patients with severe sepsis admitted to the involved ICU in the Czech Republic.

[Percutaneous dynamic interspinous stabilisation for the treatment of juxtafacet cysts of the lumbar spine: prospective study]. / Lécba juxtafacetárních cyst bederní pátere perkutánní dynamickou interspinózní stabilizací: prospektivní studie.

PURPOSE OF THE STUDY: To present the authors' philosophy on the surgical treatment of juxtafacet cysts of the lumbosacral (LS) spine, with its primary aim of dynamic lumbar stabilisation with an interspinous implant, inserted by a minimally invasive approach, without concurrent exploration of the spinal canal and cyst removal. MATERIAL AND METHODS: During a 20-month period, ten patients aged between 25 and 70 years (average age, 53.2 years) were indicated for surgical treatment of a juxtafacet cyst by percutaneous insertion of an In-Space interspinous spacer without surgical exploration of the spinal canal. The group comprised six men and four women. At a follow-up of 6 weeks to 18 months, each patient underwent MRI examination of the LS spine and the degree of cyst resorption was assessed. The visual analogue scale (VAS) scores, Oswestry Disability Index (ODI) and range of motion (ROM) values, and a sagittal angle (SA) of the segment treated obtained for the whole group at 3 to 18 months after surgery were compared with the pre-operative va - lues. The surgeon evaluated the effect of surgery on radicular and axial pain. RESULTS: Complete resorption of the cyst was found in seven patients (70%) and three (30%) showed partial resorption. Complete resolution of radicular symptoms was reported by five patients (50%); five experienced partial relief (50%). Lumbago was relieved completely in three (30%) and partially in seven (70%) patients. The average VAS score was 6.7 points (range, 4-10) pre-operatively and 3.5 (0-8) post-operatively, i.e. it decreased by 3.2 points, which meant an improvement by 48%. The average ODI value was 58.4% (range, 32-80) pre-operatively and 23.9% (0-70) post-operatively, i.e., it decreased by 34.5 percentage points and was an improvement by 59%. The average ROM measures were 5.65 degrees (range, 2°-10°) pre-operatively and 5.55 degrees (0°-19°) post-operatively. The average pre- and post-operative sagittal angles in normal lumbar lordosis were 7.1 degrees (1°-13°) and 6.2 degrees (1°-11°), respectively. DISCUSSION: The conventional surgical procedure involves cyst extirpation. However, the procedure only relieves nerve root compression but does not remove the cause of juxtafacet cyst development, which is due to facet joint degeneration and instability. This may results in persistent or recurrent clinical symptoms. On the other hand, a reduction of both mobility and loading of the intervertebral joints achieved by implantation of an interspinous spacer is the mechanism allowing for resorption of the cyst and resolution of symptoms. CONCLUSIONS: 1. The original method of treating juxtafacet cysts of the LS spine by an In-Space interspinous spacer, as presented here, was efficient in all patients and resulted in complete, or at least partial, resorption of the cyst. 2. Segmental mobility and spondyloarthritis are the major aetiological factors of juxtafacet cyst development. 3. Dynamic interspinous stabilisation will reduce loading of the intervertebral joints and will thus allow for cyst resorption and clinical symptom resolution. 4. Percutaneous implantation of an "In-Space" interspinous spacer is a minimally invasive method of dynamic stabilisation that means no restrictions in patients' activities and reduces the length of hospital stay.

[Dens fracture with concurrent subaxial cervical spine injury in patients with ankylosing spondylitis]. / Kombinace zlomenin dentu C2 a subaxiální krcní pátere u pacientu s ankylozující spondylartritidou.

Odontoid process fractures in patients with ankylosing spondylitis (AS) are rare and their finding together with subaxial cervical spine injury is a great exception. Neither the mechanism of such a combined cervical spine injury nor its surgical treatment has so far been reported in the relevant literature (MEDLINE). The authors present two such cases, one in a 30- and the other in a 74-year-old man. Both AS patients showed a common mechanism of injury sustained in a car accident, which involved hitting a solid barrier at 60 to 70 kilometres per hour, resulting in hyperextension of the cervical spine. In both patients the fractures were stabilised from the anterior approach: the dens fractures with one or two screws by the Magerl-Böhler method and the subaxial fractures with long-plate and screw fixation. At 2 post-operative years complete bone union of the subaxial spine was recorded in both patients; complete healing of the dens fracture was achieved in one patient while in the other partial fibrous union of the dens fracture occurred.

Pulsed radiofrequency therapy versus greater occipital nerve block in the management of refractory cervicogenic headache - a pilot study.

The aim of this pilot study was to compare the efficacy of pulsed radiofrequency to the greater occipital nerve versus a greater occipital nerve block with a mixture of local anaesthetic and steroid in the management of refractory cervicogenic headache. We enrolled 30 patients suffering from refractory cervicogenic headache. Patients were randomly allocated into two groups of fifteen. A greater occipital nerve block with steroid was utilised in group A, while a pulsed radiofrequency treatment was employed in group B. Success of both procedures was evaluated by comparing pre and post intervention Visual Analogue Scale of pain, Medication Quantification Scale - III. and Global Perceived Effect at three and 9 months after the procedures. At three months post therapy a significant decrease in Visual Analogue Scale (p<0.001) was identified (3.2 points in group A, 3.3 points in group B respectively). In group B pain remained reduced even after 9 months (p<0.001) when compared to pre treatment scores. The consumption of analgesic medication was reduced significantly in both groups at three months (p<0.001) and 9 months (p<0.01), respectively. No serious complication was noted. Greater occipital nerve block is a safe, efficient technique in the management of cervicogenic headaches. Despite the lack of high quality scientific evidence (level III or IV) in the literature, we have extensive experience with steroid application and pulsed radiofrequency to the greater occipital nerve and report the beneficial results in our study.

[Treatment of degenerative spondylolisthesis of the lumbosacral spine by decompression and dynamic transpedicular stabilisation]. / Operace degenerativní spondylolistézy lumbosakrální pátere dekompresí a dynamickou transpedikulární stabilizací

PURPOSE OF THE STUDY: The aim of the study was to present the effect and advantages of surgical decompression and dynamic transpedicular stabilisation in patients with degenerative spondylolisthesis of the lumbosacral spine. MATERIAL AND METHODS: This prospective study involved patients undergoing dynamic transpedicular stabilisation using Isolock or Isobar TTL (Scient X, France) systems. Between June 2003 and June 2009, 65 patients were treated and followed-up. They were aged 35 to 75 years (average, 57.17 years), and there were 32 men and 33 women. Follow-up ranged from 1 to 6 years. Based on indications for surgery they fell into two groups. Group 1 included 52 patients with grade I or II degenerative spondylolisthesis or retrolisthesis. Group 2 (control) consisted of 13 patients with degenerative disc disease or failed back surgery syndrome. The disorder had always been manifested by combined axial and radicular symptoms. Treatment included posterior decompression of nerve structures by laminectomy in conjunction with semi-rigid stabilisation, without fusion. Followup clinical (VAS, ODI), neurological and radiographic examinations were carried out at 6 weeks, 6 months and 1 to 6 years after surgery. The VAS and ODI results of both groups were statistically analysed and compared. RESULTS: During follow-up the ODI values decreased by 54 % (from 58.4 % to 26.8 %) and VAS values by 62 % (from 7.9 to 3.0) as compared with the pre-operative values, and this was statistically significant. When both groups were compared, the VAS values decreased significantly (by 5.61) in Group 1, as compared with Group 2 (decrease by 3.54). DISCUSSION: In the treatment of pseudospondylolisthesis, the semi-rigid stabilisation with spinal decompression, as presented here, is a convenient alternative to simple decompression without fixation or to various forms of instrumented or non-instrumented arthrodesis. A disadvantage associated with arthrodesis is a higher risk of ASD development; dynamic systems do not allow for reduction of spondylolisthesis and involve a change in sagittal spinal balance, and simple decompression carries the risk of slip progression and recurrent problems. CONCLUSIONS: The authors demonstrated that decompression combined with semi-rigid stabilisation had a very good effect on the clinical state of patients with degenerative spondylolisthesis (retrolisthesis) at medium-term follow-up. The procedure was less effective in other indications. Semi-rigid stabilisation with Isobar TTL or Isolock systems prevented the progression of anterolisthesis or retrolisthesis; none of the patients experienced instrumentation failure. Neither symptomatic restenosis nor disc herniation was found in the instrumented segment. Semi-rigid stabilisation can, if necessary, be converted to fusion or disc replacement.

[Identification of the lumbosacral nerve plexus during the extreme lateral interbody fusion procedure]. / Identifikace lumbosakrálního nervového plexu behem stabilizace typu XLIF.

PURPOSE OF THE STUDY: The aim of this clinical observation study was to determine the extent to which muscle relaxation induced by anesthesia must be intra-operatively reversed for a reliable identification, by intra-operative monitoring, of the lumbosacral (LS) nerve roots during extreme lateral interbody fusion (XLIF). MATERAL AND METHODS: General anesthesia (midazolam, propofol, sufentanil, oxygen/air/sevofluran - rocuronium) was administrated to all pa - tients. Train-of-four (TOF) stimulation of the ulnar nerve at 10-second intervals and an electromyographic response of the adductor pollicis muscle were used, and the duration of neuromuscular block was measured by the value of the TOF-ratio. When the level of recovery from neuromuscular block was TOF-count = 2, reversion to normal function was still accelerated by sugammadex administration at a dose of 2 mg.kg-1. Subsequently, it was determined at which level of muscle relaxation subsidence the first responses to LS nerve root stimulation were evident. Intra-operative neurophysiologial monitoring (IOM) with use of the NIM - Neuro® 3.0 device allowed for assessment of a triggered electromyographic reaction (tEMG) of LS roots to stimulation during surgery. The neuromuscular reactions were evaluated in 11 patients, five men and six women. The results were analysed by descriptive statistics and presented as median and interquartile-range values. RESULTS: In all patients a reliable monitoring of the depth of muscle relaxation was established. The value of supramaximal impulse was 46 mA (38 to 64 mA). The period from rocuronium administration to a spontaneous recovery of the TOF-count = 2 took 33 min (29 to 35 min). Duration from sugammadex administration to a TOF ratio of . 0.70 was 90 seconds (50 to 140) and to a TOF ratio of . 0.90 was 190 seconds (100 to 220 s). A reliable tEMG response of LS nerve roots to electric stimulation at 10 mA intensity was recorded at a TOF ratio of 0.68 (0.56 to 0.77) and at a 5 mA intensity it was reliable at a TOF ratio of 0.86 (0.75 to 0.90).. None of the patients reported radicular symptoms after surgery. DISCUSSION: From the anatomy of the greater psoas muscle and varied patterns of its LS plexus it is obvious that none of the zones is absolutely safe. In XLIF procedures it is therefore recommended to disect the psoas muscle under both visual and IOM control. Intra-operative checking of the depth of muscle relaxation then will provide information that conditions not affected by rocuronium administration and necessary for the detection of LS roots have been provided. CONCLUSIONS: 1. For a reliable intra-operative identification of LS nerve roots by electric stimulation at a 10 mA intensity it is recommended to achieve the value of TOF ratio equal to at least 0.70. When stimulation at a lower intensity (5 mA) is used, a TOF ratio of . 0.90 is necessary. 2. Administration of sugammadex to reverse an action of the muscle relaxant rocuronium is an effective and quick method to achieve the values required.

[Reliability of load-sharing classification in indications for anterior vertebral body replacement in thoracolumbar spine fractures]. / Spolehlivost "load-sharing" klasifikace v indikaci prední náhrady obratlového tela u zlomenin torakolumbální pátere.

INTRODUCTION: So far, the Load-Sharing Classification (LSC) has been the commonest method employed to identify indication for anterior replacement of vertebral bodies in thoracolumbar spine fractures. The aim of this study was to verify reliability of the LSC method in indications for anterior replacement surgery. METHODS: Fractures were examined using x-ray, CT and MRI methods. The prospective study included only patients with type A3 comminuted fractures (AO classification) of the thoracolumbar vertebrae (Th11-L2), with MRI confirmed grade 3 or 4 intervertebral disc injuries (according to Oner) and with no concomitant nerve injuries. All fractures were treated using isolated posterior transpedicular (TP) fixation. 18 months after the procedure, angulation of the regional kyphosis, screw rupturing, Visual Analogue Scale (VAS) scores at rest and under loading, Pain Scale (PS) scores and Work Scale (WS) scores were assessed. The study group included 42 patients aged 27-72 years (the mean age was 51.55 y.o.a.), 28 subjects were males and 14 females. Using the LSC classification system, the study group was divided into two subgroups, one including patients with LSC up to grade 6 - Group A (18 subjects) and the other one including patients with LSC 7 to 9 - Group B (24 subjects). RESULTS: Statistical assessment of clinical (PS, WS, VAS at rest and VAS after loading) and radiological findings (the degree of kyphotic changes) at month 18 identified no statistically significant correlations between the two subgroups. TP fixation failures (srews rupturing) occured only in Group A in two subjects. DISCUSSION: Based on the LSC, Group B was expected to have inferior outcomes, however, this was not the case in our study group. Therefore, it can be concluded that LSC is not a reliable predictor of the final clinical and radiological findings in the type A3 fractures with grade 3 or 4 TH-L intervertebral disc injuries. The defined LSC 6- point threshold for indications for anterior vertebral body and disc replacements is arguable. CONCLUSION: The authors do not consider the LSC method sufficiently reliable for determining indications for anterior replacements.

Effect of pulsed radiofrequency therapy on the suprascapular nerve in shoulder pain of various aetiology.

BACKGROUND: Pulsed radiofrequency treatment (PRF) applied to the suprascapular nerve may provide pain relief for patients suffering from shoulder pain as described in three case series. AIMS: The effect of PRF to the suprascapular nerve was retrospectively analysed on 28 patients with shoulder pain lasting longer than 1 month, with a 6-month follow-up. Group A was treated with PRF and local anaesthetics only while group B was treated with PRF, local anaesthetic and steroid. Pain scores were evaluated before and after the procedure and at 1, 3 and 6 months. RESULTS: More than 50% of patients in both groups had significant pain relief after 3 months. No major, but only one minor complication occurred. CONCLUSIONS: Our results suggest that the analgesic effects of PRF last more than 3 months in the majority of patients. The addition of steroid to the PRF treatment appears to have no benefit.

[XLIF--a new technique of the lumbar vertebra disc replacement: initial experience]. / XLIF--nová technika náhrady meziobratlové ploténky bederní pátere: první zkusenosti.

Extreme lateral interbody fusion (XLIF) is a novel technique for the anterior disc replacement. The aim of this report was description of the surgical technique of XLIF. Based on our experience with first eleven patients we report advantages and drawbacks of this method. Patients who presented with symptomatic degenerative disc disease or failed back surgery syndrome were considered candidates for this surgery. The patient was placed in a true right lateral decubitus position and small (6 cm) left lateral skin incision was performed. Access to the lumbar spine was achieved by approach that passes through the retroperitoneally fat and psoas major muscle, using peroperative fluoroscopy. Expandable retractor was inserted, discectomy and replacement by Oracle (Synthes, USA) cage (with synthetic cancellous bone graft) to the interbody space was performed. XLIF represents save surgical method with maximally careful approach and spacious working portal. The new benefit of XLIF is based on the minimally invasive spine surgery technique through retroperitoneal space. The lateral access to the disc avoids the major vessels and nerves and implant placement in the anterior and bilateral position provides sagital and coronal plane imbalance correction.

[Tracheal intubation without muscle relaxant--the impact of different sufentanil doses on the quality of intubating conditions: a prospective study]. / Tracheální intubace bez podání svalového relaxancia-- vliv odlisných dávek sufentanilu na kvalitu intubacních podmínek: prospektivní studie.

BACKGROUND: Following opioid and intravenous anaesthetic, tracheal intubation may be accomplished without any muscle relaxant. In this study, we evaluated the dose requirements for sufentanil with propofol without muscle relaxant administration to obtain clinically acceptable intubation conditions and cardiovascular responses. METHODS AND RESULTS: After midazolam (0.05 mg x kg(-1)), 90 patients were randomized into three equal groups, each receiving sufentanil 0.2 (SUF-0.2), 0.3 (SUF-0.3) or 0.4 (SUF-0.4) microg x kg(-1), respectively. Following induction of anaesthesia with propofol (2 mg x kg(-1)), the quality of tracheal intubation was assessed as excellent or good (clinically acceptable) and poor. Excellent intubation conditions were observed in 28%, 41% and 54% of patients in groups SUF-0.2, SUF-0.3 and SUF-0.4, respectively, while poor conditions were present in 31% (SUF-0.2; p = 0.041 vs. SUF-0.3, p = 0.006 vs SUF-0.4), 7% (SUF-0.3) and 3% (SUF-0.4). Patients with induction-related hypotension were older than those without (60 +/- 15 vs. 52 +/- 17 yr, p = 0.013). CONCLUSIONS: Sufentanil (0.3-0.4 microg x kg(-1)) in combination with propofol (2 mg.kg(-1)) provided clinically acceptable intubating conditions in 93-97% patients.

Influence of gender on the course of neuromuscular block following a single bolus dose of cisatracurium or rocuronium.

BACKGROUND AND OBJECTIVE: There is increasing evidence of gender differences in the pharmacokinetics and pharmacodynamics of aminosteroid neuromuscular blocking agents. Compared to males, females are more susceptible, requiring approximately 30% less rocuronium to achieve the same degree of neuromuscular block. However, little information is available whether this difference is applicable to modern benzylisoquinolines (cisatracurium). METHODS: In all, 848 patients (423 males, 425 females) undergoing general surgery under total intravenous anaesthesia with muscle relaxation, tracheal intubation and mechanical ventilation were studied. Patients were randomized to receive a single bolus dose of cisatracurium (0.1 mg kg-1, 221 males and 199 females) or rocuronium (0.6 mg kg-1, 202 males and 226 females). The onset time for 95% depression of T1, clinical duration until 25% recovery and recovery index (T1 from 25% to 75%) were determined with an NMT electromyographic module of the Datex-Ohmeda S/5 Anaesthesia Monitor. The data for male and female groups were compared with appropriate statistical tests (unpaired t-test, Mann-Whitney rank sum test and Fisher's exact test). RESULTS: In both groups (cisatracurium and rocuronium), males were significantly taller (P < 0.001) and heavier (P < 0.001) than females, but the body mass index was comparable. For rocuronium, the onset time was shorter 91.7 +/- 14.3 s vs. 108.0 +/- 14.6 s (P < 0.001) and the clinical duration was increased in females 43.3 +/- 7.8 min vs. 31.3 +/- 5.5 min (P < 0.001). In the cisatracurium group, both onset times (248.9 +/- 60.7 s for males vs. 253.4 +/- 70.9 s for females) and clinical duration (42.6 +/- 6.9 min for males vs. 43.1 +/- 6.9 min for females) were similar. The recovery index was identical for males and females in both groups. CONCLUSIONS: Females were more sensitive than males to a single bolus dose of rocuronium. Under the study conditions described, the onset time was shorter and the clinical duration was increased in female patients. This suggests that the routine dose of rocuronium should be reduced in females compared to males. On the contrary, we could demonstrate no gender differences in the onset time or clinical duration of cisatracurium.

[The incidence of postoperative residual curarization in the recovery room after rocuronium administration]. / V ýskyt pooperacní reziduální kurarizace na dospávacím pokoji po aplikaci rokuronia.

In 513 patients, we investigated residual curarization after general anaesthesia with rocuronium administered, without peroperative neuromuscular blockade monitoring. On admission to the recovery room, the ulnar nerve was stimulated submaximally (30 mA) and the evoked muscle response was quantified with accelerometry (TOF-Watch SX, Organon). The postoperative residual curarization was defined as a TOF-ratio < 0.9 and could be demonstrated in 174 patients (34 %). Compared to the group with adequate recovery, these patients received larger rocuronium dose [45.4 (SD 13.2) mg vs. 40.4 (SD 14.3) mg, p < 0.01], less experienced anaesthesiologists conducted their case [p <0.01], shorter time had elapsed since the last rocuronium dose [58.4 (20.9) min. vs. 64.9 (27.2) min., p < 0.05], their core temperature was lower [35.4 (0.6) degrees C vs. 35.8 (0.6) degrees C, p < 0.011 and on average, they received less neostigmine during anaesthesia [0.26 (0.47) mg vs. 0.57 (0.71) mg, p < 0.01]. We conclude that it is necessary to antagonize residual block after rocuronium, especially in the absence of perioperative neuromuscular monitoring.

Effect of the neuropeptide substance P on the rat bone marrow-derived osteogenic cells in vitro.

Substance P containing, thin, sensory nerve fibres have been demonstrated in bone and bone marrow. However the role of substance P in bone tissue is not fully understood. We investigated the effects of substance P on the growth and development of rat bone marrow-derived osteogenic cells in vitro. To examine this, the marrow-derived osteogenic cells were treated from 3rd to 6th day of subculture with substance P at concentrations 10(-10), 10(-9) and 10(-8)M. [(3)H]-thymidine, L-2,3-[(3)H]-proline incorporation, protein accumulation, alkaline phosphatase activity, and calcium deposition were measured in cultures. Substance P slightly stimulated [(3)H]-thymidine incorporation at 10(-10) M. Protein accumulation and L-2,3-[(3)H]-proline incorporation were enhanced in a dose dependent manner. Simultaneous application of spantide, a substance P receptor antagonist, could not block substance P-induced L-2,3-[(3)H]-proline incorporation probably because of statistically significant effect of spantide itself. Calcium deposits were significantly lower (about 30%) in cultures treated with SP. This effect was probably due in part by the fall in alkaline phosphatase activity which in substance P treated cultures was decreased about 17%. Our results indicate that substance P could be one of the factors modulating bone metabolism.

Synthesis of N-nicotinoyl-tryptamine (tryptamide).

N-Nicotinoyl-tryptamine was synthetized by acylation of tryptamine with mixed nicotinic anhydride. The synthesis of tryptamine via DL-tryptophan decarboxylation in cyclohexanol, in the presence of tetraline oxidation products as the catalyst, was described as well.