Analysis of the Prognostic Potential of Schlafen 11, Programmed Death Ligand 1, and Redox Status in Colorectal Cancer Patients.

The Schlafen 11 (SLFN11) protein has recently emerged as pivotal in DNA damage conditions, with predictive potential for tumor response to cytotoxic chemotherapies. Recent discoveries also showed that the programmed death ligand 1 (PD-L1) protein can be found on malignant cells, providing an immune evasion mechanism exploited by different tumors. Additionally, excessive generation of free radicals, redox imbalance, and consequential DNA damage can affect intestinal cell homeostasis and lead to neoplastic transformation. Therefore, our study aimed to investigate the significance of SLFN11 and PD-L1 proteins and redox status parameters as prognostic biomarkers in CRC patients. This study included a total of 155 CRC patients. SLFN11 and PD-L1 serum levels were measured with ELISA and evaluated based on redox status parameters, sociodemographic and clinical characteristics, and survival. The following redox status parameters were investigated: spectrophotometrically measured superoxide dismutase (SOD), sulfhydryl (SH) groups, advanced oxidation protein products (AOPP), malondialdehyde (MDA), pro-oxidant-antioxidant balance (PAB), and superoxide anion (O2•-). The prooxidative score, antioxidative score, and OXY-SCORE were also calculated. The results showed significantly shorter survival in patients with higher OXY-SCOREs and higher levels of serum SLFN11, while only histopathology-analysis-related factors showed significant prognostic value. OXY-SCORE and SLFN11 levels may harbor prognostic potential in CRC patients.

Combined Diagnostic Efficacy of Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), and Mean Platelet Volume (MPV) as Biomarkers of Systemic Inflammation in the Diagnosis of Colorectal Cancer.

BACKGROUND: Systemic inflammation in colorectal cancer (CRC) may be reflected by neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and mean platelet volume (MPV). This study was designed to investigate the efficiency of preoperative NLR, PLR, and MVP as a tool for the assessment of tumor characteristics in newly diagnosed patients with CRC. PATIENTS AND METHODS: For 300 patients and 300 healthy volunteers, complete blood counts with automated differential counts were performed. The NLR was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count; PLR was calculated by dividing the absolute platelet count by the absolute lymphocyte count. The diagnostic performance of NLR, PLR, and MVP was estimated by ROC curve. RESULTS: ROC curve analysis showed high diagnostic efficacy of NLR and PLR in CRC patients with cut-off values of 2.15 (AUC = 0.790, 95% CI 0.736-0.884, Se = 74.1%, and Sp = 73%) and 123 (AUC = 0.846, 95% CI 0.801-0.891, Se = 73.5%, and Sp = 80%) compared to healthy controls, respectively. The diagnostic efficacy of three combined markers was superior compared with individual markers (AUC = 0.904, 95% CI 0.812-0.989, Se = 96%, and Sp = 70%). CONCLUSION: NRL, PLR, and MPV may be useful markers in diagnostic and early recognition of different stages of CRC; additionally combined all together have stronger diagnostic efficacy.

Impact of Differences in Economic Development and Socioeconomic Stability on Benzodiazepine Exposure between the Three Balkans Countries.

INTRODUCTION: Anxiety disorders are among the most common mental disorders. Benzodiazepines belong to the group of anxiolytic sedatives and the most prescribed drugs in the world. The aim in ours study was to evaluate the differences in the exposure of the population to benzodiazepines (in period from 2014-2018) between Serbia, Slovenia and Croatia, the three countries of the Southwestern Balkans with varying degrees of socioeconomic development. STUDY DESIGN: A academic investigator initiated, pharmacoepidemiological difference-in-difference time series analysis of population exposure to benzodiazepines between the three, geographically close Balkans countries (Slovenia, Serbia, Croatia) with varying degrees of socioeconomic development has been carried out. Study was conducted as academic investigator initiated, in a retrospective manner on monthly basis international data set from January 2014 to December 2018. RESULTS: At the annual level, during the study period from January 2014 to December 2018, compared to Slovenia, Serbia and Croatia had higher DIDs, from 5 fold (Croatia) to 6 fold (Serbia), for all benzodiazepines in total. By analyzing the differences-in-difference, we have shown that influence of both time (month) and country on DIDs is significant as well as their mutual interaction (the country x month) for all benzodiazepines in total. CONCLUSION: Serbia and Croatia must implement explicit measures of reducing benzodiazepine prescription in health primary care based on evidence-based recommendations in the indications where general medicine practitioners/family doctors most commonly prescribe these medicines. Without providing a realistic supplement/alternative to benzodiazepines such as increasing the availability of psychotherapy and improving the structure of psychiatric professionals in healthcare settings, implicit measures are not recommended for reducing prescription, implementing accountability measures for prolonged prescription of benzodiazepines, and in particular for "masked" somatic diseases. All this comes to the fore by raising economic development and socioeconomic stability.

Cell-free DNA as biomarker and source for mutation detection in primary colorectal cancer.

PURPOSE: To analyze if cell-free (cf)DNA levels and the presence of KRAS and BRAF mutations in serum could be used as diagnostic biomarkers in patients with primary colorectal cancer (CRC). METHODS: This study included 92 individuals who were operated due to primary CRC (N=52;study group) and to hemorrhoids (N=40;control group). Serum cfDNA levels were measured with real-time PCR (RT-PCR) using PicoGreen dsDNA quantitation reagent. Colorectal tissue and related blood and serum samples taken at the time of surgery were subjected to DNA extraction and analysis of KRAS and BRAF mutations based on multiplex SNaPshot assay and DNA sequencing. RESULTS: The average cfDNA concentration was lower in patients of the study group (20±7 ng/µL) in comparison to controls (34±9 ng/µL) and this difference was statistically significant (p<0.001). The SNaPshot analysis detected KRAS c35 mutations in colorectal tumor tissue in 14 cases, but the presence of the mutation was not confirmed in cfDNA extracted from blood samples of these patients. CONCLUSIONS: The level of serum cfDNA in CRC is decreased in comparison to patients with hemorrhoids, which questions the usefulness of cfDNA as cancer biomarker. Also, cfDNA does not appear to be suitable as a source for mutation detection in this disease.

Can preoperative CEA and CA19-9 serum concentrations suggest metastatic disease in colorectal cancer patients?

OBJECTIVE: This study was designed to investigate the efficiency of preoperative serum carcinoembryonic antigen (CEA) and carbohydrate cancer antigen (CA19-9) levels for diagnosing synchronous liver metastases and lymph node in colorectal carcinoma (CRC) patients. SUBJECTS AND METHODS: A total of 300 patients with histologically diagnosed CRC were included in this study between May 2014 and March 2015. The data were obtained prospectively from patient's medical records: medical history, demographics, tumor location, differentiation (grade), depth of the tumor (T), lymph node metastases (N), distant metastases (M), lymphatics, venous and perineural invasion, and disease stage. Tumor markers were measured with an electrochemiluminescent assay and the reference value was 5ng/ml for CEA and for Ca19-9, 37u/ml. RESULTS: There was A high statistically significant difference in the levels of serum CEA and CA19-9 between different disease stages of CRC (P<0.001). Regarding different T stages of CRC, We noticed a significant statistical difference in CEA (stage I 3.76±8.73; II 5.68±17.27, III 7.56±14.81, and IV 70.90±253.23) and CA 19-9 levels (stage I 9.65±11.03, II 9.83±11.09; III 19.58±36.91, and IV 228.9±985.38, respectively). The mean CEA and CA19-9 serum levels were significantly higher in patients with regional lymph nodes involvement (CEA 37.21±177.85 vs 4.79±9.90, CA19-9 119.51±687.71 VS 12.24±17.69, respectively, P<0.05) and in liver metastases (CEA 86.56±277.65 vs. 5.98±12.98, and CA19-9 273.27±1073.46 vs. 4.98±3142, respectively, with P<0.001) in comparison to patients without lymph node involvement and liver metastases. We noticed a cut-off value for lymph nodes involvement, for CEA and CA 19-9, 3.5 ng/mL and 7.5 U/mL, respectively. While, a cut-off value for the presence of synchronous liver metastases of these two markers was 3.5ng/mL AND 5.5 U/mL. CONCLUSION: Our study showed that tumor makers, CEA and CA19-9, can be used as diagnostic factors regarding the severity of CRC specifically to suggest metastatic disease in CRC.

Current trends in clinical genetics of colorectal cancer.

Recent innovations in molecular biology and colorectal cancer (CRC) genetics have facilitated the understanding of the pathogenesis of sporadic and hereditary CRC syndromes. The development of technology has enabled data collection for a number of genetic factors, which lead to understanding of the molecular mechanisms underlying CRC. The incidence and the nature of CRC is a mixture of genetic and environmental factors. The current field of interest is to understand how molecular basis could shape predisposition for developing CRC, disease progression and response to chemotherapy. In this article, we summarize new and developing genetic markers, and assess their clinical value for inherited and sporadic CRC.

Burnout of Formal Caregivers of Children with Cerebral Palsy.

BACKGROUND: Burnout syndrome is under-researched within caregivers (CGs) of children with cerebral palsy. The primary aim was to determine the burnout level of formal CGs of children with cerebral palsy (G1) and to compare it with a control group (G2) of professional pediatric nurses, and second, to correlate the level of depression and anxiety with the burnout level. METHOD: In a total sample of 60 CGs, the Maslach Burnout Inventory Human Services Survey (MBI-HSS), consisting of three structural units - emotional exhaustion (MBIEE) subscale, depersonalization (MBI-DP) subscale and personal accomplishment (MBI-PA) subscale - was used to measure burnout. The Beck Anxiety Inventory (BAI) was used for the assessment of anxiety, and the Beck Depression Inventory (BDI) for depression. RESULTS: A significant difference was shown on the MBI-EE subscale and on the BDI test (p<0.05), in both cases higher scores were obtained by G1. High burnout was observed in all subscales, on the MBI-EE subscale registered 50% of CGs in G1, and 17% in control G2. Correlation of the MBI-EE subscale with BDI and BAI tests was highly significant (p<0.01). CONCLUSIONS: These findings indicate the need for future research aimed at formulating preventive strategies for caregivers' mental health. Better care for caregivers would provide them with better professional satisfaction, and consequently would lead to better care for patients.

Comparison of functional outcome of colonic J-pouch and latero-terminal anastomosis in low anterior resection for rectal cancer.

INTRODUCTION: Functional results after low anterior resection for rectal cancer are an issue of increasing attention among colorectal surgeons and others interested in this subject. The consensus on ideal reconstruction type has not been achieved to date, although the number of papers on this subject has been published in recent years. OBJECTIVE: We conducted a prospective, parallel group study comparing latero-terminal with colonic J-pouch anastomosis in terms of defecatory function in patients undergoing stapled low colorectal/ coloanal anastomosis. METHODS: A total of 80 patients were included in this study with either latero-terminal or colonic J-pouch anastomosis. Defecatory function was evaluated using the modified version of MSKCC questionnaire 6, 12 and 24 months after the operation. Fecal continence was evaluated using the Wexner continence score. RESULTS: In both groups, trend towards improvement was registered in all measured variables in all three control intervals. This can apply to bowel frequency, urgency, night soiling, fragmentation and incomplete evacuation. However, the difference was not statistically significant, and when reviewing the trend of results we can note that in the J-pouch group steady state has not been reached even after 24 month control. CONCLUSION: This trial did not reveal any significant differences in defecatory function 6, 12 and 24 months after low anterior resection (LAR) between patients with a latero-terminal anastomosis and those with colonic J-pouch anastomosis. Our results did not confirm superiority of colonic J-pouch over the latero-terminal anastomosis

Brain changes in patients with posttraumatic stress disorder and associated alcoholism: MRI based study.

BACKGROUND: Studies imposing rigorous control over lifetime alcohol intake usually have not found smaller hippocampal volumes in persons with posttraumatic stress disorder (PTSD). Since the majority of negative studies have used adolescent samples, it has been suggested that chronicity is a necessary condition for such findings. We have hypothesized that the volumes of hippocampus, amygdale, prefrontal cortex and the intracranial volume are reduced in the patients with PTSD and excessive alcohol intake. SUBJECTS AND METHODS: Study has been carried out on 54 therapy naive PTSD suffering subjects and healthy controls, divided in two groups: 29 with PTSD and consequent alcoholism, 25 with PTSD but without problems of excessive alcohol intake, and 25 healthy volunteers. All of the patients underwent same magnetic resonance imaging (MRI) protocol and volumetric evaluation of the region of interest. RESULTS: Only hippocampal volume appeared to be significantly reduced in patients with PTSD and alcoholism. Other differences in the volumes obtained remained to be insignificant. CONCLUSION: Alcohol intake definitely worsens the deterioration of the hippocampal formation in PTSD suffering patients. Nevertheless, other structures of interest for this study did not manifest any kind of statistical differences in volumetric analysis.

Alcoholic and postoperative delirium: a case-control study.

BACKGROUND: Delirium is an urgent condition in psychiatry and it occurs after long-lasting alcohol abuse, in surgical procedures and other organic mental syndromes with deprivation of interpersonal and social stimulations. The aim was to evaluate of sociodemographical and psychopathological differences in delirium patients with alcoholand surgical genesis, studied in period from January 1(st) 2003 to December 31(st) 2012 in Bosnia and Herzegovina (B&H). SUBJECTS AND METHODS: Subjects were divided into two groups: alcoholics (N=75) and surgical patients (N=75) and multicentric, prospective study was performed in B&H. The following instruments have been used: list of general data (according to MCD-10 criteria), Eysenck Personality Questionnaire (EPQ), Becks test of anxiety (BAI), Hamilton Depressive Rating Scale (HDRS) and Mini Mental State Examination (MMSE). Descriptive and analytical statistical processing of patients has been performed (alpha level: 0.001). RESULTS: Patients from alcohol group showed, with statistical significance p=0.001, the following: unemployment (OR=0.657, CI 0.540-670), ruined marriage (OR=0.570, CI 0.650-710), alcohol abuse (OR=0.179, CI 0.860-0.990), on represented expressed psychoticism, (OR=0.635, CI 0.550-0.715) in EPQ test, HDRS total was more frequent (OR=0.925, CI 0.870-1.120) and on MMSE test, total score was more frequent (OR=0.560, CI 0.570-810). Postoperative patients were older p=0.001 (OR=1.120, CI 1.082-1.159) with acutestress: (OR=0.735, CI 0.650-0.910) and showed neuroticism (OR=-0.660, CI 0.575-0.715). Discriminative function confirms the differences between alcohol and surgical groups of delirium patients: Canonical Fcn: r=0.771; Wilkin's lambda (λnj)=0.773 Student's test=57.551 and significance p=0.001; OR=0.760, CI 0.550-0.870. CONCLUSION: Delirium lasts longer in alcohol group with higher disalienation, depression of cognitive functions with organic lesions of cerebral functions. In surgical patients, delirium is the consequence of older age, acute stress, multi-morbidity, with neuroticism, vegetative disorders (HDRS) and temporary lesion on MMSE test. Delirium state in both groups requires intensive care and multidisciplinary work.

Cannabis and psychosis revisited.

The association between cannabinoids and psychosis has been known for almost a thousand years, but it is still speculated whether cannabis use may be a contributory cause of psychosis, that is, whether it may precipitate schizophrenia in those at risk. In this paper, we will briefly present the data from individual longitudinal studies in the field, together with the factors that are considered important for the association of cannabis abuse and occurrence of schizophrenia and prevention opportunities in the target population. The reviewed studies clearly suggest that cannabis abuse predicts an increased risk for schizophrenia, particularly in young adults. They underline both the need to create adequate prevention measures and consequently avoid the occurrence of the disease in the young at risk. Particular attention should be additionally devoted toward encouraging the young presenting with psychotic symptoms to stop or, at the very least, reduce the frequency of cannabis abuse. The issues are undoubtedly to be addressed by the health care system in general.

Food addiction-diagnosis and treatment.

In this article we summarized the recent research of the food addiction, diagnosis, treatment and prevention, which is carried out in this area. The concept of food addiction is new and complex, but proven to be very important for understanding and solving the problem of obesity. First part of this paper emphasizes the neurological studies, whose results indicate the similarity of brain processes that are being activated during drug abuse and during eating certain types of food. In this context, different authors speak of "hyper-palatable", industrial food, saturated with salt, fat and sugar, which favor an addiction. In the section on diagnostic and instruments constructed for assessing the degree of dependence, main diagnostic tool is standardized Yale Food Addiction Scale constructed by Ashley Gearhardt, and her associates. Since 2009, when it was first published, this scale is used in almost all researches in this area and has been translated into several languages. Finally, distinguish between prevention and treatment of food addiction was made. Given that there were similarities with other forms of addictive behavior, the researchers recommend the application of traditional addiction treatment.

Treatment of pathological gambling - integrative systemic model.

Pathological gambling was classified under impulse control disorders within the International Classification of Diseases (ICD-10) (WHO 1992), but the most recent Diagnostic and Statistical Manual, 5th edition (DSM-V), (APA 2013), has recognized pathological gambling as a first disorder within a new diagnostic category of behavioral addictions - Gambling disorder. Pathological gambling is a disorder in progression, and we hope that our experience in the treatment of pathological gambling in the Daily Hospital for Addictions at The Institute of Mental Health, through the original "Integrative - systemic model" would be of use to colleagues, dealing with this pathology. This model of treatment of pathological gambling is based on multi-systemic approach and it primarily represents an integration of family and cognitive-behavioral therapy, with traces of psychodynamic, existential and pharmacotherapy. The model is based on the book "Pathological gambling - with self-help manual" by Dr Mladenovic and Dr Lazetic, and has been designed in the form of a program that lasts 10 weeks in the intensive phase, and then continues for two years in the form of "extended treatment" ("After care"). The intensive phase is divided into three segments: educational, insight with initial changes and analysis of the achieved changes with the definition of plans and areas that need to be addressed in the extended treatment. "Extended treatment" lasts for two years in the form of group therapy, during which there is a second order change of the identified patient, but also of other family members. Pathological gambling has been treated in the form of systemic-family therapy for more than 10 years at the Institute of Mental Health (IMH), in Belgrade. For second year in a row the treatment is carried out by the modern "Integrative-systemic model". If abstinence from gambling witihin the period of one year after completion of the intensive phase of treatment is taken as the main criterion of the effectiveness of our model, at this time it exceeds 90%. Given the relatively short period of application, it is necessary to continue to monitor and evaluate the model after 5 years.

Volumetric analysis of amygdala, hippocampus, and prefrontal cortex in therapy-naive PTSD participants.

OBJECTIVE: In our study we have hypothesized that volume changes of amygdala, hippocampus, and prefrontal cortex are more pronounced in male posttraumatic stress disorder participants. MATERIAL AND METHODS: We have conducted a study of 79 male participants who underwent MRI brain scanning. PTSD diagnosis was confirmed in 49 participants. After MRI was taken all scans were software based volume computed and statistically processed. RESULTS: We found that left amygdala is the most significant parameter for distinction between PTSD participants and participants without PTSD. There were no significant differences in volumes of hippocampi and prefrontal cortices. Roc curve method outlined left amygdala AUC = 0.898 (95% CI = 0.830-0.967) and right amygdala AUC = 0.882 (95% CI = 0.810-0.954) in the group of PTSD participants which makes both variables highly statistically significant. CONCLUSION: The present investigation revealed significant volume decrease of left amygdala in PTSD patients. Concerning important functions of the amygdala and her neuroanatomical connections with other brain structures, we need to increase number of participants to clarify the correlation between impared amygdala and possible other different brain structures in participants with PTSD.

Increased endothelin 1 type B receptors in nasal lesions of patients with granulomatosis with polyangiitis.

BACKGROUND: Endothelin 1 (ET-1) is a locally produced vasoactive peptide with proinflammatory capabilities. Systemic levels of ET-1 seem elevated in granulomatosis with polyangiitis (GPA). The aim of this study was to examine the involvement of the endothelin system in patients with GPA using nasal mucosal biopsies. METHODS: Formalin-fixed and paraffin-embedded nasal mucous membranes from eight patients with GPA and eight controls were analyzed for ET-1 type A receptor (ETAR) and type B receptor (ETBR) expression using immunohistochemistry. RESULT: ETAR immunostaining was localized only to a few inflammatory cells and to multinucleate giant cells (MGCs) in the nasal mucosa in GPA subjects. Intense ETBR immunostaining was localized to lymphocytes and MGC in the nasal granulomatous lesions in GPA. CD3(+), CD4(+), CD8(+), and CD68(+) lymphocytes expressed ETBRs in GPA subjects. CONCLUSION: This observation shows that ETBR(+) lymphocyte expression predominates in nasal granulomatous lesions in GPA compared with ETAR. ETBR immunostaining is located to T cells, CD68(+) cells, and MGCs. ETBR may play an active role in the progression of granulomatous lesions in GPA.

Microsatellite instability affecting the T17 repeats in intron 8 of HSP110, as well as five mononucleotide repeats in patients with colorectal carcinoma.

AIM: To investigate mononucleotide markers: BAT-25, BAT-26, NR-21, NR-22 and NR-24 in patients with colorectal cancer (CRC), and the status of HSP110T17, KRAS, BRAF and the MLH1 promoter mutations in microsatellite unstable CRC. METHODS: Genetic assessments were performed on samples obtained following resection of CRC in 200 patients. RESULTS: Allelic variations of HSP110T17 were found in all 18 patients with microsatellite instabilities (MSIs) in at least three markers (high-frequency MSI). By contrast, mutations of HSP110T17 were absent in all 20 patients with no MSI frequency. Eight out of 182 patients with low (instability in one marker) or no frequency MSI had allelic shifts due to polymorphisms of BAT-25 (1.5%), NR-21 (1.75%) and NR-24 (1.5%). BRAF mutations were associated with >5 bp shortening of HSP110T17. CONCLUSION: Patients with high-frequency MSI CRC had allelic variations of HSP110T17. BRAF mutations occur along with greater shortening in HSP110T17 during oncogenesis via the MSI pathway.

Clinical and pathological tools for identifying microsatellite instability in colorectal cancer.

AIM: To assess practical accuracy of revised Bethesda criteria (BGrev), pathological predictive model (MsPath), and histopathological parameters for detection of high-frequency of microsatellite instability (MSI-H) phenotype in patients with colorectal carcinoma (CRC). METHOD: Tumors from 150 patients with CRC were analyzed for MSI using a fluorescence-based pentaplex polymerase chain reaction technique. For all patients, we evaluated age, sex, family history of cancer, localization, tumor differentiation, mucin production, lymphocytic infiltration (TIL), and Union for International Cancer Control stage. Patients were classified according to the BGrev, and the groups were compared. The utility of the BGrev, MsPath, and clinical and histopathological parameters for predicting microsatellite tumor status were assessed by univariate logistic regression analysis and by calculating the sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values. RESULTS: Fifteen out of 45 patients who met and 4 of 105 patients who did not meet the BGrev criteria had MSI-H CRC. Sensitivity, specificity, PPV, and NPV for BGrev were 78.9%, 77%, 30%, and 70%, respectively. MSI histology (the third BGrev criterion without age limit) was as sensitive as BGrev, but more specific. MsPath model was more sensitive than BGrev (86%), with similar specificity. Any BGrev criterion fulfillment, mucinous differentiation, and right-sided CRC were singled out as independent factors to identify MSI-H colorectal cancer. CONCLUSION: The BGrev, MsPath model, and MSI histology are useful tools for selecting patients for MSI testing.

Minor vs complete excision of pilonidal sinus--early postoperative period.

Pilonidal sinus arises in the natal cleft of the sacrococcigeal region either as a cyst or as an abscess collection containing hair. It is predominantly a condition of younger people. When presenting as an abscess it usually requires surgical incision and drainage, or bursts spontaneously. In general, there are various surgical approaches to this condition, from very simple to complex ones. Each technique has its supporters and justifications. In the 3 years period, from 2009-2011, 110 treatments of the pilonidal disease were performed on our department. Midline excision was performed in 75 (68.18%) patients and the rest had marsupielisation done. The average discharge time was 1.14 days. Failure to heal occurred in 15 patients (13.63%). During that period we saw recurrence in 4 patients (3.63%). All the patients were coming to our department for postoperative care. The shortest healing time was 4 weeks and longest 21 weeks. During the period may 2011-May 2012 we performed 17 less extensive excisions. All the patients were discharged from the clinic within 23 hours and returned to their daily activities within 5 days. Healing time varied from 2 weeks to 5 weeks. In only one patient with the extensive excision healing time was 8 weeks. Although we had a short follow up period of 11.11 months, we saw no recurrence yet. Our results show that simple individual approach to every patients gives fastest and most comfortable results.

Preoperative assessment and preparation of patients with diseases affecting the central nervous system.

PURPOSE OF REVIEW: This review will examine the most important issues of preoperative evaluation and preparation in relation to patients with deseases affecting the central nervous system. Those patients may undergo various forms of surgery unrelated to the central nervous system disease. We discuss the effect of physiologic and pharmacological factors on cerebral autoregulation and control of intracranial pressure alongside its clinical relevance with the help of new evidence. RECENT FINDINGS: Regardless of the reason for surgery, coexisting diseases of brain often have important implications when selecting anesthetic drugs, procedures and monitoring techniques. Suppression of cerebral metabolic rate is not the sole mechanism for the neuroprotective effect of anaesthetic agents. There are certain general principles, but also some specific circumstances, when we are talking about optimal anesthetic procedure for a patient with coexisting brain disease. Intravenous anesthesia, such as combination of propofol and remifentanil, provides best preservation of autoregulation. Among inhaled agents isoflurane and sevoflurane appear to preserve autoregulation at all doses, whereas with other agents autoregulation is impaired in a dose-related manner. During maintenance of anesthesia the patient is ventilated by intermittent positive pressure ventilation, at intermediate hyperventilation (PaCO2 25-30 mmHg). SUMMARY: Intraoperative cerebral autoregulation monitoring is an important consideration for the patients with coexisting neurological disease. Transcranial Doppler based static autoregulation measurements appears to be the most robust bedside method for this purpose.

Preoperative assessment and preparation of patients with neurologic disorders.

Ageing of populataion world wide has significant contribution as one of the major risk factor for neurodegenerative disorders. The patients with neurodegenerative as well as other neuological diseases presented the population with possible great need either of small or big surgical intervention. There are several important issues in patients with neurological diseases: the nature, disease duration, therapy, the patient's ability to live without assistance. Neurological disease may become worst by general and regional anesthesia. Stopping therapy may lead to worsening of neurological diseases. One of the main common threat is the risk of significant cardiorespiratory complications, which is important in assessing operational risk, in preoperative preparation and in terms of postoperative recovery and outcomes of surgical treatment. This has resulted in greater preoperative care by detailed patient history evaluation and examination, patient information and informed consent. Besides the effect of the anaesthetic technique upon the course of the disease, there is also the interaction of drugs administered during anaesthesia and patient medication. Several undiagnosed diseases may be disclosed following a surgical/anaesthetic intervention.