Different damaging effects of volatile anaesthetics alone or in combination with 1 and 2 Gy gamma-irradiation in vivo on mouse liver DNA: a preliminary study.

As the number of radiotherapy and radiology diagnostic procedures increases from year to year, so does the use of general volatile anaesthesia (VA). Although considered safe, VA exposure can cause different adverse effects and, in combination with ionising radiation (IR), can also cause synergistic effects. However, little is known about DNA damage incurred by this combination at doses applied in a single radiotherapy treatment. To learn more about it, we assessed DNA damage and repair response in the liver tissue of Swiss albino male mice following exposure to isoflurane (I), sevoflurane (S), or halothane (H) alone or in combination with 1 or 2 Gy irradiation using the comet assay. Samples were taken immediately (0 h) and 2, 6, and 24 h after exposure. Compared to control, the highest DNA damage was found in mice receiving halothane alone or in combination with 1 or 2 Gy IR treatments. Sevoflurane and isoflurane displayed protective effects against 1 Gy IR, while with 2 Gy IR the first adverse effects appeared at 24 h post-exposure. Although VA effects depend on liver metabolism, the detection of unrepaired DNA damage 24 h after combined exposure with 2 Gy IR indicates that we need to look further into the combined effects of VA and IR on genome stability and include a longer time frame than 24 h for single exposure as well as repeated exposure as a more realistic scenario in radiotherapy treatment.

Brain DNA damaging effects of volatile anesthetics and 1 and 2 Gy gamma irradiation in vivo: Preliminary results.

Although both can cause DNA damage, the combined impact of volatile anesthetics halothane/sevoflurane/isoflurane and radiotherapeutic exposure on sensitive brain cells in vivo has not been previously analyzed. Healthy Swiss albino male mice (240 in total, 48 groups) were exposed to either halothane/sevoflurane/isoflurane therapeutic doses alone (2 h); 1 or 2 gray of gamma radiation alone; or combined exposure. Frontal lobe brain samples from five animals were taken immediately and 2, 6, and 24 h after exposure. DNA damage and cellular repair index were analyzed using the alkaline comet assay and the tail intensity parameter. Elevated tail intensity levels for sevoflurane/halothane were the highest at 6 h and returned to baseline within 24 h for sevoflurane, but not for halothane, while isoflurane treatment caused lower tail intensity than control values. Combined exposure demonstrated a slightly halothane/sevoflurane protective and isoflurane protective effect, which was stronger for 2 than for 1 gray. Cellular repair indices and tail intensity histograms indicated different modes of action in DNA damage creation. Isoflurane/sevoflurane/halothane preconditioning demonstrated protective effects in sensitive brain cells in vivo. Owing to the constant increases in the combined use of radiotherapy and volatile anesthetics, further studies should explore the mechanisms behind these effects, including longer and multiple exposure treatments and in vivo brain tumor models.

Kidney cell DNA damage caused by combined exposure to volatile anaesthetics and 1 Gy or 2 Gy radiotherapy dose in vivo.

Patient immobilisation with volatile anaesthetics (VA) during radiotherapy is sometimes unavoidable. Although it is known that both VAs and ionising radiation can have nephrotoxic effects, there are no studies of their combined effects on DNA damage. The aim of this in vivo study was to address this gap by investigating whether 48 groups of healthy Swiss albino mice (totalling 240) would differ in kidney cell DNA damage response (alkaline comet assay) to isoflurane, sevoflurane, or halothane anaesthesia and exposure to 1 Gy or 2 Gy of ionising radiation. We took kidney cortex samples after 0, 2, 6, and 24 h of exposure and measured comet parameters: tail length and tail intensity. To quantify the efficiency of the cells to repair and re-join DNA strand breaks, we also calculated cellular DNA repair index. Exposure to either VA alone increased DNA damage, which was similar between sevoflurane and isoflurane, and the highest with halothane. In combined exposure (VA and irradiation with 1 Gy) DNA damage remained at similar levels for all time points or was even lower than damage caused by radiation alone. Halothane again demonstrated the highest damage. In combined exposure with irradiation of 2 Gy sevoflurane significantly elevated tail intensity over the first three time points, which decreased and was even lower on hour 24 than in samples exposed to the corresponding radiation dose alone. This study confirmed that volatile anaesthetics are capable of damaging DNA, while combined VA and 1 Gy or 2 Gy treatment did not have a synergistic damaging effect on DNA. Further studies on the mechanisms of action are needed to determine the extent of damage in kidney cells after longer periods of observation and how efficiently the cells can recover from exposure to single and multiple doses of volatile anaesthetics and radiotherapy.

CANCER PAIN AND THERAPY.

Cancer pain is not a homogenous and clearly understood pathological process. The best treatment is a combination of drug and non-drug measures. Pain is divided into visceral, bone or neuropathic pain and has characteristics of continuous or intermittent pain. Cancer bone pain therapy remains centered on strong opioid, radiotherapy and bisphosphonates. Invasive procedures are aimed to improve neurological function, ambulation and pain relief. Solid tumors often demand surgery. Treatment of acute postoperative pain is crucial for the prevention of chronic pain. Chemotherapy and radiation sometimes also cause pain. The management of cancer pain has improved because of rapid diagnosis and treatment, understanding of analgesics and the cooperation of patients and their family. The presence of special pain centers in hospitals also raise standard of cancer pain management. Drug therapy with non-opioid, opioid and adjuvant drugs is the base of such management. The side effects must be monitored and timely treated. Methods of regional nerve blockade in pain control are numerous. Placement of epidural, intrathecal and subcutaneous catheters, conductive nerve blocks with continuous delivery of mixed local anesthetics are very successful for selected patients. Conventional physical therapy involving lymphatic drainage is useful. Acupuncture, psychotherapy and similar methods are also applicable.

Sevoflurane and isoflurane genotoxicity in kidney cells of mice.

The aim of this study was to evaluate the DNA damage and repair in kidney cells of Swiss albino mice after repeated exposure to sevoflurane and isoflurane and compare their detrimental effects. We used the alkaline comet assay to establish the genetic damage and measured three parameters: tail length, tail moment, and tail intensity of comets. These parameters were measured immediately after exposure to the above mentioned inhalation anaesthetics, two hours, six hours, and 24 hours later and were compared with the control group. Mean values of all three parameters were significantly higher in experimental groups compared to the control group. DNA damage in kidney cells of mice exposed to sevoflurane increased continuously before it reached its peak 24 hours after exposure. Isoflurane induced the highest DNA damage two hours after exposure. Levels of DNA damage recorded 24 h after cessation of exposure to both tested compounds suggest that sevoflurane was slightly more genotoxic than isoflurane to kidney cells of mice. According to these results, the currently used volatile anaesthetics sevoflurane and isoflurane are able to damage DNA in kidney cells of mice. Such findings suggest a possibility for similar outcomes in humans and that fact must be taken into account in everyday clinical practice.

The Use of Inferior Vena Cava Filters before Surgery in Women with Ovarian Cancer with the Initial Symptom of Deep Venous Thrombosis: Case Report and Review of Literature.

Venous thromboembolism is a frequent complication of gynecologic cancer, and may be the first symptom of occult malignant disease. Although anticoagulation therapy remains the standard of care in patients presenting with acute venous thromboembolism, inferior vena cava filters are an important alternative when anticoagulants are contraindicated or ineffective. We report a case of a 69-year-old woman who presented with left leg swelling secondary to deep venous thrombosis before the diagnosis of ovarian cancer. The aim of this study is to review the respective literature and report our experience with inferior vena cava filter placement to prevent pulmonary embolism in gynecologic cancer patients.

IMMUNOHISTOCHEMICAL DIFFERENTIATION OF TRIPLE NEGATIVE BREAST CANCER.

Based on immunohistochemical staining for the basal markers cytokeratin 5/6 (CK 5/6), cytokeratin 14 (CK 14) and P-cadherin, triple negative tumors (TNT) are divided into two groups: 1) basal-like (BL) positive for one or all three markers; and 2) non basal-like (NBL) negative for all three markers. Even though the different origin of the cells of these two types of tumors implies different biological properties, they had been treated as one entity until recently. This paper analyzes TNT collected from 150 patients and distributed into two groups according to the results of immunohistochemical analysis, i.e. BL 116 (77.3%) and NBL 34 (22.67%). In this study, CK 5/6, CK 14 and P-cadherin were used as markers for identifying BL tumors. The immunohistochemical reaction was positive for CK 5/6 in 37%, for CK 14 in 50.86% and for P-cadherin in 68.34% of cases. The subclassification of triple negative breast cancer using the basal markers CK 5/6, CK 14 and P-cadherin has enabled identification of BL and NBL breast cancers in a proportion that is in line with the only accurate analysis of TNT gene expression. Using the mentioned combination of markers in daily practice is easy to perform and economically affordable.

Allergic reaction to suxamethonium during emergency caesarean section and pseudocholinesterase deficiency in the same patient.

An allergic reaction during the caesarean section can be harmful for mother and foetus. Our patient has undergone an urgent caesarean section due to the imminent threat of foetal hypoxia. After operation, we applied prolonged mechanical ventilation. The anaesthesia was induced with thiopental and suxamethonium. Suxamethonium is associated with the highest incidence of allergic reactions but it is a neuromuscular blocking agent of choice for an emergency operation. During the operation, about 10 min. after induction, the systolic blood pressure dropped suddenly to 67 mmHg, the heart rate increased to 145 beats per minute and the oxygen saturation dropped to 60 %. A small degree of bronchospasm developed but there wasn't any kind of skin reaction. We thought of an allergic reaction, the obstetrical pulmonary embolism and an acute cardiac failure. The baby was delivered promptly in good condition. Within 10 min. all vital signs normalized. The operation continued without problems. Unexpectedly, during waking up from anaesthesia the patient became dyspnoeic, laryngospasm appeared, the oxygen saturation dropped again, strong facial and tongue oedema appeared and an urgent reintubation had to be performed. The laboratory results pointed out elevated mast cell tryptase level and significant pseudocholinesterase deficiency. About 2 months later, immunologist excluded thiopental and latex, and suggested that suxamethonium was the "trigger" factor. In our case the respiratory insufficiency was caused by two different and unrelated pathological mechanisms: biphasic allergic reaction and prolonged neuromuscular block caused by pseudocholinesterase deficiency.

[Medicolegal dilemmas on restraint use in delirious patients in intensive care unit]. / Medikolegalne dileme primjene ogranicavanja delirantnih bolesnika u jedinici intenzivnog lijecenja.

The use of physical or chemical restraint in delirious patients in the intensive care unit (ICU) is related to an array of ethical and medicolegal dilemmas. In most cases, they arise from insufficient knowledge of the regulations in force or due to their vague wording. The aim of this review article is to outline the basic views of the medical profession regarding restraint use as a method in the treatment of delirium and to give an insight into the existing legislation at the national and international level. According to the contemporary research, restraint of patients in delirium, whether it is physical restraint or application of psychoactive drugs, has a number of potentially harmful side effects and must be used with clear indications, under strict supervision, and with meticulously kept medical records. A delirious patient must be treated in accordance with medical ethics, international conventions and the laws and regulations related to patient rights. This includes the general principles of respecting the patient's autonomy and dignity, giving him or her timely information, notification of informed consent, as well as abiding by the rules of the profession integrated in every hospital written instructions on the treatment of a patient in delirium. A detailed medicolegal frame of restraint use in delirious patients is given by the Croatian Hospital Accreditation Rules, which is currently the highest existing standard for restraint use in delirious patients in ICU, as well as in the other hospital departments.

[Pain, delirium and sedation in intensive unit care]. / Bol, delirij i sedacija u jedinici intenzivnog lijecenja.

Delirium is a complication of intensive care treatment associated with permanent cognitive decline and increased mortality after hospital discharge. In several studies, postoperative pain was found as a possible precipitating factor. Aggressive pain treatment is part of current multicompartment protocols for delirium prevention after hip fracture. Protocol based sedation, pain and delirium management in intensive care units have been shown to have clinical and economic advantages.

[Neurological disorders in pregnancy]. / Neuroloski poremecaji u trudnoci.

Preeclampsia is characterized by hypertension, peripheral edema and proteinuria, but very often also includes neurologic complications. Neurologic complications of severe preeclampsia are indentical to those of hypertensive encephalopathy. The most common neurologic symptoms are headache, vomiting, mental disorders, visual disturbances, sensorimotor deficits and seizures. Endothelial cell dysfunction is the main cause of multiorgan failure. It is of utmost importance to recognize these symptoms and initiate apropriate therapy. Systemic blood presure must not exceed the cerebrovascular autoregulatory capacity. Serum magnesium level is significantly decreased in pregnant women with severe preeclampsia and cerebral edema. Magnesium has been shown to be effective in reducing the occurrence of seizures in preeclampsia by decreasing neuronal excitability, protecting the endothelium against free radicals and reducing cerebral perfusion.

The in vivo genotoxicity of cisplatin, isoflurane and halothane evaluated by alkaline comet assay in Swiss albino mice.

The aim of this study was to evaluate the genotoxicity of repeated exposure to isoflurane or halothane and compare it with the genotoxicity of repeated exposure to cisplatin. We also determined the genotoxicity of combined treatment with inhalation anaesthetics and cisplatin on peripheral blood leucocytes (PBL), brain, liver and kidney cells of mice. The mice were divided into six groups as follows: control, cisplatin, isoflurane, cisplatin-isoflurane, halothane and cisplatin-halothane, and were exposed respectively for three consecutive days. The mice were treated with cisplatin or exposed to inhalation anaesthetic; the combined groups were exposed to inhalation anaesthetic after treatment with cisplatin. The alkaline comet assay was performed. All drugs had a strong genotoxicity (P<0.05 vs. control group) in all of the observed cells. Isoflurane caused stronger DNA damage on the PBL and kidney cells, in contrast to halothane, which had stronger genotoxicity on brain and liver cells. The combination of cisplatin and isoflurane induced lower genotoxicity on PBL than isoflurane alone (P<0.05). Halothane had the strongest effect on brain cells, but in the combined treatment with cisplatin, the effect decreased to the level of cisplatin alone. Halothane also induced the strongest DNA damage of the liver cells, while the combination with cisplatin increased its genotoxicity even more. The genotoxicity of cisplatin and isoflurane on kidney cells were nearly at the same level, but halothane caused a significantly lower effect. The combinations of inhalation anaesthetics with cisplatin had stronger effects on kidney cells than inhalation anaesthetics alone. The observed drugs and their combinations induced strong genotoxicity on all of the mentioned cells.

Brain toxicokinetics of prometryne in mice.

Prometryne is a methylthio-s-triazine herbicide. Significant trace amounts are found in the environment, mainly in water, soil, and food plants. The aim of this study was to establish brain and blood prometryne levels after single oral dose (1 g kg-1) in adult male and female mice. Prometryne was measured using the GC/MS assay at 1, 2, 4, 8, and 24 h after prometryne administration. Peak brain and blood prometryne values were observed 1 h after administration and they decreased in a time-dependent manner. Male mice had consistently higher brain and blood prometryne levels than female mice. The observed prometryne kinetics was similar to that reported for the structurally related herbicide atrazine.

Genotoxicity and cytotoxicity of cisplatin treatment combined with anaesthetics on EAT cells in vivo.

In this study, DNA damage in tumour cells, as well as irreversible cell damage leading to apoptosis induced in vivo by the combined application of cisplatin and inhalation anaesthetics, was investigated. The genotoxicity of anaesthetics on Ehrlich ascites tumour (EAT) cells of mice, alone or in combined application with cisplatin, was estimated by using the alkaline comet assay. The percentage of EAT cell apoptosis was quantified by flow cytometry. Groups of EAT-bearing mice were (i) treated intraperitoneally with cisplatin, (ii) exposed to repeated anaesthesia with inhalation anaesthetic, and (iii) subjected to combined treatment of exposure to anaesthetics after cisplatin for 3 days. Sevoflurane, halothane and isoflurane caused strong genotoxic effects on tumour cells in vivo. The tested anaesthetics alone showed no direct effect on programmed cell death although sevoflurane and especially halothane decreased the number of living EAT cells in peritoneal cavity lavage. Repeated anaesthesia with isoflurane had stimulatory effects on EAT cell proliferation and inhibited tumour cell apoptosis (6.11%), compared to the control group (10.26%). Cisplatin caused massive apoptosis of EAT cells (41.14%) and decreased the number of living EAT cells in the peritoneal cavity. Combined cisplatin and isoflurane treatment additionally increased EAT cell apoptosis to 51.32%. Combined treatment of mice with cisplatin and all anaesthetics increased the number of living tumour cells in the peritoneal cavity compared to cisplatin treatment of mice alone. These results suggest that the inhalation of anaesthetics may protect tumour cells from the cisplatin-induced genotoxic and cytotoxic effects.

Effects of prometryne on apoptosis and necrosis in thymus, lymph node and spleen in mice.

Prometryne is a methylthio-s-triazine herbicide. Significant traces are documented in environment, mainly waters, soil and plants used for nutrition. The aim of this study was to estimate prometryne immunotoxic properties through induction of apoptotic and/or necrotic changes in thymocytes, splenocytes and lymph node cells after repeated subchronical exposure. Three different doses of prometryne (185, 375, 555mgkg(-1)) were applied per os every 48h, over 28 days. Flow cytometry assay (annexinV-FITC and PI) was conducted to record apoptotic and necrotic damage. In the spleen significant changes in the percentage of apoptotic cells were not detected between treated and control groups respectively. In thymus and lymph node, within the lowest dose group (185mgkg(-)1), an increase in percentage of early apoptosis without any significant increase in necrosis was detected. Medium (375mgkg(-1)) as well as high dose triggered increase in late apoptosis in lymph node while in thymus; late apoptosis was increased only in animals exposed to the highest dose (555mgkg(-1)). The highest applied dose, in thymus and lymph node respectively, caused a general decrease in percentage of vital cells in favour of marked increase of percentages of all types of dying cells (apoptotic, late apoptotic/early necrotic and necrotic). Prometryne caused disbalance in major organs of immune system, markedly lymph nodes and thymus, by induction of early apoptotic changes in dose/time specific manner.

Genotoxic effects of anaesthetics in operating theatre personnel evaluated by the comet assay and micronucleus test.

Genetic damage induced by anaesthetic gases in occupationally exposed populations was investigated using the comet assay and micronucleus test. The study included two groups of subjects: 50 operating theatre medical workers (anaesthesiologists, technicians and nurses) and 50 control subjects corresponding in sex, age and smoking habit. The exposed group revealed an increase in genome damage in both tests. In the comet assay, exposure to anaesthetics was a highly significant predictor of the tail length for technicians, while sex proved to be significant predictor of tail moment for women in exposed group. Micronucleus frequency increased significantly, showing threefold increase in exposed groups (RR>3.029). Univariate analysis showed significant influence of duration of exposure, while multivariate analysis showed age to be significant predictor of micronucleus frequency. The obtained results call for further, targeted investigation of exposure risk.