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The inheritance of parental histones across the replication fork is thought to mediate epigenetic memory. Here, we reveal that fission yeast Mrc1 (CLASPIN in humans) binds H3-H4 tetramers and operates as a central coordinator of symmetric parental histone inheritance. Mrc1 mutants in a key connector domain disrupted segregation of parental histones to the lagging strand comparable to Mcm2 histone-binding mutants. Both mutants showed clonal and asymmetric loss of H3K9me-mediated gene silencing. AlphaFold predicted co-chaperoning of H3-H4 tetramers by Mrc1 and Mcm2, with the Mrc1 connector domain bridging histone and Mcm2 binding. Biochemical and functional analysis validated this model and revealed a duality in Mrc1 function: disabling histone binding in the connector domain disrupted lagging-strand recycling while another histone-binding mutation impaired leading strand recycling. We propose that Mrc1 toggles histones between the lagging and leading strand recycling pathways, in part by intra-replisome co-chaperoning, to ensure epigenetic transmission to both daughter cells., Competing Interests: Declaration of interests A.G. is co-founder and chief scientific officer (CSO) of Ankrin Therapeutics. A.G. is a member of the scientific advisory board of Molecular Cell. G.M. is a stockholder of Ensoma and a member of its scientific advisory board. The other authors declare no competing interests., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

The paper reports the results of registered conceptual replications of the indirect effect of institutional trust in the relationship between precarity and the endorsement of conspiracy beliefs (CB). The original study of Adam-Troian et al. (2023; British Journal of Social Psychology, 62(S1), 136-159) indicated that subjective appraisals of economic hardship are associated with lower trust in governments and institutions, which in turn is associated with stronger endorsement of CB. Our Studies 1 to 3 report a series of replications using Slovak panel data. Study 4 reports a replication of the mediation model using data from the European Social Survey Round 10 collected in 17 countries. To provide a quantitative synthesis of these and previous results, we conducted mini meta-analysis (N = 50,340). Although the strength of the observed relationships differed across the studies to some degree, the original patterns of relations remained robust, supporting the original model. The study corroborates the view that to curb the spread of CB, it is necessary to address structural issues, such as growing financial insecurity, socioeconomic inequalities, and the deficit of institutional trust. Finally, we discuss the role of cultural and political settings in conditioning the mechanisms through which precarity enhances the endorsement of CB., (© 2024 The Authors. British Journal of Social Psychology published by John Wiley & Sons Ltd on behalf of British Psychological Society.)

The study experimentally tested an intervention that debunks epistemically suspect beliefs about vaccines. After answering questions about pre-existing epistemically suspect beliefs (irrational health beliefs and conspiracy mentality), 565 participants were randomly assigned into one of three conditions and exposed either to neutral information about domestic animals, salient epistemically suspect content about vaccination or an intervention that debunks epistemically suspect beliefs about vaccination. Afterwards, the participants answered questions about vaccination-related conspiracy narratives (manipulation check), vaccination attitudes, intentions to vaccinate against HPV, support for an HPV vaccination programme and intentions to seek health guidance. Although the intervention demonstrated the potential to inhibit the endorsement of conspiracy narratives, we found no differences in the other outcome variables. Nevertheless, across the conditions, pre-existing epistemically suspect beliefs were associated with less favourable attitudes towards vaccination, lower intentions to vaccinate against HPV, less support for the vaccination programme and lower intentions to seek health guidance. The results indicate that debunking may be futile in curbing long-term negative impacts associated with epistemically suspect beliefs, and they contribute to the debate about assessing the effectiveness of interventions related to highly controversial topics such as vaccination. The study enhances understanding of persistent adverse impacts that epistemically suspect beliefs may have on public health outcomes., (© 2024 The Author(s). Applied Psychology: Health and Well‐Being published by John Wiley & Sons Ltd on behalf of International Association of Applied Psychology.)

The study explores the links between palliative and hegemonic dimensions of conservatism, attitudes toward migrants and restrictive migration policy preferences. Participants reported on their palliative dimension (social conservatism, traditionalism) and hegemonic dimension (social dominance orientation, collective narcissism) of conservatism, trust in government, attitudes toward migrants, and restrictive migration policy preferences. The results show that both dimensions of conservatism are indirectly linked to more restrictive migration policy preferences through negative attitudes toward migrants. Moreover, the present study indicates that increasing institutional trust may be an effective mechanism mitigating negative attitudes toward migrants for individuals high in the palliative dimension of conservatism., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Grežo, Adamus and Tencerová.)

The dataset comprises responses provided by 500 individuals (250 women) recruited by an external agency to be representative of the Slovak population concerning age and gender. Participants gave written consent to participate in the study by confirming that they are over 18 and have read all the information about the study before agreeing to participate in an online survey hosted on Qualtrics. Along with socio-demographic characteristics and vaccination hesitancy and refusal, the dataset contains variables that could explain variation in dependant variables: horizontal-vertical individualism-collectivism, consideration of future consequences, prosocial motivations, helplessness, and the sense of threat caused by vaccination but also the COVID-19 pandemic and the climate change. In the original paper, the authors performed correlational analysis and hierarchical regressions investigating antecedents of vaccination hesitancy and refusal. The data inform interventions aimed at boosting vaccination rates, particularly amongst highly sceptical societies such as Slovakia. Apart from investigating the relations between various forms of prosocial behaviour such as vaccination intentions and attitudes, helping behaviour during the pandemic, and pro-environmental behaviour, the dataset offers an opportunity to delve deeper into the drivers of various forms of socially beneficial behaviour. Ultimately, the data could help corroborate the existence of two new constructs of outward orientation (comprising future orientation, collectivism and prosocial motivations) and self-centred orientation (immediate orientation and individualism) that could be useful in explaining individual differences in prosocial intentions and behaviour., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author(s).)

Background: The present study explored moderators of the relation between environmental concerns and pro-environmental behaviour that could help close the green gap., Methods: A sample of 500 individuals (250 women) participated in the study. Apart from socio-demographic characteristics, participants answered questions about their environmental concerns and pro-environmental behaviour, collectivism and individualism, time orientation and emotional responses to climate change., Results: Our results corroborate the view that collectivism, future orientation and prosocial tendencies may form a single component of outward orientation, while individualism and immediate orientation form self-centred orientation. Generally, outwardly oriented individuals and those less self-centred reported more pro-environmental behaviour. However, strongly self-centred individuals, even when reporting elevated helplessness, showed increased involvement in pro-environmental behaviour once their concerns were high., Conclusions: The study contributes to the literature by pointing out that both outward and self-centred orientations have the potential to insulate individuals against the negative effect helplessness may have on pro-environmental behaviour. This could inform strategies that would both prompt individuals already concerned to act and arouse more concern among those who are not yet preoccupied with climate change., (© 2023. The Author(s).)

The study investigated antecedents of attitudes towards vaccines against COVID-19 and vaccination behaviour, and sought to identify areas where interventions aimed at increasing vaccination rates would be most effective. A sample of 500 Slovaks (250 women) responded to questions concerning their socio-demographic and personality characteristics, collectivism and individualism, consciousness of future consequences, and emotional responses to both vaccination and the pandemic. The study indicates that helplessness related to the vaccine efficacy evaluation and fear of its potential risks are the strongest antecedents of vaccination behaviour and anti-vaccination attitudes. Jointly with the fear of the COVID-19, they explained over 26% and 33% of variance in behaviour and attitudes, respectively. The results indicate that the efficiency of appeals to solidarity may be limited when fear and helplessness are widespread as they seem to strongly outweigh individuals' outward motivations to get vaccinated., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

The present study investigated the relationship between outward orientation and COVID-related prosocial behavior, including adherence to containment measures, caring for others and providing support, limiting one's social life and responsible purchasing behavior. A sample of 500 Slovaks (250 women) aged between 18 and 86 ( M  = 44.32, SD  = 15.66) participated in the study and responded to questions concerning their sociodemographic and personality characteristics, collectivism and individualism, the consciousness of future consequences and emotional responses to the pandemic. The results show that apart from the perceived threat of COVID-19, vertical collectivism is among the strongest antecedents of COVID-related prosocial behavior. Specifically, feelings of threat, vertical collectivism, conscientiousness, agreeableness, liberalism, and education predicted more prosocial behavior during the pandemic. Consequently, the study indicates that while excessive fear may have adverse effects on individuals' well-being, appealing to and cultivating collectivistic sentiments could contribute not only to containing the pandemic but also to making others' lives more bearable while it lasts., Competing Interests: Conflict of InterestThe Authors declare that there is no conflict of interest., (© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022.)

The present study investigated the relationship between the Light and Dark Core of personality and self-reported adherence to COVID-19 containment measures. A gender-balanced representative sample of 600 Slovaks participated in the study. We formulated a mediation model, hypothesising that the relationship between Light and Dark Core and self-reported adherence is mediated by the motivation to comply with the measures. The results of structural equation modelling showed that self-reported adherence was positively related to the Light Core and this relationship was also mediated by motivation. The Dark Core, in turn, showed a negative relationship with the adherence, while no mediation was found. Importantly, the findings of both Light and Dark Core models remained robust after including trust in government. The present study contributes to theory by providing first results corroborating the existence of Light Core of personality. The findings of this study can also help to better shape the communications about containment measures to address both individuals with high levels of benevolent and malevolent traits., (Copyright © 2021. Published by Elsevier B.V.)

Using a representative sample of 400 Slovaks, the present study investigated the mediating role of subjective perception of financial threat to the relation between psychological resources and behavioural responses in the adaptation to financial stress posed by the COVID-19 pandemic. The results of structural equation modelling analyses showed that greater neuroticism and uncertainty intolerance were positively related to aggravated perception of financial threat. This, in turn, led to greater willingness to change consumption patterns and use of mostly problem-focused coping strategies. The model remained robust after controlling for chronic financial hardship moderators, including the absence of savings and indebtedness. In contrast, the acute financial hardship caused by the deterioration of one's financial situation during the COVID-19 pandemic showed to significantly moderate the relation between one's psychological resources and perceived financial threat., (© 2021 Elsevier Ltd. All rights reserved.)

The SMC (Structural Maintenance of Chromosomes) complexes are composed of SMC dimers, kleisin and kleisin-interacting (HAWK or KITE) subunits. Mutual interactions of these subunits constitute the basal architecture of the SMC complexes. In addition, binding of ATP molecules to the SMC subunits and their hydrolysis drive dynamics of these complexes. Here, we developed new systems to follow the interactions between SMC5/6 subunits and the relative stability of the complex. First, we show that the N-terminal domain of the Nse4 kleisin molecule binds to the SMC6 neck and bridges it to the SMC5 head. Second, binding of the Nse1 and Nse3 KITE proteins to the Nse4 linker increased stability of the ATP-free SMC5/6 complex. In contrast, binding of ATP to SMC5/6 containing KITE subunits significantly decreased its stability. Elongation of the Nse4 linker partially suppressed instability of the ATP-bound complex, suggesting that the binding of the KITE proteins to the Nse4 linker constrains its limited size. Our data suggest that the KITE proteins may shape the Nse4 linker to fit the ATP-free complex optimally and to facilitate opening of the complex upon ATP binding. This mechanism suggests an important role of the KITE subunits in the dynamics of the SMC5/6 complexes.

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., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: This report examined whether a change in the perceived communication behaviour (PeCoBe) of general practitioners (GPs) influenced the effect of the Promoting Active Aging (PRACTA) intervention on activation of older patients as perceived by GPs., Methods: Pre- and post-intervention questionnaires were filled out by 225 GPs, who were assigned to three groups, e-learning, pdf-article, and control. GPs self-reported their communication behaviour and their perceptions of the attitudes of older patients toward treatment and health., Results: Participation in the e-learning intervention showed an increase in the PeCoBe of GPs, while reading the pdf-article resulted in a decrease of such behaviours. An increase in the PeCoBe of GPs was positively related to an increase in their perception of an active attitude among older patients. The indirect effects observed for e-learning and pdf-article interventions had opposite directions., Conclusion: Both types of PRACTA intervention exerted an impact on GPs' perception of the attitudes of older patients, and change in PeCoBe of GPs could be considered as a mechanism driving this effect., Practical Implications: The methods based on a combination of knowledge delivery and modelling of communication skills are strongly recommended forms of teaching for GPs on how to communicate with and activate seniors., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Aims: Patients' attitude towards treatment and health (ATH) is crucial for compliance at all stages of treatment. This study examined the psychometric properties of the developed PRACTA Attitude Towards Treatment and Health questionnaire, designed to measure ATH as perceived by seniors (PRACTA-ATH) and doctors (PRACTA-ATH-D) in primary health care., Methods: The data were collected in two waves of the Polish-Norwegian PRACTA project. Exploratory factor analyses (EFAs) were conducted on wave 1 data from senior patients ( n = 3392) and their general practitioners ( n = 491). Confirmatory factor analyses (CFAs) were conducted on wave 2 data. This was a new sample of senior patients ( n = 2765) and a follow-up sample of doctors ( n = 393)., Results: The EFAs showed that the 16-item four-factor solution is the best solution reflecting the structure of both seniors and doctors' ATH questionnaires. The CFAs conducted to establish the best unified model for PRACTA-ATH and PRACTA-ATH-D indicated three comparatively good solutions: the 16-item four-factor solution, the 12-item four-factor solution and the 12-item five-factor solution., Conclusions: The questionnaire is found appropriate for use among patients and doctors, and can be used as a good tool to monitor older patients' ATH and concordance between doctors and patients' perspectives.

Background: Active attitude toward treatment and health (ATH) leads to improved cooperation and better health outcomes in patients. Supporting it in the population of older adults is a growing need in primary care. Recognising the role of gender, health and other sociodemographic factors can help to distinguish patients who need the most assistance in activation from general practitioners (GPs). The objective of the study was to investigate gender differences in ATH as well as the moderating role of self-assessed health (SAH) and selected sociodemographic factors (age, education, financial status, marital status)., Methods: A cross-sectional, multicentre study among 4936 primary care older patients (aged 50+) was conducted. The PRACTA-Attitude toward Treatment and Health questionnaire (PRACTA-ATH) was used to measure the cognitive, emotional (positive and negative affect), and motivational dimensions of ATH. Patients were approached before and after their visits in the primary health-care facilities randomly selected in Central Poland., Results: Generalised linear models (GENLIN) revealed the main effects of gender, SAH, and sociodemographic characteristics, such as financial status, marital status and education. Interaction effects of gender and age (Wald's χ 2  = 24.767, p < 0.001 for ATH Global), as well as gender and SAH (Wald's χ 2  = 16.712, p < 0.002 for ATH Global) on ATH were found. The most assistance in regard to ATH was required by men aged 50-74 and men declaring good self-assessed health. Generally, women declared a more active attitude than men, showing more knowledge (M = 5.40, SD = 0.07 and M = 5.21, SD = 0.07, for women and men, respectively, p = 0.046), positive emotion (M = 5.55, SD = 0.06 and M = 5.33, SD =0.06, for women and men, respectively, p = 0.015) and motivation to be involved in their health issues (M = 5.71, SD = 0.07 and M = 5.39, SD = 0.07, for women and men, respectively, p = 0.001). The level of negative emotions related to health was not significantly different between genders (p = 0.971)., Conclusions: The need to create health promoting programmes taking account of particular gender differences in older adults emerges. In regard to clinical practice, building a sense of efficacy and individual responsibility for health, providing information about the means of health promotion and prevention, and recognising health-related cognitions, is recommended especially for men who feel well and are less advanced in age (50-74).

Background: Activating older adults in medical practice can benefit patients' health and quality of life, as well as the economy and burden of the healthcare system. Placing general practice in the public healthcare system gives the elderly population easy access to the promotion of active attitudes toward health, provided that the doctors have and use relevant activating tools. The aim of this study was to verify the possibility of activating senior patients through an educational intervention for doctors., Methods: Two waves of data collection from primary care patients and their doctors were separated by an intervention for doctors. The intervention took the form of an e-learning programme or article and was developed so as to improve general practitioners' (GP) communication and activation skills, especially when working with older adults. The outcome variable was the change between the waves in patients' scores on the PRACTA Attitude Toward Treatment and Health (ATH) Scale and PRACTA Self-efficacy Scale. Data from patients aged 50 + (n = 2175; 55.6% women; age: M = 69.56, SD = 9.10) appointed at the primary care facilities were analysed., Results: The analysis revealed the effect of doctors' e-learning and, to a lesser extent, the effect of article reading on patients' attitudes toward treatment and health as well as on their self-efficacy. In facilities in which the intervention was implemented, patients' attitudes were more active on follow-up than at baseline when compared with facilities without the intervention., Conclusions: Educational intervention among doctors can result in patients' ATH becoming more active. The form of intervention might diversify the impact., (© The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

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., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Major abdominal surgery (MAS) is associated with increased morbidity and mortality. The main objective of our study was to evaluate the predictive value of heart-rate variability (HRV) concerning development of postoperative complications in patients undergoing MAS. The secondary objectives were to identify the relationship of HRV and use of vasoactive drugs during anesthesia, intensive care unit length of stay (ICU-LOS), and hospital length of stay (H-LOS)., Patients and Methods: Sixty-five patients scheduled for elective MAS were enrolled in a prospective, single-center, observational study. HRV was measured by spectral analysis (SA) preoperatively during orthostatic load. Patients were divided according to cardiac autonomic reactivity (CAR; n=23) and non-cardiac autonomic reactivity (NCAR; n=30)., Results: The final analysis included 53 patients. No significant difference was observed between the two groups regarding type of surgery, use of minimally invasive techniques or epidural catheter, duration of surgery and anesthesia, or the amount of fluid administered intraoperatively. The NCAR group had significantly greater intraoperative blood loss than the CAR group (541.7±541.9 mL vs 269.6±174.3 mL, p <0.05). In the NCAR group, vasoactive drugs were used during anesthesia more frequently (n=21 vs n=4; p <0.001), and more patients had at least one postoperative complication compared to the CAR group (n=19 vs n=4; p <0.01). Furthermore, the NCAR group had more serious complications (Clavien-Dindo ≥ Grade III n=6 vs n=0; p <0.05) and a greater number of complications than the CAR group (n=57 vs n=5; p <0.001). Significant differences were found for two specific subgroups of complications: hypotension requiring vasoactive drugs (NCAR: n=10 vs CAR: n=0; p <0.01) and ileus (NCAR: n=11 vs CAR: n=2; p <0.05). Moreover, significant differences were found in the ICU-LOS (NCAR: 5.7±3.5 days vs CAR: 2.6±0.7 days; p <0.0001) and H-LOS (NCAR: 12.2±5.6 days vs CAR: 7.2±1.7 days; p <0.0001)., Conclusion: Preoperative HRV assessment during orthostatic load is objective and useful for identifying patients with low autonomic physiological reserves and high risk of poor post-operative course., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

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.

Introduction: There is evidence that meeting patients' expectations toward health care correlates with involvement in the treatment they receive. The most important patient expectations concern certain types of information: explanation of disease and treatment, health promotion, and improvement in quality of life. Other demands include proper rapport and emotional support. The aim of this paper was to examine different patient groups over the age of 50 years and their expectations toward medical visits, evaluated before a visit and after the visit., Patients and Methods: The study group consisted of 4,921 primary health-care patients. The patients received self-administered questionnaires that they filled in before and after the appointment with the doctor. Interviews with patients were conducted individually by specially trained interviewers. The PRACTA Patient Expectations Scale was used to measure the appointment-related expectations of the patients., Results: We observed differences related to age in patients' expectations before medical visits regarding the following factors: disease explanation, treatment explanation, quality of life, rapport, and emotional support. The same differences were not observed on health promotion. Evaluation of patients' appointment-related experiences after the visit showed that there were significant differences between the age-groups regarding all types of expectations included in the study. Differences between previsit and postvisit measurements were statistically significant in all age-groups. Patients who received less than they expected from doctors outnumbered those who received what they expected or more in all the groups., Conclusion: Patients' expectations toward medical visits are conditioned by age. Therefore, doctors should pay more attention to requirements related to age in their effort to identify and satisfy expectations. This is particularly important in light of the discrepancy between previsit expectations and the actual experiences of patients evaluated after the visit., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Demographic changes over the past decades call for the promotion of health and disease prevention for older patients, as well as strategies to enhance their independence, productivity, and quality of life., Objective: Our objective was to examine the effects of a computer-based educational intervention designed for general practitioners (GPs) to promote active aging., Methods: The Promoting Active Aging (PRACTA) study consisted of a baseline questionnaire, implementation of an intervention, and a follow-up questionnaire that was administered 1 month after the intervention. A total of 151 primary care facilities (response rate 151/767, 19.7%) and 503 GPs (response rate 503/996, 50.5%) agreed to participate in the baseline assessment. At the follow-up, 393 GPs filled in the questionnaires (response rate, 393/503, 78.1%), but not all of them took part in the intervention. The final study group of 225 GPs participated in 3 study conditions: e-learning (knowledge plus skills modelling, n=42), a pdf article (knowledge only, n=89), and control (no intervention, n=94). We measured the outcome as scores on the Patients Expectations Scale, Communication Scale, Attitude Toward Treatment and Health Scale, and Self-Efficacy Scale., Results: GPs participating in e-learning demonstrated a significant rise in their perception of older patients' expectations for disease explanation (Wald χ 2 =19.7, P<.001) and in perception of motivational aspect of older patients' attitude toward treatment and health (Wald χ 2 =8.9, P=.03) in comparison with both the control and pdf article groups. We observed additional between-group differences at the level of statistical trend. GPs participating in the pdf article intervention demonstrated a decline in self-assessed communication, both at the level of global scoring (Wald χ 2 =34.5, P<.001) and at the level of 20 of 26 specific behaviors (all P<.05). Factors moderating the effects of the intervention were the number of patients per GP and the facility's organizational structure., Conclusions: Both methods were suitable, but in different areas and under different conditions. The key benefit of the pdf article intervention was raising doctors' reflection on limitations in their communication skills, whereas e-learning was more effective in changing their perception of older patients' proactive attitude, especially among GPs working in privately owned facilities and having a greater number of assigned patients. Although we did not achieve all expected effects of the PRACTA intervention, both its forms seem promising in terms of enhancing the competencies of doctors in communication with and activation of older patients., (©Dorota Wlodarczyk, Joanna Chylińska, Magdalena Lazarewicz, Marta Rzadkiewicz, Mariusz Jaworski, Miroslawa Adamus, Gørill Haugan, Monica Lillefjell, Geir Arild Espnes. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 22.02.2017.)

Background: Hospital-acquired pneumonia (HAP) is associated with high mortality. In Central Europe, there is a dearth of information on the prevalence and treatment of HAP. This project was aimed at collecting multicenter epidemiological data on patients with HAP in the Czech Republic and comparing them with supraregional data., Methods: This prospective, multicenter, observational study processed data from a database supported by a Czech Ministry of Health grant project. Included were all consecutive patients aged 18 and over who were admitted to participating intensive care units (ICUs) between 1 May 2013 and 31 December 2014 and met the inclusion criterion of having HAP. The primary endpoint was to analyze the relationships between 30-day mortality (during the stay in or after discharge from ICUs) and the microbiological etiological agent and adequacy of initial empirical antibiotic therapy in HAP patients., Results: The group dataset contained data on 330 enrolled patients. The final validated dataset involved 214 patients, 168 males (78.5%) and 46 females (21.5%), from whom 278 valid lower airway samples were obtained. The mean patient age was 59.9 years. The mean APACHE II score at admission was 21. Community-acquired pneumonia was identified in 13 patients and HAP in 201 patients, of whom 26 (12.1%) had early-onset and 175 (81.8%) had late-onset HAP. Twenty-two bacterial species were identified as etiologic agents but only six of them exceeded a frequency of detection of 5% (Klebsiella pneumoniae 20.4%, Pseudomonas aeruginosa 20.0%, Escherichia coli 10.8%, Enterobacter spp. 8.1%, Staphylococcus aureus 6.2% and Burkholderia cepacia complex 5.8%). Patients infected with Staphylococcus aureus had significantly higher rates of early-onset HAP than those with other etiologic agents. The overall 30-day mortality rate for HAP was 29.9%, with 19.2% mortality for early-onset HAP and 31.4% mortality for late-onset HAP. Patients with late-onset HAP receiving adequate initial empirical antibiotic therapy had statistically significantly lower 30-day mortality than those receiving inadequate initial antibiotic therapy (23.8% vs 42.9%). Patients with ventilator-associated pneumonia (VAP) had significantly higher mortality than those who developed HAP with no association with mechanical ventilation (34.6% vs 12.7%). Patients having VAP treated with adequate initial antibiotic therapy had lower 30-day mortality than those receiving inadequate therapy (27.2% vs 44.8%)., Conclusions: The present study was the first to collect multicenter data on the epidemiology of HAP in the Central European Region, with respect to the incidence of etiologic agents causing HAP. It was concerned with relationships between 30-day patient mortality and the type of HAP, etiologic agent and adequacy of initial empirical antibiotic therapy.

Background: Severe sepsis/septic shock is associated with high mortality. In Central Europe, there is a dearth of information on the prevalence and treatment of severe sepsis. The EPOSS (Data-based Evaluation and Prediction of Outcome in Severe Sepsis) project launched in 2011 was aimed at collecting data on patients with severe sepsis/septic shock., Methods: The EPOSS study processes data from the EPOSS project database, and is a retrospective, multicentre, observational study. This included all consecutive patients aged 18 and over who were admitted to participating ICUs from 1 January 2011 to 5 November 2013 and met the inclusion criteria of severe sepsis/septic shock. The primary endpoint was to analyse the relationship between in-hospital mortality (either in ICU or after discharge from ICU) and the type and number of fulfilled diagnostic and treatment interventions during the first 6 h after the diagnosis of severe sepsis/septic shock., Results: The collected dataset involved 1082 patients meeting the criteria of severe sepsis/septic shock. Following data validation, a final dataset of 897 patients was obtained. The average age of the patient group was 64.7 years; mortality at discharge from EPOSS ICUs was 35.5% and from hospital 40.7%. Of the 10 evaluated diagnostic and treatment interventions within the initial 6 hours of identifying severe sepsis/septic shock (i.e. fulfilment of SSC bundles), four or five diagnostic and treatment interventions were administered to 58.4% patients. Combined diagnostic and treatment interventions associated with the lowest in-hospital mortality were: CVP of ≥8-12 mm Hg & MAP of ≥65 mm Hg & Urine output at ≥0.5 mL/kg/h & Lactate of ≤4.0 mmol/L & Initial lactate measured & Antibiotics in the first hour. Lactate at <4 mmol/L and MAP of ≥65 mm Hg remained statistically significant even after adjustment for patient age and APACHE II score. Statistically significantly increased in-hospital mortality was found in patients admitted from general departments (45.7%) or from other ICUs (41.6%), compared to a lower in-hospital mortality of patients transferred from outpatient clinics (26.5%) or Emergency (38.0%). Severe sepsis/septic shock patients transferred from the department of internal medicine were associated with a higher in-hospital mortality (45.1%) than surgical patients (35.5%)., Conclusions: The most effective measures associated with the lowest in-hospital mortality in septic shock patients were CVP of ≥8-12 mm Hg, MAP of ≥65 mm Hg, urine output at ≥0.5 mL/kg/h, initial lactate level of ≤4.0 mmol/L and administration of antibiotics within the first hour.

Background: Rocuronium for cesarean delivery under general anesthesia is an alternative to succinylcholine for rapid-sequence induction of anesthesia because of the availability of sugammadex for reversal of neuromuscular blockade. However, there are no large well-controlled studies in women undergoing general anesthesia for cesarean delivery. The aim of this noninferiority trial was to determine whether rocuronium and sugammadex confer benefit in time to tracheal intubation (primary outcome) and other neuromuscular blockade outcomes compared with succinylcholine, rocuronium, and neostigmine in women undergoing general anesthesia for cesarean delivery., Methods: We aimed to enroll all women undergoing general anesthesia for cesarean delivery in the 2 participating university hospitals (Brno, Olomouc, Czech Republic) in this single-blinded, randomized, controlled study. Women were randomly assigned to the ROC group (muscle relaxation induced with rocuronium 1 mg/kg and reversed with sugammadex 2-4 mg/kg) or the SUX group (succinylcholine 1 mg/kg for induction, rocuronium 0.3 mg/kg for maintenance, and neostigmine 0.03 mg/kg for reversal of the neuromuscular blockade). The interval from the end of propofol administration to tracheal intubation was the primary end point with a noninferiority margin of 20 seconds. We recorded intubating conditions (modified Viby-Mogensen score), neonatal outcome (Apgar score <7; umbilical artery pH), anesthesia complications, and subjective patient complaints 24 hours after surgery., Results: We enrolled 240 parturients. The mean time to tracheal intubation was 2.9 seconds longer in the ROC group (95% confidence interval, -5.3 to 11.2 seconds), noninferior compared with the SUX group. Absence of laryngoscopy resistance was greater in the ROC than in the SUX groups (ROC, 87.5%; SUX, 74.2%; P = 0.019), but there were no differences in vocal cord position (P = 0.45) or intubation response (P = 0.31) between groups. No statistically significant differences in incidence of anesthesia complications or in neonatal outcome were found (10-minute Apgar score <7, P = 0.07; umbilical artery pH, P = 0.43). The incidence of postpartum myalgia was greater in the SUX group (ROC 0%; SUX 6.7%; P = 0.007). The incidence of subjective complaints was lower in the ROC group (ROC, 21.4%; SUX, 37.5%; P = 0.007)., Conclusions: We conclude that rocuronium for rapid-sequence induction is noninferior for time to tracheal intubation and is accompanied by more frequent absence of laryngoscopy resistance and lower incidence of myalgia in comparison with succinylcholine for cesarean delivery under general anesthesia.

Background: Important hospital-acquired infections include pneumonia, mainly because of the increasing resistance of bacterial pathogens to antimicrobials and the associated potential failure of antibiotic therapy. The present study aimed at determining the most frequent etiological agents of hospital-acquired pneumonia (HAP) and assessing the relationship between 30-day mortality and adequacy of antibiotic therapy. Based on the obtained information, optimal patterns of antibiotic therapy were to be defined, including a pharmacoeconomic perspective., Methods: In patients with clinically confirmed HAP, bacterial etiological agents were identified, their susceptibility to antimicrobials was determined and statistical methods were used to assess the relationship between adequacy of antibiotic therapy and 30-day mortality., Results: The study comprised 68 patients with clinically confirmed HAP. The most common etiological agents were strains of Pseudomonas aeruginosa (30.8 %), Klebsiella pneumoniae (23.1 %) and Burkholderia cepacia complex (15.4 %). Gram-negative bacteria accounted for 86.5 % of all bacterial pathogens. The overall mortality reached 42.5 %. In the subgroup of patients with inadequate antibiotic therapy, 30-day mortality was significantly higher (83.3 %) than in the subgroup with adequate therapy (30.0 %; p = 0.002). The risk for 30-day mortality was 2.78 times higher in case of inadequate antibiotic therapy (95%CI: 1.52-5.07). The proportion of Pseudomonas aeruginosa strains was significantly higher in the subgroup of patients with inadequate antibiotic therapy than in those with adequate therapy (67 % vs. 27 %; p = 0.032)., Conclusion: Results of the present study suggest a significant relationship between mortality of patients with HAP and ineffective antibiotic therapy due to resistance of the bacterial pathogen. Thus, it is clear that initial antibiotic therapy must be based on qualified assumption of sufficient activity against the most common bacterial pathogens and results of surveillance of bacterial resistance in the relevant epidemiological unit. At the same time, however, it must be stressed that it is impossible to cover all potential variants of the etiological agents and their resistance phenotypes.

SMC5/6 is a highly conserved protein complex related to cohesin and condensin, which are the key components of higher-order chromatin structures. The SMC5/6 complex is essential for proliferation in yeast and is involved in replication fork stability and processing. However, the precise mechanism of action of SMC5/6 is not known. Here we present evidence that the NSE1/NSE3/NSE4 sub-complex of SMC5/6 binds to double-stranded DNA without any preference for DNA-replication/recombination intermediates. Mutations of key basic residues within the NSE1/NSE3/NSE4 DNA-binding surface reduce binding to DNA in vitro. Their introduction into the Schizosaccharomyces pombe genome results in cell death or hypersensitivity to DNA damaging agents. Chromatin immunoprecipitation analysis of the hypomorphic nse3 DNA-binding mutant shows a reduced association of fission yeast SMC5/6 with chromatin. Based on our results, we propose a model for loading of the SMC5/6 complex onto the chromatin., (© The Author(s) 2015. Published by Oxford University Press on behalf of Nucleic Acids Research.)

Aim: The aim of this study was to identify retrospectively, lumbar sympathectomy (SE) using thermography (TG) and to evaluate clinically, the severity of post-sympathectomy (post-SE) dysfunction after anterior and lateral lumbar interbody fusion procedures (ALIF, XLIF)., Methods: Twenty eight patients with suspected SE were referred for TG to both legs. They completed our questionnaire on severity of difficulties after SE. We evaluated the ability of physical examinations to reveal the SE in contrast to TG and compared the symptoms (warmer leg and inhibited leg sweating) of SE with questionnaire responses as subjective measure and TG as objective measure., Results: SE was diagnosed in 0.5% after ALIF at L5/S1, in 15% after ALIF at Th12-L5 and in 4% after XLIF at T12-L5. SE severely reduced the quality of life in two cases. The ability to distinguish differences in leg temperature by palpation after SE was found in 32%. All physical examinations together were insufficient for reliably disclosing SE. Subjective symptoms of SE were often false positive and proven SE by TG was often a clinically false negative., Conclusion: This is the first study to examine post-SE dysfunction objectivelya using TG after ALIF and XLIF, and the first to evaluate clinically, the severity of the post-SE syndrome. Before surgery we cannot foresee potentially poor SE results. For this reason, injury to the sympathetic chain during surgery must be avoided. The advantage of TG for identifying SE is its non-invasiveness and reliability.

Aim: The aim of this study was to compare resection and biopsy of glioblastoma (GBM) in eloquent brain areas (EBA)., Methods: This was a prospective evaluation of 38 patients with GBM in EBA. 22 were treated by surgical resection and 16 by biopsy. Preoperative KPS, neurological status and size of lesion on MRI were assessed. One week and three months postoperatively KPS, neurological status and Performance Status (PS) WHO were evaluated. Extent of resection (EOR) and overall survival (OS) were described. Overall mean age of the patients was 64.3 years, the mean lesion size in the resection group was 47.7 mm and in the biopsy group 51.0 mm., Results: Worsening or development of permanent neurological deficits 3 months after surgery were significantly lower in the resection group (23%), than the biopsy group (94%). In the resection group the median pre and postoperative KPS three months after surgery was 80.0. In the biopsy group the median pre and postoperative KPS was 68.1 one week after the procedure. In the resection group, 3 months after surgery, the median PS was 1, in the biopsy group one week after surgery the median PS was 2. The difference was statistically insignificant. The mean OS after resection was 12.2 months, and after biopsy 3.5 months. The difference was highly statistically significant. The mean EOR was 90%., Conclusion: This is the first prospective study, to our knowledge, that compares the results of resection and biopsy of primary GBM in EBA. For patients in good clinical condition with tumors in or near EBA, recommended is as radical resection of GBM as possible.

Background: The aim of the study was to compare the validity of bronchial secretion sampling and bronchoscopy-assisted protected specimen brushing (PSB) in patients with hospital-acquired pneumonia (HAP)., Materials and Methods: In patients with HAP, bronchial secretion samples (aspiration of lower airway secretions from an orotracheal tube with a suctioning catheter) and PSB (bronchoscopy-assisted sampling from the most affected area of the lung, verified by CT scan) were taken at the same time. Both samples were processed by semiquantitative routine microbiological techniques. Identification of microorganisms was performed by standard microbiological techniques using the MALDI-TOF automated system. For similarity or identity determination of bacterial isolates from bronchial secretion sampling and PSB, pulsed-field gel electrophoresis was used., Results: Thirty patients were enrolled into the study. Thirty pairs of bronchial secretion samples and PSB samples were obtained and processed. The samples were positive in 23 patients (77 %) and 15 patients (50 %), respectively. In 15 cases, the same pathogen was determined in both samples, and in all those cases, the isolates were genetically identical., Conclusion: The results of the study show that bronchial secretion samples analysis enabled identification of all pathogens that were identified by PSB. Given the high sensitivity of the bronchial secretion aspiration technique and genetic identity of isolates in both samples, bronchial secretion sampling may be recommended for determining HAP etiological agents as the samples are much easier to obtain from patients.

Rocuronium is a neuromuscular blocking agent acting as a competitive antagonist of acetylcholine. Results of an inhibition of eight individual liver microsomal cytochromes P450 (CYP) are presented. As the patients are routinely premedicated with diazepam, possible interaction of diazepam with rocuronium has been also studied. Results indicated that rocuronium interacts with human liver microsomal CYPs by binding to the substrate site. Next, concentration dependent inhibition of liver microsomal CYP3A4 down to 42% (at rocuronium concentration 189 μM) was found. This effect has been confirmed with two CYP3A4 substrates, testosterone (formation of 6β-hydroxytestosterone) and diazepam (temazepam formation). CYP2C9 and CYP2C19 activities were inhibited down to 75-80% (at the same rocuronium concentration). Activities of other microsomal CYPs have not been inhibited by rocuronium. To prove the possibility of rocuronium interaction with other drugs (diazepam), the effect of rocuronium on formation of main diazepam metabolites, temazepam (by CYP3A4) and desmethyldiazepam, (also known as nordiazepam; formed by CYP2C19) in primary culture of human hepatocytes has been examined. Rocuronium has caused inhibition of both reactions by 20 and 15%, respectively. The results open a possibility that interactions of rocuronium with drugs metabolized by CYP3A4 (and possibly also CYP2C19) may be observed., (Copyright © 2014 Japanese Pharmacological Society. Production and hosting by Elsevier B.V. All rights reserved.)

Gastric lavage after ingestion of excessive amounts of a drug/poison--yes or no? If yes, at what time intervals from ingestion? On one side stand some authors who emphasize the complications, contraindications, and low yield of this procedure. These authors recommended that gastric lavage should be performed only within 30-60 minutes after ingestion of toxic doses of a drug/poison. Later lavage usually has no clinical benefit. On the other side stand some other authors who recommend gastric lavage in patients as late as 6 hours after intoxication. In some cases, when the ingested substance slows gastric emptying, they even recommend lavage until 24 hours after intoxication. Based on our experience, it is necessary to support strongly the second group of the authors and recommend the extension of the time interval when to perform gastric lavage in intoxication.

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.

Purpose of the Study: The aim of the study was to evaluate the extent of fusion using synthetic β-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.

Aim: The aim of this study was to compare the complication rate of traditional minimally invasive anterior with the new minimally invasive lateral trans-psoatic retroperitoneal approaches to the intervertebral discs at levels T12-L5., Methods: A review of all cases of minimally invasive anterior (ALIF) and lateral (XLIF) intervertebral disc surgery at levels T12-L5, treated at the Department of Neurosurgery from January 1996 to September 2011. The ALIF group consisted of 120 and the XLIF group consisted of 88 patients. Preoperative diagnoses were: degenerative disc disease, failed back surgery syndrome, spondylolisthesis, retrolisthesis and posttraumatic disc injury. The surgical steps are described. All surgical intraoperative and postoperative complications directly related to the spinal surgery were prospectively documented. The outcome measure was rate of complications., Results: In the ALIF group there were no major complications, only 35 minor intra- and postoperative complications in 32 patients (26.6%). The main complication was lumbar post-sympathectomy syndrome in 19 patients (15.8%). In the XLIF group there were 26 complications in 22 patients (25%). One major intraoperative complication was partial and transient injury to the L5 nerve root (1.1%). There were 25 minor postoperative complications in the XLIF group in 21 patients (23.9%), mainly transient pain of the left groin or anterior thigh in 11 patients (12.5%) or numbness in the same dermatomas in 9 patients (10.2%). Statistically there was no difference between the ALIF and XLIF groups in complication rate., Conclusion: Anterolateral and lateral retroperitoneal minimally invasive approaches to levels T12-L5 disc spaces are safe procedures with only minor complications and one exception. The rate of complications was similar in both groups. In the case of ALIF, the particular complication was post-sympathectomy syndrome. The main complication of XLIF was transient nerve root injury in one patient due to underestimation of the procedure in the outset. Intraoperative neuromonitoring during XLIF surgery is fully recommended.

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.

Background: Patients with significant medical and social problems resulting from impaired perfusion of the upper limbs caused by micro- or macro-angiopathy are now frequent in clinical practice. Vasospastic disease of the upper limbs of combined origin is a difficult condition to treat by conservative methods and therapeutic strategies are usually multidisciplinary. In addition to standard pharmacotherapy, treatment may involve regional anaesthesia, thoracoscopic or radiofrequency sympathectomy and surgical treatment of defects, including plastic surgery., Methods: This paper describes our successful work in the treatment of upper limb critical ischemia using radiofrequency upper thoracic sympathectomy., Results: In three case reports we present the results of radiofrequency thermolysis applied to treat patients with chronic defects of the hand and fingers. These patients were diagnosed with upper limb critical ischemia of combined origin, standard conservative treatment methods failed and surgical intervention was originally not indicated, however, radiofrequency thermolysis proved to be beneficial., Conclusions: Radiofrequency thoracic sympathectomy could improve peripheral perfusion of the upper limbs and thereby contribute to healing of chronic defects, reduction of pain and improvement in the quality of life of the patients.

Aim: The aims of this study were to describe the incidence and type of perioperative complications that occur with minimally invasive anterior retroperitoneal spinal surgery performed at the level of the L5/S1 intervertebral disc., Methods: A retrospective review of 175 patients: 103 women and 72 men, average age 45, who had undergone anterior spinal surgery at level L5/S1 from January 2001 to February 2011. The preoperative diagnoses were: degenerative disc disease in 87 (50%), failed back surgery syndrome in 53 (30%) and spondylolisthesis in 35 patients (20%). The surgical steps in the minimally invasive anterior retroperitoneal approach from the right side to disc L5/S1 are described. All surgical intraoperative anatomical anomalies and complications directly related to the anterior spinal surgery were documented., Results: Intraoperative pathological-anatomical anomalies were found in 34 patients (19%) and intra - and postoperative minor complications in 24 patients (12%) but no serious complications. The main intraoperative complication was peritoneal opening without visceral injury (5%) and the main postoperative complication was weakness of the right abdominal wall (3%)., Conclusion: . Retroperitoneal access and surgery at level L5/S1 disc space is a safe procedure when performed by a knowledgeable and experienced spine team. During surgical planning for an anterior approach to the LS spine, the surgeon must carefully assess the neuroimaging results, such as MRI, to minimize potentially disastrous vascular complications.

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.

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.

Aims: To compare the pharmacodynamics of 0.6 mg kg(-1) rocuronium in young and older patients of both genders during total intravenous anesthesia., Methods: Following local ethics committee approval and informed consent, patients scheduled for surgery under total intravenous anesthesia (propofol/sufentanil) were divided into 4 study groups: 37 males aged 20-40, 40 males aged 60-75 yrs, 43 females aged 20-40 and 38 females aged 60-75 yrs. Neuromuscular block following rocuronium (0.6 mg kg(-1)) was monitored: train-of-four [TOF] stimulation of the ulnar nerve at 15-s intervals, EMG of the adductor pollicis muscle. The onset time (from application of rocuronium to maximum depression of T(1)), clinical duration (from application to 25% recovery of T(1)), and time to full spontaneous recovery (from application to TOF-ratio ≥ 0.9) were determined for each patient. The Kruskal-Wallis test was used to compare differences between groups; P<0.05 was considered statistically significant., Results: The onset time (median [interquartile range]) in the respective groups was 90 [80-110](BCD), 135 [116-165](AC), 75 [60-90](ABD), and 120 [90-146](AC) seconds. The clinical duration was 30 [25-42](BCD), 58 [53-67](AD), 50 [40-65](AD), and 85 [70-90](ABC) min. Interval to full spontaneous recovery was 59 [51-67](BCD), 102 [75-106](A), 76 [66-91](AD), and 128 [94-137](AC) min. ((A)P<0.05 vs. young males, (B)P<0.05 vs. elderly males, (C)P<0.05 vs. young females, (D)P<0.05 vs. elderly females)., Conclusion: Females and older patients were more sensitive to rocuronium.

Background: This prospective study aimed at assessing the effect of initial antibiotic therapy on the mortality of patients with hospital-acquired pneumonia (HAP) by analyzing bacterial pathogens and their resistance to antimicrobial agents., Methods: Included were patients hospitalized in the Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine and Dentistry, Palacký University Olomouc and University Hospital Olomouc in 2009 who developed HAP. Bacterial pathogens and their resistance to antibiotics were identified using standard microbiological methods. The patient's mortality with respect to their initial antibiotic therapy was statistically analyzed., Results: The group comprised 51 patients with HAP. Early-onset HAP was identified in 7 (14%) patients and late-onset HAP in 44 (86%) patients. The most frequent bacterial pathogens were strains of Klebsiella pneumoniae, Pseudomonas aeruginosa, Burkholderia cepacia complex and Escherichia coli, together accounting for 72%. Eighteen patients died directly due to HAP, an overall mortality rate of 35%. If initial therapy effective against the bacterial pathogen was selected, 21 patients survived and 9 died. If the bacterial pathogens were resistant to the selected initial antibiotic therapy, 9 patients died and 12 survived., Conclusions: The mortality rates were 30% and 43% for adequate and inadequate antibiotic therapy, respectively. Given the small group of patients, the difference has low statistical significance. However, it does document the clinical impact of bacterial resistance on the survival or death of patients with HAP.

Purpose: Extreme lateral interbody fusion (XLIF) is a method for stabilization of the lumbar spine. Intraoperatively, the surgeon identifies the lumbar nerve roots with a stimulator to prevent their injury. The objective of this study was to determine the extent to which shallow rocuronium-induced neuromuscular block must be intraoperatively reversed for reliable identification of nerve roots., Methods: General anesthesia (midazolam-propofol-sufentanil-oxygen/air/sevoflurane-rocuronium) was administered to all patients. Train-of-four (TOF) stimulation of the ulnar nerve at 15-s intervals and electromyographic response of the adductor pollicis muscle were used. During operation, the surgeon stimulated the lumbar nerve roots (5-10 mA) to identify their course. At the appearance of two twitches to the TOF stimuli, sugammadex (2 mg/kg) or neostigmine (0.04 mg/kg) was administered. When the response to nerve root stimulation appeared, the TOF ratio was recorded., Results: When the response to nerve root stimulation with 10 mA became detectable, the median (range) TOF ratios were 0.67 (0.50-0.81) and 0.65 (0.42-0.71) after sugammadex and neostigmine, respectively. Similarly, TOF ratios at the first detectable response to stimulation with 5 mA were 0.88 (0.67-0.93) and 0.83 (0.61-0.93). After sugammadex and neostigmine, the respective intervals until TOF ratio ≥0.90 were 2.0 (0.8-3.3) and 15.9 (7.3-28.8) min., Conclusion: Intraoperative reversal of shallow rocuronium-induced block with either sugammadex or neostigmine is an efficient method. For reliable detection of lumbar nerve roots with a stimulating current of 10 mA, the block should be reversed to a TOF ratio of at least 0.70. For a current intensity of 5 mA, the TOF ratio should reach 0.90.

Aim: To determine the inter-observer reproducibility of 15 tests used for predicting difficult tracheal intubation (DI)., Material and Methods: Following local ethics committee approval and informed consent, 101 volunteers were examined by two assessors using 15 tests for predicting DI. The two assessors who were blinded to the results of the other, examined each volunteer independently. Cohen's kappa (κ) or first-order agreement coefficient (AC1) were used to measure agreement between assessor ratings on a qualitative scale. Agreement between two quantitative outcomes was described using the intraclass correlation coefficient (ICC) and Pearson's (PCC) or Spearman's (SCC) correlation coefficients. The following interpretation of the coefficients was used: poor (< 0.20), fair (0.21-0.40), satisfactory (0.41-0.60), good (0.61-0.80), and excellent (0.81-1.00)., Results: Respective coefficients of inter-rater agreement and correlation coefficients were determined for the following parameters: pathologies associated with DI (κ=0.662, AC1=0.990), clinical impression (κ=-0.013, AC1=0.969), modified Mallampati test (κ=0.503, AC1=0.861), upper lip bite test (κ=0.370, AC1=0.897), temporo-mandibular joint movement (κ=0.088, AC1=0.797), max. anteroflexion of C-spine (ICC=0.136, SCC=0.391), max. retroflexion of C-spine (ICC=0.020, SCC=0.284), mandibular length (ICC=0.301, SCC=0.553), neck circumference (ICC=0.832, SCC=0.928), hyo-mental distance (ICC=0.378, SCC=0.472), thyro-mental distance (ICC=-0.002, PCC=0.265), sternomental distance (ICC=0.674, PCC=0.815), and finally, inter-incisor gap (ICC=0.695, PCC=0.785). Two tests (positive history of DI and retrogenia), were excluded from calculation because no positive cases were found., Conclusion: Best inter-rater agreement was found for the assessment of neck circumference while the highest discrepancies between raters were in goniometrically-measured mobility of the C-spine. Many of the pre-operative airway tests had only fair inter-observer reproducibility. This may be one reason why models for predicting difficult intubation are not universally reliable.

Aim: Failed endotracheal intubation and inadequate ventilation with subsequent insufficient oxygenation can result in serious complications potentially leading to permanent health damage. Difficult intubation may occur not only in patients with apparent pathologies in the orofacial region but also, unexpectedly, in those without abnormalities. This study aimed at finding anthropometric parameters that are easy to examine and that would aid in predicting difficult intubation., Method: A case-control study was undertaken. Based on defined criteria, 15 parameters were examined in patients with unanticipated difficult intubation. The parameters included a previous history of difficult intubation, pathologies associated with difficult intubation, clinical symptoms of airway pathology, the Mallampati score, upper lip bite test, receding mandible, and cervical spine and temporomandibular joint movement. Thyromental, hyomental and sternomental distances and inter-incisor gap were measured. The methods were precisely defined and the measurements were carried out by a trained anesthesiologist. Statistical analysis was performed on data from 74 patients with difficult intubation and 74 control patients with easy intubation., Results: Significant predictors of difficult intubation were inter-incisor gap (IIG), thyromental distance (TMD) and class 3 limited movement of the temporomandibular joint. The IIG and TMD cut-offs were set at 42 mm and 93 mm, respectively., Conclusion: The results will be used to confirm these predictors in an anesthesiology clinic along with the aid of the laryngoscopic findings to improve the prediction of unanticipated difficult intubation.

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.

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.

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.

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.