Analysis of biophysical and pathophysiological modifications in surgical treatment of chronic subdural hematomas

Субдурални хематом је колекција крви између дуре и арахноидее, која се сматра хроничном када се развија у току 21 дана или дуже. Један је од најчешћих неурохируршких ентитета, чија се укупна инциденција креће и до 20 на 100.000 особа годишње, а очекивања су да ће овај број бити удвостручен у наредних десет година због повећаног удела старије популације у укупној. Егзактно патофизиолошко порекло болести је контроверзно, али се стандардни облик највероватније развија услед мање повреде главе, у светлу коагулопатије или дисфункције тромбоцита, серијом међусобно повезаних механизама: инфламације, фибринолизе, формирања мембрана и ангиогенезе којом се повећава запремина хематома. Лечење хроничног субдуралног хематома (ХСДХ) у већини случајева укључује хируршку евакуацију, међутим неколико терапијских поступака, укључујући конзервативни и ендоваскуларни приступ, приказано је као погодан третман за одабране групе пацијената. Операција ХСДХ је једна од најстаријих (или чак најстарија) познатих хируршких процедура. Такође је једна од најједноставнијих операција у неурохирургији, која обилује широким спектром модификација, а без јасних препорука или смерница. Трепанација са дренажом је најчешће коришћена процедура и погодна је за велику већину пацијената са ХСДХ. Минимално инвазивни поступак може се извести у локалној анестезији и довести до потпуне резолуције ХСДХ; међутим, неки пацијенти из различитих разлога и даље морају да се подвргну процедури у општој анестезији, од којих су неки повезани са лежећим положајима који се обично користе. Рецидив ХСДХ, са или без претходног пнеумоцефалуса, је најзначајнија специфична компликација, којој су скоро све савремене студије усмерене као примарном исходу. За будног пацијента је седећи положај најудобнији, а истовремено је врло погодан и за хирурга. Узимајући у обзир биофизичке карактеристике ХСДХ и самог поступка, седећи положај задржава најбоље карактеристике класичних положаја, позиционирањем главе на дохват руку, трепанацијом која се лако постави у паријетопостериорној регији, усклади са са највишом ташком главе и ХСДХ, чиме постаје природна баријера проласку ваздуха у субдуралну шупљину, чиме може довести до смањења стопе рецидива. Циљ студије био је да се хируршка процедура (трепанација са дренажом) у седећем упореди са уобичајеним лежећим положајима (на леђима или стомаку), да се процени безбедност и презентују предности и недостаци ове модификације. Поред тога, извршен је преглед релевантних студија како би се идентификовале најприкладније модификације и дефинисао алгоритам лечења заснован на доказима за дијагностику, лечење и праћење пацијената са ХСДХ и дале препоруке за будућа истраживања и студије. Материјал и методе Kохортна студија је обухватила пацијенте оперисане због ХСДХ у Клиници зa нeурoхирургиjу Војномедицинске академије у пeриoду oд 21.12.2016. до 31.06.2020. године, а укључени су сви пацијенти са индикацијом за оперативно лечење ХСДХ, у складу са стандардним критеријумима, код којих је изведена трепанација са дренажом. а који су праћени у периоду од 6 месеци, како би се идентификовале компликације, потреба за поновљеном операцијом, као и исход лечења. Студију је одобрио етички комитет Медициског факултета Универзитета у Београду...subdural hematoma is a blood collection between the dura and arachnoid layers of meninges, which is considered chronic when developed in course of 21 days or more. It is one of the most common neurosurgical entities, with the overall incidence reported to range up to 20 per 100,000 persons per year. It is expected to double in the following ten-years-period due to the growth of the elderly population. The exact pathophysiological origin of the disease is controversial, but the usual form most likely develops due to the minor head injury, in spite of coagulopathy or platelet disfunction, through a cascade of interrelated mechanisms including inflammation, fibrinolysis, membrane formation, and angiogenesis that propagate an increase in hematoma volume. Treatment of the chronic subdural hematoma (CSDH) in the majority of cases includes surgical evacuation, however, a few therapeutic procedures, including conservative and endovascular approaches emerged as a suitable treatment in the selected groups of patients. Surgery for CSDH is one of the oldest (or even the oldest) surgical procedures known. It is also one of the simplest surgical procedures in neurosurgery, but still with a vast variety of modifications, and without clear recommendations or guidelines. Burr-hole craniostomy is the most commonly used procedure, and it is suitable for the vast majority of the patients with CSDH. The minimally invasive procedure may be carried under local anesthesia and lead to the complete recovery; however, some patients still have to undergo procedure under general anesthesia for various reasons, some of which are related to the supine or prone positions usually used. The CSDH reoccurrence with or without preceding pneumocephalus is the most significant specific complication, with almost all contemporary studies aimed at it as a primary outcome. In an awake patient, the sitting position is the most comfortable for the patient, while being convenient for the surgeon as well. Considering the biophysical features of CSDH and the procedure itself, a sitting position may retain the best characteristics of classic positioning, due to the head positioned at surgeon’s hands, the burr hole, which is easily made in the parietoposterior region, aligned with the vertex of the patient’s head (and the vertex of the CSDH), thus becoming a natural barrier for the air ingress into the subdural cavity, leading to the decrease of the reoccurrence rates. The aim of this study was to evaluate the burr-hole with drainage procedure in the sitting position in comparison to the usual supine or prone, to evaluate for safety, and discuss the benefits and shortcomings of this modification. In addition, a review of relevant studies was performed to identify the most appropriate modifications and define an evidence-based treatment algorithm for the diagnosis, treatment and the follow-up of patients with CSDH. Material and Methods The cohort study included patients operated on for CSDH in the Clinic for Neurosurgery of the Military Medical Academy in the period from 21.12.2016. to 31.06.2020. year, and included all patients with an indication for surgical treatment of CSDH, in accordance with standard criteria in which trepanation with drainage was performed, and which were followed for a period of 6 months, in order to identify complications, the need for repeated surgery, as well as the overall outcome. The study was approved by the Ethical Committee of the University of Belgrade Faculty of Medicine..

Kombinirano liječenje rupturirane aneurizme srednje moždane arterije praćene subarahnoidnim krvarenjem i akutnim subduralnim hematomom u višestrukoj aneurizmatskoj bolesti krvnih žila mozga: prikaz slučaja

Aneurysms of blood vessels at the base of the brain are pathological focal outpouchings, usually found at the branching points of the arteries. Aneurysm can remain silent for life. Clinical presentation is due to rupture and bleeding. In only 1.3% of cases it results in subdural hematoma, which is associated with direct interaction of the aneurysm with the basal arachnoid membrane. Multiple aneurysms are present in 15% to 33% of cases with subarachnoid hemorrhage. Assessment of these patients is more complicated, as there are no specific signs to pinpoint/detect the aneurysm that has ruptured. This report presents a 44-year-old female patient suffering from multiple cerebral aneurysm disease, who was urgently treated after rupture by both endovascular (for multiple aneurysms) and surgical (for acute subdural hematoma) approach in the same act under general anesthesia, which resulted in complete recovery of the patient.Aneurizme krvnih žila na bazi mozga su žarišna patološka proširenja koja se obično nalaze na račvanju arterija. Mogu ostati klinički nijeme cijelog života. Klinička slika nastaje zbog rupture i krvarenja. Samo u 1,3% slučajeva rezultira pojavom subduralnog hematoma, što je u vezi s izravnom interakcijom aneurizme i bazalne arahnoidne membrane. Višestruke aneurizme su prisutne u 15% do 33% bolesnika sa subarahnoidnim krvarenjem. Pristup ovakvim bolesnicima je složen, jer ne postoje specifični znaci koji bi ukazali na ili otkrili aneurizmu koja je rupturirala. Ovaj prikaz opisuje bolesnicu u dobi od 44 godine s višestrukom aneurizmatskom bolešću mozga koja je nakon rupture hitno podvrgnuta endovaskularnom (zbog višestrukih aneurizma) i kirurškom (zbog akutnog subduralnog hematoma) terapijskom zahvatu u istom aktu u općoj anesteziji, što je rezultiralo njezinim potpunim oporavkom

Povezanost kliničkih karakteristika i morfoloških parametara s rupturom aneurizme prednje komunikacijske arterije

We analyzed aneurysm morphology, demographic and clinical characteristics in patients with anterior communicating artery (ACoA) aneurysms to investigate the risk factors contributing to aneurysm rupture. A total of 219 patients with ACoA aneurysms were admitted to our hospital between January 2016 and December 2020, and morphological and clinical characteristics were analyzed retrospectively in 153 patients (112 ruptured and 41 unruptured). Medical records were reviewed to obtain demographic and clinical data on age, gender, presence of hemorrhage, history of hypertension, diabetes, heart disease, and kidney disease. Morphological parameters examined on 3-dimensional digital subtraction angiography included aneurysm size, neck diameter, aspect ratio, size ratio, bottleneck ratio, height/width ratio, aneurysm angle, (in)flow angle, branching angle, number of aneurysms per patient, shape of the aneurysm, aneurysm wall morphology, variation of the A1 segment, and direction of the aneurysm. Male gender, aspect ratio, height/width ratio, non-spherical and irregular shape were associated with higher odds of rupture, whilst controlled hypertension was associated with lower odds of rupture, when tested using univariate logistic regression model. In multivariate model, controlled hypertension, presence of multiple aneurysms, and larger neck diameter reduced the odds of rupture, while irregular wall morphology increased the risk of rupture. Regulated hypertension represented a significant protective factor from ACoA aneurysm rupture. We found that ACoA aneurysms in male patients and those with greater aspect ratios and height/width ratios, larger aneurysm angles, presence of daughter sacs and irregular and non-spherical shapes were at a higher risk of rupture.Analizirali smo morfologiju aneurizme, demografske i kliničke karakteristike u bolesnika s aneurizmom prednje komunikacijske arterije (ACoA) kako bismo istražili čimbenike rizika koji doprinose rupturi aneurizme. Ukupno je 219 bolesnika s aneurizmom ACoA primljeno u našu bolnicu u razdoblju od siječnja 2016. do prosinca 2020. godine, a morfološke i kliničke karakteristike analizirane su retrospektivno u 153 bolesnika (112 puknutih i 41 neprekinuta). Pregledani su medicinski zapisi kako bi se dobili demografski i klinički podaci za dob, spol, prisutnost krvarenja, povijest hipertenzije, dijabetes, srčane bolesti i bolesti bubrega. Morfološki parametri ispitani na trodimenzionalnoj digitalnoj subtrakcijskoj angiografiji uključivali su veličinu aneurizme, promjer vrata, odnos između normalne visine aneurizme i širine vrata aneurizme (aspect ratio), odnos između visine aneurizme i prosječnog promjera svih krvnih žila povezanih s aneurizmom (size ratio), odnos između širine fundusa aneurizme i širine vrata aneurizme (bottleneck ratio), odnos između najveće normalne visine aneurizme i širine aneurizme (height/width ratio), kut aneurizme, ugao ulaska tijeka krvne struje u fundus aneurizme (inflow angle), kut grananja, broj aneurizma po bolesniku, oblik aneurizme, morfologiju stijenke aneurizme, varijaciju segmenta A1 i smjer aneurizme. Muški spol, odnos između normalne visine aneurizme i širine vrata aneurizme, odnos između najveće normalne visine aneurizme i širine aneurizme, nesferičan i nepravilan oblik bili su povezani s većim izgledima za puknuće, dok je kontrolirana hipertenzija bila povezana s manjom vjerojatnosti puknuća kada je testirano primjenom modela s univarijatnom logističkom regresijom. U multivarijatnom modelu su kontrolirana hipertenzija, prisutnost više aneurizma i veći promjer vrata smanjili izglede za puknuće, dok je nepravilna morfologija stijenke povećala rizik od puknuća. Regulirana hipertenzija predstavlja značajan zaštitni čimbenik od pucanja aneurizme ACoA. Utvrdili smo da su aneurizme ACoA u muških bolesnika i one s većim odnosom između normalne visine aneurizme i širine vrata aneurizme te one s većim odnosom između najveće normalne visine aneurizme i širine aneurizme, većim kutovima aneurizme, prisutnošću kćeri vrećica te nepravilnim i nesferičnim oblicima u većem riziku od puknuća

Divovska kavernozna malformacija s neuobičajeno agresivnim kliničkim tijekom: prikaz slučaja

Giant cavernomas (GC) are rare lesions, with less than 50 cases reported so far. Clinical presentation usually involves epileptic seizures and less typically focal neurological deficit, due to repeated hemorrhages and GC mass effect and consequentially increased intracranial pressure. Although individual cases have been reported, due to the rarity and variable imaging appearance, GCs are usually not considered in the differential diagnosis of large hemorrhagic lesions, especially when significant mass effect is present. A 17-year-old boy presented due to severe headache, right-sided weakness, and slurred speech. Symptoms started three days before with occasional headaches, which intensified gradually. Emergency computed tomography revealed a left frontal massive heterogeneous lesion. Soon after, right-sided hemiparesis and speech impairment progressed, and the patient became drowsy with the slightly dilated left pupil. Emergency surgery was performed, and the lobed grayish lesion was entirely removed. Based on the macroscopic appearance, the surgeon assumed it was a metastasis of melanoma. Histopathologic analysis result was cavernoma. GC should be considered as an option in hemorrhagic lesions, especially in the young age population. Emergency surgery for mass lesions is not uncommon in neurosurgery; however, bleeding cavernomas are usually planned for elective surgery due to the specific approach and complications.Divovski kavernomi (DK) su rijetke lezije s manje od 50 dosad opisanih slučajeva. Uobičajena simptomatologija su epileptični napadaji, a rjeđe se manifestiraju žarišnim neurološkim deficitom koji je uzrokovan ponavljanim hemoragijama i posljedičnim povećanjem intrakranijskog tlaka. Iako su objavljeni pojedini slučajevi, zbog rijetke pojavnosti i raznovrsne radiološke prezentacije DK se obično ne razmatraju u diferencijalnoj dijagnostici velikih hemoragičnih ekspanzivnih lezija, pogotovo kada je prisutan značajan kompresivni učinak. Sedamnaestogodišnji dječak se javio liječniku zbog jake glavobolje, blaže desnostrane slabosti i nerazgovijetnog govora. Simtpomi su se javili 3 dana ranije u vidu blagih glavobolja koje su se postupno pojačavale. Hitna kompjutorizirana tomografija je pokazala masivnu hemoragičnu leziju frontalno lijevo. Nedugo zatim desnostrana slabost i nerazgovijetan govor su se pogoršali i bolesnik je postao pospan s blago proširenom lijevom zjenicom. Učinjena je hitna operacija, kružna sivkasta lezija je u cijelosti uklonjena. Na osnovi makroskopskog izgleda kirurg je pomislio da se radi o metastazi melanoma. Histopatološka analiza je pokazala da se radi o kavernomu. DK bi trebalo razmatrati kao mogućnost kod hemoragičnih lezija, pogotovo kod mlađih bolesnika. Hitna operacija kod kompresivnih lezija nije rijetkost u neurokirurgiji, međutim, krvareći kavernomi se obično planiraju za elektivnu operaciju zbog specifičnog pristupa i mogućih komplikacija

Liječenje projektilnih ozljeda brahijalnog pleksusa

Missile injuries are among the most devastating injuries in general traumatology. Traumatic brachial plexus injuries are the most difficult injuries in peripheral nerve surgery, and most complicated to be surgically treated. Nevertheless, missile wounding is the second most common mechanism of brachial plexus injury. The aim was to evaluate functional recovery after surgical treatment of these injuries. Our series included 68 patients with 202 nerve lesions treated with 207 surgical procedures. Decision on the treatment modality (exploration, neurolysis, graft repair, or combination) was made upon intraoperative finding. Results were analyzed in 60 (88.2%) patients with 173 (85.6%) nerve lesions followed-up for two years. Functional recovery was evaluated according to functional priorities. Satisfactory functional recovery was achieved in 90.4% of cases with neurolysis and 85.7% of cases with nerve grafting. Insufficient functional recovery was verified in ulnar and radial nerve lesions after neurolysis, and in median and radial nerve lesions when graft repair was done. We conclude that the best time for surgery is between two and four months after injury, except for the gunshot wound associated with injury to the surrounding structures, which requires immediate surgical treatment. The results of neurolysis and nerve grafting were similar.Ozljede projektilima su među najrazornijim ozljedama u općoj traumatologiji. Traumatske ozljede brahijalnog pleksusa najteže su ozljede perifernog živčanog sustava, a najkompliciranije se liječe kirurški. Ipak, projektilno ranjavanje je drugi najčešći mehanizam ozljede brahijalnog pleksusa. Cilj je bio procijeniti funkcionalni oporavak nakon kirurškog liječenja ovih ozljeda. Naša studija je obuhvatila 68 bolesnika s 202 ozljede živaca liječenih u 207 kirurških zahvata. Odluka o načinu liječenja (eksploracija, neuroliza, direktna reparacija graftom ili kombinacija) donesena je na osnovi intraoperacijskog nalaza. Rezultati su analizirani u 60 (88,2%) bolesnika sa 173 (85,6%) lezije živaca nakon kojih je slijedilo razdoblje praćenja u trajanju od dvije godine. Funkcionalni oporavak ocijenjen je prema funkcionalnim prioritetima. Zadovoljavajući funkcionalni oporavak postignut je u 90,4% neuroliza i 85,7% reparacija graftom. Slučajevi s nedovoljnim funkcionalnim oporavkom bili su povezani s neurolizom ulnarnog i radijalnog živca ili reparacijom graftom srednjih i proksimalnih lezija. Zaključujemo da je najbolje vrijeme za kirurški zahvat između dva i četiri mjeseca nakon ozljede, osim kada postoje udružene ozljede okolnih struktura, što zahtijeva neodložno kirurško liječenje. Rezultati neurolize i reparacije graftom bili su slični

Ultrasonographic assessment of the maxillary artery and middle meningeal artery in the infratemporal fossa

Purpose: To investigate with Doppler ultrasonography the maxillary and middle meningeal arteries in the infratemporal fossa, and describe their hemodynamic characteristics. Methods: We included 24 female and 11 male volunteers without vascular diseases, with a median age of 43 years. We used the acoustic window, enlarged by subjects half-opening their mouth, located below the zygomatic arch, in front of temporo-mandibular joint, to reach the maxillary and middle meningeal arteries. Results: In the 35 subjects, 112 arteries were visualized successfully: 60 maxillary (85.7%), and 52 middle meningeal arteries (74.3%), at a depth of 2.40 and 2.50 cm, respectively. Their blood flow was directed anteriorly and away from the probe. While all the measured hemodynamic characteristics differed significantly between the maxillary and the middle meningeal artery (P < 0.001), there was no significant difference between male and female subjects, nor between the left or the right side. Conclusions: The maxillary and middle meningeal arteries can be insonated in the infratemporal fossa through the easily accessible acoustic window below the zygomatic arch, when the patient holds his mouth half open. They can be differentiated by their ultrasonographic characteristics and blood flow features

Importance of angle corection in transcranial color-coded duplex insonation of arteries at the base of the brain

Background/Aim. Transcranial color-coded duplex (TCCD) sonography allows visualization of the vessels being examined and measurement of the angle of insonation. The published literature suggests that blood vessels are insonated at the angle lower than 30 degrees, hence no correction for the angle is necessary. The aim of this study was to determine the availability of intracranial blood vessels for insonation, and the percentage of arteries and their segments which can be insonated at the angles lower than 30 degrees. Methods. The study included 120 patients (mean age 51). For each of the segments the angle of insonation was registered based on TCCD vizualization, and hemodynamic parameters were measured. The angle of insonation was measured using combined B-mode and color Doppler vizualization, as the angle between the direction of the ultrasound beam and the axis of the shown arterial segment. Results. The total success rate of insonation was 86.33% (1,554 out of 1,800). The mean angle of insonation value in all the examined arterial segments was 42 degrees. The insonation angle was higher than 30 degrees in about three quarters of the examined segments, especially in the A2 segment of the anterior cerebral artery (98%), the P1 segmet of the posterior cerebral artery (87%) and in the terminal internal carotid artery (83%). The A1 segment of the anterior cerebral artery showed the best insonation conditions with the angle of insonation lower than 30 degrees in 53% of the cases. Conclusion. The presented results of angles of insonation measurements for the anterior, middle and posterior cerebral arteries and their segments, as well as the terminal portion of the internal carotid artery clearly indicate that their average values in tested segments were very often higher than 30 degrees, which can cause an error in blood flow velocity measurement that cannot be ignored. The results confirm the necessity of correcting flow velocity values on the basis of the angle of insonation in TCCD sonography

Comparative analgesic efficacy of ultrasound-guided nerve blocks induced by three anesthetics with different duration of action in the treatment of resistant neuropathic pain in the lower extremities

Background/Aim. The neuropathic pain (NP) treatment is a big medical and socioeconomical problem. The new sorts of the NP treatment was developed and are applied in case of a medical treatment failure. The aim of this work was to investigate the efficacy of the ultrasound-assisted treatment of the resistant and chronic peripheral neuropathic pain with the local anesthetic nerve blocks. Due to the inefficacy of conventional treatment, three local anesthetics (shortacting, medium-term and long-acting) were administered in a series of the same minimal dose on a daily basis. Complications, side effects, the execution time of procedure and the onset time of local anesthetic were also investigated. Methods. In this prospective, randomized and doubleblinded study, 108 patients (of which 53 were diagnosed with diabetes and 55 with radiculopathy) with the resistant and chronic peripheral neuropathic pain in the lower extremities were treated with a series of ultra-sound assisted peripheral nerve blocks. The conventional treatment was exhausted. The presence of this neuropathic pain was confirmed by, at least, one of the three scales – the Leeds Assesment of Neuropathic Simptoms and Signs (LANSS) scale, the Dolour Neuropathic 4 questions (DN4) scale and the pain DETECT(PD-Q) scale. Other therapies were not applied. The nerve blocks were administered on a daily basis until the relief of pain (visual analogue scale – VAS 50% – excellent results; 31–49% – good results; < 30% the therapy did not work. The side effects, complications, the execution duration of procedure, the onset time of numbness, the number of corrections of the needle direction were recorded as well. Results. For all three groups: nerve blocks took 5.4 ± 1.48 minutes to do (withouth difference among the groups), the onset of numbness occured, on average, within 3.75 ± 2.62 minutes (withouth differences among the groups), and the need for corrections of needle direction was minimal (1.03 ± 0.17 corrections). All the patients experienced a loss of pain sensation (VAS < 30); when a long-acting anesthetic was used, the number of required nerve blocks was significant (p < 0.001) smallest (4.33 ± 0.63 blocks), than in other two groups, and the percentage pain reduction was highest (73.13%) (p < 0.001). The pain relief lasted one month after the therapy without the application of any other therapy. Neither complications nor side effects were observed. Conclusion. The procedure dercibed is a safe, efficient and easy-to-perform and does not lead to any complications and side effects. The pain relief is achieved most effectively and rapidly with the longacting local anesthetics, and maintained even for one month without the introduction of any additional therapy

Does the blood glucose control have an effect on the success of the painful diabetic neuropathy treatment?

Background/Aim. Diabetic neuropathy (DN) is the basic complication of diabetes, associated with impared glucoregulation, metabolic distrurbances, microvascular vessel damage and increased cardiovascular risk. We monitored the impact of glucoregulation on the efficacy of painful diabetic neuropathy (PDN) treatment, when all pharmaceutical treatment options were exhausted. Methods. Patients (n = 53, both gender, average age 68.3 ± 12.6) with PDN resistant to the pharmacotherapy were treated with the ultrasound- guided local anesthetic (0.5% procaine hydrochloride, 1% lidocaine, 0.25% levobupivacaine) blocks. Neuropathy was confirmed in accordance with the applicable European Federation of Neurological Societies (EFNS) criteria. Glycosylated hemoglobin (HbA1C) and blood glucose levels were monitored before and after therapy and one month after the treatment. Neuropathic pain was confirmed by Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) or Douleur neuropathique (DN4) or pain DETECT scales. The pain intensity was assessed by Visual analog scale, Neuropathic pain symptom and Neuropathic pain symptom inventory (VAS, NPS and NPSI, respectively) scales before and after therapy and one month after the treatment. The efficacy of the therapy was assessed as: excellent result (> 50% of pain loss), good result (30%–49% of pain loss and the therapy does not work (< 30% of pain loss). The correlation between glucoregulation and the outcome was examined. Results. Because the values of glycenia and HbA1c were not different among patients treated with different local anesthetics, they were presented together. All patients had elevated blood glucose and HbA1C levels before (8.23 ± 2.77 mmol/L and 8.53% ± 2.48% respectively), after (8.43 ± 2.461 mmol/L and 8.85% ± 2.87%, respectively) and one month after the treatment (8.49 ± 2.22 mmol/L and 8.51% ± 2.09%, respectively). The loss of the pain was not result of the decrease in blood glucose and HbA1C blood levels. VAS, NPS, NPSI values were the following before the therapy: 81.53 ± 11.62 mm; 62.00 ± 13.04; 53.40 ± 17.63, respectively; after the therapy: 29.00 ± 9.23 mm; 13.79 ± 6.65; 11.83 ± 7.93, respectively; and one month later: 26.15 ± 8.41 mm; 12.68 ± 6.03; 9.81 ± 7.64, respectively]. There was no correlation between glucoregulation and excellent outcome. Conclusion. Even though the disturbance of glucose control is the key factor for the progression of PDN, it is not significant for the outcome of the pain treatment. New investigations are required

Evaluating a primary healthcare centre's preparedness for disasters using the hospital safety index: Lessons learned from the 2014 floods in Obrenovac, Serbia

Various organizations have endeavored to develop assessment methods for the identification and management of weaknesses in hospital disaster preparedness. Although the largest number of patients receive their regular care at the primary level, there is no internationally validated tool for the rapid safety assessment of primary health care centers (PHC). Flooding accounts for almost 50% of all disasters related to weather, and climate models consider these events as highly probable in the future. In May 2014, heavy rain caused floods affecting around 1.6 million people in Serbia, leaving the municipality of Obrenovac most severely impacted. This paper aims at assessing the safety of PHC Obrenovac using the Hospital Safety Index (HSI), evaluating the usefulness of HSI for safety assessment of PHCs, and drawing lessons from the 2014 floods. PHC Obrenovac had an overall safety index of 0.82, with structural, nonstructural safety, and disaster management indices of 0.95, 0.74, and 0.75, respectively, implying it is likely to function in disasters. A detailed analysis of individual HSI items underlined the necessary improvements in the field of emergency power and water supply, telecommunication, and emergency medical supplies, which rendered the PHC non-functional during the 2014 floods. Most items were considered of same relevance for primary healthcare centers as for hospitals, excluding some items in the medical equipment, patient care, and support services. Fine-tuning the HSI to primary healthcare settings, officially translating it into different languages, facilitating scoring and analysis could result in a valid safety evaluation tool of primary healthcare facilities