The importance of neuromonitoring application during operations of intradural tumors of spinal canal

Neuromonitoring je veoma važan element koji je omogućio intraoperativno praćenje akcionih potencijala nerava i mišića i time smanjio mogućnost lezije kičmene moždine i neurološkog deficita. Uvođenje u praksu intraoperativnog neuromonitoringa tokom operacija tumora kičmenog kanala, naročito intramedularnih tumora, omogućilo je direktan uvid u trenutnu funkciju kičmene moždine i time mogućnost da se izbegnu jatrogena oštećenja koja bi dovela do teških neuroloških ispada. On konkretno zamenjuje neurološki pregled pacijenta u opštoj anesteziji u toku operacije. Oštećenje tkiva kičmene moždine tokom operacije može nastupiti direktnom ili indirektnom traumom, kompresijom, ishemijom, istezanjem nervnih elemenata, hipotenzijom, elektrolitnim poremećajima, kompresijom ili krvarenjem. Primena neuromonitoringa može prikazati svaku promenu koja nastaje navedenim mehanizmima, i to u ranoj reverzibilnoj fazi, kada je moguće reagovati (hirurg i anesteziolog) i sprečiti dalje oštećenje. Rezultati hirurškog lečenja intraduralnih tumora kičmenog kanala su u poslednjih dvadesetak godina izuzetno unapređeni, zahvaljujući pre svega uvođenju u standardnu upotrebu u sve većem broju centara operacionog mikroskopa, ultrazvučnog aspiratora i neuromonitoringa. U ovoj disertaciji je prezentovana uloga neuromonitoringa, ali i ispitani prediktori ishoda pacijenata sa intraduralnim tumorima, kao i preživljavanje ovih pacijenata. CILJEVI ISTRAŽIVANJA: Ciljevi ovog istraživanja su: utvrđivanje razlike u neurološkom ishodu pacijenata sa intraduralnim ekstramedularnim i intramedularnim tumorima (pri otpustu, godinu i tri godine nakon operacije) bez i sa upotrebom neuromonitoringa. Potom, otkrivanje uticaja pojedinih nezavisnih preoperativnih i kliničkih faktora na neurološki status pacijenata, kao i otkrivanje uticaja intraoperativnih parametara i faktora na neurološki status pacijenata i krajnji ishod lečenja. Kao cilj je postavljeno i određivanje preživljavanje ovih grupa pacijenata, kao i njihov period bolesti bez recidiva, i kvalitet života. METODOLOGIJA: Istraživanje je obuhvatilo grupu od ukupno 240 pacijenata hirurški lečenih zbog postojanja intraduralnih tumora u Klinici za neurohirurgiju KCS u Beogradu u periodu od 6 godina, od januara 2008. do decembra 2013. godine.Neuromonitoring is a very important element that enabled tracking of the action potentials of neurons and muscles and thus reduce the the possibility of spinal cord lesions and neurological deficits. Introduction to the practice of intraoperative neuromonitoring during the operation of spinal canal tumors, especially intramedularnih tumors, allow a direct insight into the current function of the spinal cord and thus the ability to avoid iatrogenic damage that would have resulted in severe neurological deficit. It specifically overrides the neurological examination the patient in general anesthesia during surgery. Damage to the tissues of the spinal cord during surgery may perform from direct or indirect trauma, compression, ischemia, neural elements stretching, hypotension, electrolyte disorders, compression or bleeding. Application of neuromonitoring may show each change that occurs with the above mechanisms, and that in the early stages are reversible, when it is possible to react (surgeon and anaesthesiologist) and prevent further damage. The results of the surgical treatment of intradural tumors of the spinal canal in the last two decades are extremely improved, thanks first of all to the introduction and the standard use, in a growing number of centers, surgery microscopes, ultrasonic extraction unit and neuromonitoring. In this thesis the role of neuromonitoring is presented, but also predictors of outcome of patients with intradural tumours was investigated, as well as the survival of these patients. OBJECTIVES: The objectives of this study were: to determine the differences in neurological outcome of patients with intradural extramedullar and intramedullar tumors (at discharge, one year and three years after surgery) without and with the use of neuromonitoring. Then, to uncover the impact of individual independent preoperative and clinical factors in neurological status of patients, and detection of the influence of intraoperative parameters and factors in neurological status of patients and the outcome of treatment. As the target was also set to determine the survival of these groups of patients, and also their progression free period (PFS), and quality of life (QoL). METHODOLOGY: The survey covered a group of 240 patients operated due to the existence of intradural tumor in Clinic for neurosurgery CCS in Belgrade for a period of 6 years, as of January 2008. by December 2013..

Puncture site bleeding complications in patients with Clopidogrel hyper-response: Three case reports

Dual antiplatelet therapy (clopidogrel and acetylsalicylic acid) is a standard for the embolization of planned intracranial aneurysms with CNS stent due to the possibility of stent thrombus formation. All anti-aggregation drugs, including those listed, have bleeding as a side effect. Three patients with aneurysm had an elevated response to antiplatelet therapy with clopidogrel, which was confirmed by a multiplate test on the "VerifyNow" system. After reducing the dose of clopidogrel or after interrupting it, with the introduction of low molecular weight heparin for the duration of five days, aneurysms were successfully resolved by intracranial implantation of the stent. Perioperative angiograms and postoperative CT angiograms have verified hematomas at the place of punction of the femoral artery. Bleeding was resolved by the femoral artery suture by a vascular surgeon. All patients were discharged home without further complications and with dual antiplatelet therapy. By measuring the platelet function in vitro, the degree of inhibition of platelet activity achieved by the action of the drug can be assessed. A specific test can identify those patients who are highly responsive to the drug with increased platelet reactivity and the possibility of increased risk of bleeding. Our suggestion is to reduce the dosage of clopidogrel or to leave it out for 24 hours with preventive doses of low molecular weight heparin or to change the strategy of treatment of intracranial aneurysm, i.e. avoiding implantation of CNS stent

The importance of neuromonitoring application during operations of intradural tumors of spinal canal

Neuromonitoring je veoma važan element koji je omogućio intraoperativno praćenje akcionih potencijala nerava i mišića i time smanjio mogućnost lezije kičmene moždine i neurološkog deficita. Uvođenje u praksu intraoperativnog neuromonitoringa tokom operacija tumora kičmenog kanala, naročito intramedularnih tumora, omogućilo je direktan uvid u trenutnu funkciju kičmene moždine i time mogućnost da se izbegnu jatrogena oštećenja koja bi dovela do teških neuroloških ispada. On konkretno zamenjuje neurološki pregled pacijenta u opštoj anesteziji u toku operacije. Oštećenje tkiva kičmene moždine tokom operacije može nastupiti direktnom ili indirektnom traumom, kompresijom, ishemijom, istezanjem nervnih elemenata, hipotenzijom, elektrolitnim poremećajima, kompresijom ili krvarenjem. Primena neuromonitoringa može prikazati svaku promenu koja nastaje navedenim mehanizmima, i to u ranoj reverzibilnoj fazi, kada je moguće reagovati (hirurg i anesteziolog) i sprečiti dalje oštećenje. Rezultati hirurškog lečenja intraduralnih tumora kičmenog kanala su u poslednjih dvadesetak godina izuzetno unapređeni, zahvaljujući pre svega uvođenju u standardnu upotrebu u sve većem broju centara operacionog mikroskopa, ultrazvučnog aspiratora i neuromonitoringa. U ovoj disertaciji je prezentovana uloga neuromonitoringa, ali i ispitani prediktori ishoda pacijenata sa intraduralnim tumorima, kao i preživljavanje ovih pacijenata. CILJEVI ISTRAŽIVANJA: Ciljevi ovog istraživanja su: utvrđivanje razlike u neurološkom ishodu pacijenata sa intraduralnim ekstramedularnim i intramedularnim tumorima (pri otpustu, godinu i tri godine nakon operacije) bez i sa upotrebom neuromonitoringa. Potom, otkrivanje uticaja pojedinih nezavisnih preoperativnih i kliničkih faktora na neurološki status pacijenata, kao i otkrivanje uticaja intraoperativnih parametara i faktora na neurološki status pacijenata i krajnji ishod lečenja. Kao cilj je postavljeno i određivanje preživljavanje ovih grupa pacijenata, kao i njihov period bolesti bez recidiva, i kvalitet života. METODOLOGIJA: Istraživanje je obuhvatilo grupu od ukupno 240 pacijenata hirurški lečenih zbog postojanja intraduralnih tumora u Klinici za neurohirurgiju KCS u Beogradu u periodu od 6 godina, od januara 2008. do decembra 2013. godine.Neuromonitoring is a very important element that enabled tracking of the action potentials of neurons and muscles and thus reduce the the possibility of spinal cord lesions and neurological deficits. Introduction to the practice of intraoperative neuromonitoring during the operation of spinal canal tumors, especially intramedularnih tumors, allow a direct insight into the current function of the spinal cord and thus the ability to avoid iatrogenic damage that would have resulted in severe neurological deficit. It specifically overrides the neurological examination the patient in general anesthesia during surgery. Damage to the tissues of the spinal cord during surgery may perform from direct or indirect trauma, compression, ischemia, neural elements stretching, hypotension, electrolyte disorders, compression or bleeding. Application of neuromonitoring may show each change that occurs with the above mechanisms, and that in the early stages are reversible, when it is possible to react (surgeon and anaesthesiologist) and prevent further damage. The results of the surgical treatment of intradural tumors of the spinal canal in the last two decades are extremely improved, thanks first of all to the introduction and the standard use, in a growing number of centers, surgery microscopes, ultrasonic extraction unit and neuromonitoring. In this thesis the role of neuromonitoring is presented, but also predictors of outcome of patients with intradural tumours was investigated, as well as the survival of these patients. OBJECTIVES: The objectives of this study were: to determine the differences in neurological outcome of patients with intradural extramedullar and intramedullar tumors (at discharge, one year and three years after surgery) without and with the use of neuromonitoring. Then, to uncover the impact of individual independent preoperative and clinical factors in neurological status of patients, and detection of the influence of intraoperative parameters and factors in neurological status of patients and the outcome of treatment. As the target was also set to determine the survival of these groups of patients, and also their progression free period (PFS), and quality of life (QoL). METHODOLOGY: The survey covered a group of 240 patients operated due to the existence of intradural tumor in Clinic for neurosurgery CCS in Belgrade for a period of 6 years, as of January 2008. by December 2013..

Comparative analysis of current payment system for hospital services in Serbia and projected payments under diagnostic related groups system in urology

Background/Aim. Global budget per calendar year is a traditional method of funding hospitals in Serbia. Diagnose related groups (DGR) is a method of hospital payment based on classification of patients into groups with clinically similar problems and similar utilization of hospital resources. The aim of this study was to compare current methods of hospital services payment with the projected costs by DRG payment method in urology. Methods. The data were obtained from the information system used in the Clinical Hospital Center “Dr. Dragiša Mišović” - Dedinje in Belgrade, Serbia. The implemented hospital information system was the main criterion for selection of healthcare institutions. The study included 994 randomly selected patients treated surgically and conservatively in 2012. Results. Average costs under the current payment method were slightly higher than those projected by DRG, however, the variability was twice as high (54,111 ± 69,789 compared to 53,434 ± 32,509, p < 0,001) respectively. The univariate analysis showed that the highest correlation with the current payment method as well as with the projected one by DRG was observed in relation to the number of days of hospitalization (ρ = 0.842, p < 0.001, and ρ = 0.637, p < 0.001, respectively). Multivariate regression models confirmed the influence of the number of hospitalization days to costs under the current payment system (β = 0.843, p < 0.001) as well as under the projected DRG payment system (β = 0.737, p < 0.001). The same predictor was crucial for the difference in the current payment method and the projected DRG payment methods (β = 0.501, p <0.001). Conclusion. Payment under the DRG system is administratively more complex because it requires detailed and standardized coding of diagnoses and procedures, as well as the information on the average consumption of resources (costs) per DRG. Given that aggregate costs of treatment under two hospital payment methods compared in the study are not significantly different, the focus on minor surgeries both under the current hospital payment method and under the introduced DRG system would be far more cost-effective for a hospital as great variations in treatment performance (reduction of days of hospitalization and complications), and consequently invoiced amounts would be reduced

Reconstruction of Moderately and Severely Atrophic Scalp—A Multicentric Experience in Surgical Treatment of Patients Irradiated for Tinea Capitis in Childhood and Surgical Algorithm

Background and Objectives: Before the introduction of griseofluvin, the use of X-ray radiation was the treatment of choice for tinea capitis. More than half a century later various types of tumors have been found to be associated with childhood irradiation due to tinea capitis, most commonly cancers of the head and neck, as well as brain tumors. The often unusually aggressive and recurrent nature of these tumors necessitates the need for repeated surgeries, while the atrophic skin with an impaired vascular supply due to radiation often poses an additional challenge for defect reconstruction. We present our experience in the surgical treatment of such patients. Materials and Methods: This is a retrospective cohort study. In this study, 37 patients treated for acquired defects of the scalp with a history of irradiation therapy due to tinea capitis in childhood were included in this study, 24 male and 13 female patients. The mean age at the first appointment was 60.6 ± 7.8, with the youngest included patient being 46 and the oldest being 75 years old. Patients’ characteristics, surgical treatment, and complications were analyzed and a reconstructive algorithm was developed. Results: Local flaps were used for reconstruction in 34 patients, direct sutures were used in 10 patients and 20 patients received split-thickness skin grafts for coverage of both primary and secondary defects for reconstruction of flap donor sites. One regional flap and one dermal substitute covered by an autologous skin graft were also used for reconstruction. Complications occurred in 43.2% of patients and were significantly associated with the presence of comorbidities (p = 0.001), aseptic bone necrosis (p = 0.001), as well as skin atrophy in frontal, occipital, and parietal region (p = 0.001, p = 0.042 and p = 0.001, respectively). A significant correlation between major complications and moderate skin atrophy was found only in the parietal region (p = 0.026). Conclusions: Unfortunately, many protocols developed for scalp reconstruction are not applicable in the setting of severe or diffuse scalp skin atrophy associated with high tumor recurrence rate and radiation-induced vascular impairment, such as in tinea capitis patients in Serbia. An algorithm has been developed based on the authors’ experience in managing these patients