Analiza polazišta i okvirni nacrt modela regionalnog klastera u Ličko-senjskoj županiji

Koncentracija ekonomskih aktivnosti na lokaliziranom području može rezultirati efektima koji imaju značajan utjecaj na dinamiku ekonomskog razvoja. Jedan od fenomena koji nastaju kao posljedica prostorne koncentracije gospodarskih aktivnosti u određenom sektoru je klaster. Ovaj se rad bavi ispitivanjem uvjeta dinamike i razvoja klastera, te utjecajima koje klasteri imaju na regionalni razvoj. Objašnjeno je na koji način i pod kojim uvjetima klaster postaje žarište inovacija i pokretač regionalnog razvoja. Analizirana je mogućnost razvoja regionalnog klastera u Ličko-senjskoj županiji kao mogućeg zamašnjaka snažnijeg gospodarskog razvoja ove regije. Predložen je okvirni nacrt modela za regionalni klaster u Ličko-senjskoj županiji

Optimizing braking energy flow through charging status surface expansion

Energy savings in electric railway transportation is essential due to the ever-rising energy cost and endeavour to reduce climate change impact. A valuable method to increase energy efficiency is to recuperate and consenquently utilize the regenerative braking energy of electric railway vehicles. The system that stores and reuses the braking energy is called a regenerative braking system, consisting of an energy storage system (ESS), a birdirectional power converter, and a control system, which includes an algorithm controlling the braking energy flow. A properly designed algorithm increases energy efficiency, lessens the stress on the power grid, increases the lifetime of the energy storage system, and enables a catenary-free operation of the electric railway vehicle. The algorithm is defined by combining two algorithms with opposite features – maximum energy savings and minimal number of cycles. The algorithm is then synthesized from those two criteria using an optimization process and then simulated while its effect on energy savings and grid stability is analyzed. Energy savings and a more stable grid are achieved with the use of the algorithm, which corroborates the inclusion of a regenerative braking system in electric railway vehicles

Severe Traumatic Brain Injury after the Assault with an Axe Handle

Traumatic brain injuries represent a major cause of death and disability. We present a case of a 47-year-old patient who sustained a severe brain injury after being assaulted with a handle of an axe. The patient underwent numerous surgeries by various specialists during several months. Following a few failed attempts to cover the skull defects, the vacuum-assisted closure system had been utilized with great success in healing of her complex head wound. Traumatic brain injury requires great effort and collaboration in order to rehabilitate people to the most independent level of functioning possible

Development of the Croatian model of organ donation and transplantation

Abstract During the past ten years, the efforts to improve and organize the national transplantation system in Croatia have resulted in a steadily growing donor rate, which reached its highest level in 2011, with 33.6 utilized donors per million population (p.m.p.). Nowadays, Croatia is one of the leading countries in the world according to deceased donation and transplantation rates. Between 2008 and 2011, the waiting list for kidney transplantation decreased by 37.2% (from 430 to 270 persons waiting for a transplant) and the median waiting time decreased from 46 to 24 months. The Croatian model has been internationally recognized as successful and there are plans for its implementation in other countries. We analyzed the key factors that contributed to the development of this successful model for organ donation and transplantation. These are primarily the appointment of hospital and national transplant coordinators, implementation of a new financial model with donor hospital reimbursement, public awareness campaign, international cooperation, adoption of new legislation, and implementation of a donor quality assurance program. The selection of key factors is based on the authors’ opinions; we are open for further discussion and propose systematic research into the issue

Severe Traumatic Brain Injury after the Assault with an Axe Handle

Traumatic brain injuries represent a major cause of death and disability. We present a case of a 47-year-old patient who sustained a severe brain injury after being assaulted with a handle of an axe. The patient underwent numerous surgeries by various specialists during several months. Following a few failed attempts to cover the skull defects, the vacuum-assisted closure system had been utilized with great success in healing of her complex head wound. Traumatic brain injury requires great effort and collaboration in order to rehabilitate people to the most independent level of functioning possible

FREQUENCY, RISK FACTORS, PREVENTION AND TREATMENT OF NOSOCOMIAL INFECTION IN ADULT CARDIOSURGICAL PATIENTS AT INTENSIVE CARE UNIT, RIJEKA UNIVERSITY HOSPITAL CENTER IN 2015

Cilj ove retrospektivne studije bila je analiza učestalosti, rizičnih faktora, primjene preventivnih mjera te antimikrobnog liječenja nozokomijalnih infekcija stečenih u ranom poslijeoperacijskom razdoblju u 392 odrasla kardiokirurška bolesnika liječena u Jedinici intenzivnog liječenja (JIL) kardiokirurških bolesnika Klinike za anesteziologiju i intenzivno liječenje Kliničkog bolničkog centra (KBC) Rijeka od 1. siječnja do 31. prosinca 2015. Kriteriji za proglašenje nozokomijalne infekcije uključivali su tri skupine pacijenata: pacijente s pozitivnim mikrobiološkim kulturama uzetim rutinski prilikom prijma u JIL (urinokultura, bris nosa, VAT), pacijente s pozitivnim mikrobiološkim kulturama nakon 24 sata od prijma u JIL uz dinamsku nestabilnost, Clinical Pulmonary Infection Score (CPIS skor) 1-6 ili zbog znakova infekcije sternalne rane te pacijente s negativnim mikrobiološkim kulturama, ali sa CPIS skorom većim >6. Učestalost nozokomijalnih infekcija u JIL iznosila je 10 %, s mortalitetom of 7,5 %. Najčešći rizični faktori razvoja nozokomijalne infekcije bili su: pozitivna prijeoperacijska mikrobiološka nadzorna kultura, Sequentional Organ Failure ssessment score (SOFA) pri prijmu u JIL jednak ili >6, invazivna mehanička ventilacija dulja od 72 sata, trajanje operacije dulje od 240 min, liječenje u JIL dulje od 72 sata, poslijeoperacijska hemodinamska nestabilnost 24 sata od operacije, primjena izvantjelesnog krvotoka i hitne operacije. Studija je pokazala kako je u ovih bolesnika najčešće zabilježena infekcija respiratornog trakta čemu je pridonijela činjenica da je 6 % bolesnika pristupilo elektivnoj operaciji s pozitivnim prijeoperacijskm brisom nosa i urinokulturom, pri čemu je najčešće bio izoliran Staphylococcus aureus. Dobiveni rezultati govore u prilog potrebi primjene prijeoperacijskih mjera dekontaminacije nosa intranazalnim apliciranjem mupirocina i odgode elektivnog zahvata do izliječenja uroinfekcije. Kako bi se smanjila pojavnost nozokomijalnih infekcija nužno je i adekvatno perioperacijsko doziranje antimikrobne profi lakse s obzirom na tjelesnu težinu, stupanj krvarenja, trajanje operacije i primjenu izvantjelesnog krvotoka.The aim of this retrospective study was to assess the incidence, risk factors and effi cacy of preventive measures and perioperative antibiotic prophylaxis in 392 adult cardiac surgery patients treated early postoperatively in the Intensive Care Unit (ICU), Rijeka University Hospital Centre, Rijeka, Croatia, between January 1 and December 31, 2015. The following criteria for nosocomial infection were analyzed: patients with positive microbiological cultures routinely taken at ICU (urine culture, swab, ventilator-associated tracheobronchitis); patients with sequential organ failure assessment (SOFA) score ≥6; patients with positive microbiological cultures 24 hours after admission to ICU due to hemodynamic instability, clinical pulmonary infection score (CPIS score) 1-6 or signs of sternal infection; and patients with negative microbiological cultures but with CPIS score >6. Nosocomial infection occurred in 10% of patients and mortality was 7.5%. The following risk factors for development of nosocomial infection in these patients were identifi ed in the study: positive preoperative microbiological cultures, invasive mechanical ventilation longer than 72 hours, theatre rocedures longer than 240 minutes, postoperative ICU treatment longer than 72 hours, persistent hemodynamic instability 24 hours after postoperative admission, application of extracorporeal circulation, and emergency operations. Respiratory tract infections were the most common nosocomial infections; there was high correlation with positive nasal swabs confi rmed preoperatively in almost 6% of patients having undergone elective surgery, with Staphylococcus aureus as the most frequent isolate. Results of our study pointed to the need of preoperative eradication of nasal carriage of bacteria by topical application of mupirocin in patients undergoing elective cardiac surgery and urinary infection treatment until negative culture. Also, the doses of perioperative antibiotic prophylaxis should be administered according to body weight, level of bleeding, duration of operating procedure, and use of extracorporeal circulation

The comparison of early and late percutaneous dilatational tracheostomy in the onset of complications in mechanically ventilated patients in the intensive care unit

Cilj: Cilj istraživanja bio je utvrditi učestalost i najčešće komplikacije pri izvođenju perkutane dilatacijske traheostomije (PDT) te usporediti učinak ranog PDT-a i kasnog PDT-a na učestalost razvoja pneumonije uzrokovane strojnom ventilacijom, duljinu trajanja strojne ventilacije te duljinu boravka životno ugroženih bolesnika liječenih u jedinici intenzivnog liječenja (JIL). Ispitanici i postupci: Opservacijskom prospektivnom studijom obuhvaćeno je 338 bolesnika koji su liječeni u JIL-u (lokalitet Sušak) Klinike za anesteziologiju i intenzivno liječenje Kliničkog bolničkog centra Rijeka u razdoblju od 1. siječnja 2007. godine do 31. prosinca 2010. godine, u kojih je bio učinjen PDT. Rezultati: Od ukupnog broja bolesnika 109 (32 %) bolesnika bile su žene, a 229 (68 %) muškarci. Kod 256 (76 %) bolesnika učinjen je rani PDT, a kod 82 (24 %) bolesnika kasni PDT. Komplikacije PDT-a bile su redom: u 5 bolesnika nastupilo je krvarenje, dok se u pojedinačnim slučajevima javila hipotenzija, upala stome, ozljeda grkljana, nemogućnost promjene trahealne kanile, hipoksija te otežana dilatacija. Usporedba učestalosti komplikacija ranog PDT-a s učestalošću komplikacija kasnog PDT-a nije pokazala statistički značajnu razliku u broju komplikacija (p = 0,359). Učestalost pojave pneumonije uzrokovane strojnom ventilacijom (p < 0,001), kao i duljina liječenja u JIL-u (p = 0,038), te duljina strojne ventilacije (p = 0,002) bila je statistički značajno veća u bolesnika u kojih je učinjen kasni PDT u odnosu na bolesnike kojima je učinjen rani PDT. Rasprava i zaključak: Učestalost komplikacija PDT-a ne ovisi o vremenu njegova izvođenja, no rano izvedeni PDT skraćuje trajanje strojne ventilacije i duljinu boravka u JIL-u, te smanjuje učestalost pneumonije uzrokovane strojnom ventilacijom.Aim: The aim of the study was to determine the incidence and the most common complications of percutaneous dilatational tracheostomy (PDT), compare the effect of early and late PDT on the incidence of ventilator-associated pneumonia, duration of mechanical ventilation and the lenght of stay in critically ill patients treated in the intensive care unit (ICU). Patients and methods: The observational prospective analysis included 338 patients requiring PDT who are treated in ICU Sušak, Clinic of anesthesiology and intensive care, Clinical Hosptial Centre Rijeka in four-years period. Results: One hundred and nine (32 %) patients were women and 229 (68 %) were men. The early PDT was performed in 256 (76 %) patients while the late PDT was performed in 82 (24 %). The complications of PDT were as follows: bleeding occurred in five patients, while hypotension, inflammation of the stoma, injury of larynx, inability to change cannulae, hypoxia and difficult dilatation were identified individually. Comparing the incidence of the complications that occurred in patients receiving early and late PDT, the statistically significant difference was not found in the number of the complications (p = 0.359). The incidence of ventilator-associated pneumonia (p < 0,001), the length of stay in the ICU (p = 0,038), as well as the duration of mechanical ventilation (p = 0,002) were significantly different in patients who received late PDT in comparison to patients in whom early PDT was performed. Discussion and conclusion: The incidence of complications caused by PDT does not depend on the time when PDT is performed. However, early performed PDT shortens the duration of mechanical ventilation and length of stay in ICU, and reduces the incidence of ventilator-associated pneumonia

EVALUATION OF VIRAL HEPATITIS IN SOLID ORGAN TRANSPLANTATION

Uspješna transplantacija bubrega je optimalna metoda liječenja bolesnika koji se nalaze u završnom stadiju kronične bubrežne bolesti. Za uspjeh same transplantacije, kao i dugoročnog preživljenja bolesnika i njegovog transplantata, nužna je detaljna evaluacija primatelja i potencijalnog darivatelja organa, bilo da se radi o kadaveričnom ili živom darivatelju. Poseban problem u sklopu infektivnih bolesti su virusi hepatitisa, osobito virus hepatitisa B (HBV) i C (HCV), a u novije vrijeme sve se više spominje i virus hepatitisa E (HEV) kao značajan uzrok kroničnog hepatitisa u populaciji bolesnika s transplantatom. Unatoč poboljšanju preventivnih mjera posljednjeg desetljeća incidencija virusnih hepatitisa je u bolesnika koji se liječe postupcima hemodijalize značajno smanjena. Međutim, njihova incidencija i dalje je veća u toj skupini bolesnika kao i u bolesnika kojima je transplantiran bubreg u odnosu na opću populaciju. Virusni hepatitisi su značajan čimbenik povećanog morbiditeta i mortaliteta u tim populacijama bolesnika, ali i prema većini studija značajan čimbenik disfunkcije bubrežnog transplantata. Naime, u bolesnika koji su podvrgnuti transplantaciji bubrega primarni cilj je očuvanje dobre funkcije transplantata, uz primjenu učinkovite, a što manje toksične imunosupresivne terapije. Osim toga, nužno je praćenje i adekvatna terapija virusnih hepatitisa, s obzirom na dobro poznatu činjenicu da te infekcije vode prema kroničnom hepatitisu, cirozi jetre i hepatocelularnom karcinomu. Nadalje, HBV i HCV mogu inducirati nastanak de novo membranskog glomerulonefritisa u bubrežnom transplantatu.Renal transplantation has significantly improved survival of patients with end-stage renal disease (ESRD). Transplantation is the best treatment in this population of patients. Despite the introduction of various preventive measures, viral hepatitis, i.e. hepa¬titis B virus (HBV) and hepatitis C virus (HCV) infections, are still a major problem because they are common in patients on re¬nal replacement therapy as well as in allograft recipients. They are a significant cause of morbidity and mortality in this patient population. In recent years, hepatitis E virus (HEV) infection has been added as an emergent cause of chronic hepatitis in solid organ transplantation, mainly in renal and liver allograft recipients. Most studies show higher mortality in renal transplant recipi¬ents (RTRs) infected with HBV, compared with RTRs without HBV infection, although this topic is still under debate. Furthermore, HCV infection in RTRs is associated with a significant reduction in patient and graft survival due to liver disease and septic com¬plications related to cirrhosis and immunosuppressive therapy. The immunosuppressive therapy prescribed after transplantation modifies the natural history of chronic HCV infection. Given the high prevalence of HCV and HBV infections in RTRs, a growing incidence of hepatocellular carcinoma and the possible contribution of immunosuppression might be expected in these patients. Therefore, after renal transplantation, early screening with abdominal ultrasound (every 3 months in cirrhotic patients and every 6-12 months in non-cirrhotic RTRs) is necessary when the risk factors such as HBV and HCV are present. The European Asso¬ciation for the Study of the Liver (EASL) recommends that all HbsAg-positive patients who are candidates for solid organ trans¬plantation should be treated with nucleoside analogs. The KDIGO guidelines recommend that all HbsAg-positive RTRs receive prophylaxis with tenofovir, entecavir or lamivudine; however, tenofovir and entecavir are preferable to lamivudin. Viral suppres¬sion by inhibiting necro-inflammation may result in reduced fibrosis, thereby improving transplant survival. Active HCV infection in a dialysis patient requires evaluation of liver fibrosis. Antiviral therapy should be given to all HCV-infected dialysis patients in order to achieve a sustained virologic response (SVR) not only to avoid subsequent hepatic deterioration but also to limit the risks of HCV-related posttransplant de novo glomerulonephritis. Systematic vaccination of all HbsAg-negative patients is the best preventive treatment of HBV infection. HbsAg positive donors are only used occasionally, whereas the use of hepatitis B core antibody (HbcAb)+, HbsAg negative donors is more common but remains somewhat controversial. The presence of antibody to HCV is indicative of HCV infection because antibody to HCV appears in peripheral blood within two months of HCV exposure. However, it is important to emphasize that detection of antibody to HCV by serologic screening of the donor is not predictive of HCV transmission. Approximately 50% of patients positive for antibody to HCV have detectable hepatitis C viremia by PCR analysis of peripheral blood. Therefore, all organ donors with PCR analysis positive for HCV will transmit HCV to RTRs. On the other hand, the risk of transmission from an organ donor with negative PCR analysis is unclear. Another problem in the evalua¬tion of the potential donors of solid organs is the fact that antibody testing by enzyme-linked immunosorbent assays (ELISAs) will not detect recent infections. The use of nucleid acid testing (NAT) could be useful because it involves amplification of viral gene products and thus is not dependent on antibody formation. Therefore, by using this method the period between the infection and detectability, which is known as the window period, could be reduced. However, this method is expensive and time consuming