Aspects on the Physiological and Biochemical Foundations of Neurocritical Care

Neurocritical care (NCC) is a branch of intensive care medicine characterized by specific physiological and biochemical monitoring techniques necessary for identifying cerebral adverse events and for evaluating specific therapies. Information is primarily obtained from physiological variables related to intracranial pressure (ICP) and cerebral blood flow (CBF) and from physiological and biochemical variables related to cerebral energy metabolism. Non-surgical therapies developed for treating increased ICP are based on knowledge regarding transport of water across the intact and injured blood–brain barrier (BBB) and the regulation of CBF. Brain volume is strictly controlled as the BBB permeability to crystalloids is very low restricting net transport of water across the capillary wall. Cerebral pressure autoregulation prevents changes in intracranial blood volume and intracapillary hydrostatic pressure at variations in arterial blood pressure. Information regarding cerebral oxidative metabolism is obtained from measurements of brain tissue oxygen tension (PbtO2) and biochemical data obtained from intracerebral microdialysis. As interstitial lactate/pyruvate (LP) ratio instantaneously reflects shifts in intracellular cytoplasmatic redox state, it is an important indicator of compromised cerebral oxidative metabolism. The combined information obtained from PbtO2, LP ratio, and the pattern of biochemical variables reveals whether impaired oxidative metabolism is due to insufficient perfusion (ischemia) or mitochondrial dysfunction. Intracerebral microdialysis and PbtO2 give information from a very small volume of tissue. Accordingly, clinical interpretation of the data must be based on information of the probe location in relation to focal brain damage. Attempts to evaluate global cerebral energy state from microdialysis of intraventricular fluid and from the LP ratio of the draining venous blood have recently been presented. To be of clinical relevance, the information from all monitoring techniques should be presented bedside online. Accordingly, in the future, the chemical variables obtained from microdialysis will probably be analyzed by biochemical sensors

On severe traumatic brain injury : aspects of an intra cranial pressure-targeted therapy based on the Lund concept

Severe Traumatic Brain Injury (sTBI) is a major cause of mortality and morbidity. At the Department of Neurosurgery Umeå University Hospital subjects with sTBI are treated with an intracranial pressure (ICP) guided therapy based on physiological principles, aiming to optimise the microcirculation of the brain so avoiding secondary brain injuries. The investigations in this thesis are unique in the sense that all patients with sTBI were treated according to the guidelines of an ICP targeted therapy based on the “Lund concept”. As the treatment is based on normalisation of the ICP, the accuracy and reliability of the measuring device is of outmost importance. Therefore the accuracy, drift, and complications related to the measuring device was prospectively studied (n=128). The drift was 0,9 ± 0,2 mmHg during a mean of 7,2 ± 0,4 days and the accuracy high. No clinical significant complications were noted. In 1997 uni- or bilateral decompressive hemi-craniectomy (DC) was introduced into the treatment guidelines. The effect of DC on the ICP and outcome was retrospectively analysed for subjects with sTBI treated 1998-2001. In the subjects who underwent DC the ICP was 36,4 mmHg immediately before and 12,6 mmHg immediately after the DC. The ICP then levelled out at just above 20 mmHg. The ICP was significant lower during the 72 hours following DC. The outcome did not differ between subjects who had undergone DC or not. Subclinical electroencephalographic seizures and status epilepticus have been reported to be common in subjects treated for traumatic brain injury (TBI). This can negatively influence the outcome giving rise to secondary brain injuries. The occurrence of seizures in subjects treated for TBI using continuous EEG monitoring was therefore prospectively studied. During 7334 hours of EEG recording in 47 patients no electroencephalographic seizures were observed. Theoretically, and based on animal studies, prostacyclin (PGI2) can improve the microcirculation of the brain, decreasing the risk for secondary ischaemic brain injury. PGI2 was introduced to the treatment in a prospective randomised double blinded study (epoprostenol 0,5 ng/kg/min). The effect of PGI1 pkt was analysed using the lactate/pyruvate ratio (L/P) measured by cerebral microdialysis in order to study the energy metabolism in the brain. The outcome was measured as Glasgow Outcome Scale (GOS) at 3 months follow-up. Forty-eight subjects were included. The L/P was pathological high during the first day, thereafter decreasing. There was no significant difference in L/P or outcome between the treated and non-treated group. At 3 months the mortality was 12,5% (95,8% was discharged alive from the ICU), and favourable outcome (GOS 4-5) was 52%. In the same study the brain injury biomarkers S-100B and NSE were followed twice a day for five days to evaluate brain injury and investigate the possible use of these biomarkers for outcome prediction. Initially the biomarkers were elevated to pathological levels which decreased over time. The biomarkers were significant elevated in subjects with Glasgow Coma Scale 3 (GCS) and GOS 1 compared with subjects with GCS 4-8 and GOS 2–5, respectively. A correlation to outcome was found but this correlation could not be used to predict clinical outcome. It is concluded that the ICP measurements are valid and the treatment protocol is a safe and solid protocol, yielding among the best reported results in the world, in regard to favourable outcome as well as in regard to mortality. Epoprostenol in the given dose was not shown to have any effects on the microdialysis parameters nor the clinical outcome. In sTBI L/P and brain injury biomarkers can not be used to predict the final outcome

AS Aldaris strategic governance improvement directions.

Maģistra darba tēma ir A/S „ALDARIS” stratēģiskās vadīšanas pilnveidošanas virzieni. Savukārt darba mērķis ir izpētīt un analizēt A/S „ALDARIS” uzņēmuma darbību, tās stratēģiskās vadīšanas virzienus, jo A/S „ALDARIS” ir viena no senākajām un lielākajām alus darītavām Latvijā, turklāt uzņēmuma zīmols mūsdienās kļuvis atpazīstams arī ārpus valsts robežām. A/S „ALDARIS” ir viens no vadošajiem alus ražotājiem Latvijas alus nozarē. Maģistra darba pirmajā nodaļā tiek pētīta alus nozare Latvijas tautsaimniecībā, alus kultūra, tradicionālā pieeja un attīstības gaita. Otrajā nodaļā tiek pētīta pirmā saskarsme ar Carlsberg Grupu, uzņēmuma pievienošanās vienam no pasaules līderiem alus ražošanas nozarē, kā arī tiek aplūkotas valsts likumdošanas izmaiņas saistībā ar akcīzes nodokļa maiņām, kas būtiski ietekmē alus nozares uzņēmumus. Trešajā nodaļā tiek pētītas vadības stratēģijas, izveidota SVID analīze, kā arī veikta aptauja, lai noskaidrotu patērētāju viedokli par uzņēmuma darbību. Ceturtajā nodaļā tiek pētīta nākotnes vīzija par uzņēmuma attīstību, jaunu produktu ieviešana tirgū, papildus motivācijas sistēma, kā arī izvērtēta vadītāja un līderu loma uzņēmumā. A/S „ALDARIS” uzņēmuma analizējamais periods ir no 2008. - 2018.gadam. Maģistra darbs uzrakstīts latviešu valodā un tas sastāv no 93 lappuses, 2 pielikumiem, 14 tabulām, 25 attēliem un darbā tika izmantoti 77 literatūras avotiem.The theme of the master degree work is AS Aldaris strategic governance improvement directions. In turn, the aim of the work ir explore and analyze AS Aldaris the activities of the company, it’s strategic directions of management, because company is one of the oldest and largest breweries in Latvia, besides, the company’s brand has no become recognizable also abroad. AS Aldaris is one of the leading breweries in the Latvian beer industry. The first chapter of the master’s paper investigates the beer industry in the national economy of Latvia, the culture of beer, the tradiciocal approach and the course of development. The second chapter examines the first contact with the Carlsberg Group, the company's accession to one of the world's leaders in the beer industry, and examines changes in national legislation regarding excise tax changes that have a significant impact on beer industry companies. The third chapter examines management strategies, develops SWOT analysis, and conducts a survey to find out the views of consumers about the company's operations. The fourth chapter examines the future vision of the company's development, the introduction of new products on the market, an additional motivation system, and assesses the role of manager and leaders in the company. The analyzing period of the AS Aldaris is from 2008 to 2018. The Master job is written in Latvian and ir consist of 93 pages, 2 supplements, 14 appendixes, 25 pictures, 77 literature resources were used in the wor

Aspects on the Physiological and Biochemical Foundations of Neurocritical Care

Neurocritical care (NCC) is a branch of intensive care medicine characterized by specific physiological and biochemical monitoring techniques necessary for identifying cerebral adverse events and for evaluating specific therapies. Information is primarily obtained from physiological variables related to intracranial pressure (ICP) and cerebral blood flow (CBF) and from physiological and biochemical variables related to cerebral energy metabolism. Non-surgical therapies developed for treating increased ICP are based on knowledge regarding transport of water across the intact and injured blood-brain barrier (BBB) and the regulation of CBF. Brain volume is strictly controlled as the BBB permeability to crystalloids is very low restricting net transport of water across the capillary wall. Cerebral pressure autoregulation prevents changes in intracranial blood volume and intracapillary hydrostatic pressure at variations in arterial blood pressure. Information regarding cerebral oxidative metabolism is obtained from measurements of brain tissue oxygen tension (PbtO2) and biochemical data obtained from intracerebral microdialysis. As interstitial lactate/pyruvate (LP) ratio instantaneously reflects shifts in intracellular cytoplasmatic redox state, it is an important indicator of compromised cerebral oxidative metabolism. The combined information obtained from PbtO2, LP ratio, and the pattern of biochemical variables reveals whether impaired oxidative metabolism is due to insufficient perfusion (ischemia) or mitochondrial dysfunction. Intracerebral microdialysis and PbtO2 give information from a very small volume of tissue. Accordingly, clinical interpretation of the data must be based on information of the probe location in relation to focal brain damage. Attempts to evaluate global cerebral energy state from microdialysis of intraventricular fluid and from the LP ratio of the draining venous blood have recently been presented. To be of clinical relevance, the information from all monitoring techniques should be presented bedside online. Accordingly, in the future, the chemical variables obtained from microdialysis will probably be analyzed by biochemical sensors

Correlation of Cerebral and Subcutaneous Glycerol in Severe Traumatic Brain Injury and Association with Tissue Damage

Background: This study is a substudy of a prospective consecutive double-blinded randomized study on the effect of prostacyclin in severe traumatic brain injury (sTBI). The aims of the present study were to investigate whether there was a correlation between brain and subcutaneous glycerol levels and whether the ratio of interstitial glycerol in the brain and subcutaneous tissue (glycerolbrain/sc) was associated with tissue damage in the brain, measured by using the Rotterdam score, S-100B, neuron-specific enolase (NSE), the Injury Severity Score (ISS), the Acute Physiology and Chronic Health Evaluation Score (APACHE II), and trauma type. A potential association with clinical outcome was explored. Methods: Patients with sTBI aged 15–70 years presenting with a Glasgow Coma Scale Score ≤ 8 were included. Brain and subcutaneous adipose tissue glycerol levels were measured through microdialysis in 48 patients, of whom 42 had complete data for analysis. Brain tissue damage was also evaluated by using the Rotterdam classification of brain computed tomography scans and the biochemical biomarkers S-100B and NSE. Results: In 60% of the patients, a positive relationship in glycerolbrain/sc was observed. Patients with a positive correlation of glycerolbrain/sc had slightly higher brain glycerol levels compared with the group with a negative correlation. There was no significant association between the computed tomography Rotterdam score and glycerolbrain/sc. S-100B and NSE were associated with the profile of glycerolbrain/sc. Our results cannot be explained by the general severity of the trauma as measured by using the Injury Severity Score or Acute Physiology and Chronic Health Evaluation Score. Conclusions: We have shown that peripheral glycerol may flux into the brain. This effect is associated with worse brain tissue damage. This flux complicates the interpretation of brain interstitial glycerol levels. We remind the clinicians that a damaged blood–brain barrier, as seen in sTBI, may alter the concentrations of various substances, including glycerol in the brain. Awareness of this is important in the interpretation of the data bedside as well in research

Survival and growth success of russian olive (Elaeagnus angustifolia L.), salt cedar (Tamarix smyrnensis bunge) and white poplar (Populus alba l.) seedlings in salt-sodic central anatolia areas with gypsum and sulfur applications

YÖK Tez No: 588825İç Anadolu'daki vadi tabanlarının önemli bir kısmı tuzlu-sodik toprak özelliği göstermektedir. Bu çalışmada jips ve kükürt uygulaması ile tuzlu-sodik topraklardan fazla sodyumun yıkanarak toprağın iyileştirilmesi amaçlanmıştır. Toprağa kimyasal işlemler uygulandıktan sonra ılgın (Tamarix smymensis Bunge), iğde (Elaeagnus angustifolia L.) ve akkavak (Populus alba L.) fidanları dikilerek yaşama oranları ve büyüme performansları takip edilmiştir. Üç yaşındaki fidanlar 2013 sonbaharında 1,5 X 1,5 m aralıklarla deneme ünitelerine dikilmiştir. 2015 Eylül sonu fidanların yaşama oranları belirlenerek boy ve çap ölçümleri gerçekleştirilmiştir. İkinci büyüme sezonu sonunda %80 'lik bir oranla en fazla yaşama yüzdesine ılgın türünün sahip olduğu belirlenmiştir. Akkavak bütün işlem alanlarında ortalama %36'lık bir yaşama yüzdesi göstermiştir. İğde jips ve kükürt uygulanan sahalarda 50 cm boy büyümesi yaparken kontrol sahalarında sadece 25 cm boy büyümesi yapabilmiştir. İğde fidanlarının çap ortalaması da jips ve kükürt uygulanan sahalarda 9.3 mm olarak ölçülürken kontrol sahalarında bu değer 5 mm olarak kaydedilmiştir. Akkavak ise jips ve kükürt uygulanan alanlarda kontrol sahalarına göre %42 daha fazla büyüme gerçekleştirmiştir. Ilgının büyümesi bakımından ise sahalar arasında istatistiki olarak önemli bir farklılık bulunamamıştır. Denenen türlerden de iğdenin bütün sahalarda en iyi yaşama oranını ve büyüme performansını gösterdiği ortaya çıkmıştır.An important part of the valley bases in Central Anatolia shows salt-sodic soil characteristics. In this study, it is aimed to improve the soil by washing more sodium than salty-sodic soils with gypsum and sulfur application. After chemical treatment was applied to the soil, tamarisk (Tamarix Smymensis Bunge), spindle (Elaeagnus angustifolia L.) and abele (Populus alba L.) seedlings were planted, and their survival rates and growth performances were followed. Three-year-old seedlings were planted in trial units in the autumn of 2013 at 1.5 X 1.5 m intervals. By the end of September 2015, height and diameter measurements of saplings were made. At the end of the second growth season, it was determined that 80% of the tamarisk had the highest percentage of life. Abele showed an average survival rate of 36% in all processing areas. While spindle was 50 cm in gypsum and sulfur were applied, it was able to grow only 25 cm in the control areas. The average diameter of the seedling saplings was measured as 9.3 mm in gypsum and sulfur treated areas and this value was recorded as 5 mm in the control areas. Abele achieved 42% more growth in gypsum and sulfur treated areas than in control areas. In terms of Tamarisk growth, no statistically significant difference was found between the sites. Among the tested species, spindle was found that the spindle showed the best survival rate and growth performance in all fields