Epidemiology of hepatitis C in Croatia in the European context

We analyzed prevalence, risk factors and hepatitis C virus (HCV) genotype distribution in different population groups in Croatia in the context of HCV epidemiology in Europe, with the aim to gather all existing information on HCV infection in Croatia which will be used to advise upon preventive measures. It is estimated that 35000-45000 of the Croatian population is chronically infected with HCV. Like in other European countries, there have been changes in the HCV epidemiology in Croatia over the past few decades. In some risk groups (polytransfused and hemodialysis patients), a significant decrease in the HCV prevalence was observed after the introduction of routine HCV screening of blood/blood products in 1992. Injecting drug users (IDUs) still represent a group with the highest risk for HCV infection with prevalence ranging from 29% to 65%. Compared to the prevalence in the Croatian general population (0.9%), higher prevalence rates were found in prison populations (8.3%-44%), human immunodeficiency virus-infected patients (15%), persons with high-risk sexual behavior (4.6%) and alcohol abusers (2.4%). Low/very low prevalence was reported in children and adolescents (0.3%) as well as in blood donors (0%-0.009%). In addition, distribution of HCV genotypes has changed due to different routes of transmission. In the general population, genotypes 1 and 3 are most widely distributed (60.4%-79.8% and 12.9%-47.9%, respectively). The similar genotype distribution is found in groups with high-risk sexual behavior. Genotype 3 is predominant in Croatian IDUs (60.5%-83.9%) while in the prison population genotypes 3 and 1 are equally distributed (52.4% and 47.6%). Data on HCV prevalence and risk factors for transmission are useful for implementation of preventive measures and HCV screening

First case of imported chikungunya infection in Croatia, 2016

In recent years, several European countries reported cases of imported chikungunya infection. We present the first imported clinically manifested chikungunya fever in Croatia. A 27-year-old woman returned to Croatia on 21 March 2016, after she stayed in Costa Rica for two months where she had noticed a mosquito bite on her left forearm. Five days after the mosquito bite she developed severe arthralgias, fever and erythematous papular rash. In next few days symptoms gradually subsided. After ten days she felt better, but arthralgias re-appeared accompanied with morning stiffness. Two weeks after the onset of the disease she visited the infectious diseases outpatient department. The physical examination revealed rash on the trunk, extremities, palms and soles. Laboratory findings showed slightly elevated liver transaminases. Serological tests performed on day 20 after disease onset showed a high titer of chikungunya virus (CHIKV) IgM and IgG antibodies which indicated CHIKV infection. CHIKV-RNA was not detected. Serology to dengue and Zika virus was negative. The patient was treated with nonsteroid anti-inflammatory drugs and paracetamol. Her symptoms ameliorated, however, three months later she still complaint of arthralgias. The presented case highlights the need for inclusion of CHIKV in the differential diagnosis of arthralgia in all travelers returning from countries with documented CHIKV transmission

TICK-BORNE ENCEPHALITIS VIRUS: EPIDEMIOLOGICAL AND CLINICAL PICTURE, DIAGNOSIS AND PREVENTION

Virus krpeljnog encefalitisa (KE) je mali, ovijeni virus koji pripada porodici Flaviviridae, rodu Flavivirus, serokompleksu krpeljnog encefalitisa. Postoje tri podtipa virusa KE: europski, dalekoistočni i sibirski koji se razlikuju po zemljopisnoj rasprostranjenosti, vektoru i kliničkom očitovanju infekcije u ljudi. Bolest je rasprostranjena na širokom području od srednje Europe i Skandinavskog poluotoka do Japana. Virus KE se održava endemski u tzv. prirodnim žarištima gdje obitavaju rezervoari (mali glodavci) i vektori (krpelji roda Ixodes). I. ricinus je vektor europskog podtipa, a I. persulcatus dalokoistočnog i sibirskog podtipa virusa. Virus se u krpeljima prenosi transstadijski i transovarijski pa oni predstavljaju i rezervoare infekcije. Infekcija u ljudi najčešće nastaje nakon uboda zaraženog krpelja, ali je moguća i konzumacijom mlijeka i mliječnih proizvoda od zaraženih životinja. U tipičnom obliku bolest uzrokovana europskim podtipom virusa KE ima bifazičan tijek (50-77 % infi ciranih). Prva je faza obilježena nespecifi čnim simptomima nakon koje slijedi asimptomsko razdoblje nakon čega se u oko 20-30 % oboljelih pojavljuju znaci infekcije središnjeg živčanog sustava (meningitis, encefalitis, mijelitis, radikulitis). Mortalitet iznosi 1-2 %. Dijagnoza se obično potvrđuje serološkim metodama (imunoenzimni test, indirektni imunofl uorescentni test, neutralizacijski test redukcije plakova). U Hrvatskoj je u razdoblju od 1993. do 2013. godine prijavljeno ukupno 777 slučajeva KE. Bolest je endemska u sjeverozapadnim županijama (prosječna incidencija 3,61-6,78/100 000 stanovnika). Većina oboljelih su osobe starije od 20 godina (88 %). Najveći je broj infekcija (73 %) zabilježen u razdoblju od svibnja do srpnja.Tick-borne encephalitis virus (TBEV) is a small, enveloped virus that belongs to the family Flaviviridae, genus Flavivirus, tick-borne encephalitis serocomplex. There are three subtypes of TBEV: European, Far-Eastern and Siberian subtypes, which differ in geographical distribution, tick vector and clinical manifestation of disease in humans. TBEV is endemic in a wide geographic area ranging from Central Europe and the Scandinavian Peninsula to Japan. The virus is maintained in nature in so-called natural foci in cycles involving ticks and wild vertebrate hosts (mainly small rodents). The principal vector for the European subtype is Ixodes (I.) ricinus tick, whereas for Far-Eastern and Siberian subtypes it is I. persulcatus. In the Baltic States and Finland, co-circulation of two or all three subtypes was documented. Several animals, principally small rodents, serve as virus reservoirs. In the tick population, TBEV is transmitted by feeding/co-feed ing on the same host, transovarially (from infected females to their eggs) and trans-stadially (from one development stage to the next). An infected tick remains infected for life. While most TBE infections in humans occur following a tick bite, alimentary routes of TBEV transmission (consumption of unpasteurized milk/milk products from infected livestock) have also been described. All three tick stages can transmit the infection to humans. In the last decade, an increase of TBE incidence has been observed in some endemic areas. This could be due to a number of interacting factors such as changes in the climatic conditions affecting tick habitats, improvements in the quality of epidemiological surveillance systems and diagnostics, in landscape resources and their utilization and more outdoor recreation activity. In addition, the endemic area of TBEV has expanded to higher altitudes (up to 1500 m), apparently infl uenced by climatic changes. The typical clinical picture of infection with European subtype TBEV is characterized by a biphasic course (50%-77%). The fi rst phase is characterized by nonspecifi c, fl u-like symptoms followed by an asymptomatic interval of about one week. In 20%-30% of persons who develop symptoms, the second phase occurs with symptoms of central nervous system involvement (meningitis, encephalitis, myelitis, radiculitis). The mortality rate for European subtype is 1%-2%. Diagnosis is usually based on detection of specifi c antibodies (enzyme immunoassay, indirect immunofl uorescent assay, plaque reduction neutralization test). From 1993 to 2013, a total of 777 cases of TBE were reported in Croatia. Endemicity is highest in north-western counties (mean incidence 3.61-6.78/100,000 inhabitants). The majority of patients were older than 20 years (88%). Most cases (73%) were reported from May to July

ZIKA VIRUS – A NEWLY EMERGING ARBOVIRUS OR GLOBAL PUBLIC HEALTH THREAT

Zika virus (ZIKV) izoliran je 1947. godine iz majmuna na području šume Zika u Ugandi. Do 2007. godine virus se održavao u enzootskom ciklusu na području Afrike uz sporadične humane slučajeve. Nakon epidemije 2007. godine na mikronezijskom otoku Yap bilježe se epidemije na pacifi čkim otocima, a 2015. godine virus je unesen u Brazil odakle se proširio Srednjom i Južnom Amerikom. U prirodnom se ciklusu ZIKV održava između majmuna i različitih vrsta komaraca roda Aedes. U urbanom su ciklusu rezervoar ljudi, a vektori komarci Ae. aegypti i Ae. albopictus. Interhumani prijenos moguć je transfuzijom krvi, presatkom organa, spolnim putem te sa zaražene majke na dijete transplacentno/tijekom poroda. U većine zaraženih osoba (~80 %), ZIKV infekcija prolazi asimptomatski. Klinički se infekcija u >95 % oboljelih očituje kao blaga bolest praćena subfebrilnom temperaturom, osipom, mialgijom, artralgijom te konjunktivitisom. Infekcija nastala tijekom trudnoće može rezultirati spontanim pobačajem ili kongenitalnim malformacijama (mikrocefalija). Najčešće opisana neurološka komplikacija je Guillain-Barreov sindrom. Dijagnostika se potvrđuje detekcijom ZIKV RNA ili ZIKV protutijela. Zbog mogućih križnih reakcija s ostalim fl avivirusima, inicijalno reaktivne rezultate testa ELISA potrebno je potvrditi neutralizacijskim testovima. Na području Hrvatske do sada je testirano ukupno 106 povratnika iz endemskih područja, od kojih je u tri potvrđena klinički manifestna ZIKV infekcija.Zika virus (ZIKV) was isolated in 1947 from a febrile rhesus monkey in the Zika forest, Uganda, and subsequently (1948) from Aedes africanus mosquitoes in the same region. First human cases were reported in 1952 in Uganda and Tanzania.until 2007, ZIKV was maintained in enzootic cycle within Africa with only sporadic human cases reported. After the outbreak on the Yap Island (Federated States of Micronesia) in 2007, several outbreaks were reported on the Pacifi c Islands (French Polynesia, New Caledonia, Cook Islands, Easter Island). In 2015, ZIKV was introduced in Brazil with further spreading across Central and South America. Comparing the pre-epidemic Asian and African lineage strains with the epidemic ZIKV strains, several amino acid substitutions were only present in the epidemic strains which could be associated with changes in virulence and the rapid spread of the virus. In a sylvatic cycle, ZIKV is transmitted between monkeys and different mosquito species of the genus Aedes. In an urban cycle, the virus is transmitted between humans through the bite of infected Aedes aegypti and less effi cient, Aedes albopictus mosquitoes. Some other modes of inter-human transmission have been demonstrated, including sexual transmission, blood transfusion/organ transplantation, transplacental and perinatal transmission. Although ZIKV RNA has been detected in breastmilk, transmission through breastfeeding has not been reported. The majority of infections (~80%) are asymptomatic. The main symptoms associated with ZIKV infection include fever, rash, myalgia, arthralgia and conjunctivitis. However, meningitis, encephalitis and myelitis have also been reported. Guillain-Barre syndrome is the most commonly reported neurological complication. ZIKV infection during pregnancy can result in spontaneous abortion or congenital ZIKV syndrome. The congenital abnormalities associated with maternal ZIKV infection include microcephaly, intracerebral calcifi cations, ventriculomegaly and chorioretinal atrophy. Diagnosis of ZIKV includes direct (viral isolation, RT-PCR) and indirect (serology) methods. ZIKV RNA can be detected in blood, urine, saliva, semen and amniotic fl uid. Since cross-reactive antibodies with other fl aviviruses are commonly observed, especially with dengue virus, initially reactive results should be confirmed using neutralization tests. Due to similar clinical symptoms and geographical distribution, dengue and chikungunya should be included in the differential diagnosis of ZIKV infection. Many importations of ZIKV infections have been reported in European countries since 2013. In Croatia, 106 travelers returning from endemic areas were tested so far. Clinically manifest ZIKV infection was serologically confi rmed in three patients

ZIKA VIRUS – A NEWLY EMERGING ARBOVIRUS OR GLOBAL PUBLIC HEALTH THREAT

Zika virus (ZIKV) izoliran je 1947. godine iz majmuna na području šume Zika u Ugandi. Do 2007. godine virus se održavao u enzootskom ciklusu na području Afrike uz sporadične humane slučajeve. Nakon epidemije 2007. godine na mikronezijskom otoku Yap bilježe se epidemije na pacifi čkim otocima, a 2015. godine virus je unesen u Brazil odakle se proširio Srednjom i Južnom Amerikom. U prirodnom se ciklusu ZIKV održava između majmuna i različitih vrsta komaraca roda Aedes. U urbanom su ciklusu rezervoar ljudi, a vektori komarci Ae. aegypti i Ae. albopictus. Interhumani prijenos moguć je transfuzijom krvi, presatkom organa, spolnim putem te sa zaražene majke na dijete transplacentno/tijekom poroda. U većine zaraženih osoba (~80 %), ZIKV infekcija prolazi asimptomatski. Klinički se infekcija u >95 % oboljelih očituje kao blaga bolest praćena subfebrilnom temperaturom, osipom, mialgijom, artralgijom te konjunktivitisom. Infekcija nastala tijekom trudnoće može rezultirati spontanim pobačajem ili kongenitalnim malformacijama (mikrocefalija). Najčešće opisana neurološka komplikacija je Guillain-Barreov sindrom. Dijagnostika se potvrđuje detekcijom ZIKV RNA ili ZIKV protutijela. Zbog mogućih križnih reakcija s ostalim fl avivirusima, inicijalno reaktivne rezultate testa ELISA potrebno je potvrditi neutralizacijskim testovima. Na području Hrvatske do sada je testirano ukupno 106 povratnika iz endemskih područja, od kojih je u tri potvrđena klinički manifestna ZIKV infekcija.Zika virus (ZIKV) was isolated in 1947 from a febrile rhesus monkey in the Zika forest, Uganda, and subsequently (1948) from Aedes africanus mosquitoes in the same region. First human cases were reported in 1952 in Uganda and Tanzania.until 2007, ZIKV was maintained in enzootic cycle within Africa with only sporadic human cases reported. After the outbreak on the Yap Island (Federated States of Micronesia) in 2007, several outbreaks were reported on the Pacifi c Islands (French Polynesia, New Caledonia, Cook Islands, Easter Island). In 2015, ZIKV was introduced in Brazil with further spreading across Central and South America. Comparing the pre-epidemic Asian and African lineage strains with the epidemic ZIKV strains, several amino acid substitutions were only present in the epidemic strains which could be associated with changes in virulence and the rapid spread of the virus. In a sylvatic cycle, ZIKV is transmitted between monkeys and different mosquito species of the genus Aedes. In an urban cycle, the virus is transmitted between humans through the bite of infected Aedes aegypti and less effi cient, Aedes albopictus mosquitoes. Some other modes of inter-human transmission have been demonstrated, including sexual transmission, blood transfusion/organ transplantation, transplacental and perinatal transmission. Although ZIKV RNA has been detected in breastmilk, transmission through breastfeeding has not been reported. The majority of infections (~80%) are asymptomatic. The main symptoms associated with ZIKV infection include fever, rash, myalgia, arthralgia and conjunctivitis. However, meningitis, encephalitis and myelitis have also been reported. Guillain-Barre syndrome is the most commonly reported neurological complication. ZIKV infection during pregnancy can result in spontaneous abortion or congenital ZIKV syndrome. The congenital abnormalities associated with maternal ZIKV infection include microcephaly, intracerebral calcifi cations, ventriculomegaly and chorioretinal atrophy. Diagnosis of ZIKV includes direct (viral isolation, RT-PCR) and indirect (serology) methods. ZIKV RNA can be detected in blood, urine, saliva, semen and amniotic fl uid. Since cross-reactive antibodies with other fl aviviruses are commonly observed, especially with dengue virus, initially reactive results should be confirmed using neutralization tests. Due to similar clinical symptoms and geographical distribution, dengue and chikungunya should be included in the differential diagnosis of ZIKV infection. Many importations of ZIKV infections have been reported in European countries since 2013. In Croatia, 106 travelers returning from endemic areas were tested so far. Clinically manifest ZIKV infection was serologically confi rmed in three patients

How much and what do we know about the West Nile virus infection?

Iako virus Zapadnog Nila (engl. West Nile virus, WNV) poznajemo gotovo 80 godina, intenzivnija istraživanja o njemu se provode unatrag petnaestak godina, nakon što je u SAD-u uzrokovao veliku epidemiju infekcija središnjeg živčanog sustava. WNV je virus koji spada u porodicu Flaviviridae, rod Flavivirus. Radi se o jednom serotipu, ali se virus genotipski može podijeliti u najmanje osam linija od kojih su linije 1, 2 i 5 medicinski najbitnije. Afrika je postojbina WNV-a odakle se proširio cijelim svijetom. Prirodni rezervoari virusa su ptice, a vektori su mu komarci. Najčešćii način prijenosa virusa na čovjeka je ubod komarca, ali se virus može prenijeti i transfuzijama krvi te transplantacijom solidnih organa. Nakon inkubacije od 3 – 14 dana može se razviti bolest koja najčešće prolazi asimptomatski ili kao blaža febrilna bolest. U manjeg broja inficiranih se razvije neuroinvazivna bolest. Simptomatska terapija je osnov liječenja, a dugotrajni oporavak uz ponekad trajne sekvele su nerijetko prisutni nakon preboljele bolesti.Although we have been familiar with the West Nile virus (WNV) for the last 80 years more intense research has been conducted in the past fifteen years, just after the huge central nervous system infection outbreak. WNV is a member of the Flaviviridae family, genus Flavvirus. Though WNV consists of a single serotype, genetically it can be divided in at least eight lineages where lineages 1, 2 and 5 are medically the most important ones. The virus originated from Africa and spread worldwide. Birds are natural reservoirs of the virus and mosquitoes are their vectors. The most usual transmission to humans is the mosquito bite but the virus can also be transmitted via blood transfusion or solid organ transplantation. After 3 –14 days of the incubation period, usually an asymptomatic or mild febrile disease occurs while a neuroinvasive disease develops in a rather small number of patients. Symptomatic therapy is the basis for treatment, however prolonged recovery and neurological sequalae are sometimes seen as well

EUROPEAN RESUSCITATION COUNCIL GUIDELINES FOR RESUSCITATION 2010

Osnovno održavanje života odraslih. – Svi spašavatelji, bilo osposobljeni ili ne, kod žrtava kardijalnog aresta moraju primijeniti vanjsku masažu srca. Cilj je pritisnuti prsni koš do dubine od najmanje 5 cm, frekvencijom od najmanje 100 kompresija u minuti, ali i dopustiti ponovo odizanje prsnog koša, te smanjiti prekide u kompresijama. Osposobljeni bi spašavatelji trebali primijeniti i ventilaciju s omjerom kompresija-ventilacija od 30:2. Liječenje strujom. – Mnogo je veći naglasak na smanjivanju trajanja stanki prije ili poslije defibrilacije; preporučuje se nastavak vanjske masaže srca tijekom punjenja defibrilatora. Potiče se daljnji razvoj programa automatskih vanjskih defibrilatora (AED). Napredno održavanje života odraslih. – Naglašena je važnost visokokvalitetnih kompresija na prsni koš tijekom provođenja ALS-a, koje se prekidaju samo kako bi se omogućili specifični postupci. Uklanja se preporuka o potrebi reanimacije tijekom određenog vremena prije defibrilacije nakon kardijalnog aresta izvan bolnice, kojemu nije svjedočilo osoblje hitne medicinske pomoći. Smanjena je uloga prekordijalnog udarca. Primjena lijekova putem endotrahealnog tubusa više se ne preporučuje, već se lijekovi moraju primijeniti intraosealnim (IO) pristupom. Atropin se više ne preporučuje za rutinsku primjenu tijekom asistolije ili električne aktivnosti bez pulsa. Smanjen je naglasak na ranu endotrahealnu intubaciju ako ju ne provodi visokostručna osoba uz najmanji mogući prekid vanjske masaže srca. Povećan je naglasak na uporabu kapnografije. Prepoznat je moguć štetan učinak hiperoksemije. Revidirana je preporuka za kontrolu glikemije. Preporučuje se primjena terapijske hipotermije kod komatoznih bolesnika nakon kardijalnog aresta povezanog s početnim ritmovima koji se defibriliraju, kao i onima koji se ne defibriliraju, za ove druge sa smanjenom razinom dokaza. Početno zbrinjavanje akutnih koronarnih sindroma. – Uveden je pojam infarkt miokarda bez ST-elevacije–akutni koronarni sindrom (NSTEMI-ACS) koji obuhvaća infarkt miokarda bez elevacije ST-spojnice i nestabilnu anginu pektoris. Primarna PCI (PPCI) najpoželjniji je reperfuzijski postupak, uz uvjet da ga obavi iskusan tim i u skladu s vremenskim okvirima. U liječenju bi trebalo izbjegavati nesteroidne protuupalne lijekove, rutinsku intravensku primjenu beta-blokatora i kisik – osim u slučaju hipoksemije, zaduhe ili zastoja na plućima. Održavanje života djece. – Odluka o započinjanju reanimacije mora se donijeti u manje od 10 sekundi. Laike treba podučavati reanimaciji s omjerom 30 kompresija naprama 2 ventilacije, a spašavatelji koji imaju dužnost odgovoriti na poziv trebaju primjenjivati omjer kompresije-ventilacije od 15:2, međutim, ako su sami, mogu primijeniti omjer od 30:2. Ventilacija i dalje ostaje vrlo važna sastavnica reanimacije asfiksijskog aresta. Naglasak je na postizanju kvalitetnih kompresija frekvencije najmanje 100, ali ne više od 120 u minuti, uz minimalne prekide. Automatski vanjski defibrilatori sigurni su i uspješni kada se primjenjuju kod djece starije od jedne godine. Za defibrilaciju kod djece preporučuje se jedna defibrilacija od 4 J/kg čija se jačina ne povećava. Sa sigurnošću se mogu rabi endotrahealni tubusi s balončićem i kod dojenčadi i kod mlađe djece. Monitoriranje izdahnutog ugljikova dioksida (CO2), najbolje kapnografijom, preporučuje se tijekom reanimacije. Reanimacija novorođenčadi na porodu. – Kod neugrožene novorođenčadi sada se preporučuje odgađanje podvezivanja pupčane vrpce od najmanje jedne minute nakon potpunog rođenja djeteta. Za donošenu novorođenčad, tijekom reanimacije pri porodu trebao bi se rabiti zrak. Za nedonoščad mlađu od 32 tjedna gestacije treba razumno primijeniti mješavinu kisika i zraka te primjena treba biti vođena pulsnim oksimetrom. Nedonoščad mlađu od 28 tjedana gestacije trebalo bi neposredno nakon rođenja potpuno do područja vrata omotati plastičnom folijom, bez sušenja. Preporučen omjer kompresija-ventilacija u reanimaciji novorođenčadi ostaje 3:1. Ne preporučuje se pokušavati aspirirati mekonij iz nosa i usta još nerođenog djeteta, dok mu je glava još na međici. Ako se daje adrenalin, preporučuje se intravenska primjena u dozi od 10 do 30 µg/kg. Kod terminske ili gotovo terminske novorođenčadi s umjerenom do teškom hipoksično-ishemijskom encefalopatijom preporučuje se terapijska hipotermija. Načela podučavanja reanimacije. – Cilj je osigurati da polaznici steknu i zadrže vještine i znanje koje će im omogućiti ispravno djelovanje tijekom stvarnoga kardijalnog aresta te poboljšati ishod bolesnika. Kratki video/kompjutorski tečajevi za samostalno učenje, s minimalnom ulogom instruktora ili bez njega, udruženi s praktičnom nastavom mogu se smatrati jednako učinkovitom alternativom tečajevima osnovnog održavanja života (BLS i AED) koje vode instruktori. U najboljem slučaju, svi bi građani trebali biti osposobljeni za standardnu KPR koja uključuje vanjsku masažu srca i ventilaciju. Znanje i vještine osnovnog i naprednog održavanja života smanjuju se u samo tri do šest mjeseci. Uređaji s glasovnim uputama tijekom reanimacije ili povratnim informacijama unaprjeđuju stjecanje i zadržavanje vještina.Basic Life Support. – All rescuers trained or not, should provide chest compressions to victims of cardiac arrest. The aim should be to push to a depth of at least 5 cm at a rate of at least 100 compressions per minute, to allow full chest recoil, and to minimise interruptions in chest compressions. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. Electrical therapies. – Much greater emphasis on minimising the duration of the pre-shock and post-shock pauses; the continuation of compressions during charging of the defibrillator is recommended. Further development of AED programmes is encouraged. Adult Advanced Life Support. – Increased emphasis on high-quality chest compressions throughout any ALS intervention paused briefly only to enable specific interventions. Removal of the recommendation for a pre-specified period of cardiopulmonary resuscitation before out-of-hospital defibrillation following cardiac arrest unwitnessed by the EMS. The role of precordial thump is de-emphasized. Delivery of drugs via a tracheal tube is no longer recommended, drugs should be given by the intraosseous (IO) route. Atropine is no longer recommended for routine use in asystole or pulseless electrical activity. Reduced emphasis on early tracheal intubation unless achieved by highly skilled individuals with minimal interruptions in chest compressions. Increased emphasis on the use of capnography. Recognition of potential harm caused by hyperoxaemia. Revision of the recommendation of glucose control. Use of therapeutic hypothermia to include comatose survivors of cardiac arrest associated initially with shockable rhythms, as well as non-shockable rhythms, with a lower level of evidence acknowledged for the latter. Initial management of acute coronary syndromes. – The term non-ST-elevation myocardial infarction-acute coronary syndrome (non-STEMI-ACS) has been introduced for both NSTEMI and unstable angina pectoris. Primary PCI (PPCI) is the preferred reperfusion strategy provided it is performed in a timely manner by an experienced team. Non-steroidal anti-inflammatory drugs should be avoided, as well as routine use of intravenous beta- blockers; oxygen is to be given only to those patients with hypoxaemia, breathlessness or pulmonary congestion. Paediatric Life Support. – The decision to begin resuscitation must be taken in less than 10 seconds. Lay rescuers should be taught to use a ratio of 30 compressions to 2 ventilations, rescuers with a duty to respond should learn and use a 15:2 ratio; however, they can use the 30:2 compression-ventilation ratio if they are alone. Ventilation remains a very important component of resuscitation in asphyxial arrest. The emphasis is on achieving quality compressions with the rate of at least 100 but not greater than 120 per minute, with minimal interruptions. AEDs are safe and successful when used in children older than 1 year. A single shock strategy using a non-escalating dose of 4 J/kg is recommended for defibrillation in children. Cuffed tubes can be used safely in infants and young children. Monitoring exhaled carbon dioxide (CO2), ideally by capnography, is recommended during resuscitation. Resuscitation of babies at birth. – For uncompromised babies, a delay in cord clamping of at least one minute from the complete delivery is now recommended. For term infants, air should be used fro resuscitation at birth. For preterm babies less than 32 weeks gestation blended oxygen and air should be given judiciously and its use guided by pulse oximetry. Preterm babies of less than 28 weeks gestation should be completely covered in a plastic wrap up to their necks, without drying, immediately after birth. The recommended compression: ventilation ratio remains at 3:1 for newborn resuscitation. Attempts to aspirate meconium from the nose and mouth of the unborn baby, while the head is still on the perineum, are not recommended. If adrenaline is given the n the intravenous route is recommended using a dose of 10–30 µg /kg. Newly born infants born at term or near-term with moderate to severe hypoxic-ischaemic encephalopathy should be treated with therapeutic hypothermia. Principles of education in resuscitation. – The aim is to ensure that learners acquire and retain skill and knowledge that will enable them to act correctly in actual cardiac arrest and improve patient outcome. Short video/computer self-instruction courses, with minimal or no instructor coaching, combined with hands-on practice can be considered as an effective alternative to instructor-led basic life support (BLS and AED) courses. Ideally all citizens should be trained in standard CPR that includes compressions and ventilations. Basic and advanced life support knowledge and skills deteriorate in as little as three to six months. CPR prompt or feedback devices improve CPR skill acquisition and retention

"One health" – detection and surveillance of emerging and re-emerging arboviruses in Croatia

Posljednjih desetljeća jasno je uočljiv globalni trend porasta učestalosti emergentnih i re-emergentnih zaraznih bolesti koje ugrožavaju čovječanstvo. Najzastupljenije među njima su zoonoze i to ponajprije vektorima prenosive zoonoze. Ovi trendovi pojave novih i širenja postojećih emergentnih i re-emergentnih zoonoza zasigurno će se nastaviti pod utjecajem čimbenika emergencije koji su posljedica današnjeg modernog načina života. Složenost procesa emergencije zaraznih bolesti, koja je posljedica promjena u međuodnosu ljudi, životinja i okoliša, naglasila je potrebu za uvođenjem cjelovitog pristupa očuvanju javnog zdravlja pod nazivom "Jedno zdravlje". U posljednjih nekoliko godina dokazane su po prvi put na području Republike Hrvatske infekcije ljudi dengue virusom, virusom Zapadnog Nila i Usutu virusom, što nedvojbeno potvrđuje promjenu epidemiološke situacije u našoj zemlji. Način otkrivanja i uspostave sustava nadzora navedenih bolesti ističe značaj i učinkovitost zajedničkog multidisciplinarnog rada. Nastavak uvođenja pristupa "Jedno zdravlje" u svakodnevni rad, obveza je svih srodnih struka i jedino jamstvo uspješnog osiguravanja javnog zdravlja u današnjem modernom svijetu.Emerging and re-emerging infectious diseases have increased in incidence over the last several decades and represent a significant threat to global health. The vast majority of emerging pathogens are zoonotic, especially arthropod-borne ones. Increase in the number of outbreaks and geographical range of emerging and re-emerging zoonoses will continue because their emergence is driven by factors resulting from changes in modern lifestyle. These complex and rapidly changing interactions of humans, animals and environment highlighted the need for integrated approach to public health protection under the "One Health" initiative. Recently confirmed autochthonous human cases of dengue virus, West Nile virus and Usutu virus infections have drawn attention to change of epidemiological situation in our country. Detection and the introduction of surveillance program for these diseases point out the importance and efficiency of multidisciplinary collaboration. Enforcing the introduction of "One Health" approach in the everyday work is the obligation of all involved professions and the warranty of successful prevention and public health protection in modern world

"One health" – detection and surveillance of emerging and re-emerging arboviruses in Croatia

Posljednjih desetljeća jasno je uočljiv globalni trend porasta učestalosti emergentnih i re-emergentnih zaraznih bolesti koje ugrožavaju čovječanstvo. Najzastupljenije među njima su zoonoze i to ponajprije vektorima prenosive zoonoze. Ovi trendovi pojave novih i širenja postojećih emergentnih i re-emergentnih zoonoza zasigurno će se nastaviti pod utjecajem čimbenika emergencije koji su posljedica današnjeg modernog načina života. Složenost procesa emergencije zaraznih bolesti, koja je posljedica promjena u međuodnosu ljudi, životinja i okoliša, naglasila je potrebu za uvođenjem cjelovitog pristupa očuvanju javnog zdravlja pod nazivom "Jedno zdravlje". U posljednjih nekoliko godina dokazane su po prvi put na području Republike Hrvatske infekcije ljudi dengue virusom, virusom Zapadnog Nila i Usutu virusom, što nedvojbeno potvrđuje promjenu epidemiološke situacije u našoj zemlji. Način otkrivanja i uspostave sustava nadzora navedenih bolesti ističe značaj i učinkovitost zajedničkog multidisciplinarnog rada. Nastavak uvođenja pristupa "Jedno zdravlje" u svakodnevni rad, obveza je svih srodnih struka i jedino jamstvo uspješnog osiguravanja javnog zdravlja u današnjem modernom svijetu.Emerging and re-emerging infectious diseases have increased in incidence over the last several decades and represent a significant threat to global health. The vast majority of emerging pathogens are zoonotic, especially arthropod-borne ones. Increase in the number of outbreaks and geographical range of emerging and re-emerging zoonoses will continue because their emergence is driven by factors resulting from changes in modern lifestyle. These complex and rapidly changing interactions of humans, animals and environment highlighted the need for integrated approach to public health protection under the "One Health" initiative. Recently confirmed autochthonous human cases of dengue virus, West Nile virus and Usutu virus infections have drawn attention to change of epidemiological situation in our country. Detection and the introduction of surveillance program for these diseases point out the importance and efficiency of multidisciplinary collaboration. Enforcing the introduction of "One Health" approach in the everyday work is the obligation of all involved professions and the warranty of successful prevention and public health protection in modern world

"One health" – detection and surveillance of emerging and re-emerging arboviruses in Croatia

Posljednjih desetljeća jasno je uočljiv globalni trend porasta učestalosti emergentnih i re-emergentnih zaraznih bolesti koje ugrožavaju čovječanstvo. Najzastupljenije među njima su zoonoze i to ponajprije vektorima prenosive zoonoze. Ovi trendovi pojave novih i širenja postojećih emergentnih i re-emergentnih zoonoza zasigurno će se nastaviti pod utjecajem čimbenika emergencije koji su posljedica današnjeg modernog načina života. Složenost procesa emergencije zaraznih bolesti, koja je posljedica promjena u međuodnosu ljudi, životinja i okoliša, naglasila je potrebu za uvođenjem cjelovitog pristupa očuvanju javnog zdravlja pod nazivom "Jedno zdravlje". U posljednjih nekoliko godina dokazane su po prvi put na području Republike Hrvatske infekcije ljudi dengue virusom, virusom Zapadnog Nila i Usutu virusom, što nedvojbeno potvrđuje promjenu epidemiološke situacije u našoj zemlji. Način otkrivanja i uspostave sustava nadzora navedenih bolesti ističe značaj i učinkovitost zajedničkog multidisciplinarnog rada. Nastavak uvođenja pristupa "Jedno zdravlje" u svakodnevni rad, obveza je svih srodnih struka i jedino jamstvo uspješnog osiguravanja javnog zdravlja u današnjem modernom svijetu.Emerging and re-emerging infectious diseases have increased in incidence over the last several decades and represent a significant threat to global health. The vast majority of emerging pathogens are zoonotic, especially arthropod-borne ones. Increase in the number of outbreaks and geographical range of emerging and re-emerging zoonoses will continue because their emergence is driven by factors resulting from changes in modern lifestyle. These complex and rapidly changing interactions of humans, animals and environment highlighted the need for integrated approach to public health protection under the "One Health" initiative. Recently confirmed autochthonous human cases of dengue virus, West Nile virus and Usutu virus infections have drawn attention to change of epidemiological situation in our country. Detection and the introduction of surveillance program for these diseases point out the importance and efficiency of multidisciplinary collaboration. Enforcing the introduction of "One Health" approach in the everyday work is the obligation of all involved professions and the warranty of successful prevention and public health protection in modern world