The study area is located in cental Slovenia, and geologically located at the junction between the Alps and the Dinarides. The Middle Triassic of this region is characterised by intense rifting ...manifested by differential subsidence and volcanism. This led to a major paleogeographic reorganisation of the region, where three paleogeographic domains formed in the Upper Triassic: The Julian Carbonate Platform in the north, the intermediate Slovenian Basin, both parts of the Southern Alps, and the Dinaric (Adriatic, Friuli) Carbonate Platform in the south, which today is a part of the External Dinarides that host the area of investigation. Prior to the installation of the Dinaric Carbonate Platfrom, i.e. in the Ladinian, the entire area of the preset-day External Dinarides broke up into numerous tectonic blocks that were exposed to either erosion or continental, shallow-marine, and deep-marine sedimentation. In this study, we analyse at small scale a complex transitional area between a local carbonate platform and the Kobilji curek basin (depositional area dominated by deeper marine sediments), located in the Rute Plateau in central Slovenia south of Ljubljana. During enhanced subsidence, the basin was filled with volcanic material (tuffs and volcanogenic clays and subordinate extrusive material), while the adjacent platform aggraded. The slope was positioned above active paleofaults. During relative sea level lowstand, the platform prograded across the basin. The study area is divided into four major tectonic paleoblocks. The NW paleoblock experienced the most enhanced subsidence, and the platform prograded twice in this area and was submerged again by the rejuvenated subsidence and/or sea-level rise. The second and third paleoblocks subsided only during discrete major subsidence events, and the carbonates of the platform and slope were soon reinstated therein. In the fourth paleoblock to the east the platform persisted during the Ladinian. In the Carnian, the entire study area became emerged, and continental clastics were deposited. These were then replaced by a uniform shallow marine/intertidal Hauptdolomit (Dolomia Principale) formation at the onset of the Norian. This study provides the first detailed reconstruction of the sedimentary evolution of small-scale Ladinian basin and platforms system in the northern External Dinarides.
The purpose of this study was to develop a practical risk score to predict poor neurological outcome after out-of-hospital cardiac arrest (OOHCA) for use on arrival to a Heart Attack Centre.
From May ...2012 to December 2017, 1055 patients had OOHCA in our region, of whom 373 patients were included in the King's Out of Hospital Cardiac Arrest Registry (KOCAR). We performed prediction modelling with multivariable logistic regression to identify predictors of the primary outcome to derive a risk score. This was externally validated in two independent cohorts comprising 473 patients. The primary endpoint was poor neurological outcome at 6-month follow-up (Cerebral Performance Category 3-5). Seven independent predictors of outcome were identified: missed (unwitnessed) arrest, initial non-shockable rhythm, non-reactivity of pupils, age (60-80 years-1 point; >80 years-3 points), changing intra-arrest rhythms, low pH <7.20, and epinephrine administration (2 points). The MIRACLE2 score had an area under the curve (AUC) of 0.90 in the development and 0.84/0.91 in the validation cohorts. Three risk groups were defined-low risk (MIRACLE2 ≤2-5.6% risk of poor outcome); intermediate risk (MIRACLE2 of 3-4-55.4% of poor outcome); and high risk (MIRACLE2 ≥5-92.3% risk of poor outcome). The MIRACLE2 score had superior discrimination than the OHCA median AUC 0.83 (0.818-0.840); P < 0.001 and Cardiac Arrest Hospital Prognosis models median AUC 0.87 (0.860-0.870; P = 0.001 and equivalent performance with the Target Temperature Management score median AUC 0.88 (0.876-0.887); P = 0.092.
The MIRACLE2 is a practical risk score for early accurate prediction of poor neurological outcome after OOHCA, which has been developed for simplicity of use on admission.
Abstract Aim We investigated the impact of intensified postresuscitation treatment in comatose survivors of out-of-hospital cardiac arrest (OHCA) of presumed cardiac etiology according to the initial ...rhythm at the emergency medical team arrival. Methods Interventions and survival with Cerebral Performance Category (CPC) 1–2 within each group were retrospectively compared between the periods of conservative (1995–2003) and intensified (2004–2012) postresuscitation treatment. Results In shockable group, therapeutic hypothermia (TH) increased from 1 to 93%, immediate invasive coronary strategy from 28 to 78%, intraaortic balloon pump from 4 to 21%, vasopressors/inotropes from 47 to 81% and antimicrobial agents from 65 to 86% during the intensified period as compared to conservative period ( p < 0.001). This was associated with increased survival with CPC 1–2 from 27 to 47% ( p < 0.001). After adjusting for age, sex and prehospital confounders, TH (OR = 2.12, 95% CI 1.25–3.61), percutaneous coronary intervention (OR 1.77, 95% CI 1.15–2.73) and antimicrobial agents (OR = 12.21, 95% CI 5.13–29.08) remained associated with survival with CPC 1–2. In non-shockable patients, TH also significantly increased from 1 to 74%, immediate invasive coronary strategy from 8 to 51%, intraaortic balloon pump from 2 to 9% and vasopressors/inotropes from 56 to 84% during intensified period without concomitant increase in survival with CPC 1–2 (7% vs. 9%; p = 0.27). After adjustment, only antimicrobial agents (OR = 8.43, 95% CI: 1.05–67.72) remained associated with survival with CPC 1–2. Conclusion Intensified postresuscitation treatment was associated with doubled survival in comatose survivors of OHCA with shockable rhythm. Such association could not be demonstrated in patients with non-shockable rhythm.
Introduction: Despite advanced therapies for pulmonary arterial hypertension (PAH), maternal mortality in women with PAH and their offspring remains high (30-56% and 11-28%) and is especially high
...during the post-partum period1,2.
Case report: 39-years-old woman was presented in 24th week of pregnancy with moderate dyspnea and
cyanosis without peripheral edema. ECG showed right ventricular strain and NT-proBNP was 1300 ng/L. Echocardiogram showed severe precapillary pulmonary hypertension with systolic pulmonary pressure
(PAP) 103 mmHg, reduced stroke volume (SVI 29 ml/m2), normal cardiac output (CI 2.6 L/min/m2) and mildly reduced systolic function of the right ventricle (FAC 30%, PMI TDI 0.8) with normal central
venous pressure (CVP) 3 mmHg. Right heart catheterization confirmed echocardiographic hemodynamic measurements (mean pulmonary
pressure 61 mmHg, pulmonary vascular resistance (PVR) 9.4 WU) and the vasoreactivity test was negative. Epoprostenol was initiated,
titrated up to 22 ng/kg/min and on 30th week planned caesarean section was performed with NO inhalations, noradrenalin and dobutamine. Fortunately, standby supportive therapy - ECMO
and high urgency lung transplantation, was not needed. The baby did well. The patient was extubated on the same day and sildenafil was added. The patient was discharged after 4 weeks. After 2 months epoprostenol was switched to treprostinil up to 26 ng/kg/min and macitentan was added. NT-proBNP stabilized at 170 ng/L. Echocardiography was performed weekly to monitor CI, CVP and right systolic function indexes. Favorable echocardiographic dynamics after
therapy were observed: mean PAP 60 mmHg to 45-50 mmHg, PVR from 10 WU to 7 WU, stroke volume normalized and CVP remained normal.
However, right ventricular systolic function improved but did not normalize (Table 1).
In conclusion, with complete echocardiographic
hemodynamic assessment and thorough clinical assessment high-risk pregnancies in patients with severe PAH can be managed. In
addition, FAC, MPI TDI, 3D ejection fraction and RV free strain better assess right ventricular systolic function than TAPSE.
Only up to 20% of patients with out-of-hospital cardiac arrest (OHCA) receive immediate and optimal initial cardiac resuscitation and consequently regain consciousness soon after return of ...spontaneous circulation (ROSC). In the present study, we compared the outcome of conscious survivors of OHCA presenting with ST-elevation myocardial infarction (STEMI) in post-resuscitation electrocardiogram undergoing immediate invasive coronary strategy with randomly selected STEMI patients without preceding OHCA undergoing primary PCI.
We conducted a single-centre registry-based analysis of all conscious OHCA survivors with STEMI over the last 10 year period. We gathered clinical and angiographic data and compared them with a randomly selected cohort of non−OHCA patients with STEMI within the same period. Patients were matched by sex, age and STEMI location.
86 conscious survivors of OHCA were admitted between 2006 and 2016. OHCA was witnessed in all patients (85% EMS witnessed), and all patients presented with initial shockable rhythm. Clinical and angiographic features were well matched with randomly selected STEMI patients without OHCA presenting to our department within the same study period. Delay from symptoms to EMS arrival but not delay from EMS to PCI was significantly shorter in conscious OHCA survivors (1.2 ± 1.3 h vs 3.1 ± 3.8 h, p < 0.001), yielding decreased total myocardial ischemic time (2.6 ± 1.3 h vs 4.6 ± 4.0 h, p < 0.001). Hospital and 1-year survival with normal neurological condition in conscious survivors of OHCA (cerebral performance category 1) was excellent and numerically even better than survival of STEMI patients without OHCA.
Conscious survivors of OHCA with STEMI have excellent survival if they undergo immediate invasive coronary strategy. Since there is no obvious post-resuscitation brain injury in this subgroup of OHCA patients, it is probably shorter duration of myocardial ischemia driven by shorter delay from symptoms to EMS arrival that contributes to the good outcome, which is at least similar to STEMI patients without OHCA.
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