Jan Horak

Hyperinvasive approach to out-of hospital cardiac arrest using mechanical chest compression device, prehospital intraarrest cooling, extracorporeal life support and early invasive assessment compared to standard of care. A randomized parallel groups comparative study proposal. “Prague OHCA study”

BackgroundOut of hospital cardiac arrest (OHCA) has a poor outcome. Recent non-randomized studies of ECLS (extracorporeal life support) in OHCA suggested further prospective multicenter studies to define population that would benefit from ECLS. We aim to perform a prospective randomized study comparing prehospital intraarrest hypothermia combined with mechanical chest compression device, intrahospital ECLS and early invasive investigation and treatment in all patients with OHCA of presumed cardiac origin compared to a standard of care.MethodsThis paper describes methodology and design of the proposed trial. Patients with witnessed OHCA without ROSC (return of spontaneous circulation) after a minimum of 5 minutes of ACLS (advanced cardiac life support) by emergency medical service (EMS) team and after performance of all initial procedures (defibrillation, airway management, intravenous access establishment) will be randomized to standard vs. hyperinvasive arm. In hyperinvasive arm, mechanical compression device together with intranasal evaporative cooling will be instituted and patients will be transferred directly to cardiac center under ongoing CPR (cardiopulmonary resuscitation). After admission, ECLS inclusion/exclusion criteria will be evaluated and if achieved, veno-arterial ECLS will be started. Invasive investigation and standard post resuscitation care will follow. Patients in standard arm will be managed on scene. When ROSC achieved, they will be transferred to cardiac center and further treated as per recent guidelines.Primary outcome6 months survival with good neurological outcome (Cerebral Performance Category 1–2). Secondary outcomes will include 30 day neurological and cardiac recovery.DiscussionAuthors introduce and offer a protocol of a proposed randomized study comparing a combined “hyperinvasive approach” to a standard of care in refractory OHCA. The protocol is opened for sharing by other cardiac centers with available ECLS and cathlab teams trained to admit patients with refractory cardiac arrest under ongoing CPR. A prove of concept study will be started soon. The aim of the authors is to establish a net of centers for a multicenter trial initiation in future.Ethics and registrationThe protocol has been approved by an Institutional Review Board, will be supported by a research grant from Internal Grant Agency of the Ministry of Health, Czech Republic NT 13225-4/2012 and has been registered under ClinicalTrials.gov identifier: NCT01511666.

800 years of mining and smelting in Kutná Hora region (the Czech Republic)—spatial and multivariate meta-analysis of contamination studies

PurposeKutná Hora was a centre of medieval mining and remains an important contamination source in the present day. Surprisingly, very little attention has been paid to the associated contamination. Although some studies have been performed, the majority of information regarding contamination is only accessible in the archives and no overview has been published. The purpose of this study is to perform a meta-analysis of all accessible data and to shed light on this topic.Materials and methodsThe data mainly come from analyses of HNO3 solutions of sediments. We used statistical analyses (exploratory data analysis, PCA). The results were visualised and evaluated in the GIS environment.Results and discussionThe complex of heavy metals As, Be, Cd, Co, Cr, Cu, Hg, Pb, V, and Zn can be divided into three main groups of different interpretation: (1) uninfluenced by mining activities—Be, Co, Cr, Hg, and V; (2) smelting processes—Cu, Pb, and Zn; and (3) mining—As and Cd. These groups also show different spatial distribution patterns, absolute concentration values and binding with different environmental types—landscape features.ConclusionsThe contamination of Kutná Hora can be characterised by element grouping and also by spatial diversification. This could be used in future research as a bearer of proxy information. Surprisingly, it also seems that the spatial range of contamination of sediments could be shorter than is generally presumed.

Surgical Revascularisation in the Early Phase of ST-Segment Elevation Myocardial Infarction: Haemodynamic Status is More Important Than the Timing of the Operation

BACKGROUND Surgical revascularisation in patients with acute myocardial infarction with ST-Segment Elevation (STEMI) is usually considered as a second choice when direct angioplasty/stent fails. However, improvements in surgical technique and postoperative care may justify coronary artery bypass grafting (CABG) in STEMI. METHODS This was a retrospective analysis of prospectively gathered data of 135 patients with acute STEMI, treated with CABG in our department from February 2008 to December 2012. Patients were divided into two groups - operated up to 6 hours (35 patients) and 6 to 24hours (100 patients) from onset of symptoms. RESULTS Preoperatively, 18 (13%) patients were in cardiogenic shock, 10 (7.4%) had mechanical ventilation, and 36 (27%) had intra-aortic balloon counterpulsation (IABC). Mean number of distal anastomoses was 3.3 (range, 1 to 5), cardiopulmonary bypass time 122.7+52.6minutes. In hospital (30-day) mortality was 8.1% (11 patients) with no significant difference in both groups (p=0.541); 45 (33%) patients had one MACE, again with no difference in both groups (p=0.89). Risk factor analysis revealed that Killip class at admission, cardiogenic shock, preoperative need for catecholamines, ventilation and low ejection fraction are risk factors for early mortality. CONCLUSIONS Acute CABG in patients with STEMI can be performed with good results. Risk factors for early mortality and morbidity are cardiogenic shock, poor haemodynamic status and impaired ejection fraction. Time from infarction to reperfusion did not influence the results.

Contamination characteristics of the confluence of polluted and unpolluted rivers – range and spatial distribution of contaminants of a significant mining centre (Kutná Hora, Czech Republic)

Horák J., Hejcman M. (2016): Contamination characteristics of the confluence of polluted and unpolluted rivers – range and spatial distribution of contaminants of a significant mining centre (Kutná Hora, Czech Republic). Soil & Water Res., 11: 235−243. The study brings new insights into the topic of the contamination characteristics of the mining region of Kutná Hora (Central Bohemia). The previous meta-analysis of the contamination studies showed that there could be a surprisingly low spatial range of contaminated river sediment downstream of Kutná Hora. The study should answer the question as to whether it is justifiable to interpret the presence of contaminants as a result of Kutná Hora mining. There was found a rapid increase in concentrations between the background area and contaminated Kutná Hora. Increase of medians (in mg/kg) of As: 33 and 148, Cu: 34 and 57, Pb: 35 and 82, Zn: 85 and 232; means increased ca 10 times. Then a decrease between the contaminated area and the confluence area was observed. But this decrease was influenced by the presence of extreme values in the contaminated area and therefore it was observed only in means. Medians of the elements concentrations did not decrease. The concentrations of the elements decreased after the confluence to lower values, but they stayed at the contaminated area levels. The background levels were observed only in the probes related to Labe alluvium. But also in these probes, the contamination was traced by multivariate analyses – by clear separation of As, Cu, Pb, Zn from other elements. The contamination was manifested in probes after the confluence mainly in the topsoil levels of alluvium, ca. in 10 to 40 cm. The original starting point of this study, that the contamination is not firmly manifested in the areas after the confluence, based on meta-analysis of regional studies, is not valid.

TCT-604 Non-invasive endothelial function assessment using digital reactive hyperemia correlates with 3D intravascular ultrasound and virtual histology derived plaque volume and plaque phenotype

nos: 606 614

Pulmonary artery pulsatility indexes in differentiating chronic pulmonary thromboembolism from pulmonary arterial hypertension

ABSTRACT Background: The differentiation between chronic pulmonary thromboembolic hypertension (CTEPH) and pulmonary arterial hypertension (PAH) remains a clinical challenge. Recently, it has been suggested that pulmonary artery pulsatility indexes, determined either invasively or noninvasively, could enable the discrimination between CTEPH and PAH. Aim of the study: To evaluate the usefulness of both echocardiographically- and invasively-derived pulmonary artery pulsatility indexes in the etiologic differentiation of patients with CTEPH and PAH. Methods: We retrospectively analyzed the results of echocardiographic and invasive hemodynamic examinations in 97 patients with either CTEPH (n = 48) or PAH (n = 49). Using echocardiography, pulmonary artery systolic (PASP), diastolic (PADP) and mean (PAMP) pressures were estimated from velocities of tricuspid regurgitation and pulmonary regurgitation, respectively. Invasive data were obtained in 39 patients with CTEPH and 44 patients with PAH using a fluid-filled system that included a balloon-tipped flow catheter. Pulse pressure (PP) was calculated as a difference between PASP and PADP. To obtain pulmonary artery pulsatility indexes, we normalized PP by PASP (PP/PASP), by PAMP (PP/PAMP) and by PADP (PP/PADP). Results: Pulsatility indexes assessed by echocardiography did not differ between CTEPH and PAH patients. Invasively-derived pulsatility indexes were significantly higher in subjects with CTEPH (0.59 ± 0.09 vs. 0.52 ± 0.10 for PP/PASP; 0.95 ± 0.23 vs. 0.77 ± 0.19 for PP/PAMP; 1.52 ± 0.53 vs. 1.14 ± 0.37 for PP/PADP; all p < 0.01). The areas under the receiver-operating characteristic curves analysis were 0.68 (95% CI 0.55–0.79), 0.7 (95% CI 0.58–0.81), and 0.68 (95% CI 0.55–0.79) for invasively-derived PP/PASP, PP/PAMP and PP/PADP, respectively. Conclusions: Invasively-derived PP and pulmonary artery pulsatility indexes are higher in CTEPH compared to PAH. However, due to the important overlap, no optimal threshold values of these parameters can be given to allow satisfactory discrimination between the two diseases. Therefore, these indexes do not permit clear etiologic differentiation of CTEPH and PAH in clinical practice.