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This paper is concerned with the distribution of earthquakes, particularly their depths, with the temperature of the material in which they occur, and with the significance of both for the rheology and deformation of the continental lithosphere. Earthquakes on faults are generated by the sudden release of elastic energy that accumulates during slow plate motions. The nonlinear high-temperature creep that localizes such energy accumulation is, in principle, well understood and can be described by rheological models. But the same is not true of seismogenic brittle failure, the main focus of this paper, and severely limits the insights that can be obtained by simulations derived from geodynamical modelling of lithosphere deformation. Through advances in seismic tomography, we can now make increasingly detailed maps of lithosphere thickness on the continents. The lateral variations are dramatic, with some places up to 300 km thick, and clearly relate to the geological history of the continents as well as their present-day deformation. Where the lithosphere thickness is about 120 km or less, continental earthquakes are generally confined to upper crustal material that is colder than about 350°C. Within thick lithosphere, and especially on its edges, the entire crust may be seismogenic, with earthquakes sometimes extending into the uppermost mantle if the Moho is colder than 600°C, but the continental mantle is generally aseismic. Earthquakes in the continental lower crust at 400-600°C require the crust to be anhydrous and so are a useful guide or proxy to both composition and strength. These patterns and correlations have important implications for the geological evolution of the continents. They can be seen to have influenced features as diverse as the location of post-collisional rifting; cratonic basin formation; the location, origin and timing of granulite-facies metamorphism; and the formation, longevity and strength of cratons. In addition, they have important consequences for earthquake hazard assessment in the slowly deforming edges and interiors of continental shields or platforms, where the large seismogenic thickness can host very large earthquakes. This article is part of a discussion meeting issue 'Understanding earthquakes using the geological record'.
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Background: Out-of-hospital cardiac arrest (OHCA) is associated with very poor clinical outcomes. An optimal pathway of care is yet to be defined, but prognostication is likely to assist in the challenging decision-making required for treatment of this high-risk patient cohort. The MIRACLE2 score provides a simple method of neuro-prognostication but as yet it has not been externally validated. The aim of this study was therefore to retrospectively apply the score to a cohort of OHCA patients to assess the predictive ability and accuracy in the identification of neurological outcome. Methods: Retrospective data of patients identified by hospital coding, over a period of 18 months, were collected from a large tertiary-level cardiac centre with a mature, multidisciplinary OHCA service. MIRACLE2 score performance was assessed against three existing OHCA prognostication scores. Results: Patients with all-comer OHCA, of presumed cardiac origin, with and without evidence of ST-elevation MI (43.4% versus 56.6%, respectively) were included. Regardless of presentation, the MIRACLE2 score performed well in neuro-prognostication, with a low MIRACLE2 score (≤2) providing a negative predictive value of 94% for poor neurological outcome at discharge, while a high score (≥5) had a positive predictive value of 95%. A high MIRACLE2 score performed well regardless of presenting ECG, with 91% of patients receiving early coronary angiography having a poor outcome. Conclusion: The MIRACLE2 score has good prognostic performance and is easily applicable to cardiac-origin OHCA presentation at the hospital front door. Prognostic scoring may assist decision-making regarding early angiographic assessment.
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BACKGROUND: The use of coronary angiography (CA) for diagnosis and management of chest pain (CP) has several flaws. The assessment of coronary artery disease using fractional flow reserve (FFR) is a well-validated technique for describing lesion-level ischemia and improves clinical outcome in the context of percutaneous coronary intervention. The impact of routine FFR at the time of diagnostic CA on patient management has not been determined. METHODS AND RESULTS: Two hundred patients with stable CP underwent CA for clinical indications. The supervising cardiologist (S.C.) made a management plan based on CA (optimal medical therapy alone, percutaneous coronary intervention, coronary artery bypass grafting, or more information required) and also recorded which stenoses were significant. An interventional cardiologist then measured FFR in all patent coronary arteries of stentable diameter (≥2.25 mm). S.C. was then asked to make a second management plan when FFR results were disclosed. Overall, after disclosure of FFR data, management plan based on CA alone was changed in 26% of patients, and the number and localization of functional stenoses changed in 32%. Specifically, of 72 cases in which optimal medical therapy was recommended after CA, 9 (13%) were actually referred for revascularization with FFR data. By contrast, of 89 cases in whom management plan was optimal medical therapy based on FFR, revascularization would have been recommended in 25 (28%) based on CA. CONCLUSIONS: Routine measurement of FFR at CA has important influence both on which coronary arteries have significant stenoses and on patient management. These findings could have important implications for clinical practice. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrial.gov. Unique identifier: NCT01070771.