Food perception at lunchtime does not depend on the nutritional and perceived characteristics of breakfast.

Breakfast consumption can entail nutritional advantages positively affecting food choices. This study investigated the effect of minor changes in breakfast composition on the perceived attributes of foods, both at breakfast and at lunchtime. Four breakfasts were defined considering nutritional and perceptual factors. Three breakfasts varied just for a single cereal-based chocolate-containing food item, while a control breakfast mimicked fasting conditions. Breakfast perception was assessed before and after consumption. Subjects rated breakfast energy content on the basis of single items, while judged breakfast healthiness as a whole, suggesting that the combination of different ingredients can modify the perceived health value of foods. Additionally, 4 h after breakfast, a perceptual evaluation of lunch-related food images was performed, without differences among breakfasts. This study extends current knowledge on the relationship between subjective perceptual attributes and objective energy value and food composition, as well as on breakfast impact on food perception at lunchtime.

The modulation of the motor resonance triggered by reach-to-grasp movements: No role of human physical similarity as conveyed by age.

The activation of the mirror-neuron circuit during the observation of motor acts is thought to be the basis of human capacity to read the intentions behind the behavior of others. Growing empirical evidence shows a different activation of the mirror-neuron resonance mechanism depending on how much the observer and the observed agent share their motor repertoires. Here, the possible modulatory effect of physical similarity between the observer and the agent was investigated in three studies. We used a visuo-motor priming task in which participants were asked to categorize manipulable and non-manipulable objects into natural or man-made kinds after having watched precision and power reach-to-grasp movements. Physical similarity was manipulated by presenting reach-to-grasp movements performed by the hands of actors of three different age ranges that are adults of the same age as the participants, children, and elderly. Faster responses were observed in trials where power grip movements were performed by the adults and precision grip movements were performed by the elderly (Main Study). This finding is not in keeping with the idea that physical similarity shapes the mirror-neuron resonance. Instead, it suggests an effect of the kinematic organization of the reach-to-grasp movements, which systematically changed with the actor age as revealed by a kinematic analysis. The differential effect played by adult and elderly actor primes was lost when static grasping hands (Control Study 1) and reach-to-grasp movements with uniform kinematic profiles (Control Study 2) were used. Therefore, we found preliminary evidence that mirror-neuron resonance is not shaped by physical similarity but by the kinematics of the observed action. This finding is novel as it suggests that human ability to read the intentions behind the behavior of others may benefit from a mere visual processing of spatiotemporal patterns.

The Effect of Limited Health Literacy on How Internet Users Learn About Diabetes.

The Internet continues to be an important supplemental health information resource for an increasing number of U.S. adults, especially for those with a new or existing chronic condition. Here we examine how people use the Internet to learn about Type 2 diabetes and how health literacy (HL) influences this information-seeking behavior. We analyzed the searches of approximately 2 million people who queried for diabetes-related information on Microsoft's Bing search engine. The HL of searchers was imputed through a community-based HL score. Topics searched were categorized and subsequent websites were assessed for readability. Overall, diabetes information-seeking strategies via the Internet are similar among adults with limited and adequate HL skills. However, people with limited HL take a longer time to read pages that are quickly read by people with adequate HL and vice versa. Information seeking among the former is terminated prematurely, as is evident from a Hidden Markov Model of the search process. Our findings indicate that the reading level required to understand the majority of diabetes-related information is high. Especially on government websites, more than 80% of information requires a reading level corresponding to 7th grade or higher. Our results indicate that individuals with lower HL may disproportionately struggle with Internet searches and fail to get an equivalent benefit from this information resource compared to users with greater HL. Future interventions should target the quality and ease of navigation of health care websites and find ways to leverage other relevant professionals to encourage and promote successful information access on the Web.

How the motor system handles nouns: a behavioral study.

It is an open question whether the motor system is involved during understanding of concrete nouns, as it is for concrete verbs. To clarify this issue, we carried out a behavioral experiment using a go-no go paradigm with an early and delayed go-signal delivery. Italian nouns referring to concrete objects (hand-related or foot-related) and abstract entities served as stimuli. Right-handed participants read the stimuli and responded when the presented word was concrete using the left or right hand. At the early go-signal, slower right-hand responses were found for hand-related nouns compared to foot-related nouns. The opposite pattern was found for the left hand. These findings demonstrate an early lateralized modulation of the motor system during noun processing, most likely crucial for noun comprehension.

Impact of a population-based colorectal cancer screening program on local health services demand in Italy: a 7-year survey in a northern province.

OBJECTIVES: In 2005, the National Health Service recommended a population-based colorectal cancer (CRC) screening program using biennial fecal occult blood testing (FOBT), followed by total colonoscopy in positive patients. So far, no studies have been performed to evaluate the impact of a mass-screening CRC campaign on the health system services at the community level in Italy. We have therefore assessed the workload generated by the first two biennial rounds of screening program on the activity of hospital services involved in CRC diagnosis in the Lecco province. METHODS: Routine data from all hospital services of our province were collected on activity levels related to CRC diagnosis from January 2003 to December 2009. This time span covered the 2 years prior to, as well as the two biennial rounds of the CRC screening program. In particular, we focused on the volume of outpatient FOBTs and colonoscopies (both diagnostic and interventional) performed among subjects outside the screening program. Joinpoint models were used to test whether an apparent change in trend of examination over time was statistically significant in different age cohorts of the population (<50 years, 50-69 years, and ≥70 years). RESULTS: The volume of "extra-screening" per-patient/FOBTs and colonoscopies increased significantly over the evaluated periods in all ages, until year 2008, when a steady trend was beginning; the AAPCs (average of the annual percent changes) values were 5.7, 3.1, and 8.4 for FOBT and 14.6, 13.4, and 16.7 for colonoscopy in the three age cohorts, respectively. However, the increase in both FOBT and colonoscopy demand was maximal in the cohort ≥70 years, where three statistically significant annual percent changes (APCs) were identified (in 2003-2005, 2005-2006, and 2006-2007 APCs were 12.3, 14.9, and 15.9 for FOBT, and 18.7, 36.8, and 25.4 for colonoscopy, respectively). CONCLUSIONS: After the implementation of a FOBT-based mass-screening program for CRC, careful consideration must be given to the significant increase in the workload of hospital services involved in CRC diagnosis, outside the screening campaign. The extra-work mainly involves gastroenterologists performing colonoscopy, whose activity increased over the 5-year period by 118%, as well as laboratory services, where the demand of FOBTs rose by 40%. This phenomenon, mainly attributable to a profound change in the attitude toward CRC screening by those age cohorts outside the program, covers a time span of two full rounds of screening, whereupon a steady trend for colonoscopy is apparent.

Adjectives Modulate Sensorimotor Activation Driven by Nouns.

We performed three experiments to investigate whether adjectives can modulate the sensorimotor activation elicited by nouns. In Experiment 1, nouns of graspable objects were used as stimuli. Participants had to decide if each noun referred to a natural or artifact, by performing either a precision or a power reach-to-grasp movement. Response grasp could be compatible or incompatible with the grasp typically used to manipulate the objects to which the nouns referred. The results revealed faster reaction times (RTs) in compatible than in incompatible trials. In Experiment 2, the nouns were combined with adjectives expressing either disadvantageous information about object graspability (e.g., sharp) or information about object color (e.g., reddish). No difference in RTs between compatible and incompatible conditions was found when disadvantageous adjectives were used. Conversely, a compatibility effect occurred when color adjectives were combined with nouns referring to natural objects. Finally, in Experiment 3 the nouns were combined with adjectives expressing tactile or shape proprieties of the objects (e.g., long or smooth). Results revealed faster RTs in compatible than in incompatible condition for both noun categories. Taken together, our findings suggest that adjectives can shape the sensorimotor activation elicited by nouns of graspable objects, highlighting that language simulation goes beyond the single-word level.

Social categorization and joint attention: Interacting effects of age, sex, and social status.

In the present study, we examine how person categorization conveyed by the combination of multiple cues modulates joint attention. In three experiments, we tested the combinatory effect of age, sex, and social status on gaze-following behaviour and pro-social attitudes. In Experiments 1 and 2, young adults were required to perform an instructed saccade towards left or right targets while viewing a to-be-ignored distracting face (female or male) gazing left or right, that could belong to a young, middle-aged, or elderly adult of high or low social status. Social status was manipulated by semantic knowledge (Experiment 1) or through visual appearance (Experiment 2). Results showed a clear combinatory effect of person perception cues on joint attention (JA). Specifically, our results showed that age and sex cues interacted with social status information depending on the modality through which it was conveyed. In Experiment 3, we further investigated our results by testing whether the identities used in Experiments 1 and 2 triggered different pro-social behaviour. The results of Experiment 3 showed that the identities resulting as more distracting in Experiments 1 and 2 were also perceived as more in need and prompt helping behaviour. Taken together, our evidence shows a combinatorial effect of age, sex, and social status in modulating the gaze following behaviour, highlighting a complex and dynamic interplay between person categorization and joint attention.

Autonomic vulnerability to biased perception of social inclusion in borderline personality disorder.

BACKGROUND: Individuals with Borderline Personality Disorder (BPD) feel rejected even when socially included. The pathophysiological mechanisms of this rejection bias are still unknown. Using the Cyberball paradigm, we investigated whether patients with BPD, display altered physiological responses to social inclusion and ostracism, as assessed by changes in Respiratory Sinus Arrhythmia (RSA). METHODS: The sample comprised 30 patients with BPD, 30 with remitted Major Depressive Disorder (rMDD) and 30 Healthy Controls (HC). Self-report ratings of threats toward one's fundamental need to belong and RSA reactivity were measured immediately after each Cyberball condition. RESULTS: Participants with BPD showed lower RSA at rest than HC. Only patients with BPD, reported higher threats to fundamental needs and exhibited a further decline in RSA after the Inclusion condition. CONCLUSIONS: Individuals with BPD experience a biased appraisal of social inclusion both at the subjective and physiological level, showing higher feelings of ostracism and a breakdown of autonomic regulation to including social scenarios.

Are colonoscopy and bowel ultrasound useful for assessing response to short-term therapy and predicting disease outcome of moderate-to-severe forms of ulcerative colitis?: a prospective study.

OBJECTIVES: Mucosal healing has been proposed as an important sign of the efficacy of medical treatment of inflammatory bowel disease; however, direct evidence in ulcerative colitis (UC) is scarce. We evaluated the usefulness of colonoscopy and bowel ultrasound (US) as indexes of response to short-term therapy and as predictors of subsequent outcome in UC. METHODS: A total of 83 patients with moderate-to-severe UC were recruited; endoscopic and US severity was graded 0-3 at entry according to validated scores. Of the recruited patients, 74, who were clinically responsive to steroids, were followed up with repeated colonoscopy and bowel US at 3, 9, and 15 months from recruitment. Concordance between clinical, endoscopic, and US scores at various visits was determined by kappa statistics. Multiple unconditional logistic regression models were used to assess the predictivity of clinical, endoscopic, and US scores measured at 3 and 9 months on the development of endoscopic UC relapse within 15 months. RESULTS: A variable concordance was found over time between endoscopic and clinical score (weighted kappa between 0.38 and 0.95), with high and consistent concordance between endoscopic and US scores (weighted kappa between 0.76 and 0.90). On logistic regression analysis, moderate-to-severe endoscopic and US scores at 3 months were associated with a high risk of endoscopic activity at 15 months (odds ratio (OR): 5.2; 95% confidence interval (CI): 1.6-17.6 and OR: 9.1; 95% CI: 2.5-33.5, respectively). CONCLUSIONS: Bowel US may be used as a surrogate of colonoscopy in assessing the short-term response of severe forms of UC to therapy. Both US score and endoscopic score after 3 months of steroid therapy predict outcome of disease at 15 months.

Distorting the visual size of the hand affects hand pre-shaping during grasping.

Vision of the body is known to affect somatosensory perception (e.g. proprioception or tactile discrimination). However, it is unknown whether visual information about one's own body size can influence bodily action. We tested this by measuring the maximum grip aperture (MGA) parameter of grasping while eight subjects viewed a real size, enlarged or shrunken image of their hand reaching to grasp a cylinder. In the enlarged view condition, the MGA decreased relative to real size view, as if the grasping movement was actually executed with a physically larger hand, thus requiring a smaller grip aperture to grasp the cylinder. Interestingly, MGA remained smaller even after visual feedback was removed. In contrast, no effect was found for the reduced view condition. This asymmetry may reflect the fact that enlargement of body parts is experienced more frequently than shrinkage, notably during normal growth. In conclusion, vision of the body can significantly and persistently affect the internal model of the body used for motor programming.

TMS-EEG approach unveils brain mechanisms underlying conscious and unconscious face perception.

BACKGROUND: Conscious perception of external stimuli has been related to recurrent activity in distributed cortical networks, although brain mechanisms controlling unconscious processing and stimuli access to conscious report need to be clarified. OBJECTIVE: This study aims at investigating modulations in cortical excitability related to conscious perception and unconscious processing of face stimuli with different visibility levels. METHODS: We used TMS-EEG over the right occipital face area (rOFA), or the right premotor cortex (rPMC) as control site, to measure cortical excitability during a backward masking paradigm with individually defined stimuli visibility. RESULTS: Event related potentials showed significant differences for faces compared to houses, and detected faces compared to missed ones, 200 ms post target onset. TMS over rOFA, but not over rPMC, triggered a relative positivity starting 150 ms post target when faces with high visibility were consciously reported. Moreover, rOFA TMS evoked differential responses for high versus low visible faces in conscious and unconscious processing at 290-390 and 180-240 ms, respectively. CONCLUSION: Results unveiled a causal link between rOFA excitability and late responses related to access to conscious perception, suggesting a critical role of recurrent activity, but distinct components, for consciously perceived stimuli and unconscious face processing.

Implementing myocardial infarction systems of care in low/middle-income countries.

Ischaemic heart disease is the leading cause of death worldwide, with an increasing trend from 6.1 million deaths in 1990 to 9.5 million in 2016, markedly driven by rates observed in low/middle-income countries (LMIC). Improvements in myocardial infarction (MI) care are crucial for reducing premature mortality. We aimed to evaluate the main challenges for adequate MI care in LMIC, and possible strategies to overcome these existing barriers.Reperfusion is the cornerstone of MI treatment, but worldwide around 30% of patients are not reperfused, with even lower rates in LMIC. The main challenges are related to delays associated with patient education, late diagnosis and inadequate referral strategies, health infrastructure and insufficient funding. The implementation of regional MI systems of care in LMIC, systematising timely reperfusion strategies, access to intensive care, risk stratification and use of adjunctive medications have shown some successful strategies. Telemedicine support for remote ECG, diagnosis and organisation of referrals has proven to be useful, improving access to reperfusion even in prehospital settings. Organisation of transport and referral hubs based on anticipated delays and development of MI excellence centres have also resulted in better equality of care. Also, education of healthcare staff and task shifting may potentially widen access to optimal therapy.In conclusion, efforts have been made for the implementation of MI systems of care in LMIC, aiming to address particularities of the health systems. However, the increasing impact of MI in these countries urges the development of further strategies to improve reperfusion and reduce system delays.

Persistencia del cavum septum pellucidum y cavum vergae asociado a retraso psicomotor. Informe de caso

Fundamento: Dos de las tres formas en que se presentan los quistes intracraneales de la línea media anterior son: cavum septum pellucidum y cavum vergae; estos normalmente desaparecen después del nacimiento, de persistir suelen ser asintomáticos, pero también pueden estar asociados a manifestaciones obstructivas, trastornos psicóticos o alteraciones del neurodesarrollo que demandan de un seguimiento clínico. Objetivo: Reportar el caso de un paciente de 6 meses con persistencia de estructuras del periodo embrionario en posible asociación con retraso del desarrollo psicomotor. Presentación de caso: Por lo infrecuente que resulta en la práctica, se informa el caso de un paciente de 6 meses con una persistencia del cavum septum pellucidum y cavum vergae en el que se destaca la posible asociación del retraso del neurodesarrollo a la persistencia de estas estructuras. El diagnóstico se realizó de forma precoz y se intervino oportunamente. Conclusiones: La presentación del caso aportó evidencias epidemiológicas que favorecen la posible asociación entre la persistencia de estas estructuras embrionarias y el retraso del desarrollo psicomotor.

Background: Two out of the three forms in which intracranial anterior midline cysts present are: These usually disappear after birth; if they persist, they are often asymptomatic, but may also be associated with obstructive manifestations, psychotic disorders or neurodevelopmental disorders that require clinical follow up. Objective: To report a case of a 6-month-old patient with persistence of embryonic period structures in possible association with psychomotor developmental retardation. Case presentation: Because of how infrequent it is in practice, a case of a 6-month-old patient with a persistent cavum septum pellucidum and cavum vergae is reported in which the possible association of neurodevelopmental delay with the persistence of these structures is pointed out. The diagnosis was made in an early manner and it was timely intervened. Conclusions: The case presentation provided epidemiological evidences that encourage the possible association among the persistence of these embryonic structures and psychomotor developmental retardation.

Context Modulates Congruency Effects in Selective Attention to Social Cues.

Head and gaze directions are used during social interactions as essential cues to infer where someone attends. When head and gaze are oriented toward opposite directions, we need to extract socially meaningful information despite stimulus conflict. Recently, a cognitive and neural mechanism for filtering-out conflicting stimuli has been identified while performing non-social attention tasks. This mechanism is engaged proactively when conflict is anticipated in a high proportion of trials and reactively when conflict occurs infrequently. Here, we investigated whether a similar mechanism is at play for limiting distraction from conflicting social cues during gaze or head direction discrimination tasks in contexts with different probabilities of conflict. Results showed that, for the gaze direction task only (Experiment 1), inverse efficiency (IE) scores for distractor-absent trials (i.e., faces with averted gaze and centrally oriented head) were larger (indicating worse performance) when these trials were intermixed with congruent/incongruent distractor-present trials (i.e., faces with averted gaze and tilted head in the same/opposite direction) relative to when the same distractor-absent trials were shown in isolation. Moreover, on distractor-present trials, IE scores for congruent (vs. incongruent) head-gaze pairs in blocks with rare conflict were larger than in blocks with frequent conflict, suggesting that adaptation to conflict was more efficient than adaptation to infrequent events. However, when the task required discrimination of head orientation while ignoring gaze direction, performance was not impacted by both block-level and current trial congruency (Experiment 2), unless the cognitive load of the task was increased by adding a concurrent task (Experiment 3). Overall, our study demonstrates that during attention to social cues proactive cognitive control mechanisms are modulated by the expectation of conflicting stimulus information at both the block- and trial-sequence level, and by the type of task and cognitive load. This helps to clarify the inherent differences in the distracting potential of head and gaze cues during speeded social attention tasks.

Satisfaction of Emergency Physicians with the Care Provided to Patients with Cardiovascular Diseases in the Northern Region of Minas Gerais.

BACKGROUND: The dissatisfaction of health professionals in emergency services has a negative influence on both the quality of care provided for acute myocardial infarction (AMI) patients and the retention of those professionals. OBJECTIVE: To assess physicians' satisfaction with the structure of care and diagnosis at the emergency services in the Northern Region of Minas Gerais before the implementation of the AMI system of care. METHODS: This cross-sectional study included physicians from the emergency units of the ambulance service (SAMU) and level II, III and IV regional hospitals. Satisfaction was assessed by using the CARDIOSATIS-Team scale. The median score for each item, the overall scale and the domains were calculated and then compared by groups using the non-parametric Mann-Whitney test. Correlation between time since graduation and satisfaction level was assessed using Spearman correlation. A p value < 0.05 was considered significant. RESULTS: Of the 137 physicians included in the study, 46% worked at SAMU. Most of the interviewees showed overall dissatisfaction with the structure of care, and the median score for the overall scale was 2.0 [interquartile range (IQR) 2.0-4.0]. Most SAMU physicians expressed their dissatisfaction with the care provided (54%), the structure for managing cardiovascular diseases (52%), and the technology available for diagnosis (54%). The evaluation of the overall satisfaction evidenced that the dissatisfaction of SAMU physicians was lower when compared to that of hospital emergency physicians. Level III/IV hospital physicians expressed greater overall satisfaction when compared to level II hospital physicians. CONCLUSION: This study showed the overall dissatisfaction of the emergency physicians in the region assessed with the structure of care for cardiovascular emergencies.

Adiponectin in Relation to Coronary Plaque Characteristics on Radiofrequency Intravascular Ultrasound and Cardiovascular Outcome.

BACKGROUND: Prospective data on the associations of adiponectin with in-vivo measurements of degree, phenotype and vulnerability of coronary atherosclerosis are currently lacking. OBJECTIVE: To investigate the association of plasma adiponectin with virtual histology intravascular ultrasound (VH-IVUS)-derived measures of atherosclerosis and with major adverse cardiac events (MACE) in patients with established coronary artery disease. METHODS: In 2008-2011, VH-IVUS of a non-culprit non-stenotic coronary segment was performed in 581 patients undergoing coronary angiography for acute coronary syndrome (ACS, n = 318) or stable angina pectoris (SAP, n = 263) from the atherosclerosis-intravascular ultrasound (ATHEROREMO-IVUS) study. Blood was sampled prior to coronary angiography. Coronary plaque burden, tissue composition, high-risk lesions, including VH-IVUS-derived thin-cap fibroatheroma (TCFA), were assessed. All-cause mortality, ACS, unplanned coronary revascularization were registered during a 1-year-follow-up. All statistical tests were two-tailed and p-values < 0.05 were considered statistically significant. RESULTS: In the full cohort, adiponectin levels were not associated with plaque burden, nor with the various VH-tissue types. In SAP patients, adiponectin levels (median[IQR]: 2.9(1.9-3.9) µg/mL) were positively associated with VH-IVUS derived TCFA lesions, (OR[95%CI]: 1.78[1.06-3.00], p = 0.030), and inversely associated with lesions with minimal luminal area (MLA) ≤ 4.0 mm2 (OR[95%CI]: 0.55[0.32-0.92], p = 0.025). In ACS patients, adiponectin levels (median[IQR]: 2.9 [1.8-4.1] µg/mL)were not associated with plaque burden, nor with tissue components. Positive association of adiponectin with death was present in the full cohort (HR[95%CI]: 2.52[1.02-6.23], p = 0.045) and (borderline) in SAP patients (HR[95%CI]: 8.48[0.92-78.0], p = 0.058). In ACS patients, this association lost statistical significance after multivariable adjustment (HR[95%CI]: 1.87[0.67-5.19], p = 0.23). CONCLUSION: In the full cohort, adiponectin levels were associated with death but not with VH-IVUS atherosclerosis measures. In SAP patients, adiponectin levels were associated with VH-IVUS-derived TCFA lesions. Altogether, substantial role for adiponectin in plaque vulnerability remains unconfirmed.

Fluent Speakers of a Second Language Process Graspable Nouns Expressed in L2 Like in Their Native Language.

According to embodied cognition, language processing relies on the same neural structures involved when individuals experience the content of language material. If so, processing nouns expressing a motor content presented in a second language should modulate the motor system as if presented in the mother tongue. We tested this hypothesis using a go-no go paradigm. Stimuli included English nouns and pictures depicting either graspable or non-graspable objects. Pseudo-words and scrambled images served as controls. Italian participants, fluent speakers of English as a second language, had to respond when the stimulus was sensitive and refrain from responding when it was not. As foreseen by embodiment, motor responses were selectively modulated by graspable items (images or nouns) as in a previous experiment where nouns in the same category were presented in the native language.

Chained Activation of the Motor System during Language Understanding.

Two experiments were carried out to investigate whether and how one important characteristic of the motor system, that is its goal-directed organization in motor chains, is reflected in language processing. This possibility stems from the embodied theory of language, according to which the linguistic system re-uses the structures of the motor system. The participants were presented with nouns of common tools preceded by a pair of verbs expressing grasping or observational motor chains (i.e., grasp-to-move, grasp-to-use, look-at-to-grasp, and look-at-to-stare). They decided whether the tool mentioned in the sentence was the same as that displayed in a picture presented shortly after. A primacy of the grasp-to-use motor chain over the other motor chains in priming the participants' performance was observed in both the experiments. More interestingly, we found that the motor information evoked by the noun was modulated by the specific motor-chain expressed by the preceding verbs. Specifically, with the grasping chain aimed at using the tool, the functional motor information prevailed over the volumetric information, and vice versa with the grasping chain aimed at moving the tool (Experiment 2). Instead, the functional and volumetric information were balanced for those motor chains that comprise at least an observational act (Experiment 1). Overall our results are in keeping with the embodied theory of language and suggest that understanding sentences expressing an action directed toward a tool drives a chained activation of the motor system.

Coordinated regional care of myocardial infarction in a rural area in Brazil: Minas Telecardio Project 2.

AIMS: In Brazil, there are considerable disparities in access to healthcare. The aim of this study was to assess how implementation of a coordinated regional management protocol for patients with ST-elevation myocardial infarction (STEMI) affected quality of care and outcomes in a rural and deprived Brazilian region with considerable social inequalities. METHODS AND RESULTS: The quality of care and outcomes of STEMI was evaluated in two cohorts before (n = 214) and after (n = 143) implementation of the coordinated regional management protocol. Central to this protocol was a tablet-based digital electrocardiogram (ECG) recording in the emergency ambulance that was transmitted for analysis by trained professionals. If the pre-hospital ECG was diagnostic, it triggered a management cascade involving a direct transfer to the regional intervention centre with reperfusion by primary percutaneous coronary intervention (PPCI) or pre-hospital fibrinolysis for anticipated journey times of less than or greater than 2 h, respectively. Following implementation of the protocol, the adjusted medical delay (system delay - transport time) decreased by 40% (95% confidence intervals: -66%, -13%). The proportion of patients who received reperfusion therapy increased from 70.6 to 80.8% (P = 0.045), with increases in treatment with aspirin [94.2-100% (P = 0.003)] and P2Y12 inhibitors [87.5-100% (P < 0.001)]. The odds of in-hospital death showed a non-significant decrease [odds ratio 0.73 (95% confidence intervals: 0.34-1.60)]. CONCLUSION: The implementation of a coordinated regional management protocol for patients with STEMI led to marked improvements in the quality of care in a remote Brazilian region with limited resources.