Contact-to-balloon time and door-to-balloon time after initiation of a formalized data feedback in patients with acute ST-elevation myocardial infarction.

For many patients with ST-segment elevation myocardial infarctions (STEMIs), the time from presentation to percutaneous coronary intervention exceeds established goals. This study was conducted to examine the effects of formalized data assessment and systematic feedback on treatment times. All patients with STEMIs treated with percutaneous coronary intervention in a semi-rural 3-hospital network from January 1, 2006, to December 31, 2006, were prospectively analyzed (n = 114). Patients presenting during the first 3-month period (January 1, 2006, to March 31, 2006) were included as the reference group (n = 33). Time points from initial contact with the medical system to revascularization were assessed, analyzed, and presented in an interactive session to hospital and emergency services staff members. Data from patients with STEMIs presenting during the next 3 quarters were presented in the same manner (n = 28, 25, and 28). The median contact-to-balloon time was 113 minutes in the reference quarter, decreasing to 83, 66, and 74 minutes in the intervention groups (p <0.0001), whereas the median door-to-balloon time decreased from 54 minutes in the reference group to 35, 31, and 26 minutes in the intervention groups (p <0.0001). The proportion of patients with contact-to-balloon times <90 minutes increased from 21% to 79% (p <0.0001). There were significant reductions in the durations of initial treatment on location and in the emergency room and in puncture-to-balloon-time in the catheterization laboratory, and more patients were transported directly to the catheterization laboratory, bypassing the emergency room (from 23% in the reference quarter to 76% in the last intervention quarter, p <0.0001). In conclusion, formalized data feedback leads to marked reduction in revascularization times in patients with STEMIs.

[Optimizing systems of care for patients with acute myocardial infarction. STEMI networks, telemetry ECG, and standardized quality improvement with systematic data feedback]. / Prozessentwicklung in der Herzinfarktversorgung: Netzwerkbildung, Telemetrie und standardisiertes Qualitätsmanagement mit systematischer Ergebnisrückkopplung.

Rapid revascularization of the infarct-related artery importantly affects prognosis in the treatment of acute ST elevation myocardial infarction (STEMI). Treatment results can be improved significantly when a STEMI-specific structure of care is created and when systematic quality improvement measures are implemented. The necessary structural measures include establishing or participating in myocardial infarction networks. When local hospitals collaborate in a network, it becomes feasible to offer round-the-clock primary coronary intervention to patients of those participating hospitals that do not have a catheterization laboratory on site. Another important structural step is to acquire and install prehospital twelve-lead ECG systems capable of remote telemetric transmission. This provides a solid basis for diagnosing STEMI with speed and accuracy and can prove to be highly effective in anchoring the chain of alert and treatment. As a consequence, two important goals can be realized: (1) intentionally bypassing the non-interventional hospital, and (2) systematically bypassing the emergency room of the interventional center. Both of these measures entail important time savings. An efficient instrument for improving treatment times is the implementation of a standardized quality improvement process with formalized data collection and analysis as well as with systematic data feedback to all systems and individuals involved in the early phase of treating STEMI patients within the hospital network including the emergency medical responder systems. The positive effect of such data feedback on treatment quality is contingent on the perception by all those involved that the data obtained for each patient are absolutely valid. Thus, those data need to be verifiable and an independent monitoring process should be created.Furthermore, the systematic use of standardized risk scores should be promoted in an effort to compare and adjust patient risk when analyzing network data. It is critically important that all appropriate patients-including those with a high risk of mortality--have access to rapid interventional treatment. Only when the individual risk of treated patients is taken into account will it be possible to compare quality of care and mortality rates. In general, the comparison between different hospitals, systems and regions is highly problematic and not feasible without considering local factors. It harbors the danger of inducing changes in practice in order to compete rather than in order to advance patient care, and thus it may be counterproductive when such a comparison leads to the implication that treatment may have been inferior. Therefore, the comparison of results (e.g., treatment times and mortality rates) should be undertaken as much as possible within an established system, with the use of a "before and after" design. Quality, then, will be defined as a documented consistent effort to improve results, and this approach will be distinctly productive. It is of fundamental importance that the involved hospitals, physicians and emergency staff perceive themselves as a team. The structures and processes outlined above can and should be applied broadly. The necessary resources will need to be provided through political and societal consensus. The multicenter FITT-STEMI project ("Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction") is currently pursuing such an approach.

On the pathogenesis and clinical course of mesenteric lymph node cavitation and hyposplenism in coeliac disease.

BACKGROUND: Coeliac disease is a disorder characterised by malabsorption related to abnormal small bowel structure and intolerance to gluten. There are several reports of an increased risk for malignancy in coeliac disease and its relation to gluten-free, reduced gluten, or normal diet. While a normal diet is associated with an excess of cancer of the mouth, pharynx, oesophagus, and also of lymphoma, treatment with a gluten-free diet restores the cancer risk back to normal. PATIENT: In the present study, we report on a 63-year-old female patient with a history of coeliac disease for twenty years who presented with persistent diarrhoea, weight loss, and an abdominal mass. RESULTS: The gastroenterological work-up revealed small bowel mucosal atrophy, absence of functional splenic tissue, and evidence for an involution of a mesenteric lymph node, termed cavitation. DISCUSSION: This triad has been previously described to represent a rare disease entity related to coeliac disease. We report a two-year follow-up and a review of the literature on the pathogenesis, prognosis, and therapeutical implications of this disease entity.