Sex disparities in pre-hospital and hospital treatment of ST-segment elevation myocardial infarction.

OBJECTIVE: To determine whether sex disparities exist in pre-hospital and hospital time to treatment in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Evidence suggests that women experience poorer quality of care for STEMI. METHODS: A retrospective cohort study was conducted on 177 consecutive patients with STEMI who received primary percutaneous coronary intervention at a rural, tertiary medical center between January 2006 and October 2009. A subgroup analysis was conducted to evaluate time to treatment during a period of no-focused process improvement compared with a time period of focused, non­sex-specific process improvement; the post period included implementation of the STEMI process upgrade (STEP-UP) quality-improvement (QI) program. RESULTS: Median first-emergency-medical-services-contact-to-balloon (E2B) angioplasty time was significantly longer for women compared with men. A Cox proportional hazards model revealed that men had a significantly shorter E2B time than women. After adjustment for differences between sex groups at presentation, the effect of sex on E2B was no longer statistically significant. A similar effect was observed in door-to-balloon (D2B) angioplasty time. The subgroup analysis revealed that from baseline, both men and women experienced improvement in E2B time after implementation of the STEP-UP QI program. Men and women also experienced improvement in D2B time after implementation of the STEP-UP QI program. CONCLUSIONS: Women with STEMI experienced significantly longer E2B and D2B times compared with men with STEMI, although these differences did not persist after adjustment for differences between sex groups at presentation. In addition to standard STEMI-care QI practices, sex-specific processes and interventions at the systems level may be needed to improve time to treatment for women with STEMI.

Primary percutaneous coronary intervention for patients presenting with ST-segment elevation myocardial infarction: process improvement in a rural ST-segment elevation myocardial infarction receiving center.

BACKGROUND: Rural ST-segment elevation myocardial infarction (STEMI) care networks may be particularly disadvantaged in achieving a door-to-balloon time (D2B) of less than or equal to 90 minutes recommended in current guidelines. ST-ELEVATION MYOCARDIAL INFARCTION PROCESS UPGRADE PROJECT: A multidisciplinary STEMI process upgrade group at a rural percutaneous coronary intervention center implemented evidence-based strategies to reduce time to electrocardiogram (ECG) and D2B, including catheterization laboratory activation triggered by either a prehospital ECG demonstrating STEMI or an emergency department physician diagnosing STEMI, single-call catheterization laboratory activation, catheterization laboratory response time less than or equal to 30 minutes, and prompt data feedback. EVALUATING SUCCESS: An ongoing regional STEMI registry was used to collect process time intervals, including time to ECG and D2B, in a consecutive series of STEMI patients presenting before (group 1) and after (group 2) strategy implementation. Significant reductions in time to first ECG in the emergency department and D2B were seen in group 2 compared with group 1. CONCLUSIONS: Important improvement in the process of acute STEMI patient care was accomplished in the rural percutaneous coronary intervention center setting by implementing evidence-based strategies.

Primary percutaneous coronary intervention for patients presenting with ST-elevation myocardial infarction: process improvements in rural prehospital care delivered by emergency medical services.

BACKGROUND: Safe and effective patient care for ST-elevation myocardial infarction (STEMI) relies on prompt emergency medical service (EMS) and established care coordination with receiving hospitals to conduct primary percutaneous coronary intervention (PCI). Likewise, a new emphasis has been placed on first medical contact-to-balloon (E2B) times as opposed to door-to-balloon times, identifying prehospital care as an important contributing factor for high-quality STEMI care. Therefore, we evaluated EMS processes of care before and after a period of continuous quality improvement to improve E2B times in our rural tertiary care medical center. METHODS: A retrospective, consecutive cohort study was conducted on 177 patients who received primary PCI at Dartmouth-Hitchcock Medical Center, a rural hospital, from January 1, 2006 to October 31, 2009. This cohort was stratified from January 1, 2008 to May 1, 2008 (n = 88) and May 1, 2008 to October 31, 2009 (n = 89), to acknowledge periods of no improvement (pre) and continuous quality improvement (post) in STEMI care. Primary outcome measures included frequency of non-PCI-capable hospital bypass, E2B, and frequency of prehospital electrocardiogram (ECG) and cardiac catheterization laboratory (CCL) activation. Descriptive statistics and log-rank tests were used to determine whether measures differed significantly by time period. A time-to-event analysis was conducted using a Cox proportional hazards model to assess the impact of outcomes measures on E2B pre/post-May 1, 2008. RESULTS: Patients who presented before May 1, 2008 had longer E2B times compared with patients in the post-May 1, 2008 cohort (145.1 minutes vs 115.2 minutes, t test P = .01). A log-rank test confirmed this (pre: 130 minutes vs post: 106 minutes, χ(2) = 5.3, log-rank P = .02). Similarly, patients who presented before May 1, 2008 had lower percentages of prehospital ECGs (49% vs 80%, P = .001) and CCL activations (4% vs 32%, P < .001). When prehospital ECGs (140 minutes vs 106 minutes, χ(2) = 5.9, log-rank P = .01) or CCL activations (125 minutes vs 98 minutes, χ(2) = 4.2, log-rank P = .04) were conducted, E2B times were significantly reduced. Patients who received both prehospital ECGs and prehospital CCL activations had significantly reduced E2B times compared with those who did not (125 minutes vs 91 minutes, χ(2) = 4.8, P = .02). CONCLUSIONS: The time saving benefits of prehospital ECGs may not be fully realized unless prehospital CCL activations also occur. EMS providers achieved further reductions in median E2B of approximately 24 minutes when prehospital ECGs were combined with prehospital CCL activation. Every effort should be made by PCI-capable medical centers to assess prehospital STEMI care and to integrate EMS providers into regional STEMI care quality improvement initiatives and education.

The intron 5/6 promoter region of the ship1 gene regulates expression in stem/progenitor cells of the mouse embryo.

The s-SHIP protein is a shorter isoform of the longer SHIP1 protein and lacks the N-terminal SH2 domain region contained in SHIP1. s-SHIP is expressed in ES cells and in enriched bone marrow stem cells, and may be controlled by a promoter within intron 5 of the ship1 gene. We therefore examined the potential specificity of promoter activity in ES cells of an intron 5/intron 6 ship1 genomic segment and its tissue specificity within transgenic mice expressing GFP from this promoter region. The results indicate that s-SHIP promoter activity is specific for ES cells in vitro and for known and presumptive stem/progenitor cells throughout embryo development of the transgenic mice. Specific GFP expression was observed in the blastocyst, primordial germ cells, thymus, arterioles, osteoblasts, and skin epidermis. The epidermis/epithelium is the progenitor for hair follicles, mammary tissue, and prostate. Interestingly, each of these latter tissues acquired a few GFP-positive cells in the course of their development from the epithelial layers, and these cells express marker proteins for stem/progenitor cells. These results identify potential stem cell populations, mark these cells for analyses in normal and cancer development, and implicate s-SHIP as an important protein in stem/progenitor cell function.