ABSTRACT
BACKGROUND: Regionalized integrated networks for ST-segment-elevation myocardial infarction (STEMI) care have been proposed as a step forward in overcoming real-world obstacles, but data are lacking on its performance in developing countries. We describe an integrated regional STEMI network in Salvador, Bahia, Brazil. METHODS AND RESULTS: The network was created in 2009. It was coordinated by the prehospital emergency medical service and encompassed the public emergency system (prehospital mobile units, community-based emergency units, general hospitals, and cardiology reference centers). The 12-lead ECGs are interpreted via telemedicine. This network operates as follows: The Telemedicine Center sends each ECG suggestive of STEMI to a Regional STEMI Alert Team, which, together with emergency medical services, offers support for thrombolysis or immediate transfer for primary percutaneous coronary intervention. In 14 months, there were 433 suspected victims, of which in 287 (76.5%) the STEMI could be confirmed (age, 62.1±12.5 years; 63.4% men). Most of them were self-transported. The median pain-to-admission time was 180 minutes (interquartile range, 90-473 minutes), and the median admission-to-ECG time was 159.5 minutes (interquartile range, 83.5-340 minutes). The median interval time between the ECG and the telemedicine report was 31 minutes (interquartile range, 21-44 minutes). For those who sought medical attention and had an ECG performed within 12 hours after symptoms onset (n=119), the reperfusion rate was 75.6% (34.4% by thrombolysis and 65.6% by primary percutaneous coronary intervention). CONCLUSIONS: Regional STEMI networks may be feasible in developing countries. Preliminary results showed this network to be effective, achieving primary reperfusion rtes comparable with those reported internationally despite the obstacles faced.
Subject(s)
Community Networks/organization & administration , Developing Countries , Electrocardiography , Myocardial Infarction/epidemiology , Myocardial Infarction/therapy , Percutaneous Coronary Intervention , Aged , Brazil/epidemiology , Cardiology Service, Hospital/organization & administration , Emergency Medical Services/organization & administration , Female , Hospitals, General/organization & administration , Humans , Male , Middle Aged , Myocardial Infarction/physiopathology , Registries , Retrospective Studies , Telemedicine/organization & administration , Time FactorsABSTRACT
BACKGROUND AND OBJECTIVES: The Japanese protocol considers metastases to retroperitoneal or lateral pelvic lymph nodes (RLPNs) as regional lymphatic dissemination in rectal adenocarcinoma patients and recommends total mesorectal excision (TME) plus retroperitoneal and lateral pelvic lymphadenectomy (RLPL). Western protocols consider RLPN metastases to indicate advanced disease. METHODS: All outcomes were evaluated among a cohort of 102 rectal adenocarcinoma patients subjected to TME plus RLPL with a nerve-preserving technique. Chemoradiotherapy was delivered in patients with T3/T4 tumors or metastases to mesorectal nodes or RLPNs. RESULTS: Surgical mortality was 3.9%; surgical morbidity was 33.3%. Incidence of RLPN metastases was 17%. Pelvic recurrence was 14.5% in pT3/pT4 patients and 29.4% in patients with metastases to RLPNs. Survival at 50 months was 28.6% in patients with RLPN metastases versus 84.5% in patients without RLPN metastases (P < 0.0001). Survival at 50 months was 33.3% in TME stage II patients with RLPN metastases versus 97.1% in TME stage II patients without RLPN metastases (P < 0.0001), and 21.9% in TME stage III patients with RLPN metastases versus 68.9% in TME stage III patients without RLPN metastases (P = 0.0237). CONCLUSIONS: Patients who underwent RLPL had acceptable morbidity and mortality rates. Metastases to RLPNs indicated unfavorable survival and considerable pelvic recurrence rates.
