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More grouper restrictions
Published: Wednesday, January 13, 2010 at 1:00 a.m.
Last Modified: Tuesday, January 12, 2010 at 9:41 p.m.
Restrictions on commercial and recreational grouper fishing in the Gulf of Mexico are undergoing another revision and will likely get tighter next year.
The Gulf of Mexico Fisheries Management Council is holding a meeting tonight in Fort Myers inform people of the need for stronger rules to protect the grouper population. There will also be time for public comment.
Recreational fishing for shallow water grouper species, such as gag and red, this year will be off limits for a month longer than last year. The new closed season begins Feb. 1 and ends March 31.
The meeting begins at 6 p.m. It will be at the Ramada Inn, 4760 S. Cleveland Ave., Fort Myers.
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The Classic 'Who's This?'
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The Tough Love
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11 exquisite photos that evoke road trips of a time gone by
25 jokes — from dads all over the Internet — guaranteed to make you groan
Even for those of us who were there, it's hard to believe what things cost in the '60s
30 powerful images of the conflict that defined a generation

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Missed last week's issue? You can still view its magnificent property pages and articles here.
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This Welsh masterpiece is the finest piece of John Nash architecture still in private ownership
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Petits pois a la Francaise
Go green: a fine dish in its own right, Petits pois a la Francaise is also the perfect accompaniment to roast quail or squab pigeon.
The best pubs in Britain
From brilliant beer and fine wines to first-class food and scenic locations, we reveal our list of our favourite public houses.
Beautiful beach & poolside furniture ideas
Enjoy a long, leisurely summer in or near the water with these stylish accessories.
Jaguar F-Type R AWD: car review
Jaguar's latest all-wheel-drive F-type is not only good-looking, it's also the perfect fly-fishing wagon, purrs Charles Rangeley-Wilson.


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The six owners of North Scott Barber Salon know each other quite well, since they all met and trained at the same salon before opening their own styling spot. Between them, they share 90 years of industry experience, which they deftly wield while performing services for both men and women such as haircuts, highlights, conditioning treatments, and mani-pedis. Inside, purple, green, and beige walls surround tidy stations equipped with square full-length mirrors, and outside, an iconic candy-striped pole hangs out front, signaling the hair services within.


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dulce underground base-cattle mutilations and alien craft
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These technologically advanced weapons are going to be revealed when the aliens take over in the very near future. The technology is exclusively alien and, as such, belongs to the aliens.
The aliens don't want humans to know about them or their hardware (yet), but are content to let them use their own 'primitive' weapons against eachother in wars - wars the aliens engineer through their hybrid illuminati operatives.
That's funny. You ASSume that there is only one type of "alien" around and that they are all bad. The "good" ETs would welcome these technologies come out into the light of day, not for use, but to prove that the government(s) have been lying, hiding, and turning most of humanity into debt slaves to create all of this technology and NWO infrastructure. Thus we might actually pull our heads out of the sand, unfurl our nuticles, and deal with the problems.
You also ASSume that these weapons have never been used, yet credible people have told of them being used in 9/11, in Iraq, in recent volcanic activity and most of the 3D "UFOs" people see these days are man-made. I was just watching a "UFO" video from Crotia and it was actually one of the US TR3B "UFOs".
Anonymous Coward 652204
Hey dudeski, I'm not arguing with you about alien types and whether or not secret weapons are being used in Iraq et al; I wasn't in Iraq during the war, so I wouldn't know. Maybe the credible sources you cite are correct, I'm just saying that the Draco/malevolent ET's, along with their servants (global elitists), tend to horde these technologies for themselves.
As I understand it, from what I've read from numerous sources, the good guys (God and his angels) are observing this planet, but won't intervene because it will interfere with our spiritual evolution. If they came in and rid the planet of the bad guy ET's then what lesson would we have learned? We wouldn't have learned the consequences of giving our power away to a ruthless predator, a we have ben doing for thousands of years.
It's our duty, and our duty alone, to take our power back.
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13 Important Elements To Look For In Every Staged Shooting Event
Gestapo In The USA: FCC Intimidates Press and Kills Free Speech at 5G Rollout
Democratic National Convention in Philly Is Not What We're Told About in the Media
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Email this article from PlasticsNews.com
Packaging firms put stewardship up front
It's encouraging to see progress with some issues of critical interest to the plastics industry — reducing packaging waste and incorporating voluntary product stewardship. One key word here is "voluntary." Very few companies are lobbying for extended producer responsibility (EPR) legislation, like we've seen in Europe.
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I was refactoring the package structure inside a scala project with eclipse. In the middle of this I used a package statement with
_root_, like this
package _root_.com.workday.foo.bar
Now my eclipse project will not build although I can still build everything in the command line. The problem is that all my
com.* imports are broken
import com.workday.some.thing.Else
The error is:
Multiple markers at this line
- object workday is not a member of package com.workday.foo.bar.com
- object workday is not a member of package com.workday.foo.bar.com
It appears that it is trying to find all imports relative to the package statement at the top of each source file.
I have removed the
_root_ from my package and tried to clean my project and the workspace. I have also tried changing the scala compiler from "sbt" to "refined" and back but to no avail
Does anyone know how to kick the eclipse scala compiler back on track???


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Hourly - Intermediate ($$) - Est. Time: 3 to 6 months, 10-30 hrs/week - PostedSkills: JMS Elasticsearch
. - Profound insight of Core Java and JEE internals (Class loading, Memory Management, Transaction management etc.) - Familiarity with Java Message Service (JMS) - Familiarity with Cluster Database and Elastic search - Experience in using at least one popular web framework preferably NETTY - Experience in Service Oriented Architecture preferably REST Other expectations: - Willingness to work in a flexible schedule - An independent freelancer (not associated with any agency) - Good English communication (verbal and written) - Must be available to work at least 20 hours a week that can be converted into full-time shortly. - Ready to provide 5 to 6 hour time overlap in (UTC+2) time zone.


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Category:Youth charities based in the United Kingdom
From Wikipedia, the free encyclopedia
This category has only the following subcategory.
- ► The Scout Association (3 C, 65 P)
Pages in category "Youth charities based in the United Kingdom"
The following 25 pages are in this category, out of 25 total. This list may not reflect recent changes (learn more).


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M & M MarineAdditional Locations
Phone: (530) 661-0074 View Additional Phone Numbers 117 W Brannan Island Rd Unit B, Isleton, CA 95641 View Additional Email Addresses http://www.mm-marine.com
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We specialize in all varieties of parts for top personal watercraft - both newer and vintage. This year celebrating our 30th anniversary, we specialize in both hard to find parts, as well as traditional parts needed for ongoing maintenance and repair.
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M & M Marine is a full service personal water craft center including sales, service, parts and repair.
Customer Review Rating plus BBB Rating Summary
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Hombre - spanish english translation | spanish central, Translation of hombre at merriam-webster's spanish-english dictionary. audio pronunciations, verb conjugations, quizzes and more.. Hombre amsterdam, Hi. welcome at hombre amsterdam, a premium fashion & lifestyle blog with stores in amsterdam, the netherlands and online!. Hombre golf club – panama city beach golf courses , Learn. practice. relax. hombre golf club has everything to enjoy the best in golf available. get professional instruction from the academy, hone your skills at our.
Hombre (film) - wikipedia, free encyclopedia, Hombre 1967 revisionist western film directed martin ritt, based elmore leonard starring paul newman, fredric march. https://en.wikipedia.org/wiki/Hombre_(film) Hombre., Address. 1503 nw 82nd ave, doral, fl 33126, united states. collection 2000 cosmetics body sprays. home; ; collection 2000 ® perfumed talc red gold. http://www.hombre.com/ Hombre (1967) - rotten tomatoes, Yes, paul newman blue-eyed indian hombre, apparent ethnic error carefully justified body story. newman plays white man . https://www.rottentomatoes.com/m/hombre/


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Authorities say a county attorney found dead in his southern Iowa home died of natural causes.
The Appanoose County Sheriff's Office says 40-year-old Richard F. Scott was found deceased Friday morning inside his Centerville home. An investigation by local authorities and the county medical examiner's office determined the cause of death.
Centerville police sent officers to the home after Scott did not show up for court proceedings as Appanoose County attorney.
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ALSO- check out "Shop Samples" for Sale on the Fabrics page
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Quilt Ventura now has a FaceBook Page!!!
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Need HELP with a project? We have a QUILTING TUTOR 4 U!!!
$15.00 per hour, availability to be determined with either Debbie Bayer, Dawn Knoeller or Joey. We feel you!
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UPS Freight, a leader in the LTL trucking industry, is currently seeking an Operations Supervisor to produce maximum profit while providing excellent service to...
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Assisting with running a high-volume souvenir photography retail operation. We're seeking motivated, outgoing, friendly and professional team players to join...
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Freight Operations Supervisor. Supervise and plan hourly employee schedules to meet daily operations goals....
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Qualifications of the Operations Supervisor:. Union City, CA is seeking an Operations Supervisor. Genesis Logistics, Inc....
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Adhere to the approved operations annual budget and provide budget updates and adjustments as requested by the Operations Director or SVP of Operations....
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We are currently in search of a Production Supervisor supporting our processing facility in Pelion, SC. The 2nd Shift Production Supervisor will manage and...
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Consistent and safe execution of duties associated with forklift operation when certified to Seattle Goodwill standards.*....
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Notify supervisors when produced materials fail tomeet standards. Monitor machine operations andobserve lights / gauges to detect malfunctions....
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Organizers of this yearĺs New Yearĺs Eve festivities in downtown Mount Clemens say it will be the largest -- and coldest -- event theyĺve hosted.
Both the Macomb County New Yearĺs Gala and the Childrenĺs New Yearĺs Eve in Never Never Land have expanded to welcome in 2014 but the weather will also be a hot topic as evening temperatures are expected to be only in the teens.
ôWeĺve never had it this cold before,ö said Michelle Weiss of the host entity Downtown Development Authority. ôItĺs been as nice as 48 degrees and down to 28 but weĺre expecting it to be about 18 degrees on Tuesday.ö
There will be several warming stations as well as businesses welcoming in guests to take a break from the bone-chilling cold before heading back out. There will also be indoor as well as outdoor activities for the kids.
The family-oriented Never Never Land event is a five-hour package of mostly free entertainment and activities including sing-alongs, crafts, a petting zoo and storybook characters in the local restaurants. It runs from 4 to 9 p.m. Tuesday and is capped off with a ball drop and mini fireworks display.
Highlights include:
* 4-6 p.m.-- Meet-and-greet Cinderella at John Barleycornĺs, Tinkerbell at Detroit Pub, Ninja Turtle at Gus Coney Island, Spiderman at Orleans, and Dora the Explorer at Seeburgerĺs Cheeseburgers.
* 4:30-7:30 p.m. -- Unicorn pony rides and petting zoo on Main Street at Macomb Place
* 4:30-5:30 p.m. -- Sing-along with Fairy Godmother at Gumboĺs Courtyard
* 5-9 p.m. -- Thomas the Train Rides (has a small fee) Main Street at Macomb Place
* 6-7:15 p.m. -- Magic and ventriloquism show at Gumboĺs Courtyard (has a small fee)
* 6:15-7:15 p.m. -- Craft with Tinkerbell at The MINDĺs Eye Books
* 8 p.m. -- Crossroads Band performs on stage on Main Street
* 9 p.m. -- Childrenĺs New Yearĺs Eve ball drop and fireworks
Meanwhile, the New Yearĺs Gala has expanded the live band performance times and eliminated karaoke. Eastside Westside will perform two sets of classic rock hits starting at 9:30 p.m. There also will be a 50/50 raffle taking place for $2 a ticket, with proceeds going to pay for the fireworks.
Steve Ferdig, a guitarist-vocalist with Eastside Westside, said the band will depend on heaters near the stage and keeping their hands in their pockets in between songs to stay warm in what he calls a ômost challenging environment.ö
ôThe whole thing is we are willing to do this because we love the music and being out with the people,ö he said. ôItĺs so much fun to see people enjoying what weĺre doing.ö
The New Yearĺs Eve Gala typically attracts up to 5,000 people, who often eat and drink in the cityĺs renowned bars and restaurants prior to the big show.
A full schedule is available at downtownmountclemens.com.


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Army Prop. V Recruits Our Kids for War
Proposition V on the San Francisco ballot supports the Army JROTC program, whose most fundamental propose is to recruit our children into the military. With wars in both Iraq and Afghanistan, military recruitment is the central issue of this campaign. The war in Iraq alone has cost over 4,000 American dead and 30,000 wounded, plus an estimated 1 million Iraqis, the majority of them civilians. The pro-Army JROTC people admit that the national JROTC program is a recruiting tool for the military, but they claim that the local program is "different," and is not a recruiting tool. Let's examine that claim more closely.
According to testimony given to Congress in 2000 by the chiefs of staff of each of the armed services – including General Eric K. Shinseki – 30-50% of JROTC cadets nationally join the military after high school. Former U.S. Secretary of Defense William Cohen said that JROTC is "one of the best recruitment programs we could have."
Local pro-JROTC advocates claim that in San Francisco, only "two of almost 1,500 cadets enlisted" in 2007 (AsianWeek editorial, 10/10-16/08), but this claim defies logic. The local Army JROTC program is the same as the national program in its curriculum and its instructors. Cadets learn the same marching drill, wear the same Army uniforms, and study the same Army belief system – blind obedience to authority. Why would the same program produce such different results locally? The truth is that the 2 out of 1,500 statistic is undocumented and is so absurdly low as to be unbelievable. The "No on V" campaign has requested the official figures from the school district and was told that there are no such official figures. This claim has no more proof than George Bush's "Weapons of Mass Destruction" in Iraq. Simple logic tells us that the Army would not continue to pour resources into a program that did not produce results for it – the recruitment of our children into war.
Another Army JROTC claim that greatly influences the Asian community is the claim that JROTC teaches "discipline" and "leadership." Asians value these qualities greatly, so we are especially vulnerable to this particular sales pitch. But consider the type of "discipline" and "leadership" taught by the Army: a leader yells out orders, and marching cadets instantly obey without question. This is the very foundation of all military leadership, and in a combat situation this is in fact exactly what is needed.
But in today's fast paced, complex, constantly changing work environment, this is exactly the kind of thinking that will get a person quickly left behind, at least in the professional jobs. Today's modern work environment requires a person to think fast, on their feet, and creatively, out of the box. Spending years of your life in high school – a formative time in a young person's life – thinking only in the box, paying blind obedience to the box, and believing only and absolutely in the box is exactly the kind of static thinking that will make it extremely different for a young person to adjust to a professional role. Such a person may be excellent working at McDonald's, but not in today's high tech, multi-cultural, international world. Consider that fact that upwards of one-third of homeless people are military veterans, yet veterans are only 11% of the general adult population. Iraq and Afghanistan veterans are now turning up on San Francisco streets, joining the Viet Nam veterans who came before them. Army JROTC is not the road to success. We Asian activists and community leaders urge all Asians to vote NO on V.


text: The Apache Directory Team is proud to announce the availability of the 1.0.0-M10 version of the Apache Directory LDAP API.The Apache Directory LDAP client API is an ongoing effort to provide an enhanced LDAP API, as a replacement for JNDI and the existing LDAP API (jLdap and Mozilla LDAP API). This is a schema aware API, with some convenient ways to access a LDAP server. This API is not only targeting the Apache Directory Server, but should work pristine with any LDAP server. It's also an extensible API : new Controls, schema elements and network layer could be added or used in the near future. It's also OSGi capable.In this milestone, we have fixed some issues, one of them being critical : Here are the release notes for Apache Directory LDAP API 1.0.0-M10:* [DIRAPI-68] - Unable to bind on an Active Directory server using 'domain\userid'Feel free to experiment, we highly appreciate your feedback ! Web site : http://directory.apache.org/api/Download : http://directory.apache.org/api/downloads.html User Guide : http://directory.apache.org/api/user-guide.htmlThe Apache Directory Team


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Changing the site of delivery of thrombolytic treatment for acute myocardial infarction from the coronary care unit to the emergency department greatly reduces door to needle time
Hourigan, C
Mountain, D
Langton, P
Jacobs, I
Rogers, I
Jelinek, G
Thompson, P
OBJECTIVE—To quantify the change in door to needle time when delivery of thrombolytic treatment of acute myocardial infarction was changed from the coronary care unit to the emergency department. DESIGN—A comparative observational study using prospectively collected data. SETTING—Coronary care unit and emergency department of an Australian teaching hospital. PARTICIPANTS—89 patients receiving thrombolysis in coronary care unit between June 1994 and January 1996, and 100 patients treated in the emergency department between April 1997 and May 1998. INTERVENTIONS—From April 1997, by agreement between cardiology and emergency medicine, all patients with acute myocardial infarction receiving thrombolysis were treated by emergency physicians in the emergency department. MAIN OUTCOME MEASURE—Door to needle time measured from time of arrival at the hospital to start of thrombolysis. Other outcomes included pain to needle time and mortality. RESULTS—Median door to needle times were less for patients treated in the emergency department than in the coronary care unit (37 minutes, 95% confidence interval (CI) 33 to 44 v 80 minutes, 95% CI 70 to 89, respectively; p < 0.0001). Door to needle time was under 60 minutes in 83% of emergency department patients and 26% of coronary care unit patients (57% difference, 95% CI 45% to 69%; p < 0.0001). Median pain to needle time was less for emergency department patients than for coronary care unit patients (161 minutes, 95% CI 142 to 177 v 195 minutes, 95% CI 180 to 209; p = 0.004); times of less than 90 minutes occurred in 18% of emergency department patients v 1% of coronary care unit patients (17% difference, 95% CI 9% to 25%; p < 0.05). Overall mortality was similar in patients treated in the emergency department and the coronary care unit. CONCLUSIONS—With a collaborative interdepartmental approach, thrombolytic treatment of acute myocardial infarction was more rapid in the emergency department, without compromising patient safety. This should improve the outcome in patients with infarcts treated with thrombolytic agents. Keywords: thrombolysis; door to needle time; treatment delay; acute myocardial infarction
Related Articles
Safety and efficacy of nurse initiated thrombolysis in patients with acute myocardial infarction
Qasim, Asif
Malpass, Kerry
O'Gorman, Daniel J
Heber, Mary E
BMJ : British Medical Journal
Delay in starting thrombolytic treatment in patients arriving at hospital with chest pain who are diagnosed as having acute myocardial infarction.
Audit of "door to needle times" for patients presenting with chest pain and an electrocardiogram on admission that confirmed acute myocardial infarction. A one year period in each of three phases of development was studied.
Background and setting
The goal of the national service framework for coronary heart disease is that by April 2002, 75% of eligible patients should receive thrombolysis within 30 minutes of arriving at hospital. A district general hospital introduced a strategy to improve door to needle times. In phase 1 (1989-95), patients with suspected acute myocardial infarction, referred by general practitioners, were assessed in the coronary care unit; all other patients were seen first in the accident and emergency department. In phase 2 (1995-7), all patients with suspected acute myocardial infarction were transferred directly to a fast track area within the coronary care unit, where nurses assess patients and doctors started treatment.
Key measures for improvement
Median door to needle time in phase 1 of 45 minutes (range 5-300 minutes), with 38% of patients treated within 30 minutes. Median door to needle time in phase 2 of 40 minutes (range 5-180 minutes), with 47% treated within 30 minutes
Strategies for change
In phase 3 (1997-2001), all patients with suspected acute myocardial infarction were transferred directly to the fast track area and assessed by a "coronary care thrombolysis nurse." If electrocardiography confirmed the diagnosis of acute myocardial infarction, the nurse could initiate thrombolytic therapy (subject to guidelines and exclusions determined by the consultant cardiologists).
Effects of change
Median door to needle time in phase 3 of 15 minutes (range 5-70 minutes), with 80% of patients treated within 30 minutes. Systematic clinical review showed no cases in which a nurse initiated inappropriate thrombolysis.
Lessons learnt
Thrombolysis started by nurses is safe and effective in patients with acute myocardial infarction. It may provide a way by which the national service framework's targets for door to needle times can be achieved.
Related Articles
Hospital Improvement in Time to Reperfusion in Patients with Acute Myocardial Infarction, 1999-2002
McNamara, Robert L.
Herrin, Jeph
Bradley, Elizabeth H.
Portnay, Edward L.
Curtis, Jeptha P.
Wang, Yongfei
Magid, David
Blaney, Martha
Krumholz, Harlan M.
Journal of the American College of Cardiology
Background: Rapid reperfusion improves survival for patients with acute ST-segment elevation myocardial infarction (STEMI). We sought to analyze recent trends in door-to-reperfusion time and identify hospital characteristics associated with improved performance.
Methods: In this retrospective observational study from the National Registry of Myocardial Infarction 3 and 4 between 1999 and 2002, we analyzed door-to-needle and door-to-balloon times in patients admitted with STEMI and receiving fibrinolytic therapy (n=68,439 patients in 1,015 hospitals) or percutaneous coronary intervention (n=33,647 patients in 421 hospitals) within 6 hours of hospital arrival.
Results: In 1999, only 46% of the patients in the fibrinolytic therapy cohort were treated within the recommended 30-minute door-to-needle time; only 35% of the patients in the percutaneous coronary intervention cohort were treated within the recommended 90-minute door-to-balloon time. Improvement in these times to reperfusion over the 4-year study period was not statistically significant (door-to-needle: -0.01 min/yr, CI -0.24, +0.23, p > 0.9; door-to-balloon: -0.57 min/yr, CI -1.24, +0.10, p=0.09). Only 33% (337/1,015) of hospitals improved door-to-needle time by more than 1 minute per year, and 26% (110/421) improved door-to-balloon time by more than 3 minutes per year. No hospital characteristic was significantly associated with improvement in door-to-needle time. Only high annual percutaneous coronary intervention volume and location in New England were significantly associated with greater improvement in door-to-balloon time.
Conclusions: Fewer than half of patients with STEMI receive reperfusion in the recommended door-to-needle or door-to-balloon time, and mean time to reperfusion has not decreased significantly in recent years. Relatively few hospitals have shown substantial improvement.
Condensed Abstract
We analyzed door-to-needle and door-to-balloon times in patients admitted with ST-segment elevation myocardial infarction and receiving fibrinolytic therapy (n=68,439 patients in 1,015 hospitals) or percutaneous coronary intervention (n=33,647 patients in 421 hospitals) within 6 hours of hospital arrival in the National Registry of Myocardial Infarction 3 and 4. Despite national initiatives to measure and reduce these times, guideline recommendations were met less than half of the time, with no substantial trend toward improvement. Nevertheless, some individual hospitals experienced substantial improvement while others worsened. Structural features of hospitals did not adequately predict change in performance. Other factors need to be identified and used by hospitals for performance improvement programs.
Related Articles
Time to treatment with thrombolytic therapy: determinants and effect on short-term nonfatal outcomes of acute myocardial infarction
Cox, J L
Lee, E
Langer, A
Armstrong, P W
Naylor, C D
CMAJ: Canadian Medical Association Journal
OBJECTIVES: To characterize the extent of delay in administration of thrombolytic therapy to patients with acute myocardial infarction (AMI) in Canada, to examine patient-specific predictors of such delay and to measure the effect of delay on short-term nonfatal cardiac outcomes. DESIGN: Secondary cohort analysis of data from the first international Global Utilization of Streptokinase and tPA for Occluded Coronary Arteries (GUSTO-I) trial. SETTING: Sixty-three acute care hospitals across Canada. SUBJECTS: All 2898 Canadian patients with an AMI enrolled in GUSTO-I. MAIN OUTCOMES: Time before arrival at a hospital ("symptom-to-door" time) and time from arrival to administration of therapy ("door-to-needle" time) for patients who had an AMI outside of a hospital, in clinically relevant categories; proportions of patients with nonfatal, serious cardiac events, including shock, sustained ventricular tachycardia, ventricular fibrillation and asystole. RESULTS: Of the total number of patients enrolled, records were complete for 2708; 2542 of these patients (93.9%) had an AMI outside of a hospital. These 2542 patients presented a median 81 (interquartile range 50 to 130) minutes after the onset of symptoms, and the median time to treatment in hospital was 85 (interquartile range 61 to 115) minutes. Whereas a greater proportion of Canadian patients than of patients enrolled in GUSTO-I in other countries reached hospital within 2 hours of symptom onset (71.5% v. 61.2%, p < 0.001), a greater proportion of Canadian patients experienced in-hospital treatment delays of more than 1 hour (75.3% v. 57.1%, p < 0.001). In an analysis of all 2708 patients with complete records, both the unadjusted and adjusted odds of nonfatal cardiac events for those treated 4 to 6 hours after symptom onset were significantly higher than for those treated within 2 hours (odds ratio 1.60, 95% confidence interval 1.09 to 2.37). CONCLUSION: After arrival at a hospital, Canadian patients enrolled in GUSTO-I received thrombolytic therapy more slowly than trial enrollees in other countries. Such delays are already known to decrease the rate of short-term survival after AMI. The findings further show that long time to treatment also increases the odds of nonfatal, serious cardiac events. Hospitals and physicians caring for patients with AMI should routinely assess whether and how they can improve door-to-needle times.
Related Articles
Primary Angioplasty for the Treatment of Acute ST-Segment Elevated Myocardial Infarction
Ontario Health Technology Assessment Series
Executive Summary
One of the longest running debates in cardiology is about the best reperfusion therapy for patients with evolving acute myocardial infarction (MI). Percutaneous transluminal coronary angioplasty (ANGIOPLASTY) is a surgical treatment to reopen a blocked coronary artery to restore blood flow. It is a type of percutaneous (through-the-skin) coronary intervention (PCI) also known as balloon angioplasty. When performed on patients with acute myocardial infarction, it is called primary angioplasty. Primary angioplasty is an alternative to thrombolysis, clot-dissolving drug therapy, for patients with acute MI associated with ST-segment elevation (STEMI), a change recorded with an electrocardiogram (ECG) during chest pain.
This review of the clinical benefits and policy implications of primary angioplasty was requested by the Ontario Health Technology Advisory Committee and prompted by the recent publication of a randomized controlled trial (RCT) in the New England Journal of Medicine (1) that compared referred primary angioplasty with on-site thrombolysis. The Medical Advisory Secretariat reviewed the literature comparing primary angioplasty with thrombolysis and other therapies (pre-hospital thrombolysis and facilitated angioplasty, the latter approach consisting of thrombolysis followed by primary angioplasty irrespective of response to thrombolysis) for acute STEMI.
There have been many RCTs and meta-analyses of these RCTs comparing primary angioplasty with thrombolysis and these were the subject of this analysis. Results showed a statistically significant reduction in mortality, reinfarction, and stroke for patients receiving primary angioplasty. Although the individual trials did not show significant improvements in mortality alone, they did show it for the outcomes of nonfatal reinfarction and stroke, and for an end point combining mortality, reinfarction, and stroke. However, researchers have raised concerns about these studies.
A main concern with the large RCTs is that they lack consistency in methods. Furthermore, there is some question as to their generalizability to practice in Ontario. Across the RCTs, there were differences in the type of thrombolytic drug, the use of stenting versus balloon-only angioplasty, and the use of the newer antiplatelet glycoprotein IIb/IIIa. The largest trial did not offer routine follow-up angioplasty for patients receiving thrombolysis, which is the practice in Ontario, and the meta-analysis included trials with streptokinase, an agent seldom used in hospitals in Ontario. Thus, the true magnitude of mortality benefit can only be surmised from head-to-head comparisons of current standard therapies for primary angioplasty and for thrombolysis.
By taking a more restrictive sample of the available studies, the Medical Advisory Secretariat conducted a review that was more consistent with patterns of practice in Ontario and selected trials that used accelerated alteplase as the thrombolytic agent.
Results from this meta-analysis suggest that the rates for primary angioplasty are significantly better for mortality, reinfarction, and stroke, in the short term (30 days), and for mortality, reinfarction, and the combined end point at 6 months. When primary angioplasty was compared with in-hospital thrombolysis, results showed a significant reduction in adverse event rates associated with primary angioplasty. However, 1 large RCT of pre-hospital thrombolysis (i.e., thrombolysis given by paramedics before arriving at the hospital) compared with primary angioplasty documented that pre-hospital thrombolysis is an equivalent intervention to primary thrombolysis in terms of survival. Furthermore, a meta-analysis of studies that compared pre-hospital thrombolysis with in-hospital thrombolysis showed a reduction in all hospital mortality rates in favour of pre-hospital thrombolysis, supporting the findings of the pre-hospital thrombolysis study. (2)
Clinical trials to date have reported that hospital stay is often reduced for patients who receive primary angioplasty compared with thrombolysis. Using a cost-analysis performed alongside the only study from Ontario, the Medical Advisory Secretariat concluded that there might be savings associated with primary angioplasty. These savings may partly offset the investment the provincial government would have to make to increase access to this technology. These savings should also be shown outside of a clinical trial protocol if the overall efficiencies of primary angioplasty are to be verified.
Based on this health technology policy analysis, the Medical Advisory Secretariat concludes that primary angioplasty has advantages with respect to mortality and combined end points compared with in-hospital thrombolysis (Level 1 evidence). However, pre-hospital thrombolysis improves survival compared with in-hospital thrombolysis (Level 1 evidence) and is equivalent to primary angioplasty (Level 1 evidence).
Results from the literature review raise concerns about the loss of therapeutic advantage due to treatment delays, time lapse from symptom onset to revascularization, time-of-day variations, the hospital volume of procedures, and the ability of hospitals to achieve in practice what RCTs have shown.
Furthermore, questions relevant to applying primary angioplasty widely, involve the diagnosis by paramedics, ambulance diversion protocols, paramedic training, and inter-hospital transfer protocols. These logistical considerations need to be addressed to realise the potential to improve patient outcomes. In its analysis, the Medical Advisory Secretariat concludes that it is unrealistic to reorganise the emergency medical services across Ontario to fully implement a primary angioplasty program.
Finally, it is important to evaluate the potential of this technology in the context of Ontario's health system. This includes urban and rural considerations, the ability to expand access to primary angioplasty and to minimize symptom-to-assessment time through a diverse strategy including public awareness. Therefore, a measured, evaluative approach to adopting this technology is warranted.
Furthermore, the alternative approach to pre-hospital or early thrombolysis, especially within 120 minutes from onset of symptoms, should be considered when developing the approach to improving outcomes for acute MI. This could include efforts to decrease the symptom-to-thrombolysis time through strategies such as a concerted public education program to expedite presentation to emergency rooms after onset of symptoms, a pre-hospital ECG and thrombolysis checklist in ambulances to reduce door-to-needle time on arrival at emergency rooms, and, especially in remote areas, access to pre-hospital thrombolysis.
The Medical Advisory Secretariat therefore recommends that this analysis of primary angioplasty be viewed in the overall context of all interventions for the management of acute MI and, in particular, of improving access to primary angioplasty and maximising the use of early thrombolysis.
Outcomes for patients with acute MI can be improved if efforts are made to optimise the interval from symptom onset to thrombolysis or angioplasty. This will require concerted efforts, including public awareness through education to reduce the symptom-to-emergency room time, and maximising efficiencies in door-to-intervention times for primary angioplasty and for early thrombolysis.
Primary angioplasty and early thrombolysis cannot be considered in isolation from one another. For example, patients who have persistent STEMI 90 minutes after receiving thrombolysis should be considered for angioplasty ("rescue angioplasty"). Furthermore, for patients with acute MI who are in cardiac shock, primary angioplasty is considered the preferred intervention. The concomitant use of primary angioplasty and thrombolysis ("facilitated angioplasty") is considered experimental and has no place in routine management of acute MI at this time. In remote parts of the province, consideration should be given to introducing pre-hospital thrombolysis as the preferred intervention through upgrading a select number of paramedics to advanced care status.
Related Articles
Nurse initiated thrombolysis in the accident and emergency department: safe, accurate, and faster than fast track
Heath, S
Bain, R
Andrews, A
Chida, S
Kitchen, S
Walters, M
Emergency Medicine Journal : EMJ
Objective: To reduce the time between arrival at hospital of a patient with acute myocardial infarction and administration of thrombolytic therapy (door to needle time) by the introduction of nurse initiated thrombolysis in the accident and emergency department.
Methods: Two acute chest pain nurse specialists (ACPNS) based in A&E for 62.5 hours of the week were responsible for initiating thrombolysis in the A&E department. The service reverts to a "fast track" system outside of these hours, with the on call medical team prescribing thrombolysis on the coronary care unit. Prospectively gathered data were analysed for a nine month period and a head to head comparison made between the mean and median door to needle times for both systems of thrombolysis delivery.
Results: Data from 91 patients were analysed; 43 (47%) were thrombolysed in A&E by the ACPNS and 48 (53%) were thrombolysed in the coronary care unit by the on call medical team. The ACPNS achieved a median door to needle time of 23 minutes (IQR=17 to 32) compared with 56 minutes (IQR=34 to 79.5) for the fast track. The proportion of patients thrombolysed in 30 minutes by the ACPNS and fast track system was 72% (31 of 43) and 21% (10 of 48) respectively (difference=51%, 95% confidence intervals 34% to 69%, p<0.05).
Conclusion: Diagnosis of acute myocardial infarction and administration of thrombolysis by experienced cardiology nurses in A&E is a safe and effective strategy for reducing door to needle times, even when compared with a conventional fast track system.
Related Articles
Impact of Delay in Door-to-Needle Time on Mortality in Patients with ST-Segment Elevation Myocardial Infarction
McNamara, Robert L.
Herrin, Jeph
Wang, Yongfei
Curtis, Jeptha P.
Bradley, Elizabeth H.
Magid, David J.
Rathore, Saif S.
Nallamothu, Brahmajee K.
Peterson, Eric D.
Blaney, Martha E.
Frederick, Paul
Krumholz, Harlan M.
The American journal of cardiology
Fibrinolytic therapy remains the most common reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI), particularly in smaller centers. Previous studies evaluated the relationship between time to treatment and outcomes when few patients were treated within 30 minutes of hospital arrival and many did not receive modern adjunctive medications. To quantify the impact of delay in door-to-needle time on mortality in a recent and representative cohort of STEMI patients, we analyzed a cohort of 62,470 STEMI patients treated with fibrinolytic therapy at 973 hospitals that participated in the National Registry of Myocardial Infarction from 1999–2002. We employed hierarchical models to evaluate the independent effect of door-to-needle time on in-hospital mortality. In-hospital mortality was lower with shorter door-to-needle times (2.9% for ≤30 minutes, 4.1% for 31–45 minutes, and 6.2% for >45 minutes; p< 0.001 for trend). Compared with those experiencing door-to-needle times ≤30 minutes, the adjusted odd ratios (OR) of dying were 1.17 (confidence interval (CI) 1.04–1.31) and 1.37 (CI 1.23–1.52; p for trend <0.001) for those patients with door-to-needle times of 31–45 minutes and >45 minutes, respectively. This relationship was particularly pronounced in those presenting within 1 hour of symptom onset to presentation time [OR: 1.25 (CI 1.01–1.54) and 1.54 (CI 1.27–1.87) respectively; p for trend <0.001]. In conclusion, timely administration of fibrinolytic therapy continues to significantly impact mortality in the modern era, particularly in patients presenting early after symptom onset.
myocardial infarction; mortality; reperfusion; fibrinolysis; thrombolysis
Related Articles
Fibrinolytic Therapy in CCU Instead of Emergency Ward: How It Affects Door to Needle Time?
Zeraati, Fatemeh
Homayounfar, Shahram
Esna-Ashari, Farzaneh
Khalili, Marzieh
International Journal of Preventive Medicine
The door-to-needle-time (DNT) is considered a standard time for scheduling thrombolysis for acute ST-segment elevation of myocardial infarction and this time can be reduced by minimizing the delay in starting thrombolytic treatment once the patient has reached to the hospital. This study was carried out on a sample of Iranian patients with acute myocardial infarction to determine the DNT in those after changing schedule of thrombolysis during 8 years from emergency to coronary care unit (CCU).
A descriptive cross-sectional study was carried out on all consecutive patients with a confirmed diagnosis of acute myocardial infarction admitted to the emergency ward of Ekbatan Hospital in Hamadan, Iran, within 2011 and had an indication of fibrinolytic therapy, which 47 patients were finally indicated to receive streptokinase in the part of CCU.
The mean time interval between arrival at the hospital and electrocardiogram (ECG) assessment was 6.30 min, taking ECG and patient's admission was 21.6 min and transferring the patient from admission to CCU ward was 31.9. The time between transferring the patients to CCU ward and fibrinolytic administration order and the time between its ordering and infusion was 31.2 min and 14.0 min respectively. In sum, the DNT was estimated 84.48 ± 53.00 min ranged 30-325 min that was significantly more than standard DNT (P <0.01). Furthermore, DNT mean in this study is significantly more than a study conducted 8 years ago in the same hospital (P <0.01).
The DNT is higher than the standard level and higher than the estimated level in the past. This shows that DNT was longer after transferring to CCU.
Door to needle time; fibrinolytic; myocardial infarction
Related Articles
The Golden Hour and Acute Brain Ischemia: Presenting Features and Lytic Therapy in Over 30,000 Patients Arriving Within 60 Minutes of Onset
Saver, Jeffrey L.
Smith, Eric E.
Fonarow, Gregg C.
Reeves, Mathew J.
Zhao, Xin
Olson, DaiWai M.
Schwamm, Lee H
Stroke; a journal of cerebral circulation
The benefit of intravenous thrombolytic therapy in acute brain ischemia is strongly time dependent.
The Get with the Guidelines-Stroke (GWTG-Stroke) database was analyzed to characterize ischemic stroke patients arriving to hospital Emergency Departments (EDs) within 60 minutes of last known well time from 4/1/2003-12/30/2007.
During the 4.75 year study period, among 253,148 ischemic stroke patients arriving directly by ambulance or private vehicle to 905 hospital EDs, 106,924 (42.2%) had documented exact last known well times. Onset to door time was ≤ 60 minutes in 30,220 (28.3%), 61-180 minutes in 33,858 (31.7%), and >180 minutes in 42,846 (40.1%). Features most strongly distinguishing ≤ 60, 61-180, and > 180 minutes arriving patients were: greater stroke severity (median NIHSS 8.0 vs 6.0 vs 4.0, p <.0001) and more frequent arrival by ambulance (79.0%. vs 72.2% vs 55.0%, p <.0001). Compared with 61-180 minute arrivers, golden hour patients received IV thrombolytic therapy more frequently (27.1% vs 12.9%, OR 2.51, 95% CI 2.41-2.61, p <.0001), but door to needle time (DTN) was longer (mean 90.6 vs 76.7 minutes, p <.0001). DTN ≤ 60 minutes was achieved in 18.3% of golden hour patients.
At GWTG-Stroke hospital EDs, more than one quarter of patients with documented onset time, and at least one eighth of all ischemic stroke patients, arrive within 1 hour of onset, where they receive thrombolytic therapy more frequently but more slowly than late arrivers. These findings support public health initiates to increase early presentation and shorten door to needle times in patients arriving within the "golden hour."
Related Articles
Improving door to needle times with nurse initiated thrombolysis
Wilmshurst, P
Purchase, A
Webb, C
Jowett, C
Quinn, T
OBJECTIVE—To evaluate the effect of nurse initiated thrombolysis on door to needle time (the interval between arriving at the hospital and starting thrombolytic treatment) in patients with acute myocardial infarction. DESIGN—Comparison of door to needle times before and after the employment of nurses trained and approved to initiate thrombolysis without prescription by a doctor but with a protocol for rapid triage of patients with chest pain. SETTING—A district general hospital. SUBJECTS—All patients admitted with suspected myocardial infarction between April 1995 and March 1999. MAIN OUTCOME MEASURES—Speed (door to needle time) and appropriateness of administration of thrombolytic drugs to patients with acute myocardial infarction who gave a characteristic history and had appropriate criteria on the admission ECG. RESULTS—During seven periods (each of four months) before the introduction of nurse initiated thrombolysis and a new chest pain triage protocol, the median door to needle time varied from 50-58 minutes. In four periods (each of 4-6 months) following the introduction of the changes, the median door to needle time was 25-30 minutes. The improvement was significant (p < 0.001). Nurses trained to initiate thrombolysis currently provide cover for 66% of the time. Median door to needle time for nurses was 15 minutes. Median door to needle time for junior doctors improved to 35 minutes. The median door to needle times when nurses initiated thrombolysis was significantly shorter than when doctors did so (p < 0.001). There have been no inappropriate management decisions by nurses approved to initiate thrombolysis. CONCLUSIONS—The use of nurse initiated thrombolysis has resulted in a clinically important reduction in the time taken for thrombolysis to be started in patients with acute myocardial infarction. Keywords: thrombolysis; acute myocardial infarction; door to needle time
Related Articles
Clinical Profile and Mortality of ST-Segment Elevation Myocardial Infarction Patients Receiving Thrombolytic Therapy in the Middle East
Panduranga, Prashanth
Al-Zakwani, Ibrahim
Sulaiman, Kadhim
Al-Habib, Khalid
Al Suwaidi, Jassim
Al-Motarreb, Ahmed
Alsheikh-Ali, Alawi
Al Saif, Shukri
Al Faleh, Hussam
Almahmeed, Wael
Asaad, Nidal
Amin, Haitham
Al-Lawati, Jawad
Hersi, Ahmad
Heart Views : The Official Journal of the Gulf Heart Association
Little is known about thrombolytic therapy patterns in patients with ST-elevation myocardial infarction (STEMI) in the Middle East. The objective of this study was to evaluate the clinical profile and mortality of STEMI patients who arrived in hospital within 12 hours from pain onset and received thrombolytic therapy.
Patients and Methods:
This was a prospective, multinational, multi-centre, observational survey of consecutive acute coronary syndrome patients admitted to 65 hospitals in six Middle Eastern countries during the period between October 2008 and June 2009, as part of Gulf RACE-II (Registry of Acute Coronary Events). Analyses were performed using univariate statistics.
Out of 2,465 STEMI patients, 66% (n = 1,586) were thrombolysed with namely: streptokinase (43%), reteplase (44%), tenecteplase (10%), and alteplase (3%). 22.7% received no reperfusion. Median age of the study cohort was 50 (45-59) years with majority being males (91%). The overall median symptom onset-to-presentation and door-to-needle times were 165 (95- 272) minutes and 38 (24-60) minutes, respectively. Generally, patients presenting with higher GRACE risk scores were treated with newer thrombolytic agents (reteplase and tenecteplase) (P < 0.001). The use of newer thrombolytic agents was associated with a significantly lower mortality at both 1-month (0.8% vs. 1.7% vs. 4.2%; P = 0.014) and 1-year (0% vs. 1.7% vs. 3.4%; P = 0.044) compared to streptokinase use.
Majority of STEMI patients from the Middle East were thrombolysed with streptokinase and reteplase in equal numbers. Nearly one-fifth of patients did not receive any reperfusion therapy. There was inappropriately long symptom-onset to hospital presentation as well as door-to-needle times. Use of newer thrombolytic agents in high risk patients was appropriate. Newer thrombolytic agents were associated with significantly lower mortality at 1-month and 1-year compared to the older agent, streptokinase.
Acute coronary syndrome; GRACE score; Middle East; mortality; reteplase; STEMI; streptokinase; tenecteplase; thrombolytic therapy
Related Articles
Thrombolysis in acute myocardial infarction: the safety and efficiency of treatment in the accident and emergency department.
Edhouse, J A
Sakr, M
Wardrope, J
Morris, F P
Journal of Accident & Emergency Medicine
OBJECTIVES: To assess the safety and efficiency with which the accident and emergency (A&E) department provides thrombolytic treatment for patients with acute myocardial infarction (AMI). METHODS: A prospective observational study based in a teaching hospital for one year. All patients who presented with the clinical and electrocardiographic indications for thrombolytic treatment were studied. Patients were grouped according to route of admission. After logarithmic transformation, the "door to needle times" of the groups were compared using a two tailed Student's t test. Arrhythmias and complications after thrombolytic treatment were noted. The appropriateness of the treatment was assessed retrospectively by review of the clinical records and electrocardiograms, judged against locally agreed eligibility criteria. RESULTS: Data from 153 patients were analysed; 138/153 (90%) patients were admitted via the A&E department. The shortest door to needle times were seen in those patients thrombolysed by A&E staff within the A&E department (mean 43.8 minutes). The transfer of A&E patients to the coronary care unit (CCU) was associated with a significant increase in the door to needle time (mean 58.8 minutes, p = 0.004). Only one malignant arrhythmia occurred during the administration of thrombolysis in the A&E department, and this was managed effectively. No arrhythmias occurred during transfer of thrombolysed patients to the CCU. In every case, the decision to administer thrombolysis was retrospectively judged to have been appropriate. CONCLUSIONS: The A&E department provides appropriate, safe, and timely thrombolytic treatment for patients with AMI. Transferring A&E patients to the CCU before thrombolysis is associated with an unnecessary treatment delay.
Related Articles
Retrospective observational case-control study comparing prehospital thrombolytic therapy for ST-elevation myocardial infarction with in-hospital thrombolytic therapy for patients from same area
Chittari, M
Ahmad, I
Chambers, B
Knight, F
Scriven, A
Pitcher, D
Emergency Medicine Journal : EMJ
Design: Retrospective observational case-control study comparing patients with suspected acute myocardial infarction (AMI) treated with thrombolytic therapy in the prehospital environment with patients treated in hospital.
Setting: Wyre Forest District and Worcestershire Royal Hospital, UK.
Participants: (A) All patients who received prehospital thrombolytic therapy for suspected AMI accompanied by electrocardiographic features considered diagnostic.
(B) Patients who received thrombolytic therapy after arrival at hospital for the same indication, matched with group A by age, gender and postcode.
Main outcome measures:
1. Call to needle time
2. Percentage of patients treated within one hour of calling for medical help
3. Appropriateness of thrombolytic therapy
4. Safety of thrombolytic therapy
Results: 1. The median call to needle time for patients treated before arriving in hospital (n = 27) was 40 minutes with an inter-quartile range 25–112 (mean 43 minutes). Patients from the same area who were treated in hospital (n = 27) had a median time of 106 minutes with an inter-quartile range 50–285 (mean 126 minutes). This represents a median time saved by prehospital treatment of 66 minutes.
2. 60 minutes after medical contact, 96 % of patients treated before arrival in hospital had received thrombolytic therapy; this compares with 4% of patients from similar areas treated in hospital.
3. Myocardial infarction was confirmed in 92% (25/27) of patients who received prehospital thrombolytic therapy and similarly 92% (25/27) of those given in-hospital thrombolytic therapy.
4. No major bleeding occurred in either group. Group A suffered fewer in-hospital deaths than group B (1 versus 4). Cardiogenic shock (3 patients) and ventricular arrhythmia (5 patients) were seen only in group B.
Conclusion: Paramedic-delivered thrombolytic therapy can be delivered appropriately, safely, and effectively. Time gains are substantial and can meet the national targets for early thrombolytic therapy in the majority of patients.
Related Articles
National Performance on Door-In to Door-Out Time Among Patients Transferred for Primary Percutaneous Coronary Intervention
Herrin, Jeph
Miller, Lauren E.
Turkmani, Dima F.
Nsa, Wato
Drye, Elizabeth E.
Bernheim, Susannah M.
Ling, Shari M.
Rapp, Michael T.
Han, Lein F.
Bratzler, Dale W.
Bradley, Elizabeth H.
Nallamothu, Brahmajee K.
Ting, Henry H.
Krumholz, Harlan M.
Archives of internal medicine
Delays in treatment time are commonplace for patients with ST-segment elevation acute myocardial infarction who must be transferred to another hospital for per-cutaneous coronary intervention. Experts have recommended that door-in to door-out (DIDO) time(ie, time from arrival at the first hospital to transfer from that hospital to the percutaneous coronary intervention hospital) should not exceed 30 minutes. We sought to describe national performance in DIDO time using a new measure developed by the Centers for Medicare & Medicaid Services.
We report national median DIDO time and examine associations with patient characteristics (age, sex, race, contraindication to fibrinolytic therapy, and arrival time) and hospital characteristics (number of beds, geographic region, location [rural or urban], and number of cases reported) using a mixed effects multivariable model.
Among 13 776 included patients from 1034 hospitals, only 1343 (9.7%) had a DIDO time within 30 minutes, and DIDO exceeded 90 minutes for 4267 patients (31.0%). Mean estimated times (95% CI) to transfer based on multivariable analysis were 8.9 (5.6-12.2) minutes longer for women, 9.1 (2.7-16.0) minutes longer for African Americans, 6.9 (1.6-11.9) minutes longer for patients with contraindication to fibrinolytic therapy, shorter for all age categories (except >75 years) relative to the category of 18 to 35 years, 15.3 (7.3-23.5) minutes longer for rural hospitals, and 14.4 (6.6-21.3) minutes longer for hospitals with 9 or fewer transfers vs 15 or more in 2009 (all P<.001).
Among patients presenting to emergency departments and requiring transfer to another facility for percutaneous coronary intervention, the DIDO time rarely met the recommended 30 minutes.
Related Articles
Thrombolysis after acute myocardial infarction: Are Canadian physicians up to the challenge?
Williams, W L
CMAJ: Canadian Medical Association Journal
Acute myocardial infarction (AMI) evolves as a time-dependent wave front of ischemia when the abrupt rupture of an unstable fatty plaque initiates coronary thrombosis. The prospect of salvaging potentially viable myocardial tissue has led to the development of reperfusion strategies using thrombolytic agents. The efficacy of thrombolytic therapy is determined in large measure by the speed with which it is initiated. It is therefore vital to minimize the "door-to-needle" time once a patient with AMI arrives at the emergency department. In this issue (see pages 497 to 505) Dr. Jafna L. Cox and associates report that Canadian centres participating in the GUSTO-I trial were significantly slower to initiate thrombolytic therapy than their US counterparts. In this editorial Cox and associates' report is reviewed against the background of similar trials, and strategies to minimize delays in the initiation of thrombolytic therapy are suggested.
Related Articles
Meeting National Service Framework goals for patients presenting with acute myocardial infarction
Gilby, E
Lloyd, G
Chan, L
Tosh, S
Brierley, S
Emergency Medicine Journal : EMJ
Background: The National Service Framework for coronary heart disease established clear standards for the management of patients with acute myocardial infarction in March 2000. This study evaluates an emergency department's thrombolysis performance in light of these standards.
Setting: Inner city teaching hospital emergency department.
Methods: The data were prospectively collected using a formal clinical pathway for all patients receiving thrombolysis in the emergency department between February 2000 and January 2001. Cases were reviewed at monthly multidisciplinary audit meetings. Regular feedback complemented routine teaching for both nursing and medical staff.
Results: 127 patients were thrombolysed, of whom 92 (72%) were immediately eligible. Some 77% of these had a door to needle time of less than 30 minutes and 38% less than 20 minutes. Twenty per cent of patients had a call to door time of less than 30 minutes. Some 84% of patients managed by the emergency department team had a door to needle time of less than 30 minutes compared with 53% of those patients seen by duty physicians.
Conclusions: The thrombolysis target set by the National Service Framework for April 2002 is achievable. The target set for April 2003 remains an ambitious goal. Overall call to needle times are undermined by call to door times. Emergency department teams may be more efficient than duty physicians in processing patients needing thrombolysis.
Related Articles
Symptom-to-door time in ST segment elevation myocardial infarction: Overemphasized or overlooked? Results from the AMI-McGill study
Afilalo, Jonathan
Piazza, Nicolo
Tremblay, Sonia
Soucy, Nathalie
Huynh, Thao
The Canadian Journal of Cardiology
Ischemic time is a major determinant of infarct size in ST segment elevation myocardial infarction (STEMI). Emphasis is placed on reducing the door-to-reperfusion therapy time component, whereas the symptom-to-door time is often overlooked.
To correlate the symptom-to-door time with left ventricular ejection fraction (LVEF) in patients with STEMI.
Acute Myocardial Infarction (AMI)-McGill was a cohort study of consecutive patients with STEMI who presented to three adult university hospitals. Multivariate linear regression was performed to correlate the symptom-to-door time with postinfarction LVEF adjusted for reperfusion method, prior myocardial infarction and components of the Thrombolysis In Myocardial Infarction (TIMI) risk score.
There were 188 patients, with a mean age of 66 years. On arrival to hospital, 23% of patients were in Killip class II to IV and 87% received reperfusion therapy (20% fibrinolytic therapy and 67% primary percutaneous coronary intervention). The median symptom-to-door time was 120 min (first quartile: 60 min, third quartile: 290 min) and the median door-to-reperfusion therapy time was 93 min (first quartile: 54 min, third quartile: 155 min). Three variables were independently correlated with LVEF in the study's regression model: symptom-to-door time (beta: –0.66, 95% CI –1.18 to –0.14; P=0.01), Killip class II to IV on arrival (beta: –6.43, 95% CI –11.87 to –0.99; P=0.02) and anterior territory of the infarction (beta: –5.86, 95% CI –10.55 to –1.18; P=0.02).
Symptom-to-door time was negatively correlated with postinfarction LVEF in patients with STEMI. Strategies to shorten this delay, such as educating high-risk patients about the symptoms of AMI, should be considered.
Angioplasty; Echocardiography; Fibrinolysis; Myocardial infarction; Thrombolysis
Related Articles
The effect of a charted history of depression on emergency department triage and outcomes in patients with acute myocardial infarction
Atzema, Clare L.
Schull, Michael J.
Tu, Jack V.
CMAJ : Canadian Medical Association Journal
Patients with acute myocardial infarction may have worse outcomes if they also have a history of depression. The early management of acute myocardial infarction is known to influence outcomes, and patients with a coexisting history of depression may be treated differently in the emergency department than those without one. Our goal was to determine whether having a charted history of depression was associated with a lower-priority emergency department triage score and worse performance on quality-of-care indices.
We conducted a retrospective population-based cohort analysis involving patients with acute myocardial infarction admitted to 96 acute care hospitals in the province of Ontario from April 2004 to March 2005. We calculated the adjusted odds of low-priority triage (Canadian Emergency Department Triage and Acuity Scale score of 3, 4 or 5) for patients with acute myocardial infarction who had a charted history of depression. We compared these odds with those for patients having a charted history of asthma or chronic obstructive pulmonary disease (COPD). Secondary outcome measures were the odds of meeting benchmark door-to-electrocardiogram, door-to-needle and door-to-balloon times.
Of 6784 patients with acute myocardial infarction, 680 (10.0%) had a past medical history of depression documented in their chart. Of these patients, 39.1% (95% confidence interval [CI] 35.3%–42.9%) were assigned a low-priority triage score, as compared with 32.7% (95% CI 31.5%–33.9%) of those without a charted history of depression. The adjusted odds of receiving a low-priority triage score with a charted history of depression were 1.26 (p = 0.01) versus 0.88 (p = 0.23) with asthma and 1.12 (p = 0.24) with COPD. For patients with a charted history of depression, the median door-to-electrocardiogram time was 20.0 minutes (v. 17.0 min for the rest of the cohort), median door-to-needle time was 53.0 (v. 37.0) minutes, and median door-to-balloon time was 251.0 (v. 110.0) minutes. The adjusted odds of missing the benchmark time with a charted history of depression were 1.39 (p < 0.001) for door-to-electrocardiogram time, 1.62 (p = 0.047) for door-to-needle time and 9.12 (p = 0.019) for door-to-balloon time.
Patients with acute myocardial infarction who had a charted history of depression were more likely to receive a low-priority emergency department triage score than those with other comorbidities and to have worse associated performance on quality indicators in acute myocardial infarction care.
Related Articles
Thrombolytic therapy for myocardial infarction facilitated by mobile coronary care.
Wilson, C.
O'Mullan, S.
Moore, M.
McCarthy, M.
The Ulster Medical Journal
BACKGROUND: The benefit of Thrombolytic Therapy (TT) for acute myocardial infarction is time sensitive. In Northern Ireland widespread availability of mobile coronary care units facilitates delivery of TT to heart attack victims. This region-wide prospective observational study assessed the efficacy of various methods of delivery of TT. METHODS: All 15 acute hospitals providing acute coronary care in Northern Ireland participated and data were collected prospectively over six months on all patients admitted with acute myocardial infarction or who received TT. The information was analysed regarding appropriateness of TT, methods and timeliness of delivery of TT and mortality rates. Performance was measured against National Service Framework standards. FINDINGS: Of 1638 patients with acute myocardial infarction 584 were considered eligible for TT and 494 (85 %) received it, in addition to 18 patients without infarction. Of the 512 thrombolysed patients 282 (55%) were treated in hospital coronary care units, 131 (26%) were treated pre-hospital, 97 (19%) in accident and emergency departments, and two in general medical wards. Overall median call-to-needle time was 87 (7-1110) mins and this was shortest for pre-hospital treatment when 55% of call-to-needle times were < or = 60 mins. For patients treated in hospital median door-to-needle time was 46 (0-1065) mins and this was shortest when TT was administered by accident and emergency staff, when 65% of door-to-needle times were < or = 30 mins. In patients with ST elevation myocardial infarction TT was associated with lower mortality, especially when administered pre-hospital. INTERPRETATION: NSF targets for TT are unlikely to be met in Northern Ireland without increasing pre-hospital delivery of TT and by improving collaboration between coronary care and accident and emergency staff with TT availability in accident and emergency departments.
Related Articles
Bangladeshi patients present with non-classic features of acute myocardial infarction and are treated less aggressively in east London, UK
Barakat, K
Wells, Z
Ramdhany, S
Mills, P G
Timmis, A D
Objective: To analyse differences in the presentation and management of Bangladeshi and white patients with Q wave acute myocardial infarction (AMI).
Design: Prospective observational study.
Setting: East London teaching hospital.
Participants: 263 white and 108 Bangladeshi patients admitted with Q wave AMI.
Main outcome measure: Character of presenting symptoms, their interpretation by the patient, and the provision of emergency treatment.
Results: There were no significant differences between Bangladeshi and white patients in the time from pain onset to hospital arrival (arrival time 64.5 (117.5) minutes v 63.0 (140.3) minutes, p = 0.63), but once in hospital it took almost twice as long for Bangladeshi as for white patients to receive thrombolysis (median (interquartile range) door to needle time 42.5 (78.0) minutes v 26.0 (47.7) minutes, p = 0.012). Bangladeshis were significantly less likely than whites to complain of central chest pain (odds ratio (OR) 0.11, 95% confidence interval (CI) 0.03 to 0.38; p = 0.0006) or to offer classic descriptions of the character of the pain (OR 0.25, 95% CI 0.09 to 0.74; p = 0.0118). These differences persisted after adjustment for age, sex, and risk factor profile differences including diabetes. Proportions of Bangladeshi and whites interpreting their symptoms as "heart attack" were similar (45.2% v 46.9%; p = 0.99).
Conclusions: Bangladeshi patients with AMI often present with atypical symptoms, which may lead to slower triage in the casualty department and delay in essential treatment. This needs recognition by emergency staff if mortality rates in this high risk group are to be reduced.
acute myocardial infarction; patient management; racial differences
Related Articles
The Outcomes of Emergency Pharmacist Participation During Acute Myocardial Infarction
Acquisto, Nicole M.
Hays, Daniel P.
Fairbanks, Rollin J. (Terry)
Shah, Manish N.
Delehanty, Joseph
Nobay, Flavia
Guido, Joseph
Haas, Curtis E.
The Journal of Emergency Medicine
Current guidelines recommend door-to-balloon times of 90 minutes or less for patients presenting to the emergency department (ED) with ST-segment elevation myocardial infarction (STEMI).
To determine if a clinical pharmacist for the ED (EPh) is associated with decreased door/diagnosis-to-cardiac catheterization laboratory (CCL) time and decreased door-to-balloon time.
A retrospective observational cohort study of ED patients with STEMI requiring urgent cardiac catheterization was conducted. Blinded data collection included timing of ED and CCL arrival, diagnostic ECG, and balloon angioplasty. For cases diagnosed after ED arrival, diagnosis time was substituted for door time. Diagnosis was the time ST-elevations were evident on serial ECG. EPh present and not present groups were compared. During the study period there were two emergency pharmacists and presence was determined by their scheduled time in the ED. Univariate and multivariate analyses was used to detect differences.
Multivariate analysis of 120 patients, controlled for CCL staff presence and arrival by pre-hospital services, determined EPh presence is associated with a mean 13.1 minute (95% CI, 6.5, 21.9) and 11.5 minute (95% CI, 3.9, 21.5) decrease in door/diagnosis-to-CCL and door-to-balloon times, respectively. Patients were more likely to achieve a door/diagnosis-to-CCL time ≤ 30 minutes (odds ratio 3.1, 95% CI, 1.3, 7.8) and ≤ 45 minutes (odds ratio 2.9, 95% CI, 1.0, 8.5) and a door-to-balloon time ≤ 90 minutes (odds ratio, 1.9, 95% CI, 0.7, 5.5) times more likely when the EPh was present.
EPh presence during STEMI presentation to the ED is independently associated with a decrease in door/diagnosis-to-CCL and door-to-balloon times.
pharmacist; acute myocardial infarction; ST-segment myocardial infarction; STEMI; door-to-balloon time
Related Articles
STOP STEMI©-A Novel Medical Application to Improve the Coordination of STEMI Care: A Brief Report On Door-to-Balloon Times After Initiating the Application
Dickson, Robert
Nedelcut, Adrian
Seupaul, Rawle
Hamzeh, Mohammed
Critical Pathways in Cardiology
The objective of our study was to evaluate the effect of the STOP STEMI© medical application on door-to-balloon (D2B) time in patients arriving to our emergency department with an acute ST Elevation Myocardial Infarction (STEMI). STOP STEMI© is a novel medical application developed by physicians to improve the coordination and communication tasks essential to rapid assessment and care of the patients suffering from a STEMI.
We conducted a retrospective before and after review of the Good Shepherd Health System STEMI quality assurance/improvement dashboard for a 10-month period between November, 2012 and September, 2013 (4 months before STOP STEMI© and 6 months after). Data was collected using a standard data collection form and entered on the dashboard by a STEMI coordinator blinded to study objectives. We calculated the average D2B times before and after initiation of STOP STEMI© along with the improvement in the benchmarks of D2B less than 90 min and D2B less than 60 minutes. A subgroup analysis of Center for Medicare and Medicaid services (CMS) reportable cases was conducted to evaluate these benchmarks in the subset of patients meeting the criteria for CMS reporting by our facility.
During the study period, we received 155 STEMI patients, average 0.5 patients per day. One hundred twelve of the patients underwent percutaneous coronary intervention (PCI), 37 preSTOP STEMI©, and 75 postSTOP STEMI©. Of the 112 PCI cases, 7 were excluded leaving 105 cases for analysis, 36 preapplication and 69 postapplication. We found a 22% reduction in the average door-to-balloon time after implementing the STOP STEMI© application (91–71 minutes) respectively, the average difference of 20 minutes P = 0.05 (95% CI, -1–40minutes). In the analysis of CMS reportable cases (n = 64 cases), we observed a decrease in the average D2B of 15 minutes (68–53 minutes), a 22% reduction P = 0.03 (95% CI 1–29min). In the CMS reportable cases, we saw an improvement in the D2B time less than 90 minutes from 78–95% and less than 60 minutes D2B improvement from 56–80%. We also observed an appropriate absolute reduction in PCI resource utilization by 11%.
In this cohort of patients, the utilization of STOP STEMI© decreased the average door-to-balloon times by 22% in the patients with acute STEMI arriving at our emergency department. This effect was maintained when looking at the subset of all STEMI cases reportable to CMS. We also observed modest improvements in meeting the less than 60-minute, less than 90-minute benchmarks, and improvements in the resource utilization.
STEMI; STOP STEMI©; percutaneous coronary intervention; door-to balloon-time
Related Articles
Does initiation of an ambulance pre‐alert call reduce the door to needle time in acute myocardial infarct?
Learmonth, S R
Ireland, A
Mckiernan, C J
Burton, P
Emergency Medicine Journal : EMJ
To assess the effect an ambulance pre‐alert call for patients with suspected acute myocardial infarction (AMI) would have on door to needle (DTN) times.
We carried out back to back audits of DTN times following the initiation of the pre‐alert calls.
All patients thrombolysed within the emergency department between July 2003 and April 2004 (inclusive).
Statistical analysis
Mean DTN times and time to ECG pre‐change and post‐change were compared using the Two sample t test. The Fisher's exact test was used to compare pre‐change and post‐change proportions of patients seen within guideline times.
In total, 73 patients were thrombolysed with 40 of these arriving by ambulance. Eighteen of these 40 were pre‐change and 22 were post‐change. Four patients were excluded. Fifty per cent of the pre‐change group had a DTN time of <30 minutes compared with 91% of the post‐change group (p = 0.005, Fisher's exact test). The phase one mean DTN time was found to be significantly greater than that for phase two (Two sample t test, p = 0.016; 95% CI 1.6 to 14.6).
There was a significant reduction in DTN times after the introduction of the pre‐alert call.
acute myocardial infarct; thrombolysis; MI; ambulance; pre‐alert; DTN
Related Articles
Recommendations for ensuring early thrombolytic therapy for acute myocardial infarction. The Heart and Stroke Foundation of Canada, the Canadian Cardiovascular Society and the Canadian Association of Emergency Physicians for the Emergency Cardiac Care Coalition.
CMAJ: Canadian Medical Association Journal
OBJECTIVE: To recommend practical steps to ensure early thrombolytic therapy and thereby reduce mortality and morbidity associated with acute myocardial infarction (AMI). OPTIONS: Various factors were considered that influence time to thrombolysis related to patients, independent practitioners and health care systems. OUTCOMES: Reduction in morbidity and mortality associated with AMI. EVIDENCE: Early initiation of thrombolytic therapy reduces morbidity and mortality associated with AMI. The ECC Coalition analysed the factors that might impede early implementation of thrombolytic therapy. VALUES: Published data were reviewed, and recommendations were based on consensus opinion of the Emergency Cardiac Care (ECC) Coalition. The ECC Coalition comprises 20 professional, nongovernment and government organizations and has a mandate to improve emergency cardiac care services through collaboration. BENEFITS, HARMS AND COSTS: Early thrombolytic therapy reduces morbidity and mortality associated with AMI. Implementation of the recommendations will result in reduced time to thrombolytic therapy, streamlining of current practices and enhanced cooperation among health care professionals to expedite care. Depending on existing practices, implementation may require protocol development, and public and professional education. Although costs are associated with educating the public and health care professionals, they are outweighed by the financial and social benefits of reduced morbidity and mortality. RECOMMENDATIONS: Early recognition of AMI symptoms by the public and health care professionals, early access to the emergency medical services system and early action by emergency care providers in administering thrombolytic therapy (within 30 minutes after the patient's arrival at the emergency department). VALIDATION: No similar consensus statements or practice guidelines for thrombolytic therapy in Canada are available for comparison.
Related Articles
A Review of Interventions and System Changes to Improve Time to Reperfusion for ST-Segment Elevation Myocardial Infarction
McDermott, Kelly A.
Helfrich, Christian D.
Sales, Anne E.
Rumsfeld, John S.
Ho, P. Michael
Fihn, Stephan D.
Journal of General Internal Medicine
Identify and describe interventions to reduce time to reperfusion for patients with ST-segment elevation myocardial infarction (STEMI).
Data Source
Key word searches of five research databases: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Web of Science, and Cochrane Clinical Trials Registry.
We included controlled and uncontrolled studies of interventions to reduce time to reperfusion. One researcher reviewed abstracts and 2 reviewed full text articles. Articles were subsequently abstracted into structured data tables, which included study design, setting, intervention, and outcome variables. We inductively developed intervention categories from the articles. A second researcher reviewed data abstraction for accuracy.
Measurements and Main Results
We identified 666 articles, 42 of which met inclusion criteria. We identified 11 intervention categories and classified them as either process specific (e.g., emergency department administration of thrombolytic therapy, activation of the catheterization laboratory by emergency department personnel) or system level (e.g., continuous quality improvement, critical pathways). A majority of studies (59%) were single-site pre/post design, and nearly half (47%) had sample sizes less than 100 patients. Thirty-two studies (76%) reported significantly lower door to reperfusion times associated with an intervention, 12 (29%) of which met or exceeded guideline recommended times. Relative decreases in times to reperfusion ranged from 15 to 82% for door to needle and 13–64% for door to balloon.
We identified an array of process and system-based quality improvement interventions associated with significant improvements in door to reperfusion time. However, weak study designs and inadequate information about implementation limit the usefulness of this literature.
Electronic supplementary materials
The online version of this article (doi:10.1007/s11606-008-0563-7) contains supplementary material, which is available to authorized users.
cardiac reperfusion; myocardial infarction; systematic review; quality improvement
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We welcome you to worship with us at
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The staff couldn't have been more helpful, the room was fine and beds very comfortable. WiFi was free and worked well in the rooms.
The location in Hivernage area is close to the Medina (10 minutes walk)
The restaurants were very expensive but the food good.
Eat out as there are dozens of restaurants to choose from within 2 miles, at much better prices.
Try to get breakfast included in the room charge as its pricey (£25) but a large range of buffet food.
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Fantasia Gives Critics The "Middle Finger" In New Rant
Just moments ago, we were discussing Fantasia's weird Instgram message about how gays can get married and people can smoke pot, but somehow she gets crucified.
The former American Idol singer later explained that all of that was taken out of context and she actually loves the gays.
And now comes her latest act of self martyrdom:
An Instagram rant in which she offers "middle finger up to those who seak [sic] to destroy me".
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She goes on to explain that her manager is gay and in fact her whole team is gay and all she meant was....
Well, read it. With spell check.
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Top Definition
Unreleased song by nirvana that is good and very sad, talks about how he felt a little before when he killed himself.
Pain.Pain.Pain. You Know Your Right.
by UrbanDude April 19, 2004
Trending Now
The best Nirvana song ever created, this is the last song that Kurt Cobain made and people say its his goodbye.
Thing have never been so swell I have never felt this well...
by George April 14, 2004