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In 2005, an emergency coronary angiography was performed at the authors' clinic in 215 patients (148 men, 67 women) with troponin-positive acute coronary syndrome. In five of these patients (exclusively women, mean age [+/- SD] 61 +/- 12 years), tako-tsubo cardiomyopathy was identified. This represents a frequency of 2.3% (5/215 patients) of all investigated patients and of 7.5% (5/67 patients) within the group of women. In these patients, levocardiography revealed severe left ventricular dysfunction with apical wall motion abnormality known as \"apical ballooning\". At angiography, a significant coronary artery disease could be excluded. Chest pain was present in all patients, combined with ST segment elevation in one (20%) and T-wave inversion in four (80%). Elevated cardiac markers were found in all cases. All patients experienced psychologically stressful circumstances preceding the onset of symptoms. The patients all survived, showing normalized ejection fraction and rapid restoration of previous cardiovascular function within a mean (+/- SD) of 15 +/- 11 days. Tako-tsubo cardiomyopathy is a distinctive form of regional left ventricular dysfunction triggered by psychologically stressful events, which has a favorable clinical outcome. With a remarkable frequency of 7.5% especially in women, tako-tsubo cardiomyopathy should be included in the differential diagnosis of acute myocardial infarction.

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

Zusammenfassung Die schnelle Wiedereröffnung des verschlossenen Herzkranzgefäßes ist beim akuten ST-Hebungsinfarkt (STEMI) ein wesentlicher Faktor für die Prognose des Patienten. Der Wettlauf mit der Zeit bis zur Wiedereröffnung kann aber nur gewonnen werden, wenn eine hierauf eingerichtete Basisstruktur geschaffen wird, die durch ein systematisches Qualitätsmanagement (QM) in allen Details und im Zusammenspiel begleitet und kontinuierlich optimiert wird. Zur notwendigen Basisstruktur gehört die Einrichtung eines Herzinfarktnetzes, das in einer bestimmten Region die Möglichkeit zur rund um die Uhr verfügbaren Akut-Koronarintervention schafft und auch die Krankenhäuser involviert, die selbst kein Herzkatheterlabor vor Ort zur Verfügung haben. Ein weiterer wichtiger struktureller Schritt ist die Ausrüstung des Rettungsdiensts mit Zwölf-Kanal-EKG-Systemen, die die EKG-Daten mittels Telemetrie an das Interventionszentrum übermitteln können. Dadurch können auf der Basis einer raschen und sicheren Diagnose des STEMI im Interventionszentrum und der Rückmeldung an den Rettungsdienst zwei wesentliche Ziele realisiert werden, die zu erheblichen Zeitgewinnen führen: 1. das organisierte „Bypassing der Nichtinterventionsklinik“ und 2. das systematische „Bypassing der Notaufnahme“ der Interventionsklinik. Ein effizientes Instrument zur Verbesserung des komplexen Prozessablaufs und zur Verkürzung der Zeitintervalle ist die Etablierung eines standardisierten QM-Systems . Dies beinhaltet die formalisierte Datenerfassung und -analyse sowie die systematische Ergebnisrückkopplung an alle in der Frühphase des STEMI an der Behandlung der Patienten beteiligten Personen und Systeme innerhalb des Herzinfarktnetzes. Eine wichtige Voraussetzung für den positiven Effekt einer solchen Rückkopplung auf die Ergebnisqualität ist, dass die vor Ort erfassten Daten von allen Beteiligten als nachvollziehbar und valide angesehen werden können. Daher sollten die Datendokumentation und -analyse überprüfbar gemacht werden. Bewertende Vergleiche unterschiedlicher Krankenhäuser, Rettungsdienste und Regionen zeigen sich als ausgesprochen problematisch. Hier spielen lokale Besonderheiten und auch der Einschluss oder Ausschluss von STEMI-Patienten mit hohem Mortalitätsrisiko, die unbedingt einer raschen interventionellen Behandlung zugeführt werden sollten, sowie die Gefahr eines missbräuchlichen Einsatzes aus reinen Wettbewerbsgründen eine Rolle. Vergleiche von Behandlungszeiten und Sterblichkeiten sollten daher möglichst ausschließlich innerhalb eines festen Systems vor Ort in einem „Vorher-Nachher-Ansatz“ vorgenommen werden. Des Weiteren ist eine Risikoadjustierung der Patienten unter Verwendung von einheitlichen Risikoscores zu fordern. In diesem Sinne definiert sich Qualität als dokumentiertes Bemühen um ständige Ergebnisverbesserung. Von grundsätzlicher Bedeutung ist dabei das Selbstverständnis der behandelnden Ärzte, Kliniken und Rettungsdienste als Team. Die Umsetzung der aufgezeigten Strukturen und Maßnahmen ist flächendeckend zu fordern, und die dafür nötigen Maßnahmen und Ressourcen müssen von der Politik und der Gesellschaft mitgetragen werden. Ein solcher Ansatz wird aktuell im multizentrischen FITT-STEMI-Projekt („Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction“) verfolgt.

Coxiellosis is a zoonotic disease caused by the obligate intracellular bacterium Coxiella burnetii affecting the productive and reproductive capabilities of animals. This study was conducted to gain insight into the seroprevalence of coxiellosis in small ruminants in seven farms of the Punjab, Pakistan. Potential risk factors were assessed. In total, 1000 serum samples (500 from sheep and 500 from goats) and 163 ticks were collected from the ruminants. All these 163 ticks were merged into 55 pools (29 pools for ticks from sheep and 26 pools for ticks from goat). Serum samples were investigated using an indirect ELISA and PCR. Coxiella burnetii DNA was detected in 29 pooled seropositive samples and 11 pooled ticks by real-time qPCR. Serological analysis revealed a prevalence of 15.6% and 15.0% in sheep and goats, respectively. A significant association was found between seropositivity and different variables like district, lactational status, reproductive status, body condition and reproductive disorders. Univariate analysis showed that detection of C. burnetii DNA in tick pools was significantly associated with the presence of ticks on sheep and goats. However, a non-significant association was found for the prevalence of C. burnetii DNA in serum pools. Hence, C. burnetii infection is prevalent in small ruminants and ticks maintained at livestock farms in Punjab, Pakistan.

Bovine anaplasmosis is a tick-borne disease with zoonotic potential, caused by the obligate intracellular bacterium Anaplasma marginale. The disease is distributed worldwide in tropical and subtropical regions. The economic losses from anaplasmosis in animals is of significant importance because it causes severe morbidity and mortality in cattle. Recovered animals may become persistent carriers. Epidemiological information on the actual status of bovine anaplasmosis in Egypt is scarce. Thus, this study aimed to determine anti-Anaplasma antibody and DNA in serum samples using ELISA and PCR, respectively. In total, 758 bovine sera were collected from cattle farms located in 24 Egyptian governorates in 2015 to 2016. Sera were analyzed with the commercially available ‘Anaplasma antibody competitive ELISA v2’ kit and ‘AmpliTest Anaplasma/Ehrlichia spp. real time TaqMan TM PCR. Anaplasma spp. antibodies were detected in 140 (18.5%) (CI: 15.8–21.4%) of the investigated sera by ELISA, and Anaplasma/Ehrlichia-DNA was detected in 40 (5.3%) (CI: 3.8–7.1%) of the positive sera by real time PCR. Co-detection of both Anaplasma spp. and Coxiella burnetii-specific antibodies was proven in 30 (4%) of the investigated sera. The results of this work confirm the significant prevalence of bovine anaplasmosis in Egypt. Raising awareness in decision makers of the public health, veterinarians and animal owners is required to reduce the spread of infection.