Backgrounds ST-elevation myocardial infarction （STEMI） guidelines recommend reperfusion by primary percutaneous coronary in- tervention （PCI） ≤ 90 min from time of first medical contact （FMC）. This strategy is ...Backgrounds ST-elevation myocardial infarction （STEMI） guidelines recommend reperfusion by primary percutaneous coronary in- tervention （PCI） ≤ 90 min from time of first medical contact （FMC）. This strategy is challenging in rural areas lacking a nearby PCI-capable hospital. Recommended reperfusion times can be achieved for STEMI patients presenting in rural areas without a nearby PCI-capable hospital by ground transportation to a central PCI-capable hospital by use of protocol-driven emergency medical service （EMS） STEMI field triage protocol. Methods Sixty STEMI patients directly transported by EMS from three rural counties （Nassau, Camden and Charlton Counties） within a 50-mile radius of University of Florida Health-Jacksonville （UFHJ） from 01/01/2009 to 12/31/2013 were identified from its PCI registry. The STEMI field triage protocol incorporated three elements： （1） a cooperative agreement between each of the rural emergency medical service （EMS） agency and UFHJ; （2） performance of a pre-hospital ECG to facilitate STEMI identification and laboratory activation; and （3） direct transfer by ground transportation to the UFHJ cardiac catheterization laboratory. FMC-to-device （FMC2D）, door-to-device （D2D）, and transit times, the day of week, time of day, and EMS shift times were recorded, and odds ratio （OR） of achieving FMC2D times was calculated. Results FMC2D times were shorter for in-state STEMIs （81 ± 17 vs. 87± 19 min）, but D2D times were similar （37 ± 18 vs. 39 ± 21 min）. FMC2D 〈 90 min were achieved in 82.7% in-state STEMIs compared to 52.2% for out-of-state STEMIs （OR = 4.4, 95% CI： 1.24-15.57; P = 0.018）. FMC2D times were homogenous after adjusting for weekday vs. weekend, EMS shift times. Nine patients did not meet FMC2D ≤ 90 min. Six were within 10 min of target; all patient achieved FMC2D 〈 120 min. Conclusions Guideline-compliant FMC2D ≤90 min is achievable for rural STEMI patients within a 50 mile radius of a PCI-capable hospital by use of protocol-driven EMS ground transportation. As all patients achieved a FMC2D time 〈 120 min, bypass of non-PCI capable hospitals may be reasonable in this situation.展开更多
Farmer-managed irrigation systems(FMIS) in the high altitude valleys of the Karakorum,Pakistan, continue to be managed effectively despite increased pressure on the social arrangements that sustain them. Colonial era ...Farmer-managed irrigation systems(FMIS) in the high altitude valleys of the Karakorum,Pakistan, continue to be managed effectively despite increased pressure on the social arrangements that sustain them. Colonial era records shows that over a century ago government agencies undertook irrigation support projects. In the past three decades,government agencies and the non-government agency Aga Khan Rural Support Programme(AKRSP), which channels foreign funds into the region, have actively engaged in the provision of irrigation support. This article seeks to explore whether such projects support or undermine farmer-managed irrigation systems and the complex institutional arrangements that underpin them. Field research using ethnographic and participatory methods was conducted in spring 2013 in the upper Shigar valley, Skardu district, GilgitBaltistan. The findings show that irrigation development is a political activity that involves village-based actors, religious leaders, local politicians,and government and non-government agencies.Government agencies operate in a largely top-down,engineering mode, their larger projects limited to villages suffering water scarcity. The local government provides small funds for renovation work of FMIS,though allocation of funds is highly politicized. Nongovernment agencies, for a variety of reasons including donor-funding cycles, apply a one-size-fitsall ‘participatory' model in an attempt to socially engineer rules and institutions. In communities divided by factionalism the use of such external models that stress formation of committees are unlikely to yield positive results, and could instead contribute to undermining the very systems they seek to support. This research argues that irrigation interventions should take care to build upon the rich and complex social arrangements that have sustained FMIS through the centuries.展开更多
文摘Backgrounds ST-elevation myocardial infarction （STEMI） guidelines recommend reperfusion by primary percutaneous coronary in- tervention （PCI） ≤ 90 min from time of first medical contact （FMC）. This strategy is challenging in rural areas lacking a nearby PCI-capable hospital. Recommended reperfusion times can be achieved for STEMI patients presenting in rural areas without a nearby PCI-capable hospital by ground transportation to a central PCI-capable hospital by use of protocol-driven emergency medical service （EMS） STEMI field triage protocol. Methods Sixty STEMI patients directly transported by EMS from three rural counties （Nassau, Camden and Charlton Counties） within a 50-mile radius of University of Florida Health-Jacksonville （UFHJ） from 01/01/2009 to 12/31/2013 were identified from its PCI registry. The STEMI field triage protocol incorporated three elements： （1） a cooperative agreement between each of the rural emergency medical service （EMS） agency and UFHJ; （2） performance of a pre-hospital ECG to facilitate STEMI identification and laboratory activation; and （3） direct transfer by ground transportation to the UFHJ cardiac catheterization laboratory. FMC-to-device （FMC2D）, door-to-device （D2D）, and transit times, the day of week, time of day, and EMS shift times were recorded, and odds ratio （OR） of achieving FMC2D times was calculated. Results FMC2D times were shorter for in-state STEMIs （81 ± 17 vs. 87± 19 min）, but D2D times were similar （37 ± 18 vs. 39 ± 21 min）. FMC2D 〈 90 min were achieved in 82.7% in-state STEMIs compared to 52.2% for out-of-state STEMIs （OR = 4.4, 95% CI： 1.24-15.57; P = 0.018）. FMC2D times were homogenous after adjusting for weekday vs. weekend, EMS shift times. Nine patients did not meet FMC2D ≤ 90 min. Six were within 10 min of target; all patient achieved FMC2D 〈 120 min. Conclusions Guideline-compliant FMC2D ≤90 min is achievable for rural STEMI patients within a 50 mile radius of a PCI-capable hospital by use of protocol-driven EMS ground transportation. As all patients achieved a FMC2D time 〈 120 min, bypass of non-PCI capable hospitals may be reasonable in this situation.
基金funded by the Federal Ministry of Education and Research (BMBF), Germany
文摘Farmer-managed irrigation systems(FMIS) in the high altitude valleys of the Karakorum,Pakistan, continue to be managed effectively despite increased pressure on the social arrangements that sustain them. Colonial era records shows that over a century ago government agencies undertook irrigation support projects. In the past three decades,government agencies and the non-government agency Aga Khan Rural Support Programme(AKRSP), which channels foreign funds into the region, have actively engaged in the provision of irrigation support. This article seeks to explore whether such projects support or undermine farmer-managed irrigation systems and the complex institutional arrangements that underpin them. Field research using ethnographic and participatory methods was conducted in spring 2013 in the upper Shigar valley, Skardu district, GilgitBaltistan. The findings show that irrigation development is a political activity that involves village-based actors, religious leaders, local politicians,and government and non-government agencies.Government agencies operate in a largely top-down,engineering mode, their larger projects limited to villages suffering water scarcity. The local government provides small funds for renovation work of FMIS,though allocation of funds is highly politicized. Nongovernment agencies, for a variety of reasons including donor-funding cycles, apply a one-size-fitsall ‘participatory' model in an attempt to socially engineer rules and institutions. In communities divided by factionalism the use of such external models that stress formation of committees are unlikely to yield positive results, and could instead contribute to undermining the very systems they seek to support. This research argues that irrigation interventions should take care to build upon the rich and complex social arrangements that have sustained FMIS through the centuries.
