Understanding Why Patients Delay Seeking Care for Acute Coronary Syndromes

Number of comorbidities and the risk of delay in seeking treatment for coronary heart disease: a longitudinal study in Bogor City, Indonesia

BACKGROUND

The aim of this study was to investigate the relationship between the number of patient comorbidities and the delays in seeking treatment for coronary heart disease (CHD).

METHODS

This longitudinal study utilized secondary data from the Non-Communicable Disease Risk Factor (NCDRF) cohort study conducted in Bogor City. Individuals who participated in the NCDRF cohort study and were diagnosed with CHD within the 6-year study period met the inclusion criteria. Respondents who were not continuously monitored up to the 6th year were excluded. The final sample included data from respondents with CHD who participated in the NCDRF cohort study and were monitored for the full 6-year duration. The final logistic regression analysis was conducted on data collected from 812 participants.

RESULTS

Among the participants with CHD, 702 out of 812 exhibited a delay in seeking treatment. The risk of a delay in seeking treatment was significantly higher among individuals without comorbidities, with an odds ratio (OR) of 3.5 (95% confidence interval [CI], 1.735-7.036; p<0.001). Among those with a single comorbidity, the risk of delay in seeking treatment was still notable (OR, 2.6; 95% CI, 1.259-5.418; p=0.010) when compared to those with 2 or more comorbidities. These odds were adjusted for age, sex, education level, and health insurance status.

CONCLUSION

The proportion of patients with CHD who delayed seeking treatment was high, particularly among individuals with no comorbidities. Low levels of comorbidity also appeared to correlate with a greater tendency to delay in seeking treatment.

Women Acute Myocardial Infarction-Identifying and Understanding the Gender Gap (WAMy-GAP): A Study Protocol

Barriers to accessing care and misinterpretations of ischemic heart disease symptoms due to lack of awareness contribute to women's delay in seeking care. Women may delay seeking treatment for up to 3 h or even up to 5 days. They often perceive themselves to be at low risk of cardiovascular disease (CVD) and prioritize family responsibilities or household chores. The causes of this delay are multifactorial and influence the decision-making process, particularly in the pre-hospital phase. The objective of this study protocol is to evaluate prodromal symptoms and identify risk behaviors in women with acute myocardial infarction (AMI). This is a protocol for a multicenter study that will be conducted using the mixed-method methodology using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS) to evaluate symptoms and semi-structured interviews to investigate behaviors. This study protocol is intended to fill an important knowledge gap on premonitory and acute symptoms of AMI in women in Italy, as well as to understand the causes and mechanisms underlying delays in accessing healthcare services during an acute event such as AMI. The investigation of this issue will facilitate the removal of gender-related inequalities in the diagnosis and treatment of acute myocardial infarction while also fostering dialogue on the barriers to behavior change.

Attachment styles and healthcare utilization: exploring the role of the patient-doctor relationship

BACKGROUND

With the purpose of improving healthcare, past research has examined the link between healthcare utilization and attachment. It is suggested that an individual's attachment style influences both the quality of their patient-physician relationship and healthcare utilization patterns. Nevertheless, most studies concentrate on the individual aspect, overlooking the dyadic dimension; specifically, the investigation of how insecure attachment relates to health behavior within patient-physician relationships. This gap leaves the role of the patient-doctor relationship in this process unclear. Therefore, to elucidate this complex interplay, we hypothesized that the correlation between attachment and healthcare utilization is mediated by the quality of the patient-physician-relationship.

METHOD

Participant selection was based on electoral districts, a random-route procedure, and the Kish selection grid. The participants were visited by a trained interviewer who collected psychometric and sociodemographic information. Participants answered the Experiences in Close Relationships-Revised questionnaire (ECR-RD8) and the Patient-Doctor Relationship Questionnaire (PDRQ-9). Additionally, participants were asked about their healthcare utilization. The final sample consisted of N = 2.275 participants.

RESULTS

In average the participants reported consulting their primary health care practitioner M(SD) = 4.44 (4.76) times in the past 12 months. Generally, the participants rated the quality of the relationship with their primary health care practitioner close to "totally appropriate" (M = 4.12 ± .69). The degree of insecure attachment manifested towards the lower extremity of the scale. The total effect of the mediation analyses was significant. Regardless, the indirect effect indicated a trend result with minimal effect sizes.

CONCLUSION

The findings of the current study bridged the gap between attachment styles and healthcare utilization. Nonetheless, our results suggested insufficient support for the mediating role of the primary care physician in the relationship between attachment style and healthcare utilization. Considering the characteristics of the sample, this outcome may not apply in a clinical context. However, further research is needed to shed light in the revealed trends and indicate implications.

Ampliando o método clínico centrado na pessoa

Introdução: A Teoria do Apego pode ser útil para complementar o Método Clínico Centrado na Pessoa, sobretudo em seu quarto componente, “Fortalecendo a relação médico-paciente”. Objetivo: Realizar revisão integrativa de pesquisas que associem a Teoria do Apego à relação médico-paciente e extrair sua aplicabilidade no dia a dia do médico de família e comunidade. Métodos: Revisão integrativa nas bases de dados United States National Library of Medicine (PubMed) e Scientific Electronic Library Online (SciELO) utilizando os termos “relação médico-paciente” e “teoria do apego”. Resultados: Identificamos 184 artigos na PubMed e um na SciELO em fevereiro de 2021, que foram reduzidos a 11 artigos. Estes tinham como cenário oncologia/cuidados paliativos ou atenção primária em geral e consideravam as vulnerabilidades de cada contexto e como elas podem ativar o sistema de apego. Percebe-se o impacto dos princípios da Teoria do Apego em diversos aspectos da relação médico-paciente e até em desfechos clínicos. Correlacionar os estilos de apego com os modelos de relação médico-paciente de Emanuel e Emanuel (1992) ajuda-nos a entender que modelo é melhor para cada estilo. Pessoas com apego “seguro” beneficiam-se de relações deliberativas; aquelas com apego “ansioso-preocupado” precisam que o médico seja mais ativo para compensar sua baixa confiança em si, como no modelo paternalista; no apego “desprendido”, o paciente necessita sentir-se independente, e o modelo informativo contribui para fortalecer a relação; e quem apresenta apego “ansioso-assustado” tende a trazer sentimentos negativos ao médico, sendo necessário compreender isso e reafirmar o elo apesar de atitudes contraproducentes por parte da pessoa, e o modelo interpretativo traz uma forma de lidar com a situação. Conclusão: A Teoria do Apego tem potencial de responder a muitas angústias que assolam a prática diária do médico de família e comunidade e que o Método Clínico Centrado na Pessoa não consegue resolver sozinho. Pode-se dizer que a Teoria do Apego complementa o Método, fornecendo ferramentas para continuar conduzindo-o em seus quatro componentes.

Inequities in ambulance allocation associated with transfer delay and mortality in acute coronary syndrome patients: evidence from 89 emergency medical stations in China

BACKGROUND

Allocation of healthcare resources has a great influence on treatment and outcome of patients. This study aimed to access the inequality of ambulance allocation across regions, and estimate the associations between ambulance density and pre-hospital transfer time and mortality of acute coronary syndromes (ACS) patients.

METHODS

This cross-sectional study was based on an integrated database of electronic medical system for 3588 ACS patients from 31 hospitals, ambulance information of 89 emergency medical stations, and public geographical information of 8 districts in Shenzhen, China. The primary outcomes were the associations between ambulance allocation and transfer delay and in-hospital mortality of ACS patients. The Theil index and Gini coefficient were used to assess the fairness and inequality degree of ambulance allocation. Logistic regression was used to model the associations.

RESULTS

There was a significant inequality in ambulance allocation in Shenzhen (Theil index: 0.59), and the inequality of inter-districts (Theil index: 0.38) was greater than that of intra-districts (Theil index: 0.21). The gap degree of transfer delay, ambulance allocation, and mortality across districts resulted in a Gini coefficient of 0.35, 0.53, 0.65, respectively. Ambulance density was negatively associated with pre-hospital transfer time (OR = 0.79, 95%CI: 0.64,0.97, P = 0.026), with in-hospital mortality (OR = 0.31, 95%CI:0.14,0.70, P = 0.005). The ORs of Theil index in transfer time and in-hospital mortality were 1.09 (95%CI:1.01,1.10, P < 0.001) and 1.80 (95%CI:1.15,3.15, P = 0.009), respectively.

CONCLUSIONS

Regional inequities existed in ambulance allocation and has a significant impact on pre-hospital transfer delay and in-hospital mortality of ACS patients. It was suggested to increase the ambulance accessibility and conduct health education for public.

Job Burnout Is Associated With Prehospital Decision Delay: An Internet-Based Survey in China

Background

Prehospital delay is associated with non-modifiable factors such as age, residential region, and disease severity. However, the impact of psychosocial factors especially for job burnout on prehospital decision delay is still little understood.

Method

This internet-based survey was conducted between 14 February 2021 and 5 March 2021 in China through the Wechat platform and web page. Self-designed questionnaires about the expected and actual length of prehospital decision time and the Chinese version of Maslach Burnout Inventory-General Survey, Type D Personality Scale-14, and Social Support Rating Scale were applied. A total of 1,039 general participants with a history of perceptible but tolerable body discomfort were included.

Results

The top six reasons for prehospital decision delay were: (1) endure until self-healing (50.7%), (2) too busy to ask for leave (40.3%), (3) process for seeing a doctor too complicated (35.8%), (4) too tired after work (26.2%), (5) worry about the expenditure (16.6%), and (6) fear of being identified as with serious problem (14.5%). The univariate analyses revealed that older age (p = 0.001), type D personality (p = 0.025), job burnout (p = 0.055), and worrying about expenditure (p = 0.004) were associated with prolonged prehospital decision time, while engaged in medical-related job (p = 0.028) and with more social support (p = 0.066) would shorten the delay. The multivariate analysis using logistic regression model with forward selecting method showed that age [per 10 years, odds ratio (OR) 1.19 (1.09–1.31), p < 0.001], job burnout [per 10 points in Maslach Burnout Inventory-General Survey (MBI-GS), OR 1.17 (1.04–1.31), p = 0.007], and worrying about expenditure [OR 1.75 (1.25–2.47), p = 0.001] were the three determinants for prehospital decision delay (>7 days). Mediating effects were analyzed by using bias-corrected percentile bootstrap methods (N = 10,000). Social support was found partially mediated the relationship between the determinants and prehospital decision time. The partial mediating effect of social support accounted for 24.0% of the total effect for job burnout and 11.6% for worrying about expenditure.

Conclusion

Psychosocial factors have a non-negligible impact on prehospital decision delay. The crucial part of prehospital decision delay may be the lack of motivation inside. Job burnout and lack of social support, as two commonly seen features in the modern world, should be given enough consideration in disease prevention and treatment.

From Suspicion to Recognition-Being a Bystander to a Relative Affected by Acute Coronary Syndrome

Within cardiac research, an overwhelming number of studies have explored factors related to pre-hospital delay. However, there is a knowledge gap in studies that explore the bystander's experiences or significance when an individual is affected by acute coronary syndrome (ACS). We conducted an interview study with 17 individuals affected by ACS and the bystander(s) involved and performed a qualitative thematic analysis. In the pre-hospital phase, the bystander moved from suspicion of illness to recognition of illness while trying to convince the individual affected by ACS (p-ACS) to respond to bodily sensations. This led to conflicts and dilemmas which affected the bystander both before and after the p-ACS was hospitalized. Bystanders may influence pre-hospital delay in both positive and negative direction depending on their own knowledge, convictions, and the nature of their interaction with the p-ACSs. The bystander's influence during the pre-hospital delay is more extensive than previously recognized.

The relationship between attachment, treatment compliance and treatment outcomes in patients with obstructive sleep apnea

OBJECTIVE

Obstructive sleep apnea (OSA) is a common condition with numerous health and psychological consequences. While treatment with Continuous Positive Airway Pressure (CPAP) is highly effective, it seems to be impacted by interpersonal aspects of the patient. The current study explores the role of two major interpersonal descriptors (attachment and relationship satisfaction) on treatment initiation and compliance with CPAP. The benefit of CPAP treatment on sleep measures and psychological functioning is also examined.

METHODS

Participants in stable relationships, diagnosed with OSA following an inpatient polysomnography test (N = 83), were recruited. Participants were appraised on their decision to initiate treatment and completed interpersonal measures (couples' satisfaction, attachment dimensions) as well as sleep measures and mental health measures. Participants were invited to repeat the measures after 3 months (N = 31 agreed). Associations between interpersonal measures and CPAP initiation and compliance as well as the impact of CPAP on sleep and all psychological measures was assessed.

RESULTS

Individuals with high attachment anxiety pursued OSA treatment based on a mutual decision with the partner, while individuals with lower attachment anxiety made the decision themselves. Couples' satisfaction was positively associated with CPAP compliance over 3 months. CPAP compliance significantly improved sleep measures, mood and anxiety symptoms.

CONCLUSION

The study brings evidence for a positive role of interpersonal factors in the initiation and compliance with OSA treatment as well as longitudinal benefits on sleep, mood and anxiety levels. The results can inform clinical approaches meant to increase treatment engagement and adherence in OSA patients through psychoeducation.

Symptoms awareness, emergency medical service utilization and hospital transfer delay in myocardial infarction

BACKGROUND

The length of time between symptom onset and reperfusion therapy in patients with ST-segment elevation acute myocardial infarction (STEMI) is a key determinant of mortality. Information on this delay is scarce, particularly for developing countries. The objective of the study is to prospectively evaluate the individual components of reperfusion time (RT) in patients with STEMI treated at a University Hospital in 2012.

METHODS

Medical records were reviewed to determine RT, its main (patient delay time [PDT] and system delay time [SDT]) and secondary components and hospital access variables. Cognitive responses were evaluated using a semi-structured questionnaire.

RESULTS

A total of 50 patients with a mean age of 59 years (SD = 10.5) were included, 64% of whom were male. The median RT was 430 min, with an interquartile range of 315-750 min. Regarding the composition of RT in the sample, PDT corresponded to 18.9% and SDT to 81.1%. Emergency medical services were used in 23.5% of cases. Patients treated in intermediate care units showed a significant increase in SDT (p = 0.008). Regarding cognitive variables, PDT was approximately 40 min longer among those who answered "I didn't think it was serious" (p = 0.024).

CONCLUSIONS

In a Brazilian tertiary public hospital, RT was higher than that recommended by international guidelines, mainly because of long SDT, which was negatively affected by time spent in intermediate care units. Emergency Medical Services underutilization was noted. A patient's low perception of severity increased PDT.

Delays in Seeking Health Care: Comparison of Veterans and the General Population

OBJECTIVES

Recent reports of delays in receiving care among U.S. Veterans have received national attention. Such delays may have an effect on veterans' propensity to seek healthcare as well, which could be detrimental to their health. There exists no evidence at the national level of the magnitude of perceived care delay in the Veterans Affairs (VA) system and how it compares to populations with other types of insurance coverage in the U.S.

STUDY DESIGN AND METHODS

This cross-sectional study analyzed a recent nationally representative survey database (n = 10,907). Descriptive and multivariate regression analyses were performed to determine how care delay for veterans compares with the general population.

RESULTS

We found that 17.2% of Americans delayed seeking needed healthcare in 2010-2011, but the figure was 29% for veterans. Also, there was a significant association of care delay with VA health care coverage after adjusting for other personal factors and region of the country.

CONCLUSIONS

Study results suggest a possible link between VA access problems and veterans' behavior in seeking needed healthcare, which may be creating disparities in the effectiveness of care for this vulnerable and deserving population. Our study provides evidence of self-reported care delay among veterans. More studies are necessary to further understand factors in relation to delaying seeking care among veterans.

Health Care Engagement Among LGBT Older Adults: The Role of Depression Diagnosis and Symptomatology

PURPOSE OF THE STUDY

Optimal engagement in health care plays a critical role in the success of disease prevention and treatment, particularly for older adults who are often in greater need of health care services. However, to date, there is still limited knowledge about the relationship between depression and health care engagement among lesbian, gay, bisexual, and transgender (LGBT) older adults.

DESIGN AND METHODS

This study utilized data from Aging with Pride: National Health, Aging, Sexuality/Gender Study, from the 2014 survey with 2,450 LGBT adults 50 years old and older. Multiple-variable regression was utilized to evaluate relationships between three indicators of health care engagement and four depression groups after controlling for background characteristics and discrimination in health care. Health care engagement indicators were "not using preventive care," "not seeking care when needed," and "difficulty in adhering to treatments." Depression groups were defined by depression diagnosis and symptomatology, including Diagnosed-Symptomatic group (Diag-Sympt), Diagnosed-Nonsymptomatic group (Diag-NoSympt), Nondiagnosed-Symptomatic group (NoDiag-Sympt), and Nondiagnosed-Nonsymptomatic group (NoDiag-NoSympt).

RESULTS

Depression groups displayed different patterns and levels of health care engagement. The Diag-Sympt group displayed the highest "difficulty in adhering to treatments." Diag-NoSympt group displayed the lowest "not using preventive care." The NoDiag-Sympt group reported the highest "not using preventive care" and "not seeking care when needed." The NoDiag-NoSympt group had the lowest "not seeking care when needed" and "difficulty in adhering to treatments."

IMPLICATIONS

Depression diagnosis and symptomatology are jointly associated with health care engagement among LGBT older adults. Interventions aiming to promote health care engagement among this population should simultaneously consider both depression diagnosis and symptomatology.

Usage of ambulance transport and influencing factors in acute coronary syndrome: a cross-sectional study at a tertiary centre in China

OBJECTIVES

The aim of this study was to explore the choice of transportation mode to hospital in patients with acute coronary syndrome (ACS) and to determine the factors influencing the use of ambulance.

DESIGN, SETTING AND PARTICIPANTS

This cross-sectional study was conducted in a tertiary and teaching hospital in China. The study was carried out between 24 August 2015 and 24 July 2016. A total of 828 patients with ACS presented at the emergency department (ED) were included. The study population was dichotomised according to their primary mode of transport (ambulance or self-transport) to hospital. Social demographics, cardiovascular history, risk factors, prehospital medications, clinical characteristics and symptom characteristics were collected. Multivariable logistic regression was used to examine the factors associated with ambulance use.

RESULTS

We found that only 179 (21.6%) patients with ACS chose taking ambulance to hospital. Factors associated with ambulance use were single (OR 1.66, 95% CI 1.07 to 2.57), taking Suxiaojiuxin pills (OR 1.91, 1.31 to 2.80) or nitrates (OR 2.91, 1.70 to 4.99) before going to hospital, diagnosed as ST-elevation myocardial infarction (STEMI) (OR 2.43, 1.45 to 4.05), with persistent symptoms (OR 1.95, 1.33 to 2.86) and symptoms accompanied with vomiting (OR 2.35, 1.19 to 4.62). The patients who had symptoms precipitated or aggravated by exercise (OR 0.37, 0.14 to 0.98) tended to choose self-transport.

CONCLUSION

The usage of ambulance in patients with ACS presenting to the ED was low in China. Factors like single, taking Suxiaojiuxin pills or nitrates before going to hospital, diagnosed as STEMI, accompanied with vomiting and persistent symptoms were independently associated with ambulance use. Future education programmes should focus on these factors and increase people's knowledge on ACS and the benefits of ambulance use.

Is denial a maladaptive coping mechanism which prolongs pre-hospital delay in patients with ST-segment elevation myocardial infarction?

OBJECTIVE

During an acute myocardial infarction, patients often use denial as a coping mechanism which may provide positive mood regulating effects but may also prolong prehospital delay time (PHD). However, empirical evidences are still sparse.

METHODS

This cross-sectional study included 533 ST-elevated myocardial infarction (STEMI) patients from the Munich Examination of Delay in Patients Experiencing Acute Myocardial Infarction (MEDEA) study. Data on sociodemographic, clinical and psycho-behavioral characteristics were collected at bedside. The outcome was assessed using the Cardiac Denial of Impact Scale (CDIS) with the median split as cutoff point. A total of 206 (41.8%) STEMI patients were thus classified as deniers.

RESULTS

Deniers were less likely to suffer from major depression (p=0.04), anxiety (p=0.01) and suboptimal well-being (p=0.01) compared to non-deniers during the last six months prior to STEMI. During STEMI, they were less likely to perceive severe pain strength (p=0.04) and racing heart (p=0.02). Male deniers were also less likely to perceive shortness of breath (p=0.03) and vomiting (p=0.01). Denial was not associated with overall delay time. However, in the time window of 3 to 24h, denial accounted for roughly 40min extra delay (356 vs. 316.5min p=0.02 n=196).

CONCLUSIONS

Denial not only contributes to less suffering from acute heart related symptoms and negative affectivity but also leads to a clinically significant delay in the prevalent group.

Ischemic-reperfusion of unilateral external iliac artery in rat: A new model for vasculitic femoral neuropathy

Clinically, ischemic environment during gynecological surgery at lithotomy position is most common causative factor for the development of vasculitic femoral neuropathy (VFN). The present study was designed to induce the clinically relevant rat model of VFN by ischemic-reperfusion (I/R) injury of unilateral external iliac artery (uEIA). The VFN was induced by 3, 4 and 5h occlusion of uEIA followed by reperfusion. The I/R of uEIA induced VFN was evaluated by (i) behavioral parameters i.e., hind limb temperature; weight bearing capacity; (ii) kinematic analysis i.e., paw posture, splay angle, static sciatic index (SSI), and ankle-angle tests; (iii) evaluation of pain perception i.e., plantar and pin prick; (iv) serum biochemical estimation i.e., nitrate, lipid peroxidation, TNF-α and calcium level; (v) evaluation of motor and sensory nerve conduction velocity; and (vi) measurement of nerve fiber density. The 4 and 5h occlusion of uEIA has produced the potential changes in behavioral, functional, electrophysiological, biochemical and histopathological assessment. The 5h occlusion of uEIA has shown to produce the mortality. Whereas, 3h occlusion does not produce the significant changes in the development of VFN. The 4h ischemic occlusion of uEIA has shown potential rat model of VFN due to its close mimicking capacity of VFN in human. Therefore, it can be useful to explore the newer anti-neuralgic medicine and with their pharmacodynamic action in the field of various neurovascular disorders.

Symptom Representation and Treatment-Seeking Prior to Diagnosis of Atrial Fibrillation

Early treatment-seeking for symptoms of atrial fibrillation (AF) is critical to avert AF-related stroke and heart failure, but early treatment is hindered if symptoms are not accurately interpreted. The purpose of this research was to describe symptom representation and treatment-seeking responses prior to diagnosis of AF. For this descriptive study, 150 participants were surveyed to describe the type and temporality of symptoms, perceptions regarding the cause, seriousness, controllability of symptoms, and responses to symptoms prior to diagnosis. Participants' mean age was 66.5 years, and 51% were female. Participants perceived symptoms as having nondisease-based causes, as not very serious, and as amenable to self-management. The majority took a wait and see response with 69% waiting more than 1 week after symptom onset to seek treatment. Lack of recognition of the seriousness of symptoms of AF and delayed treatment put patients at risk of poorer outcomes.

I like it when my partner holds my hand: development of the Responses and Attitudes to Support during Pain questionnaire (RASP)

Social support can have beneficial effects on psychological and physiological well-being. During acute bodily pain, however, the effects of social support on pain are mixed. This variability may be due to the multifaceted nature of both pain and social support, as well as individual differences. In this paper, we present the development, psychometric assessment, and initial validation of the first self-report measure designed to address this variability in the general population; the Responses and Attitudes to Support during Pain questionnaire (RASP). The RASP includes questions on social support from the romantic partner as well as healthcare professionals (HCPs) and addresses different types of social support and pain responses. The development and validation of the RASP comprised four studies. In Study 1, a preliminary RASP version was completed by 179 healthy individuals regarding any type of acute pain. In Study 2, the reduced RASP was completed by 256 women with experiences of menstrual pain. Principal component analysis indicated a 22-item solution with five underlying dimensions reflecting General Partner Support, Emotional Support from HCPs, Anxiety in the Context of HCPs, Pain Behaviors during Partner Support, and Distraction by the Partner. Construct validity was assessed using a measure of adult attachment style. The RASP showed good validity and test-retest reliability. In Study 3, the 5-factor model received initial support through confirmatory factor analysis in a new sample of 120 individuals with recent musculoskeletal pain. Study 4 provided additional validation of the RASP in a sample of 180 individuals responding in reference to acute back pain. Overall, the RASP is a valid and reliable measure for assessing individual differences in attitudes and responses to social support in relation to acute pain.

Factors associated with longer delays in reperfusion in ST-segment elevation myocardial infarction

Background/objectives

The goal of this paper is to identify the predictors of delay in total ischemia time that would be the focus of improvement efforts in patients with ST-segment elevation myocardial infarction.

Methods

Data was collected retrospectively through the patient's clinical records and by direct telephone interview.

Total ischemic time was categorized in two classes according to the elapsed time since symptom presentation until restored flow, less than 6 h and 6 h or less. Logistic regression analysis was applied to evaluate the relationship between total ischemic time and a set of variables. Discrimination ability of the model was also assessed, as well as sensitivity and specificity, through ROC curves.

Results

Data from 128 patients, 74.22% males and 25.78% females, were analyzed. The average age was approximately 62 years (± 13.6).

Six variables associated with total ischemia were selected in the final model: the patient age, the level of pain intensity, the region of origin, the socioeconomic status, the activity that the patient was performing at the time of symptoms onset, and the fact that the patient has been transferred from another hospital.

Conclusion

The identification of variables associated with the total ischemia time allows the recognition of patients with possibility of worse prognosis, for which should be directed educational efforts and also the identification of variables that can be modified to optimize the therapy.

Serotoninergic effects on judgments and social learning of trustworthiness

RATIONALE

Certain disorders, such as depression and anxiety, to which serotonin dysfunction is historically associated, are also associated with lower assessments of other people's trustworthiness. Serotonergic changes are known to alter cognitive responses to threatening stimuli. This effect may manifest socially as reduced apparent trustworthiness of others. Trustworthiness judgments can emerge from either direct observation or references provided by third parties.

OBJECTIVE

We assessed whether explicit judgments of trustworthiness and social influences on those judgments are altered by changes within serotonergic systems.

METHODS

We implemented a double-blind between-subject design where 20 healthy female volunteers received a single dose of the selective serotonin reuptake inhibitor (SSRI) citalopram (2 × 20 mg), while 20 control subjects (matched on age, intelligence, and years of education) received a placebo. Subjects performed a face-rating task assessing how trustworthy they found 153 unfamiliar others (targets). After each rating, the subjects were told how other subjects, on average, rated the same target. The subjects then performed 30 min of distractor tasks before, unexpectedly, being asked to rate all 153 faces again, in a random order.

RESULTS

Compared to subjects receiving a placebo, subjects receiving citalopram rated targets as less trustworthy. They also conformed more to opinions of others, when others rated targets to be even less trustworthy than subjects had initially indicated. The two effects were independent of negative effects of citalopram on subjective state.

CONCLUSIONS

This is evidence that serotonin systems can mediate explicit assessment and social learning of the trustworthiness of others.

Use of emergency medical services expedites in-hospital care processes in patients presenting with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

To determine whether door-to-balloon (DTB) times of patients presenting with ST-elevation myocardial infarction (STEMI) were reduced in patients transported by emergency medical services (EMS) compared to those who were self-transported. DTB time is an important measure of hospital care processes in STEMI. Use of EMS may expedite in-hospital processing and reduce DTB times. A total of 309 consecutive STEMI patients who underwent primary percutaneous coronary intervention in our institution were analyzed. Excluded were patients who received fibrinolytics, presented in cardiac arrest, were intubated, or were transferred from another hospital. EMS-transported patients (n=83) were compared to self-transported patients (n=226). The primary outcome measure was DTB time and its component time intervals. Secondary end points included symptom-to-door and symptom-to-balloon times, and correlates for DTB >90 minutes. A higher percentage of EMS-transported patients reached the time goal of DTB <90 minutes compared to self-transported patients (83.1 versus 54.3%; p<0.001). EMS-transported patients had shorter DTB times [median (IQR) minutes, 65 (50-86) versus 85 (61-126); p<0.001] due to a reduction of emergency department processing (door-to-call) time, whereas catheterization laboratory processing (call-to-balloon) times were similar in both groups. EMS-transported patients had shorter symptom-to-door [median (IQR) hours, 1.2 (0.8-3.5) versus 2.3 (1.2-7.5); p<0.001] and symptom-to-balloon [median (IQR) hours, 2.5 (1.9-4.7) versus 4.3 (2.6-9.1); p<0.001]. Independent correlates of DTB times >90 minutes were self-transport (odds ratio 5.32, 95% CI 2.65-10.70; p<0.001) and off-hours presentation (odds ratio 2.89, 95% CI 1.60-5.22; p<0.001). Use of EMS transport in STEMI patients significantly shortens time to reperfusion, primarily by expediting emergency department processes. Community education efforts should focus not only on the importance of recognizing symptoms of myocardial infarction, but also taking early action by calling the EMS.

Thoughts and behaviors of women with symptoms of acute coronary syndrome

OBJECTIVE

Women delay seeking care for symptoms of acute coronary syndrome (ACS) because of atypical symptoms, perceptions of invulnerability, or keeping symptoms to themselves. The purpose of this study was to explore how women recognized and interpreted their symptoms and subsequently decided whether to seek treatment within the context of their lives.

METHOD

Grounded theory was used to provide the methodological basis for data generation and analysis. Data were collected using in-depth interviews with 9 women with ACS.

RESULTS

All participants went through a basic social process of searching for the meaning of their symptoms which informed their decisions about seeking care. Stages in the process included noticing symptoms, forming a symptom pattern, using a frame of reference, finding relief, and assigning causality. The evolving MI group (n = 5) experienced uncertainty about bodily cues, continued life as usual, until others moved them toward care. The immediately recognizable MI group (n = 4) labeled their condition quickly, yet delayed, as they prepared themselves and others for their departure.

CONCLUSIONS

All women delayed, regardless of their ability to correctly label their symptoms. Education aimed at symptom recognition/interpretation addresses only part of the problem. Women should also be educated about the potential danger of overestimating the time they have to seek medical attention.

Influence of psychological attachment patterns on periodontal disease - a pilot study with 310 compliant patients

OBJECTIVES

Psychosocial variables have received increased attention in periodontology. Attachment theory adds to known risk factors by linking early interactional experiences with adult tendencies of stress-regulation, health behaviour, symptom reporting, and healthcare utilization. The study investigates associations between attachment patterns and periodontal parameters.

METHODS

Within the context of a longitudinal study on periodontal diseases, 310 patients with aggressive (AgP) and chronic periodontitis (CP) filled out questionnaires on psychological attachment patterns. The influence of attachment style on health behaviour, treatment attendance and utilization, and periodontal variables was tested.

RESULTS

We found associations between psychological attachment anxiety on smoking and higher number of session use, independent of disease severity, which was more pronounced for women. Patients with higher attachment avoidance attended periodontal treatment later when diagnosed with CP and earlier with AgP. For men, we found differential associations for attachment avoidance and anxiety and number of teeth at beginning of treatment.

CONCLUSION

Psychological attachment patterns are a promising target for understanding periodontal disease in addition to known psychosocial risk factors.

Factors associated with decision time for patients with ST-segment elevation acute myocardial infarction

Increased delay in visiting a hospital for patients with ST-segment elevation myocardial infarction (STEMI) is often associated with poor outcomes. The factors associated with the decision time were analyzed by comparing the characteristics of patients with delays longer or shorter than the median of 60 min. Pre-hospital delay tended to be longer for patients living in suburban areas compared to those in urban areas (P=0.015). Shorter decision time was more likely among older patients. Being married, medical insurance coverage, and the level of educational qualification did not affect decision time. More efforts should be paid to educate the patients with high risk in suburban areas in order to effectively reduce pre-hospital delays.

Reducing the time-lag between onset of chest pain and seeking professional medical help: a theory-based review

BACKGROUND

Research suggests that there are a number of factors which can be associated with delay in a patient seeking professional help following chest pain, including demographic and social factors. These factors may have an adverse impact on the efficacy of interventions which to date have had limited success in improving patient action times. Theory-based methods of review are becoming increasingly recognised as important additions to conventional systematic review methods. They can be useful to gain additional insights into the characteristics of effective interventions by uncovering complex underlying mechanisms.

METHODS

This paper describes the further analysis of research papers identified in a conventional systematic review of published evidence. The aim of this work was to investigate the theoretical frameworks underpinning studies exploring the issue of why people having a heart attack delay seeking professional medical help. The study used standard review methods to identify papers meeting the inclusion criterion, and carried out a synthesis of data relating to theoretical underpinnings.

RESULTS

Thirty six papers from the 53 in the original systematic review referred to a particular theoretical perspective, or contained data which related to theoretical assumptions. The most frequently mentioned theory was the self-regulatory model of illness behaviour. Papers reported the potential significance of aspects of this model including different coping mechanisms, strategies of denial and varying models of treatment seeking. Studies also drew attention to the potential role of belief systems, applied elements of attachment theory, and referred to models of maintaining integrity, ways of knowing, and the influence of gender.

CONCLUSIONS

The review highlights the need to examine an individual's subjective experience of and response to health threats, and confirms the gap between knowledge and changed behaviour. Interventions face key challenges if they are to influence patient perceptions regarding seriousness of symptoms; varying processes of coping; and obstacles created by patient perceptions of their role and responsibilities. A theoretical approach to review of these papers provides additional insight into the assumptions underpinning interventions, and illuminates factors which may impact on their efficacy. The method thus offers a useful supplement to conventional systematic review methods.

Associations between adult attachment style and health risk behaviors in an adult female primary care population

OBJECTIVE

To examine the relationship between adult attachment style and health risk behaviors among adult women in a primary care setting.

METHODS

In this analysis of a population of women enrolled in a large health maintenance organization (N=701), we examined the relationship between anxious and avoidant dimensions of adult attachment style and a variety of sexual, substance-related, and other health risk behaviors. After conducting descriptive statistics of the entire population, we determined the relationships between the two attachment dimensions and health behaviors using multiple regression analyses in which we controlled for demographic and socioeconomic factors.

RESULTS

After adjustment for covariates, the anxious dimension of attachment style was significantly associated with increased odds of self-report of having sex without knowing a partner's history, having multiple (≥2) male partners in the past year, and history of having a sexually transmitted infection (ORs [95% CIs]=1.11 [1.03, 1.20], 1.23 [1.04, 1.45]; and 1.17 [1.05, 1.30], respectively). The avoidant attachment dimension was associated with increased odds of being a smoker and not reporting regular seatbelt use (ORs [95% CIs]=1.15 [1.01, 1.30] and 1.16 [1.01, 1.33], respectively).

CONCLUSIONS

Both anxious and avoidant dimensions of attachment were associated with health risk behaviors in this study. This framework may be a useful tool to allow primary care clinicians to guide screening and intervention efforts.

Post-traumatic stress disorder (PTSD) symptoms predict delay to hospital in patients with acute coronary syndrome

BACKGROUND

Increased delay to hospital presentation with acute coronary syndrome (ACS) is associated with poor outcomes. While demographic factors associated with this delay have been well described, scarce data are available on the role of modifiable factors, such as psychosocial disorders, on pre-hospital delay. Patients with symptoms of post-traumatic stress disorder (PTSD) often avoid stressful situations and may delay presenting for care when they experience cardiac symptoms. It is unknown, however, whether PTSD symptoms negatively impact the time to presentation during an ACS.

METHODS

We assessed the relationship between PTSD symptoms and pre-hospital delay in 241 adults with an ACS in the ongoing Prescription Use, Lifestyle, Stress Evaluation (PULSE) study.

RESULTS

Overall, 66% of patients were male; 40% were Hispanic or Latino. The mean age was 61.9±11.6 years old. PTSD symptoms were present in 17.8% of patients. Pre-hospital delay was longer for patients with PTSD symptoms compared to those without [geometric mean: 25.8 hours (95% CI 13.8-44.8) vs. 10.7 hours (95% CI 8.3-13.8)]; P = 0.005. After multivariable adjustment for age, sex, ethnicity, depression, left ventricular ejection fraction and history of myocardial infarction, the mean pre-hospital delay was 173% (95% CI: 36%-450%) longer for patients with versus without PTSD symptoms.

CONCLUSION

Among patients presenting with an ACS, PTSD symptoms were independently associated with longer pre-hospital delays. Future studies of pre-hospital delay should examine the mechanisms underlying this association.

A depressed post-menopausal woman

BACKGROUND

Post-menopausal women are at significant risk for coronary artery disease, have increased rates of depression compared to their male counterparts, and often present atypically with coronary insufficiency. The symptoms of depression and coronary ischemia overlap greatly. Complaints like fatigue, body aches, and sleep disturbance reported by a depressed elderly woman may be cardiac related and need to be investigated seriously without physician bias.

OBJECTIVES

To ensure that clinicians are cautious when evaluating older women with a history of depression who are presenting with atypical complaints.

CASE REPORT

A 61-year-old woman with history of depression presented to the Emergency Department with multiple complaints atypical for acute coronary syndrome. She had an immediate electrocardiogram and troponin-T Biosite point-of-care test (Biosite Incorporated, San Diego, CA) performed, which were positive for cardiac ischemia and myocardial infarction. The patient underwent immediate cardiac catheterization, which revealed occlusion of the mid left circumflex. After aspiration of thrombus and balloon dilatation of the site, a bare metal stent was deployed, restoring excellent flow. The patient did well medically but her depression worsened after the procedure and continues despite psychiatric intervention.

CONCLUSION

For years there have been gender differences in medical treatment of coronary artery disease, and often women's complaints are not investigated aggressively. Post-menopausal women are at great risk for cardiac ischemia and depression, and their symptoms, which are often atypical, may not be diagnosed as anginal equivalents. In addition, depression is an independent risk factor for cardiovascular disease and, if it occurs after myocardial infarction, may lead to poor quality of life and increased morbidity and mortality. Patients who have had a coronary event must be thoroughly evaluated for signs of depression and receive the necessary treatment.

Use of emergency medical service transport among patients with ST-segment-elevation myocardial infarction: findings from the National Cardiovascular Data Registry Acute Coronary Treatment Intervention Outcomes Network Registry-Get With The Guidelines

BACKGROUND

Activation of emergency medical services (EMS) is critical for the early triage and treatment of patients experiencing ST-segment-elevation myocardial infarction, yet data regarding EMS use and its association with subsequent clinical care are limited.

METHODS AND RESULTS

We performed an observational analysis of 37 634 ST-segment-elevation myocardial infarction patients treated at 372 US hospitals participating in the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines between January 2007 and September 2009, and examined independent patient factors associated with EMS transportation versus patient self-transportation. We found that EMS transport was used in only 60% of ST-segment-elevation myocardial infarction patients. Older patients, those living farther from the hospital, and those with hemodynamic compromise were more likely to use EMS transport. In contrast, race, income, and education level did not appear to be associated with the mode of transport. Compared with self-transported patients, EMS-transported patients had significantly shorter delays in both symptom-onset-to-arrival time (median, 89 versus 120 minutes; P<0.0001) and door-to-reperfusion time (median door-to-balloon time, 63 versus 76 minutes; P<0.0001; median door-to-needle time, 23 versus 29 minutes; P<0.0001).

CONCLUSIONS

Emergency medical services transportation to the hospital is underused among contemporary ST-segment-elevation myocardial infarction patients. Nevertheless, use of EMS transportation is associated with substantial reductions in ischemic time and treatment delays. Community education efforts are needed to improve the use of emergency transport as part of system-wide strategies to improve ST-segment-elevation myocardial infarction reperfusion care.

The impact of personality factors on delay in seeking treatment of acute myocardial infarction

Background

Early hospital arrival and rapid intervention for acute myocardial infarction is essential for a successful outcome. Several studies have been unable to identify explanatory factors that slowed decision time. The present study examines whether personality, psychosocial factors, and coping strategies might explain differences in time delay from onset of symptoms of acute myocardial infarction to arrival at a hospital emergency room.

Methods

Questionnaires on coping strategies, personality dimensions, and depression were completed by 323 patients ages 26 to 70 who had suffered an acute myocardial infarction. Tests measuring stress adaptation were completed by 180 of them. The patients were then categorised into three groups, based on time from onset of symptoms until arrival at hospital, and compared using logistic regression analysis and general linear models.

Results

No correlation could be established between personality factors (i.e., extraversion, neuroticism, openness, agreeableness, conscientiousness) or depressive symptoms and time between onset of symptoms and arrival at hospital. Nor was there any significant relationship between self-reported patient coping strategies and time delay.

Conclusions

We found no significant relationship between personality factors, coping strategies, or depression and time delays in seeking hospital after an acute myocardial infraction.

Age and sex differences and 20-year trends (1986 to 2005) in prehospital delay in patients hospitalized with acute myocardial infarction

BACKGROUND

The prompt administration of coronary reperfusion therapy for patients with an evolving acute myocardial infarction (AMI) is crucial in reducing mortality and the risk of serious clinical complications in these patients. However, long-term trends in extent of prehospital delay and factors affecting patient's care-seeking behavior remain relatively unexplored, especially in men and women of different ages. The objectives of this study were to examine the overall magnitude and 20-year trends (1986 to 2005) in duration of prehospital delay in middle-aged and elderly men and women hospitalized with AMI.

METHODS AND RESULTS

The study sample consisted of 5967 residents of the Worcester, Mass, metropolitan area hospitalized at all greater Worcester medical centers for AMI between 1986 and 2005 who had information available about duration of prehospital delay. Compared with men <65 years, patients in other age-sex strata exhibited longer prehospital delays over the 20-year period under study. The multivariable-adjusted medians of prehospital delay were 1.96, 2.07, and 2.57 hours for men <65 years, men 65 to 74 years, and men ≥75 years and 2.08, 2.33, and 2.27 hours for women <65 years, women 65 to 74 years, and women ≥75 years, respectively. These age and sex differences have narrowed over time, which has been largely explained by changes in patient's comorbidity profile and AMI-associated characteristics.

CONCLUSIONS

Our results suggest that duration of prehospital delay in persons with symptoms of AMI has remained essentially unchanged during the 20-year period under study and elderly individuals are more likely to delay seeking timely medical care than younger persons.

Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities

Background

The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably.

In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count.

This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase.

Method

A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases.

Results

In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women).

With regard to detection of AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably.

In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke.

Conclusion

Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.