Keerat Grewal

Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo.

We aimed to determine the risk of short‐ and long‐term stroke, as well as accidental injury, in patients discharged from an emergency department who were given a diagnosis of a peripheral vestibular disorder.

A prospective, controlled multisite study of psychosocial and behavioral change following women's cardiac rehabilitation participation.

BACKGROUND Despite its proven benefits and need, women are significantly less likely than men to participate in and complete cardiac rehabilitation (CR). Thus, there are few reports of CR outcomes among women, particularly when compared with women who do not participate in CR. The purpose of this study was to prospectively assess psychosocial and behavioral changes, comparing women who participated in CR with those who did not. METHODS One hundred fifty-seven female cardiac inpatients from three hospitals consented to participate in a prospective study, and 110 (79%) were retained 18 months postdischarge. A mailed survey discerned CR participation 9 months postdischarge. Quality of life (Short-Form Health Survey Physical and Mental Component Summary [SF-12 PCS and MCS]), exercise behavior (Health-Promoting Lifestyle Profile II [HPLPII]), Exercise Benefits and Barriers Scale (EBBS), and anxiety and depressive symptoms (Hospital Anxiety and Depression Scale [HADS]) were assessed in hospital and 18 months postdischarge. RESULTS Fifty-one (45.1%) women self-reported participating in CR at 1 of 18 sites, and site-verified participation was 82.43% +/- 29.97% of prescribed sessions. For CR participants, paired t tests assessing change from hospitalization to 18 months postdischarge revealed significant improvements in physical quality of life (p < 0.001), anxiety (p < 0.05), and exercise behavior (p = 0.01). Women who did not participate in CR experienced significant improvements in physical quality of life (p = 0.02), and depressive symptoms (p = 0.03) but not exercise behavior. CONCLUSIONS Following a cardiac event, female patients improved their physical quality of life and affect, but only patients who participated in CR increased their exercise behavior. Given the cardiac benefits of exercise and that women are often sedentary and given that this exercise behavior was sustained post-CR, these findings are significant. Randomized controlled trials of womens CR outcomes are needed.

Factors affecting cardiac rehabilitation referral by physician specialty.

PURPOSE Cardiac rehabilitation (CR) is widely underutilized because of multiple factors including physician referral practices. Previous research has shown CR referral varies by type of provider, with cardiologists more likely to refer than primary care physicians. The objective of this study was to compare factors affecting CR referral in primary care physicians versus cardiac specialists. METHODS A cross-sectional survey of a stratified random sample of 510 primary care physicians and cardiac specialists (cardiologists or cardiovascular surgeons) in Ontario identified through the Canadian Medical Directory Online was administered. One hundred four primary care physicians and 81 cardiac specialists responded to the 26-item investigator-generated survey examining medical, demographic, attitudinal, and health system factors affecting CR referral. Results Primary care physicians were more likely to endorse lack of familiarity with CR site locations (P < .001), lack of standardized referral forms (P < .001), inconvenience (P = .04), program quality (P = .004), and lack of discharge communication from CR (P = .001) as factors negatively impacting CR referral practices than cardiac specialists. Cardiac specialists were significantly more likely to perceive that their colleagues and department would regularly refer patients to CR than primary care physicians (P < .001). CONCLUSIONS Where differences emerged, primary care physicians were more likely to perceive factors that would impede CR referral, some of which are modifiable. Marketing CR site locations, provision of standardized referral forms, and ensuring discharge summaries are communicated to primary care physicians may improve their willingness to refer to CR.

Differences in social support and illness perceptions among South Asian and Caucasian patients with coronary artery disease.

OBJECTIVE Social support and illness perceptions may affect recovery from a cardiac event or procedure. Previous research has found that patients of South Asian origin with coronary artery disease (CAD) have lower levels of social support and may perceive different causes of their condition. The purpose of this study was to quantitatively investigate differences in social support and illness perceptions between Caucasian and South Asian patients with CAD. METHODS A total of 562 inpatients with CAD (53 [9%] South Asian) were recruited from 2 hospitals. The Medical Outcomes Study social support scale and Illness Perception Questionnaire were administered to examine ethnocultural differences in total social support and subscales, and in illness perceptions subscales, including causes of illness. RESULTS South Asian participants had significantly lower levels of tangible (P=.001) and emotional/informational support (P < .001) compared with Caucasian participants. South Asians were less likely than Caucasians to believe they have personal control over their illness (P < .001). Trends were observed, with South Asian participants being more likely to attribute their condition to stress/worry (P=.04) and poor medical care in the past (P=.02) and less likely to attribute their illness to aging (P=.03) compared with Caucasian participants. CONCLUSION Lower levels of social support among South Asians in Canada may have negative effects on recovery and prognosis. Our results support qualitative findings suggesting South Asians perceive their illness to be a result of fate or related to stress. Future studies should investigate interventions targeted at modifying illness perceptions among this group in an attempt to improve risk-reducing behavior and secondary prevention use.

Missed Strokes Using Computed Tomography Imaging in Patients With Vertigo: Population-Based Cohort Study

Background and Purpose— The purpose of this study was to determine the proportion of emergency department (ED) patients with a diagnosis of peripheral vertigo who received computed tomography (CT) head imaging in the ED and to examine whether strokes were missed using CT imaging. Methods— This population-based retrospective cohort study assessed patients who were discharged from an ED in Ontario, Canada, with a diagnosis of peripheral vertigo, April 2006 to March 2011. Patients who received CT imaging (exposed) were matched by propensity score methods to patients who did not (unexposed). If performed, CT imaging was presumed to be negative for stroke because brain stem/cerebellar stroke would result in hospitalization. We compared the incidence of stroke within 30, 90, and 365 days subsequent to ED discharge between groups, to determine whether the exposed group had a higher frequency of early strokes than the matched unexposed group. Results— Among 41 794 qualifying patients, 8596 (20.6%) received ED head CT imaging, and 99.8% of these patients were able to be matched to a control. Among exposed patients, 25 (0.29%) were hospitalized for stroke within 30 days when compared with 11 (0.13%) among matched nonexposed patients. The relative risk of a 30- and 90-day stroke among exposed versus unexposed patients was 2.27 (95% confidence interval, 1.12–4.62) and 1.94 (95% confidence interval, 1.10–3.43), respectively. There was no difference between groups at 1 year. Strokes occurred at a median of 32.0 days (interquartile range, 4.0–33.0 days) in exposed patients, compared with 105 days (interquartile range, 11.5–204.5) in unexposed patients. Conclusions— One fifth of patients diagnosed with peripheral vertigo in Ontario received imaging that is not recommended in guidelines, and that imaging was associated with missed strokes.

A simultaneous test of the relationship between identified psychosocial risk factors and recurrent events in coronary artery disease patients

Abstract Psychosocial factors are increasingly recognized as risk indicators for coronary artery disease (CAD) prognosis and they are likely interrelated. The objective of this study is to simultaneously test the relationship between key psychosocial constructs as independent factor scores and recurrent events in CAD patients. There were 1268 CAD outpatients of 97 cardiologists surveyed at two points. Recurrent events or hospitalization in the intervening nine months were reported. Factor analysis of items from the Hospital Anxiety and Depression Scale, Perceived Stress Scale, the ENRICHD Social Support Inventory, and Hostile Attitudes Scale was performed to generate orthogonal factor scores. With adjustment for prognostic variables, logistic regression analysis was performed to examine the relationship between these factor scores and recurrent events. Factor analysis resulted in a six-factor solution: hostility, stress, anxiety, depressive symptoms, support, and resilience. Logistic regression revealed that functional status and anxiety, with a trend for depressive symptoms, were related to experiencing a recurrent event. In this simultaneous test of psychosocial constructs hypothesized to relate to cardiac prognosis, anxiety may be a particularly hazardous psychosocial factor. While replication is warranted, efforts to investigate the potential benefits of screening and to investigate treatments are needed.

Timing of Depressive Symptom Onset and In-Hospital Complications Among Acute Coronary Syndrome Inpatients

Background Recent research has reported an association between in-hospital depression and poorer long-term prognosis and a greater risk of in-hospital complications. Objective The purpose of the current study was to examine the relationship between past and incident depressive symptoms and in-hospital complications in acute coronary syndrome (ACS) inpatients. Method A group of 906 ACS inpatients from 12 coronary-care units participated in the study. Incident depressive symptoms were assessed through the Beck Depression Inventory, and participants’ were asked about past history of prolonged depressed mood. In-hospital complications were noted as present or absent by nurses, and authors conducted logistic-regression analyses. Results A subset of 492 patients (58.4%) experienced an in-hospital complication, the most common being ischemia (48.8%) and cardiac arrest (7.2%). After adjusting for prognostic indicators, incident and past-combined-with-incident depressive symptoms were significantly associated with an increased risk of experiencing an in-hospital complication. Conclusion Incident symptoms, in particular, seem to be prognostic. This finding suggests that acute emotions may be triggering cardiac complications, and early identification of emotional symptoms is warranted.

Gender differences in motivations and perceived effects of Mind-Body Therapy (MBT) practice and views on integrative cardiac rehabilitation among acute coronary syndrome patients: why do women use MBT?

BACKGROUND Over one-third of cardiac patients practice Mind-Body Therapy (MBT), particularly women. Considering women are less likely to engage in conventional physical activity, few studies have examined why MBT is well-accepted by women. OBJECTIVES To qualitatively explore gender differences in the motivations for, and perceived effects of MBT, and the inter-relationships among alternative and conventional physical activities and secondary prevention programs. METHODS A random subsample of 16 participants (8 female) who reported practicing MBT in a larger study of 661 cardiac patients was interviewed until theme saturation was achieved. Audiotapes were transcribed and coded based on interpretive-descriptive technique within Nvivo-7 software. An audit trail and second coder were utilized to ensure the transparency and validity of results. After main themes emerged, the data were split by gender to identify differences for each theme. RESULTS Five themes emerged: (1) promotes positive well-being, (2) physical health benefits, (3) intrinsic and extrinsic motivations, (4) proactive health orientation, and (5) MBT as a preferred complementary and/or alternative physical activity. Men more often expressed preference for MBT for increased positive mood and cardiac-specific benefits, whereas women emphasized stress reduction, increasing self-efficacy, and physical activity, and were eager to see MBT offered in cardiac rehabilitation (CR). CONCLUSIONS Both male and female users perceived substantial psychosocial and physical benefits of MBT practice. MBT addresses some of womens common barriers to CR.

Quality of Life Following Participation in Cardiac Rehabilitation Programs of Longer or Shorter than 6 Months: Does Duration Matter?

Cardiac rehabilitation (CR) participation results in significant health benefits. However, there is wide variation in program duration, and little is known about the optimal duration of CR for patient outcomes. The objective of this study was to compare quality of life (QoL) of patients who participated in CR programs of < or ≥6 months duration versus patients who did not attend CR. A total of 1056 cardiac outpatients completed mailed surveys at baseline and 9 months later. Patients were categorized based on CR participation in one of 31 programs: a program of < or ≥6 months duration, or nonattendance. Outcomes were body mass index, activity status, depressive symptoms, physical activity, QoL, posttraumatic growth inventory (PTGI), and percentage of CR sessions attended. Generalized estimating equations were used. A total of 148 (14%) patients participated in a program of < 6 months, and 183 (17.3%) participated in a program of ≥6 months. Patients who participated in the former completed a greater percentage of CR sessions (P = 0.02). Activity status (P = 0.002), several domains of QoL (P > 0.0001), and PTGI (P = 0.007) were significantly greater regardless of CR duration when compared to those who did not attend CR. There were no significant differences in outcomes when comparing patients attending CR programs of < or ≥6 months duration. Patients achieve greater activity status and QoL when compared to those who did not attend CR, regardless of program duration. This could be a result of greater program adherence among those who attend shorter programs. Future research is needed using a randomized design to assess effects of program duration on cardiac events and mortality.

The impact of opioid medications on subsequent fractures in discharged emergency department patients with peripheral vertigo

BACKGROUND Vertigo is common in the emergency department (ED). Most aetiologies are peripheral and do not require hospitalization, but many patients still fear falling. Some patients may be taking opioid analgesic medications (for other reasons); the risk of falls leading to fractures among patients with vertigo could be potentiated by the simultaneous use of opioids. OBJECTIVES To examine the risk of fractures in discharged ED patients with peripheral vertigo who were being prescribed opioids during the same time period. METHODS Linked administrative databases from Ontario were used to compare discharged ED patients aged ≥65 with peripheral vertigo to patients with urinary tract infection (UTI) from 2006 to 2011. We used Cox regression analysis with an interaction term to estimate the modifying effect of an opioid prescription on the hazard of fracture within 90 days. RESULTS There were 13,012 patients with a peripheral vertigo syndrome and 76,885 with a UTI. Thirteen percent of the vertigo cohort and 25% of the UTI cohort had access to a filled opioid prescription. Compared to vertigo patients who did not fill an opioid prescription, the adjusted hazard of fracture among vertigo patients who did fill a prescription was 3.59 (95% CI 1.97-6.13). Among UTI patients who filled an opioid prescription the hazard ratio was 1.68 (95% CI 1.43-1.97) compared to UTI patients who did not. CONCLUSIONS Patients discharged from the ED with peripheral vertigo who were also being prescribed opioids had a higher hazard of subsequent fracture compared to those who were not, and the effect was much greater than among UTI patients. These results suggest that in the acutely vertiginous older patient, opioid analgesic medications should be modified, where possible.