Patient Denial of Myocardial Infarction in the Prehospital Phase: Prevalence and Correlates.

BACKGROUND: Limited knowledge exists regarding patients' denial of myocardial infarction (MI) before hospitalization for an MI. OBJECTIVE: The aim of this study was to determine the prevalence and correlates of denial of MI in the prehospital phase of a confirmed MI. METHODS: This secondary analysis included 166 hospitalized patients (mean [SD] age, 54.1 [10.5] years) who developed MI outside a healthcare facility and had high congruence between their experienced and expected symptoms. Measurements included the Denial subscale of the Brief COPE Inventory, the modified Response to Symptoms Questionnaire, and a Likert scale measuring perceived risk for MI. Patients who arrived at a hospital at least 1 hour after the onset of their symptoms were considered to have prolonged prehospital delay. RESULTS: Despite their high symptom congruence, 77% of patients denied the possibility of having an MI before hospitalization. The lower denial group was characterized by cardiac history, whereas the higher denial group was distinguished by nonsmoking, a lower perceived risk of MI, less anxiety at symptom onset, and more concerns about seeking medical help. Compared with the lower denial group, patients in the higher denial group were more likely to underestimate the seriousness of their symptoms and delay seeking medical help. The higher denial group responded to symptoms in a more passive manner (eg, waiting), whereas the lower denial group showed a more problem-solving approach (eg, contacting emergency services). CONCLUSIONS: Denial of MI is highly prevalent in the prehospital phase and is negatively linked with cognitive, emotional, and behavioral responses to MI symptoms.

Functional health literacy and caregiving burden among family caregivers of patients with end-stage renal disease.

Family caregivers of patients with end-stage renal disease (ESRD) experience significant caregiver-related burden, yet the contribution of their functional health literacy (FHL) to caregiving burden has not been elucidated. We investigated the magnitude of FHL and caregiving burden and their association in a descriptive, correlational cross-sectional study of family caregivers of Jordanian patients with ESRD (N = 88). The short versions of the FHL for Adults and the Zarit Burden Interview were used for assessment of caregivers. Demographic and clinical information of patients and their family caregivers were self-reported. Of family caregivers, 41% had limited FHL and 38% experienced high caregiver burden. FHL and history of comorbidity in family caregivers predicted caregiving burden independent of demographic and clinical factors. Consideration of FHL in support interventions for family caregivers may minimize some of the high perceived caregiving burden, but clinical trials of such interventions are needed to confirm this conclusion.

A Survey on Sexual Counseling for Patients With Cardiac Disease Among Nurses in Jordan.

BACKGROUND: Recovery among patients with cardiac disease also requires attention to their sexual health. However, cultural, religious, and social factors may make Arab Muslim patients reluctant to disclose their sexual concerns and nurses hesitant to discuss patients' sexuality matters. OBJECTIVE: The aim of this study was to explore sexual counseling (SC) among nurses in Jordan in terms of responsibility, confidence, and practice. METHOD: This was a descriptive, correlational study. Staff nurses were recruited from 10 hospitals in Jordan. Nurses completed the cardiac version of the Survey of Sexuality-Related Nursing Practice and reported their demographics. RESULTS: The sample consisted of 379 nurses (female, 59%; mean age, 28.1 years). A significant proportion of nurses viewed assessment/discussion of patients' sexuality matters as not within their responsibilities (39%), did not feel confident to address sexuality matters (50%), and rated themselves as not at all/not very knowledgeable about sexuality (60%). Few nurses were routinely integrating SC in clinical practice (9%). Sexual counseling was associated with nurses' gender (male, higher confidence and practice) and previous training on sexuality in nursing practice. CONCLUSIONS: Nurses in Jordan, especially female nurses, are neither prepared nor competent to provide SC. Nurses need focused education on sexuality to optimize patients' sexual health.

The association of co-morbid symptoms of depression and anxiety with all-cause mortality and cardiac rehospitalization in patients with heart failure.

BACKGROUND: Patients with heart failure (HF) experience multiple psychologic symptoms. Depression and anxiety are independently associated with survival. Whether co-morbid symptoms of anxiety and depression are associated with outcomes in patients with HF is unknown. OBJECTIVE: To determine whether co-morbid symptoms of depression and anxiety are associated with all-cause mortality or rehospitalization for cardiac causes in patients with HF. METHOD: A total of 1260 patients with HF participated in this study. Cox regression analysis was used to determine whether co-morbid symptoms of depression and anxiety independently predicted all-cause mortality and cardiac rehospitalization. Anxiety and depression were treated first as continuous-level variables, then as categorical variables using standard published cut points. Patients were then divided into 4 groups based on the presence of anxiety and depression symptoms. RESULTS: When entered as a continuous variable, the interaction between anxiety and depression (hazard ratio = 1.02; 95% CI: 1.01-1.03; p = 0.002) was a significant predictor of all-cause mortality in patients with HF. When entered as a categorical variable, co-morbid symptoms of depression and anxiety (vs no symptoms or symptoms of anxiety or depression alone) independently predicted all-cause mortality (hazard ratio = 2.59; 95% CI: 1.49-4.49; p = 0.001). None of the psychologic variables was a predictor of cardiac rehospitalization in patients with HF whether using the continuous or categorical level of measurement. CONCLUSION: To improve mortality outcomes in patients with HF, attention must be paid by health care providers to the assessment and management of co-morbid symptoms of depression and anxiety.

The contribution of symptom incongruence to prehospital delay for acute myocardial infarction symptoms among Jordanian patients.

Qualitative investigators have suggested that symptom incongruence, or a mismatch between symptoms that patients expect and those they experience in acute myocardial infarction (AMI), increases the time to hospitalization by affecting emotional, cognitive, and behavioral factors. No quantitative studies have been conducted that verify these relationships. We aimed to (a) examine the relationships among symptom incongruence, prehospital delay, anxiety level at onset of symptoms, perceived seriousness and importance of symptoms, source to which symptoms were attributed, and patients' first response at symptom onset and (b) test the independent association of symptom incongruence to prehospital delay. Jordanian patients with AMI (n = 299) were interviewed using validated questionnaires, and medical records were reviewed to collect information on patients' prehospital delay time, symptom incongruence, and response to AMI symptoms. Patients had low mean (7.5 ± 3.6) symptom incongruence scores (range 0-21 out of 24) and relatively short median prehospital delay (1.3 hours). Symptom incongruence was positively correlated with and independently predicted prehospital delay. Greater anxiety and greater perceived seriousness and importance of symptoms were associated with less incongruence and shorter prehospital delay. Patients who attributed their symptoms to a cardiac etiology had significantly shorter prehospital delay and less symptom incongruence than their counterparts. Patients who contacted the emergency medical service directly after symptom onset had shorter prehospital delay than their counterparts who did not, but did not differ on the level of symptom incongruence. Symptom incongruence may increase prehospital delay by complicating patients' efforts to label and respond to AMI symptoms.

Anxiety and adverse health outcomes among cardiac patients: a biobehavioral model.

BACKGROUND: Anxiety is a common experience among patients with acute coronary syndrome (ACS) that can have a negative impact on health outcomes. Nonetheless, the negative role of anxiety remains underappreciated, as reflected by clinicians' underrecognition and undertreatment of anxious hospitalized and nonhospitalized patients with ACS. Underappreciation of the role of anxiety is possibly related to inadequate understanding of the mechanisms whereby anxiety may adversely affect health outcomes. PURPOSE: The aim of this study was to synthesize the evidence about potential mechanisms by which anxiety and adverse health outcomes are related. CONCLUSIONS: A biobehavioral model links anxiety to the development of thrombogenic and arrhythmic events in patients with ACS. Biologically, anxiety may interfere with the immune system, lipid profile, automatic nervous system balance, and the coagulation cascade, whereas behaviorally, anxiety may adversely affect adoption of healthy habits and cardiac risk-reducing behaviors. The biological and behavioral pathways complement each other in the production of poor outcomes. CLINICAL IMPLICATIONS: Anxiety requires more attention from clinical cardiology. The adverse impact of anxiety on health outcomes could be avoided by efficient assessment and treatment of anxiety.

Development and psychometric evaluation of the Chronic Kidney Disease Screening Index.

OBJECTIVE: Public understanding of chronic kidney disease (CKD) is important to ensure informed participation in CKD prevention programs. This study aimed to develop and to test the psychometric profile of the CKD Screening Index that measures patient's knowledge, attitudes, and practices regarding CKD prevention and early detection. METHODS: A cross-sectional design was implemented and a total of 740 Jordanian patients recognized at risk for CKD were recruited by convenience sampling from out-patient departments. Development and psychometric validation of the CKD Screening Index were conducted in four phases: (1) item generation, (2) pilot study, (3) preliminary psychometric validation study to examine factor structure, and (4) final psychometric validation with 740 participants. RESULTS: On factor analysis, 24 items categorical knowledge items loaded into one factor and yielded a Guttman Split-Half Coefficient of 0.80. In a separate factor analysis, 15 items were loaded on two attitude factors (Cronbach alpha coefficient = 0.69), and nine items loaded on two practice factors (Cronbach alpha coefficient = 0.68). The CKD Screening Index associated significantly and negatively with depressed and anxious patients compared to their counterparts. PRACTICE IMPLICATIONS: This promising CKD Screening Index can be used for an early identification of patients at risk for CKD, thus, allowing the development of interventions to raise these patients' awareness. Future studies are needed on other populations with different cultural background to support reliability and validity of this new instrument.

Perceived social support is a partial mediator of the relationship between depressive symptoms and quality of life in patients receiving hemodialysis.

BACKGROUND: The meaning of social support is well documented, but less is known about mediating characteristics that examine which patients with end stage renal disease (ESRD) and depressive symptoms are most likely to benefit. AIMS: The aim of this study was to examine whether perceived social support mediated depressive symptoms on the outcome of quality of life (QoL). DESIGN: A correlational, cross-sectional study was conducted with a convenience sampling of 190 patients with ESRD. RESULTS: There was partial mediation effect of social support on depressive symptoms in the prediction of QoL. CONCLUSION: Effective management of depressive symptoms will improve QoL mostly when social support is promoted in patients with ESRD receiving hemodialysis.

Anxiolytic medication use is not associated with anxiety level and does not reduce complications after acute myocardial infarction.

AIMS AND OBJECTIVES: To examine the association of anxiety level and anxiolytic medication use with in-hospital complications in patients following acute myocardial infarction (AMI). BACKGROUND: There are conflicting data about the protective effect of anxiolytic medication used in patients after acute myocardial infarction. Examination of the interaction of anxiolytic medication and anxiety level may explain these disparate results. DESIGN: This was a secondary analysis of existing data from a multisite, prospective study of the impact of anxiety on in-hospital complications in patients with AMI. METHODS: Patients were primarily men, Caucasians, with Killip class 1 or 2, from the USA and Australia (n = 156). Anxiety level in the emergency department and intensive care unit and in-hospital complications were collected using self-report measures and medical record review. Logistic regression analyses examined whether the use of anxiolytic medication influenced the relationship between anxiety and in-hospital complications after controlling for demographic and clinical covariates. RESULTS: In the ED, 31% of participants were very or extremely anxious; anxiolytic medication was given to only 5%. In the intensive care unit, nearly half of participants received anxiolytic medication. There was no association between anxiety level and use of anxiolytic medication. Anxiety was an independent predictor of the probability of in-hospital complications. The administration of anxiolytic medication did not alter the relationship between anxiety and in-hospital complications. CONCLUSION: Use of anxiolytics in patients with AMI was not associated with anxiety level and did not reduce the probability of in-hospital complications. RELEVANCE TO CLINICAL PRACTICE: Clinicians need to regularly assess anxiety and treat it appropriately. Regular anxiety assessment may promote appropriate use of anxiolytic medication. Clinical guidelines for the management of patients with an AMI should address anxiety assessment and appropriate use of anxiolytic medication to improve patients' outcomes.

Predictors of dietary and fluid non-adherence in Jordanian patients with end-stage renal disease receiving haemodialysis: a cross-sectional study.

AIMS AND OBJECTIVES: The purpose of this study is to provide insight into the relationship between dietary and fluid non-adherence, depressive symptoms, quality of life, perceived barriers and benefits of exercise, and perceived social support among Jordanian patients with end-stage renal disease receiving haemodialysis using Pender's health promotion model. BACKGROUND: Non-adherence to dietary and fluid restrictions is a leading cause of treatment failure and poor outcomes in end-stage renal disease. Yet, factors that interfere with the patients' ability to follow their dietary restrictions are unknown. DESIGN: A descriptive, correlational, cross-sectional design was used. METHODS: Jordanian patients (n = 190) with end-stage renal disease receiving haemodialysis from three main Jordanian cities were included. The dialysis diet and fluid nonadherence questionnaire, Beck Depression Inventory-II, Quality Of Life Index, Dialysis Patient-Perceived Exercise Benefits and Barriers Scale, and the Multidimensional Perceived Social Support were employed to measure the key variables. RESULTS: Patients were more likely men with mean age of 48·2 ± 14·9. Only 27% of the patients showed full commitment to diet guidelines and 23% to fluid guidelines during the last 14 days. Depression (M = 18·8 ± 11·4) had significant negative association with quality of life (importance and satisfaction) (r = -0·60, r = -0·32, p = 0·001, respectively). Multiple hierarchal regressions revealed a predictive model of only two variables: age (B = -0·22, p = 0·05) and residual renal function (B = -0·23, p = 0·012) for dietary non-adherence. CONCLUSIONS: Non-adherence to diet and fluid guidelines association with individual characteristics, health perception and psychosocial variables should be investigated in a longitudinal design. Relationship of non-adherence with culture-related factors should deeply be assessed among Jordanian patients with end-stage renal disease receiving haemodialysis. RELEVANCE TO CLINICAL PRACTICE: Identification of the factors that may worsen dietary and fluid non-adherence may lead to improved therapeutic interventions within the mainstream of medical practice for Jordanian patients with end-stage renal disease receiving haemodialysis.

Psychometric Evaluation of Three Translated Measures of Functional Health Literacy among Jordanians.

Assessment of functional health literacy (FHL) is not integrated into clinical settings in Jordan possibly because relevant psychometric studies are lacking. The aim of this secondary analysis of data on family caregivers (N = 115) was to evaluate the internal consistency reliability and construct validity of three measures of FHL among Jordanians: the Short Test of Functional Health Literacy in Adults (S-TOFHLA), the Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R), and the Single Item Literacy Screener (SILS). Cronbach's alpha was excellent for the S-TOFHLA (.92), but suboptimal for the REALM-R (.67). In bivariate analysis, FHL measured by the S-TOFHLA and the REALM-R, but not the SILS, was positively associated with educational attainment (p < .05) and negatively related to self-reported anxiety (p < .05). Among Jordanians, psychometric rigor was fully demonstrated for the S-TOFHLA and partially for the REALM-R, but not for the SILS.

The impact of somatic and cognitive depressive symptoms on medical prognosis in patients with end-stage renal disease.

PURPOSE: To determine whether somatic or cognitive depressive symptoms affect hospitalization and death in patients with end-stage renal disease. DESIGN AND METHOD: In an observational retrospective design, the patients (n = 190) completed the Beck Depression Inventory-II at baseline and were followed for 5 years to collect data all-cause mortality and hospitalization. FINDINGS: High somatic (53.7%, n = 102) and cognitive (52.1%, n = 99) depressive symptoms scores significantly associated with mortality (38% vs. 19%; hazard ratio [HR] = 2; 95% CI, 1.1-3.7; p = 0.02) and hospitalization (62.5% vs. 49.4%; HR = 1.6; 95% CI, 1.0-2.6; p = 0.03), respectively. PRACTICE IMPLICATIONS: In the context of diagnosing and intervening, awareness of depressive symptoms dimensionality is crucial.

Spielberger's state anxiety inventory: development of a shortened version for critically ill patients.

The length of Spielberger's State Anxiety Inventory (SAI) makes its use difficult for critically ill populations. To shorten it, exploratory factor analysis was used with data from 530 acute myocardial infarction patients. The resulting 6-item shortened version demonstrated good internal reliability consistency with a Cronbach's alpha of .84. Construct validity of the shortened version was supported by strong correlations with the original SAI and the Brief Symptom Inventory (BSI), another measure of state anxiety, and through support of known hypotheses. This study offered a short version of the SAI with excellent psychometric properties that can be used in critically ill patients.

Pre-existing chronic kidney disease and acute kidney injury among critically ill patients.

BACKGROUND: The impact of pre-existing chronic kidney disease (CKD) and acute kidney injury (AKI) on health outcomes in critically ill patients is unclear. Yet, CKD complicated by AKI in critically ill patients is common. OBJECTIVES: To compare risk of death within one-month of admission in critically ill patients with and without pre-existing CKD who developed AKI. METHODS: A multicenter retrospective comparative study using medical records review was conducted. Study participants consisted of 826 adult patients who received mechanical ventilation for at least 6 h in the critical care units from January 2012 to December 2017. Assessment of kidney function was established by serum creatinine. Severity and staging of AKI were defined using RIFLE criteria: Risk, Injury, Failure, Loss and End stage of renal disease. Chronic kidney disease was defined as eGFR > 60 ml/mg/1.73 m2 on admission. RESULTS: Pre-existing CKD was present in 55% of patients and 7% had AKI within 7 days of admission. The overall mortality rate among these patients was 87.3%. The mortality rate was highest in patients with CKD (70.1%) followed by that of patients without pre-existing CKD but with AKI (20.7%) and that of patients with pre-existing CKD (7.1%) and AKI. Risks associated with mortality were APACHE II score (1.03; 95% CI 1.02-1.05;(P<0.001) and AKI (1.68; 95% CI 1.12-2.5;P<0.01) in patients with pre-existing CKD. Only APACHI-II (1.03; 95% CI 1.0-1.1; p < 0.001) was predictive of death in patients without pre-existing CKD. CONCLUSION: Pre-existing comorbid CKD increases risks of death among critically ill patients compared to patients without CKD and regardless of whether they develop AKI or not. Early identification of CKD and recognition of the risk for mortality among these patients may result in earlier intervention that could reduce mortality.

Risk profile of myocardial infarction in young versus older adults.

BACKGROUND: In developing countries, the number of adults who develop myocardial infarction (MI) at a young age is high. The popularity of waterpipe smoking (WPS) has increased among the same age group. It is unknown if WPS contributes to the incidence of early-onset MI. OBJECTIVE: To study the association of WPS with early-onset MI, which is defined as first MI occurring in individuals 18 ≥ age ≤ 45 years compared to those older than 45 years. METHODS: This was a cross-sectional study. The association of WPS with first-time MI was compared between younger and older adults (N = 225). RESULTS: Twenty-five percent of all participants developed an acute MI before the age of 46 years. Both cigarette and WPS were more common among younger first-time MI patients than older first-time MI patients. CONCLUSIONS: WPS is one risk factor that distinguishes the risk profile of young adults with early-onset MI.

Under-diagnosed chronic kidney disease in Jordanian adults: prevalence and correlates.

BACKGROUND: Jordan has no relevant database or registry by which chronic kidney disease (CKD) would be early identified. The purpose of the present study is to uncover the prevalence of CKD in a national sample of Jordanian patients at high risk and examine the association of CKD with demographic and clinical factors. METHODS: This is a cross-sectional, correlational study that involved 540 outpatients at high risk for CKD. Demographic and clinical data were obtained in the period from September 2013 to March 2014. Prevalence of CKD was defined based on the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Classification of CKD using estimated glomerular filtration rate. Associations of CKD and demographic and clinical factors were examined using bivariate analysis. RESULTS: The majority of the sample were females (64%), their mean age (±SD) was 55.0 ± 12.5 years, their mean eGFR (±SD) was 116.0 ± 47.5. One third of patients had eGFR of 23.5%, 5.4%, 0.7% and 0.7% which corresponds with mild, moderate, severe and very severe reduction in eGFR, respectively. Ageing, being male, unemployment, packs/years of smoking, co-morbidities [hypertension (HTN), diabetes mellitus (DM) and cardiovascular disease] and low high density lipoprotein (HDL) correlated positively with development of CKD. CONCLUSION: This study demonstrates a high rate of under-diagnosed CKD among Jordanians. Several demographic and clinical factors are linked with the development of CKD. Policymakers and healthcare providers need to establish an evidence-based practice project to prevent and screen for CKD in Jordan.

Awareness of modifiable acute myocardial infarction risk factors has little impact on risk perception for heart attack among vulnerable patients.

BACKGROUND: Poor awareness of modifiable risks for acute myocardial infarction (AMI) may explain the reported weak relationship between patients' actual and perceived risk for AMI. OBJECTIVES: To assess the level of awareness of modifiable risks and perceived vulnerability for AMI among Jordanian patients, and to determine their independent association. METHODS: This was a cross-sectional correlational study (N = 231). Perceived risk, awareness of risk factors and risk profile were collected by self-reports and medical chart review. RESULTS: Patients were mostly males (80%) and had a mean of 55.3 ± 12.6 years for age. Perceived and actual AMI risks were not highly congruent even though patients had, on average, two modifiable risks and were knowledgeable of them. Awareness of risk factors independently explained 3.5% of the variance in perceived risk. CONCLUSIONS: The risk for developing AMI is underestimated among cardiac patients and it is only weakly linked with their awareness of AMI risk factors.

Symptoms of acute myocardial infarction: A correlational study of the discrepancy between patients' expectations and experiences.

BACKGROUND: Patients' responses to acute myocardial infarction symptoms are affected by symptom incongruence, which is the difference between the symptoms they expect to experience and the symptoms they actually experienced during an acute myocardial infarction. OBJECTIVE: To examine the relationship of patients' demographics, clinical characteristics and sources of information about acute myocardial infarction with their symptom expectations, actual experiences and symptom incongruence. DESIGN: Descriptive correlational study. SETTING: Patients were recruited from ten hospitals in the two most populated cities in Jordan (Amman and Al Zarqa). PARTICIPANTS: Jordanian patients with acute myocardial infarction were recruited. Inclusion criteria were age 18 years or older, diagnosis of acute myocardial infarction, oriented, mentally competent and fluent in Arabic. Exclusion criteria were experiencing acute myocardial infarction during a hospitalization or having severe psychiatric illnesses. METHODS: The Morgan Incongruence of Heart Attack Symptoms Index was used to quantify symptom incongruence and identify patients' expected and experienced acute myocardial infarction symptoms. Patients' information sources about acute myocardial infarction and demographic and clinical characteristics were collected by interview and medical chart review. RESULTS: Patients (N=299) were mostly males (80%) and married (92%). The average age was 56±12.3 years. Patients expected a limited number of acute myocardial infarction symptoms and these expectations were largely confined to typical symptoms and matched their experiences. Patients who were female, elderly, nonsmokers, poorly educated, with low income, and those who were normolipidemic, had no personal or family cardiac history, and were informed about acute myocardial infarction by relatives expected fewer symptoms (mostly typical and atypical) than their counterparts. Elderly patients and those with hyperlipidemia experienced fewer typical symptoms than their counterparts. Patients with ST-elevation myocardial infarction or previous myocardial infarction experienced more symptoms than their counterparts, yet only the former had more typical complaints. Characteristics that improved patients' awareness of AMI symptoms were mostly similar to those that decreased symptom incongruence. CONCLUSIONS: Patients' expected and experienced acute myocardial infarction symptoms and symptom incongruence varied according to their demographic and clinical characteristics. Information sources that patients used to learn about acute myocardial infarction may contribute to symptom incongruence.