Demographic, belief, and situational factors influencing the decision to utilize emergency medical services among chest pain patients. Rapid Early Action for Coronary Treatment (REACT) study.

BACKGROUND: Empirical evidence suggests that people value emergency medical services (EMS) but that they may not use the service when experiencing chest pain. This study evaluates this phenomenon and the factors associated with the failure to use EMS during a potential cardiac event. METHODS AND RESULTS: Baseline data were gathered from a randomized, controlled community trial (REACT) that was conducted in 20 US communities. A random-digit-dial survey documented bystander intentions to use EMS for cardiac symptoms in each community. An emergency department surveillance system documented the mode of transport among chest pain patients in each community and collected ancillary data, including situational factors surrounding the chest pain event. Logistic regression identified factors associated with failure to use EMS. A total of 962 community members responded to the phone survey, and data were collected on 875 chest pain emergency department arrivals. The mean proportion of community members intending to use EMS during a witnessed cardiac event was 89%; the mean proportion of patients observed using the service was 23%, with significant geographic differences (range, 10% to 48% use). After controlling for covariates, non-EMS users were more likely to try antacids/aspirin and call a doctor and were less likely to subscribe to (or participate in) an EMS prepayment plan. CONCLUSIONS: The results of this study indicate that indecision, self-treatment, physician contact, and financial concerns may undermine a chest pain patient's intention to use EMS.

Knowledge of heart attack symptoms in a population survey in the United States: The REACT Trial. Rapid Early Action for Coronary Treatment.

BACKGROUND: Greater use of thrombolysis for patients with myocardial infarction has been limited by patient delay in seeking care for heart attack symptoms. Deficiencies in knowledge of symptoms may contribute to delay and could be a target for intervention. We sought to characterize symptom knowledge. METHODS: Rapid Early Action for Coronary Treatment is a community trial designed to reduce this delay. At baseline, a random-digit dialed survey was conducted among 1294 adult respondents in the 20 study communities. Two open-ended questions were asked about heart attack symptom knowledge. RESULTS: Chest pain or discomfort was reported as a symptom by 89.7% of respondents and was thought to be the most important symptom by 56.6%. Knowledge of arm pain or numbness (67.3%), shortness of breath (50.8%), sweating (21.3%), and other heart attack symptoms was less common. The median number of correct symptoms reported was 3 (of 11). In a multivariable-adjusted model, significantly higher mean numbers of correct symptoms were reported by non-Hispanic whites than by other racial or ethnic groups, by middle-aged persons than by older and younger persons, by persons with higher socioeconomic status than by those with lower, and by persons with previous experience with heart attack than by those without. CONCLUSIONS: Knowledge of chest pain as an important heart attack symptom is high and relatively uniform; however, knowledge of the complex constellation of heart attack symptoms is deficient in the US population, especially in low socioeconomic and racial or ethnic minority groups. Efforts to reduce delay in seeking medical care among persons with heart attack symptoms should address these deficiencies in knowledge.

Breast cancer worry and mammography use by women with and without a family history in a population-based sample.

Worry about breast cancer risk has been found to be a barrier to mammography use by women with a family history of breast cancer in some studies, although worry is generally found to increase mammography use among average risk women. Our study sought to examine the association of worry with mammography use in a population-based sample of women stratified by family history associated risk for breast cancer. A population-based sample of 6512 women completed a telephone interview. Fourteen percent (n = 948) of these reported a family history suggestive of elevated risk, including at least one affected first-degree relative. To examine the effects of worry on mammography use in women, a logistic regression model, including family history associated risk, age, and worry, was tested. Although family history was a significant predictor of mammography use in bivariate examinations, in the multivariate model it was not significant after adjustment for age and worry, which remained statistically significant predictors of mammography (P < 0.05). The association between worry and mammography use was best described by a quadratic term. Interaction terms for family history-associated risk and worry were not statistically significant predictors of mammography use. Worry about breast cancer risk appears to be associated with mammography use in an inverted u-shaped pattern. Women reporting moderate levels of worry were more likely to use mammography annually than those who were either mildly or severely worried. Severe worry may be a barrier to mammography use for all women not only those with a family history.

The effectiveness of mammography promotion by volunteers in rural communities.

INTRODUCTION: The Community Trial of Mammography Promotion assessed the effectiveness of mammography promotion by community volunteer groups in rural areas. Three interventions were tested. One used an individual counseling strategy, one used a community activities strategy, and a third combined the two strategies. METHODS: The effects of the interventions were tested by randomizing 40 communities either to the study interventions or to a control group. A cohort of 352 women from each community was randomly selected and used to evaluate the interventions' effectiveness. Of these, 6592 women were eligible for screening mammography at baseline and follow-up and were successfully interviewed prior to and after study intervention activities. RESULTS: Although the interventions did not significantly increase women's overall use of mammography, the community activities intervention increased use at follow-up by regular users over baseline by 2.9% (p = 0.01). Intervention appears to have increased the use of mammography among certain groups of women who were not regular users at baseline, including those in communities without female physicians (10% to 16%; p < 0.05), and among women with no health insurance (10% to 23%; p

REACT theory-based intervention to reduce treatment-seeking delay for acute myocardial infarction. Rapid Early Action for Coronary Treatment.

Coronary heart disease (CHD) remains the leading cause of mortality in the U.S. Innovations in reperfusion therapies can potentially reduce CHD morbidity and mortality associated with acute myocardial infarction (AMI) when treatment is initiated within the first few hours of symptom onset. However, delay in seeking treatment for AMI is unacceptably lengthy, resulting in most patients being ineligible for reperfusion therapies. The Rapid Early Action for Coronary Treatment (REACT) Trial is a four-year, 20-community, randomized trial to design and test the effectiveness of a multi-component intervention to reduce patient delay for hospital care-seeking for AMI symptoms. This manuscript describes the development and content of the theoretically-based REACT intervention and summarizes: (1) the research literature used to inform the intervention; (2) the behavioral theories used to guide the development, implementation, and evaluation of the intervention; (3) the formative research undertaken to understand better decision-making processes as well as barriers and facilitators to seeking medical care as perceived by AMI patients, their families, and medical professionals; (4) the intervention design issues that were addressed; (5) the synthesis of data sources in developing the core message content; (6) the conceptualization for determining the intervention target audiences and associated intervention components and strategies, their integration with guiding theoretical approaches and implementation theories for the study, and a description of major intervention materials developed to implement the intervention; and (7) the focus of the outcome, impact, and process measurement based on the intervention components and theories on which they were developed.

Causes of delay in seeking treatment for heart attack symptoms.

With the advent of thrombolytic therapy and other coronary reperfusion strategies, rapid identification and treatment of acute myocardial infarction greatly reduces mortality. Unfortunately, many patients delay seeking medical care and miss the benefits afforded by recent advances in treatment. Studies have shown that the median time from onset of symptoms to seeking care ranges from 2 to 61/2 hours, while optimal benefit is derived during the first hour from symptom onset. The phenomenon of delay by AMI patients and those around them needs to be understood prior to the design of education and counseling strategies to reduce delay. In this article the literature is reviewed and variables that increase patient delay are identified. A theoretical model based on the health belief model, a self regulation model of illness cognition, and interactionist role theory is proposed to explain the response of an individual to the signs and symptoms of acute myocardial infarction. Finally, recommendations are made for future research.

Prevalence of aspirin use among patients calling 9-1-1 for chest pain.

OBJECTIVE: Early aspirin administration during an acute myocardial infarction (AMI) decreases morbidity and mortality. This investigation examined the extent to which patients with a complaint of chest pain, the symptom most identified with AMI by the general population, self-administer aspirin before the arrival of emergency medical services (EMS) personnel. METHODS: In this prospective, cross-sectional prevalence study, data were derived through the analysis of EMS incident reports for patients with a complaint of chest pain from June 1, 1997, to August 31, 1997. RESULTS: The study included 694 subjects. One hundred two (15%) took aspirin for their chest pain before the arrival of EMS personnel. Of the 322 subjects who reported taking aspirin on a regular basis, 82 (26%) took additional aspirin for their acute chest pain. Only 20 (5%) of the 370 patients who were not using regular aspirin therapy self-administered aspirin acutely (p<0.001). In addition, patients with lower intensity of chest pain (p = 0.03) were more likely to take aspirin for their chest pain. CONCLUSION: Only a relatively small fraction of individuals calling 9-1-1 with acute chest pain take aspirin prior to the arrival of EMS personnel. These individuals are more likely to self-administer aspirin if they are already taking it on a regular basis. It is also possible that they are less likely to take aspirin if their chest pain is more severe.

Dispatcher assistance and automated external defibrillator performance among elders.

OBJECTIVES: Automated external defibrillators (AEDs) provide an opportunity to improve survival in out-of-hospital, ventricular fibrillation (VF) cardiac arrest by enabling laypersons not trained in rhythm recognition to deliver lifesaving therapy. The potential role of emergency dispatchers in the layperson use of AEDs is uncertain. This study was performed to examine whether dispatcher telephone assistance affected AED skill performance during a simulated VF cardiac arrest among a cohort of older adults. The hypothesis was that dispatcher assistance would increase the proportion who were able to correctly deliver a shock, but might require additional time. METHODS: One hundred fifty community-dwelling persons aged 58-84 years were recruited from eight senior centers in King County, Washington. All participants had received AED training approximately six months previously. For this study, the participants were randomized to AED operation with or without dispatcher assistance during a simulated VF cardiac arrest. The proportions who successfully delivered a shock and the time intervals from collapse to shock were compared between the two groups. RESULTS: The participants who received dispatcher assistance were more likely to correctly deliver a shock with the AED during the simulated VF cardiac arrest (91% vs 68%, p = 0.001). Among those who were able to deliver a shock, the participants who received dispatcher assistance required a longer time interval from collapse to shock [median (25th, 75th percentile) = 193 seconds (165, 225) for dispatcher assistance, and 148 seconds (138, 166) for no dispatcher assistance, p = 0.001]. CONCLUSIONS: Among older laypersons previously trained in AED operation, dispatcher assistance may increase the proportion who can successfully deliver a shock during a VF cardiac arrest.

Assessment of chest pain onset and out-of-hospital delay using standardized interview questions: the REACT Pilot Study. Rapid Early Action for Coronary Treatment (REACT) Study Group.

OBJECTIVE: To determine the consistency of responses to a standardized 2-part "key" question (Key-Q) about acute symptom onset in patients presenting with chest pain when measured using alternative questions (Qs) about symptom perception and decisions to seek treatment. METHODS: A structured patient interview was performed at 3 university teaching hospitals and 1 community hospital. Convenience samples of adult patients presenting to these EDs with chest pain were asked specific questions related to their symptoms and recognition of illness. Information obtained included the 2-part Key-Q: "What are the symptoms that brought you here today?" and "When did those symptoms start?" The alternative Qs (in order of use) were as follows: Q1 = "When did your very first symptom or sensation begin?"; Q2 = "When did your symptoms lead you to think something was wrong or that you were ill?"; Q3 = "When did your symptoms become serious enough for you to seek medical care?"; and Q4 = "When did you actually call 9-1-1/emergency medical services (EMS) or go to the hospital?" The documented ED arrival time, demographic variables, and whether the patient arrived by ambulance were obtained from the medical record. Patients also were queried regarding potential barriers to seeking medical care and their cardiac risk factors. RESULTS: Of the 135 patients surveyed, 9 were unsure of the date and time of symptom onset. For the 126 patients with analyzable data, the mean (+/- SD) patient age was 62 +/- 16 years, and 59% were male. The general sequence of events reported from acute symptom onset until hospital care was Q1/Key-Q-->Q2-->Q3-->Q4-->ED arrival. The median differences and interquartile ranges (IQRs) in minutes between Q times and the Key-Q response were: Q1 = 0 (0-0); Q2 = 30 (0-210); Q3 = 140 (30-720); Q4 = 265 (90-1,215); and ED arrival = 340 (120-1,230). The interval from the Key-Q response until calling 9-1-1/EMS or going to the hospital was shorter for those who used an ambulance and for those who did not consult a physician first. The interval from the Key-Q response until considering symptoms to be serious was shorter for those with a family history of heart disease, but longer for non-white patients. CONCLUSION: The Key-Q elicited a response recalled near the time of first symptoms and generally before the patient had concluded something was "wrong or that he or she was ill." Measurement of the out-of-hospital delay in chest pain patients using the Key-Q appears promising.

A health priorities model: application to mammography screening.

This study describes and empirically tests a health priorities model. This model predicts underuse of regular mammography screening among adult women within the larger health context in which such decisions are made. The model incorporates women's comparative illness threats, comparative importance of health behaviors, and demographic variables. A telephone survey was conducted with a sample of women (N = 887) older than 50, in 40 rural communities in the state of Washington. Logistic regression analyses showed that women who perceived themselves at low risk for getting breast cancer and/or who perceived another disease (i.e. heart attack) as an equal or greater threat than breast cancer were less likely to be regular screeners of mammography. In addition, women who perceived other health behaviors as more important than regular mammography screening were less likely to be regular screeners than those women who perceived regular mammography screening as more important. Current or anticipated health problems were not related to screening behavior. The results are discussed in light of the practical, theoretical, and empirical implications.

Health care providers' perspectives on patient delay for seeking care for symptoms of acute myocardial infarction.

To inform intervention development in a multisite randomized community trial, the Rapid Early Action for Coronary Treatment (REACT) project formative research was undertaken for the purpose of investigating the knowledge, beliefs, perceptions, and usual practice of health care professionals. A total of 24 key informant interviews of cardiologists and emergency physicians and 15 focus groups (91 participants) were conducted in five major geographic regions: Northeast, Northwest, Southeast, Southwest, and Midwest. Transcript analyses revealed that clinicians are somewhat unaware of the empirical evidence related to the problem of patient delay, are concerned about the practice constraints they face, and would benefit from concrete suggestions about how to improve patient education and encourage fast action. Findings provide guidance for selection of educational strategies and messages for health providers as well as patients and the public.

Barriers and facilitators to the prescription of automated external defibrillators for home use in patients with heart disease: a survey of cardiologists.

OBJECTIVE: Because the majority of cardiac arrests occur at home, the use of automated external defibrillators (AEDs) in the home could potentially improve survival of out-of-hospital cardiac arrest. Currently, physicians must prescribe AEDs for home use by patients. The purpose of this study was to investigate the barriers and facilitators to prescription of home use of AEDs. DESIGN: Telephone interviews were conducted with 85 cardiologists and paper and pencil surveys (via fax) with 59 additional cardiologists in Washington State. OUTCOME MEASURES: Cardiologists were asked about their current practices and their perceived barriers and facilitators to prescription of AEDs for home use. RESULTS: Eighty-five percent of the sample believed that AEDs could be effective in preventing death, although only 7% of the cardiologists had ever prescribed an AED. Reasons for nonprescription included the use of implantable cardioverter defibrillators, perceived lack of a clear patient niche, and lack of knowledge about the device. The majority of respondents reported that they would be more likely to prescribe AEDs if they were the standard of care (71%), were covered by insurance (67%), and came with comprehensive training (58%). CONCLUSION: The results showed that cardiologists believe that home use of AEDs can be effective but that many issues regarding the prescription of AEDs remain.

How women label and respond to symptoms of acute myocardial infarction: responses to hypothetical symptom scenarios.

OBJECTIVE: To investigate how women label and intend to respond to common and less common symptoms of acute myocardial infarction (AMI). DESIGN: Telephone interviews were conducted with 862 women older than age 50 years in the state of Washington. OUTCOME MEASURES: Intended coping strategies, labeling of hypothetical symptoms, perceived risk of AMI, knowledge of AMI symptoms, medical and family history of AMI and demographics. RESULTS: Women who labeled common or less common symptoms as a heart attack (65% and 36%, respectively) were more likely to report they would call 911 or go to a hospital right away than women who labeled these symptoms as something else. The results of a multiple logistic regression analysis suggests that knowledge of less common AMI symptoms, AMI information seeking, and personal risk perceptions were significant predictors of labeling less common symptoms as a heart attack. CONCLUSIONS: The findings suggest that many women might be in danger of mislabeling their symptoms and not taking appropriate action. Women need to be educated about the less common symptoms of AMI and need to be encouraged to seek out information regarding AMI.

Utilization of emergency medical services for symptoms of acute myocardial infarction.

OBJECTIVE: To examine patient characteristics and situational and clinical factors that affect utilization of Emergency Medical Services (EMS) for symptoms of acute myocardial infarction (AMI). DESIGN: Telephone interview of patients hospitalized with suspected AMI. SETTING: Nine hospitals in King County, Washington. PATIENTS: Patients admitted to a coronary or intensive care unit between October 1, 1986, and December 31, 1987, with suspected AMI occurring out of hospital. Spouses of patients who met criteria but died during the hospitalization also participated. OUTCOME MEASURES: Patient demographics, coping strategies, situational factors, prior cardiac history, perceived symptom severity, belief about the nature of condition, and method of transportation. RESULTS: Descriptive statistics showed that although few patients called EMS as a "first thing" in response to symptoms, almost half of all patients called EMS before being hospitalized. Stepwise logistic regression analyses revealed that being older, the belief that one was experiencing a heart attack, the presence of other people (including the spouse), and the lack of physical activity at time of symptom onset, were related to both greater and quicker utilization of EMS. Additionally, education, medical history of angina, and severity of symptoms also were related to utilization of EMS. CONCLUSION: The findings are discussed in a theoretical context, using Leventhal's self-regulatory model to suggest avenues for future research and interventions.

What can you teach about cardiopulmonary resuscitation (CPR) in 30 seconds? Evaluation of a television campaign.

This study evaluated an 8-month media campaign, implemented in western Washington, to educate people on the basic steps of cardiopulmonary resuscitation (CPR) for cardiac arrest. A telephone survey was conducted with a total of 384 adults randomly selected from two towns, one that had been exposed to the campaign (intervention town) and one that had not been exposed to the campaign (comparison town). Results showed that respondents in the intervention town were more likely than respondents in the comparison town to report (a) having heard messages on CPR in the past month, (b) having seen the CPR media campaign, and (c) knowing the three basic steps of CPR. Respondents who had seen the campaign evaluated it very favorably. There were no differences between respondent groups in self-reported CPR training or intentions to perform CPR, suggesting that the campaign had a greater impact on knowledge and awareness than on intentions and behavior.

Impact of direct mail intervention on knowledge, attitudes, and behavioral intentions regarding use of emergency medical services for symptoms of acute myocardial infarction.

This study evaluated a direct mail intervention called the "Call Fast, Call 911" campaign designed to increase use of emergency medical services for symptoms of acute myocardial infarction. The campaign was targeted at individuals over the age of 50. Persons over 50 years of age (N = 130,000) in King County, Washington, were randomly assigned to intervention or control groups. Individuals in the intervention groups received six direct mail pieces over a 1-year period encouraging them to call 911 quickly in response to chest pain. A postintervention telephone survey of a random sample of households (N = 434) assessed the impact of the campaign on knowledge, attitudes, and behavioral intentions regarding use of emergency medical services for symptoms of acute myocardial infarction. The results showed no significant differences between intervention and control groups in terms of knowledge of AMI. However, there were significant differences in beliefs and behavioral intentions to call 911 in a cardiac emergency.

Suspected lysosomal storage disease in kangaroos.

A probable neurovisceral lysosomal storage disease is reported, for the first time, in immature red and grey kangaroos (Macropus rufus and M. giganteus). Foamy, pale eosinophilic, periodic acid-Schiff positive, intracytoplasmic material was stored in the liver, lymphoid tissue, kidney, adrenal gland, stomach, blood vessels and central nervous system. Extensive Wallerian-type degeneration was present in the central nervous system. Electron microscopic study of one animal revealed electron dense, cytoplasmic lamellar bodies in neurons and foamy visceral cells. The disease differs from other reported storage diseases in the distribution and nature of the lesions.

Factors that influence personal perceptions of the risk of an acute myocardial infarction.

Personal risk perceptions of acute myocardial infarction (AMI) affect people's preventive health behaviors as well as their beliefs during a heart attack episode. The authors investigated factors that are associated with personal risk perceptions of having an AMI. A random-digit-dial survey was conducted among 1294 respondents, aged 18 years or older, in 20 communities across the nation as part of the Rapid Early Action for Coronary Treatment (REACT) trial. Results of two mixed-model linear regression analyses suggested that worse perceived general health, more risk factors, and greater knowledge were associated with greater perception of AMI risk. The results also showed that women who answered, incorrectly, that heart disease is not the most common cause of death for women in the United States reported significantly lower risk perceptions than women who answered this question correctly. The findings in this study suggest that interventions need to target specific misconceptions regarding AMI risk.

Experimental transmission of bovine papilloma virus (BPV) extracted from morphologically distinct teat and cutaneous lesions and the effects of inoculation of BPV transformed fetal bovine cells.

Bovine papilloma virus (BPV) was extracted from five cattle each affected with only one of five morphologically distinct lesion types. When inoculated into experimental calves either by scarification or intradermal injection, the BPV extracts produced lesions macroscopically and microscopically similar to those from which individual extracts were made. Fetal bovine cells, transformed in vitro with BPV, failed to produce fibromas, fibropapillomas or papillomas when inoculated into experimental calves. When calves inoculated with virus or BPV transformed cells were challenged with the five original BPV extracts, a differential immunity was demonstrated, while control calves were susceptible to all extracts. Post mortem examination revealed the presence of upper alimentary tract papillomas in three of eight calves forming one group. These results suggest that different strains of BVP, causing morphologically separable lesion types, exist. There may be additional BPV variants causing fibropapillomas of the teat and anogenital regions of cattle. The inoculation of BPV transformed fetal bovine cells conferred a relative immunity to later challenge with some but not all BPV extracts.

Filiform viral squamous papillomas on sheep.

Filiform squamous papillomas occur rarely on young sheep and correspond closely to those on cattle and other species; they lack the fibromatous component of papillomas reported previously. This paper describes microscopical, immunological and molecular evidence for the presence of a putative ovine papillomavirus in these lesions.