Health-Seeking Behavior of Afghan Women Immigrants: An Ethnographic Study.

BACKGROUND: Nowadays, in light of gender inequity, new concern has been raised for health-seeking behavior of women in clinical setting. The aim of this study was to investigate the perceptions and health-seeking behaviors of Afghan immigrant women residing in Mashhad, Iran. METHOD: An ethnographic design was used to examine the health-seeking behavior of Afghan women. This study took place in Tollab Tabarsi area of Mashhad, Iran, from March 2013 to July 2014. For gathering of data, participant observations, fieldwork, and formal interviews were included. Data were analyzed using thematic analysis. RESULTS: Fourteen Afghan women immigrants and five health care professionals were interviewed. The overarching category derived from the data was gender inequity. The emergent three themes were cultural taboos, women position, and information gap. DISCUSSIONS: The displaced Afghan women were found to be at significant risk of adverse health events, which affected both their physical health and mental health.

Perceptions of Adolescent Patients of the "Lived Experience" of Type 1 Diabetes.

The care and management of adolescents with type 1 diabetes presents numerous challenges that are inherent to the fears, attitudes, and perceptions of their illness. This qualitative study aimed to explore the "lived experience" of individuals with type 1 diabetes. In-depth interviews were conducted with 20 patients diagnosed with type 1 diabetes in their adolescent years to elicit their views, perceptions, and concerns regarding living with diabetes. All interviews were conducted and analyzed using the principles of grounded theory. Five categories defining the patients' lived experience were elicited: Barriers, Develop Skills, Manage Emotion, Social World, and Health Care Professionals. The problems experienced by adolescents with type 1 diabetes are multifactorial. Existentially, type 1 diabetes affects their daily activities and impinges on their academic achievement and personal aspirations. They have great difficulty coping with their health status and highlight a lack of empathy from health care professionals (HCPs). Their major fear is of hypoglycemia, resulting in their subsequent focus of preventing hypoglycemic episodes. Indeed, regardless of consequence, blood glucose levels are often deliberately kept above recommended levels, which serves to decrease the effectiveness of their health care management. This study shows that the quality of care provided for adolescent patients with type 1 diabetes is failing to meet their expectations and falls short of the essential standards commensurate with current health care policy. Improvements in long-term care management for these patients require changes in both patients' and professionals' understanding of the disease and of the ways it is managed.

Adhesive-enhanced sternal closure to improve postoperative functional recovery: a pilot, randomized controlled trial.

BACKGROUND: We previously established a proof-of-concept in a human cadaveric model where conventional wire cerclage was augmented with a novel biocompatible bone adhesive that increased mechanical strength and early bone stability. We report the results of a single-center, pilot, randomized clinical trial of the effects of adhesive-enhanced closure of the sternum on functional postoperative recovery. METHODS: In 55 patients undergoing primary sternotomy, 26 patients underwent conventional wire closure and were compared with 29 patients who underwent adhesive-enhanced closure, which consisted of Kryptonite biocompatible adhesive (Doctors Research Group Inc, Southbury, CT) applied to each sternal edge in addition to conventional 7-wire cerclage. Patients were monitored postoperatively at 72 hours, weekly for 12 weeks, and then after 12 months for incisional pain, analgesic use, and maximal inspiratory capacity measured by spirometry. Standardized assessment tools measured postoperative physical disability and health-related quality of life. RESULTS: No adverse events or sternal complications from the adhesive were observed early or after 12 months. Incisional pain and narcotic analgesic use were reduced in adhesive-enhanced closure patients. Inspiratory capacity was significantly improved, postoperative health-related quality of life scores normalized more rapidly, and physical disability scores were reduced. Computed tomography imaging was suggestive of sternal healing. CONCLUSIONS: Adhesive-enhanced closure is a safe and simple addition to conventional wire closure, with demonstrated benefits on functional recovery, respiratory capacity, incisional pain, and analgesic requirements. A large, multicenter, randomized controlled trial to examine the potential of the adhesive to prevent major sternal complications in higher risk patients is warranted.

Cardiac medication prescribing and adherence after acute myocardial infarction in Chinese and South Asian Canadian patients.

BACKGROUND: Failure to adhere to cardiac medications after acute myocardial infarction (AMI) is associated with increased mortality. Language barriers and preference for traditional medications may predispose certain ethnic groups at high risk for non-adherence. We compared prescribing and adherence to ACE-inhibitors (ACEI), beta-blockers (BB), and statins following AMI among elderly Chinese, South Asian, and Non-Asian patients. METHODS: Retrospective-cohort study of elderly AMI survivors (1995-2002) using administrative data from British Columbia. AMI cases and ethnicity were identified using validated ICD-9/10 coding and surname algorithms, respectively. Medication adherence was assessed using the 'proportion of days covered' (PDC) metric with a PDC ≥ 0.80 indicating optimal adherence. The independent effect of ethnicity on adherence was assessed using multivariable modeling, adjusting for socio-demographic and clinical characteristics. RESULTS: There were 9926 elderly AMI survivors (258 Chinese, 511 South Asian patients). More Chinese patients were prescribed BBs (79.7% vs. 73.1%, p = 0.04) and more South Asian patients were prescribed statins (73.5% vs. 65.2%, p = 0.001). Both Chinese (Odds Ratio [OR] 0.53; 95%CI, 0.39-0.73; p < 0.0001) and South Asian (OR 0.78; 95%CI, 0.61-0.99; p = 0.04) patients were less adherent to ACEI compared to Non-Asian patients. South Asian patients were more adherent to BBs (OR 1.3; 95%CI, 1.04-1.62; p = 0.02). There was no difference in prescribing of ACEI, nor adherence to statins among the ethnicities. CONCLUSION: Despite a higher likelihood of being prescribed evidence-based therapies following AMI, Chinese and South Asian patients were less likely to adhere to ACEI compared to their Non-Asian counterparts.

Examining and establishing translational and conceptual equivalence of survey questionnaires for a multi-ethnic, multi-language study.

AIM: This paper is a report of techniques used to examine and establish translational and conceptual equivalence of survey questionnaires. BACKGROUND: A major concern arose about standardization of translated survey questionnaires, when preparing to evaluate differences in acute coronary syndrome presentation in European (White), Chinese and South Asian patients. METHODS: The survey questionnaires were first translated by an accredited translation company. Between July and November 2009, materials were taken to like-speaking healthcare reviewers to ensure that the clinical meaning was appropriate. Like-speaking lay reviewers were then asked to make comment about grammar; meaning and understanding of questions; and any concerns about the suitability of graphics. A key informant from each language group reviewed all comments and worked with the investigators and the translation company to create final sets of survey questionnaires. RESULTS: Readability of the questionnaires (too complex or too basic) was the most common concern. A major discrepancy between ethnic groups arose about a graphic of 'squeezing' pain. A hand grasping a balloon was considered appropriate for European and South Asian groups, while a picture of a towel being wrung out was identified as more appropriate for the Chinese. There were no negative comments about the graphics. Soliciting key informants who were highly fluent in both English and the language under study was critical to ensure that the participants' feedback was appropriately reconciled. CONCLUSION: Traditional forward-backward translation of study materials is insufficient. Translation must be accompanied by a process whereby equivalence and acceptability are also established.

Tackling health literacy: adaptation of public hypertension educational materials for an Indo-Asian population in Canada.

BACKGROUND: Indo-Asians in Canada are at increased risk for cardiovascular diseases. There is a need for cultural and language specific educational materials relating to this risk. During this project we developed and field tested the acceptability of a hypertension public education pamphlet tailored to fit the needs of an at risk local Indo-Asian population, in Calgary, Alberta, Canada. METHODS: A community health board representing Calgary's Indo-Asian communities identified the culturally specific educational needs and language preferences of the local population. An adaptation of an existing English language Canadian Public Hypertension Recommendations pamphlet was created considering the literacy and translation challenges. The adapted pamphlet was translated into four Indo-Asian languages. The adapted pamphlets were disseminated as part of the initial educational component of a community-based culturally and language-sensitive cardiovascular risk factor screening and management program. Field testing of the materials was undertaken when participants returned for program follow-up seven to 12 months later. RESULTS: Fifty-nine English-speaking participants evaluated and confirmed the concept validity of the English adapted version. 28 non-English speaking participants evaluated the Gujarati (N = 13) and Punjabi (N = 15) translated versions of the adapted pamphlets. All participants found the pamphlets acceptable and felt they had improved their understanding of hypertension. CONCLUSIONS: Involving the target community to identify health issues as well as help to create culturally, language and literacy sensitive health education materials ensures resources are highly acceptable to that community. Minor changes to the materials will be needed prior to formal testing of hypertension knowledge and health decision-making on a larger scale within this at risk community.

Outcomes after acute myocardial infarction in South Asian, Chinese, and white patients.

BACKGROUND: Cardiac mortality rates vary substantially between countries and ethnic groups. It is unclear, however, whether South Asian, Chinese, and white populations have a variable prognosis after acute myocardial infarction (AMI). To clarify this association, we compared mortality, use of revascularization procedures, and risk of recurrent AMI and hospitalization for heart failure between these ethnic groups in a universal-access healthcare system. METHODS AND RESULTS: We used a population cohort study design using hospital administrative data linked to cardiac procedure registries from British Columbia and the Calgary Health Region Area in Alberta (1994 to 2003) to identify AMI cases. Patient ethnicity was categorized using validated surname algorithms. There were 2190 South Asian, 946 Chinese, and 38479 white patients with AMI identified. There was no significant difference in use of revascularization procedures between ethnic groups at 30 d and 1 year. Short-term (30-day) mortality was higher among Chinese relative to white patients (odds ratio, 1.23; 95% confidence interval, 1.02 to 1.48). There was no significant difference in 30-day mortality between South Asian and white patients. South Asian patients had a 35% lower relative risk of long-term mortality compared with white patients (hazard ratio, 0.65; 95% confidence interval, 0.57 to 0.72). There was no significant difference in long-term mortality between Chinese and white patients. Among AMI survivors, Chinese patients had a lower risk of recurrent AMI, whereas there was no difference between South Asian and white patients. CONCLUSION: The ethnic groups studied have striking differences in outcomes after AMI, with South Asian patients having significantly lower long-term mortality after AMI.

Kryptonite bone cement prevents pathologic sternal displacement.

BACKGROUND: Wire cerclage closure of sternotomy is the standard of care despite evidence of pathologic sternal displacement (> 2 mm) during physiologic distracting forces (coughing). Postoperative functional recovery, respiration, pain, sternal dehiscence, and infection are influenced by early bone stability. This translational research report provides proof-of-concept (part A) and first-in-man clinical data (part B) with use of a triglyceride-based porous adhesive to rapidly enhance the stability of conventional sternal closure. METHODS: In part A, fresh human cadaver blocks were subjected to midline sternotomy and either conventional wire closure or modified adhesive closure. After 24 hours at 37 degrees C, using a biomechanical test apparatus, a step-wise increase in lateral distracting force simulated physiologic stress. Sternal displacement was measured by microdisplacement sensors. In part B, a selected clinical case series was performed and sternal perfusion assessed by serial single photon emission computed tomography imaging. RESULTS: Wire closure resulted in measurable bony displacement with increasing load. Pathologic displacement (> or = 2 mm) was observed in all regional segments at loads 400 newton (N) or greater. In contrast, adhesive closure completely eliminated pathologic displacement at forces 600 N or less (p < 0.001). In patients, adhesive closure was not associated with adverse events such as adhesive migration, embolization, or infection. There was excellent qualitative correlation between cadaver and clinical computed tomographic images. Sternal perfusion was not compromised by adhesive closure. CONCLUSIONS: This first-in-man series provides proof-of-concept indicating that a novel biologic bone adhesive is capable of rapid sternal fixation and complete elimination of pathologic sternal displacement under physiologic loading conditions. A randomized clinical trial is warranted to further define the potential risks and benefits of this innovative technique.

Home care utilization and outcomes among Asian and other Canadian patients with heart failure.

BACKGROUND: Heart failure (HF) is a major cause of hospitalization and death in the aging population around the world. Home care utilization is associated with improved survival for the patients with HF, and varies by ethno-culture. The purpose of this study was to investigate the difference in hospital readmission rate and mortality between Asian and other Canadian HF patients. METHODS: HF patients were identified using hospital discharge abstracts from March 31, 2000 to April 1, 2006 in Calgary Health Region. Readmission and one-year mortality for HF were determined by linking hospital discharge and vital statistics data. Stratified by home care services use, readmission and mortality rates were compared between the Asians and other Canadians while controlling for age, sex, comorbidities, and household income. RESULTS: Of 26,171 HF patients discharged from hospital, 56.6% of Asians and 58.0% of other Canadians used home care services [adjusted odds ratio (OR) for Asian: 0.84, 95% confidence interval (CI): 0.74-0.89]. The hospital readmission rate was similar between Asians and other Canadians regardless of home care services use. Mortality was similar between those who used home care services (adjusted OR for Asian: 0.96, 95% CI: 0.81-1.13). For patients who did not use home care services, Asians had significantly lower mortality than other Canadians (adjusted OR for Asian: 0.76, 95% CI: 0.60-0.86). CONCLUSION: Mortality was similar between Asian and other Canadian patients when home care services were utilized. However, among those without home care, Asian patients had a significantly lower mortality than other Canadian patients.

Using social exchange theory to guide successful study recruitment and retention.

Participant attrition (withdrawal or loss after entering a study) is a major threat to the completion of valid studies. It can result in systematic error (selection bias), thus decreasing the statistical power of studies and limiting the generalisability of study findings. This paper demonstrates how key social exchange theory principles form the theoretical context for our practice, which, in turn enables us to form enduring relationships with study participants.

Functional and psychosocial outcomes 1 year after mild stroke.

BACKGROUND: Mild stroke survivors are generally discharged from acute care within a few days of the stroke event, often without rehabilitation follow-up. We aimed to examine the recovery trajectory for male patients and their wife-caregivers during the 12 months postdischarge. METHODS: A descriptive study was undertaken to examine functional outcomes, quality of life (QOL), depression, caregiver strain, and marital function in a prospective cohort of male survivors of mild stroke and their wife-caregivers during the 12 months postdischarge. Data from each point in time were summarized and repeated measures analyses undertaken. Logistic regression was used to determine which baseline demographic and biopsychosocial variables influenced or predicted marital functioning 1 year postdischarge. RESULTS: A total of 38 male patients (mean age 63.4 years) and their wife-caregivers (mean age 58.5 years) were examined. The median discharge National Institutes of Health Stroke Scale score was 1.5, modified Rankin Scale score was 1.0, Barthel Index was 100.0, and Stroke Impact Scale-16v2 score was 78.5. The patients' modified Rankin Scale (function) and QOL scores improved significantly over time (F (2) = 4.583, P = .017; and F (6) = 5.632, P < .001, respectively). However, the wife-caregiver QOL scores did not change. Multivariate analysis revealed overall worsening of depression for both the patient and wife-caregivers (F (6, 32) = 3.087, P = .017) and marital function (F (6, 32) = 3.961, P = .004), although the wife-caregivers' perceptions of caregiver strain improved (F (6, 32) = 3.923, P = .007). None of the measured variables were associated with marital functioning 1 year postdischarge. CONCLUSIONS: Despite improvement in patients' functional status, other patient and wife-caregiver psychosocial outcomes during the 12 months postdischarge may be negatively affected. Thus, attention needs to focus on recovery beyond functional outcomes.

Achieving interprofessional practice in cardiac rehabilitation.

PURPOSE: Cardiac rehabilitation staff members consider interprofessional practice to be the standard for delivering effective care. However, it is not known how interprofessional teams collaborate or what they consider to be important elements of collaboration. Thus, it is important to investigate how healthcare professionals plan and communicate care, work together, and define their roles as members of the cardiac rehabilitation teams. The purpose of this report was to provide an analysis of current literature related to interprofessional practice in cardiac rehabilitation, with a particular focus on examining the terms interprofessional practice and collaboration. METHODS: For this review, published articles in peer-reviewed journals for the preceding 20-year period were included from online databases (CINAHL, MEDLINE, EBM Reviews, PubMed, and Google Scholar). Key words used in the search included "cardiac rehabilitation," "cardiac recovery," and "interprofessional and interdisciplinary practice and collaboration." Of the 67 articles reviewed, 7 met inclusion criteria specifically addressing interprofessional practice in cardiac rehabilitation. RESULTS: Analysis revealed that (1) the terms interprofessional and multidisciplinary are commonly used interchangeably in healthcare, revealing a lack of clarity regarding interprofessional practices and approaches, and (2) there are few articles that clearly describe, define, or discuss interprofessional practice or collaboration in cardiac rehabilitation settings, rendering it difficult for practitioners to adhere to published practice guidelines. CONCLUSION: It is unclear why and how professional team members practice in specific ways to form cardiac teams. Further research is required to increase an understanding of these issues and to develop possibilities for the enhancement of cardiac rehabilitation practice.

Risk-taking attitudes and their association with process and outcomes of cardiac care: a cohort study.

BACKGROUND: Prior research reveals that processes and outcomes of cardiac care differ across sociodemographic strata. One potential contributing factor to such differences is the personality traits of individuals within these strata. We examined the association between risk-taking attitudes and cardiac patients' clinical and demographic characteristics, the likelihood of undergoing invasive cardiac procedures and survival. METHODS: We studied a large inception cohort of patients who underwent cardiac catheterization between July 1998 and December 2001. Detailed clinical and demographic data were collected at time of cardiac catheterization and through a mailed survey one year post-catheterization. The survey included three general risk attitude items from the Jackson Personality Inventory. Patients' (n = 6294) attitudes toward risk were categorized as risk-prone versus non-risk-prone and were assessed for associations with baseline clinical and demographic characteristics, treatment received (i.e., medical therapy, coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI)), and survival (to December 2005). RESULTS: 2827 patients (45%) were categorized as risk-prone. Having risk-prone attitudes was associated with younger age (p < .001), male sex (p < .001), current smoking (p < .001) and higher household income (p < .001). Risk-prone patients were more likely to have CABG surgery in unadjusted (Odds Ratio [OR] = 1.21; 95% CI 1.08-1.36) and adjusted (OR = 1.18; 95% CI 1.02-1.36) models, but were no more likely to have PCI or any revascularization. Having risk-prone attitudes was associated with better survival in an unadjusted survival analysis (Hazard Ratio [HR] = 0.78 (95% CI 0.66-0.93), but not in a risk-adjusted analysis (HR = 0.92, 95% CI 0.77-1.10). CONCLUSION: These exploratory findings suggest that patient attitudes toward risk taking may contribute to some of the documented differences in use of invasive cardiac procedures. An awareness of these associations could help healthcare providers as they counsel patients regarding cardiac care decisions.

Using the cardiac depression scale in men recovering from coronary artery bypass surgery.

AIMS: To examine the utility and validate the use of the Cardiac Depression Scale in patients who had first-time coronary artery bypass graft surgery. BACKGROUND: The Beck Depression Inventory, though frequently used, may not be sufficiently sensitive for use in cardiac patients. The Cardiac Depression Scale has been shown to identify the range of depression in medical cardiac patients. DESIGN: Survey. METHODS: The Beck Depression Inventory and Cardiac Depression Scale were administered to 120 men at hospital discharge, as well as six, 12 and 36 weeks postoperatively. Cronbach's alpha scores were calculated for the measures at each point. Changes in scores over time were analysed using repeated measures analysis of variance. Associations between the measures scores were calculated using Pearson product-moment correlations. Agreement between the measures' dichotomised scores (depression/no depression) was examined using Cohen's Kappa statistic. RESULTS: Internal consistency was similar for the Beck Depression Inventory (0.793-0.904) and Cardiac Depression Scale (0.859-0.910). Depression scores decreased over time with the Beck Depression Inventory [F(2.50, 175.29) = 22.27, p < 0.001] and Cardiac Depression Scale [F(2.68, 190.37) = 13.18, p < 0.001]. The measures had similar power [Cohen's f = 0.65 (Beck Depression Inventory) and 0.43 (Cardiac Depression Scale)] to reveal changes over time. The continuous scores were highly correlated at each point [0.737 (p < 0.001)-0.819 (p < 0.001)]. However, when dichotomised scores were compared, the chance corrected level of agreement was less impressive [0.198 (p = 0.014)-0.381 (p < 0.001)]. CONCLUSIONS: The Cardiac Depression Scale may have utility for use with surgical cardiac patients. However, continued examination of this measure of depression is warranted. RELEVANCE TO CLINICAL PRACTICE: Given the prevalence of depression and its negative impact on coronary artery disease, it is important to identify even mild depression in cardiac patients. Using a measure of depression specifically for cardiac patients, rather than a generic measure, may best accomplish this goal.

Ethnic variation in acute myocardial infarction presentation and access to care.

Given the growing ethnic diversity in Canada, it is essential to recognize potential ethnic variability in acute myocardial infarction (AMI) symptoms to increase timely and effective treatment. We thus examined ethnic variation in symptom presentation and access to care of patients presenting to the emergency department (ED) with AMI. A random sample of 406 health records of Caucasian, Chinese, South Asian, Southeast Asian, and First Nations patients discharged from hospitals in the Calgary Health Region (Alberta, Canada) was audited. Measured variables were compared across ethnic groups and associations with classic AMI symptom profile and timely presentation to a hospital were examined. Chinese, South Asian, and Southeast Asian patients were 64% to 69% less likely than Caucasian patients to have a classic symptom profile reported and were less likely to speak English than their Caucasian and First Nations counterparts (p <0.001). Thirty-nine percent of patients who had a reported distinct time of symptom onset waited >12 hours to present to the ED; even in patients who presented with a classic symptom profile, South Asians were 70% less likely than Caucasians to report to the ED within 3 hours of symptom onset. Caucasians were significantly more likely to undergo angiography within 3 hours of presentation to the ED (42%, p = 0.001). In conclusion, explanatory variables associated with variability in symptom presentation and access to care associated with ethnicity require further exploration to ultimately develop effective strategies aimed at increasing timely presentation and care access.

Experiences of male patients and wife-caregivers in the first year post-discharge following minor stroke: a descriptive qualitative study.

BACKGROUND: Most patients with minor stroke are discharged directly home from acute care, under the assumption that little will be required in the way of adaptation and adjustment because informal caregivers will manage the stroke recovery process. We explored male patients with minor stroke and their wife-caregivers' perceptions of factors affecting quality of life and caregiver strain encountered during the first year post-discharge. METHODS: Data were obtained from responses to two open-ended questions, part of quality of life and caregiver strain scales administered to participants in a larger descriptive study. Conventional content analysis was used to assess narrative accounts of living with minor stroke provided by 26 male patients and their wife-caregivers over a period of 1-year post-discharge. RESULTS: Two major themes that emerged from these data were 'being vulnerable' and 'realization'. Subthemes that arose within the vulnerability theme included changes to patients' masculine image and wife-caregivers' assumption of a hyper-vigilance role. In terms of 'realization' patients and their wife-caregivers shared 'loss' as well as 'changing self and relationships'. Patients in this study focused primarily on their physical recovery and their perceptions of necessary changes. Wife-caregivers were actively involved in managing the day-to-day demands that stroke placed on individual, family and social roles. CONCLUSIONS: We conclude that patients and wife-caregivers expend considerable time and energy reestablishing control of their lives following minor stroke in an attempt to incorporate changes to self and their relationship into the fabric of their lives.

The influence of coronary artery bypass graft harvest site on women's pain, functional status, and health services utilization throughout the first post-operative year: a longitudinal study.

BACKGROUND: Coronary artery bypass graft surgery is a commonly performed procedure aimed at managing coronary symptoms and prolonging life. Researchers have typically examined morbidity and mortality outcomes of predominantly male populations. Less is known about the influence of graft harvest site on recovery outcomes such as surgery-related pain, functional status, and health services utilization, especially in women. OBJECTIVES: We aimed to examine the relationships between coronary artery bypass graft harvest site (saphenous vein, internal mammary arteries or both) and surgery-related pain, functional status, health services use at 6 weeks, 12 weeks and 12 months post-operatively. DESIGN: Longitudinal extension survey following participation in a clinical trial. SETTING: Ten Canadian centres. PARTICIPANTS: Women (222) who participated in the Women's Recovery from Sternotomy Trial, underwent coronary artery bypass graft surgery with or without heart valve surgery, and completed the 12-month follow-up interview. METHODS: Harvest site data were collected by health record audit at the time of hospital discharge. Surgery-related pain, functional status, pain medication use and health services use data were collected by standardized interview over the telephone at 6 weeks, 12 weeks and 12 months post-operatively. Surgery-related pain and functional status were measured using the short Health Assessment Questionnaire. Health services use was measured by questionnaire and recorded as reported by the participants. RESULTS: Surgery-related pain, functional disability and health services use decreased over the first post-operative year. Participants who had left internal mammary artery grafts were more likely to have surgery-related pain (Adjusted Odds Ratio (AOR)=2.79; 95% Confidence Interval (CI) 1.40-5.70) and use pain medication (AOR=4.32; 95% CI 1.44-12.91) than those who had saphenous vein grafts. Conversely, participants who had saphenous vein grafts reported significantly more functional disability (AOR=2.63; 95% CI 1.16-6.25) over 12 months post-surgery than those with left internal mammary artery grafts. Participants who had pain over the course of follow-up were more likely to visit their family physician or nurse practitioner (p=0.017), visit another type of provider (i.e., naturopath or chiropractor, p=0.004), or use any health care service (p<0.0001). CONCLUSIONS: Following coronary artery bypass graft surgery, women who had left internal mammary artery grafts reported more pain and health services use while those who had saphenous vein grafts were more functionally disabled. Women who reported surgery-related pain also used more health services.

Elevated body mass index and use of coronary revascularization after cardiac catheterization.

BACKGROUND: Obese persons suffer discrimination in society that may extend to health care use. We investigated whether overweight and obese patients are as likely to undergo coronary reperfusion or revascularization as patients of normal body weight. METHODS: Detailed clinical data were collected for an inception cohort of patients from Alberta, Canada, who underwent cardiac catheterization between April 2001 and March 2004. The patients' likelihood of receiving any revascularization, percutaneous coronary intervention, or coronary artery bypass graft surgery in the year after cardiac catheterization was examined on the basis of body mass index (BMI) grouping. Use of revascularization was examined separately for patients with high- and low-risk coronary disease. RESULTS: Of 27,460 patients who had BMI data recorded, 24% were of normal weight, 42% were overweight, and 35% were obese. Although overweight and obese patients were more likely to have percutaneous coronary intervention (adjusted hazard ratio [HR]=1.07, 95% confidence interval [CI], 1.01-1.12 and HR 1.08, 95% CI, 1.01-1.13, respectively), obese patients (BMI>30) were less likely to receive coronary artery bypass graft surgery (adjusted HR=0.93, 95% CI, 0.87-1.00). This was primarily because of less use of coronary artery bypass graft surgery for the most obese patients (obesity class III) with low-risk coronary anatomy (adjusted HR=0.61, 95% CI, 0.36-1.02). CONCLUSION: The pattern of use of revascularization procedures after cardiac catheterization differs somewhat across BMI subgroups. These differences might be clinically appropriate, but they warrant further exploration.

A descriptive examination of the impact of sternal scar formation in women.

Formation of abnormal scars is a significant source of morbidity following sternotomy. We undertook a descriptive exploratory mixed methods study of women (n=13) who participated in the Women's Recovery from Sternotomy Trial to examine the: (1) qualitative impact of the cosmetic result of sternotomy, and (2) quantitative association between subjective satisfaction and objective ratings of the sternal scar. Conventional content analysis was used to analyze the data generated from semi-structured interviews. Though the participants appreciated that having the scar was a cost of reaping the benefits of having cardiac surgery, they were not well prepared to learn to live with the scar. The scar was a poignant personal reminder that they had a health problem and underwent a distressing surgery, and it often rendered them feeling less attractive. The scar also had a public presence that they perceived rendered judgment from others. There was little association between the participants' subjective satisfaction (rated on a likert-type scale) and the objective scar rating using the Beausang Clinical Scar Assessment (r=0.348, p=0.294). The subjective perception of the sternal scar is of importance to women. Thus, appropriate preparation, post-operative counseling and support regarding the sternal scar are warranted.

A randomized trial of the effect of community pharmacist and nurse care on improving blood pressure management in patients with diabetes mellitus: study of cardiovascular risk intervention by pharmacists-hypertension (SCRIP-HTN).

BACKGROUND: Blood pressure (BP) control in patients with diabetes mellitus is difficult to achieve and current patterns are suboptimal. Given increasing problems with access to primary care physicians, community pharmacists and nurses are well positioned to identify and observe these patients. This study aimed to determine the efficacy of a community-based multidisciplinary intervention on BP control in patients with diabetes mellitus. METHODS: We performed a randomized controlled trial in 14 community pharmacies in Edmonton, Alberta, Canada, of patients with diabetes who had BPs higher than 130/80 mm Hg on 2 consecutive visits 2 weeks apart. Care from a pharmacist and nurse team included a wallet card with recorded BP measures, cardiovascular risk reduction education and counseling, a hypertension education pamphlet, referral to the patient's primary care physician for further assessment or management, a 1-page local opinion leader-endorsed evidence summary sent to the physician reinforcing the guideline recommendations for the treatment of hypertension and diabetes, and 4 follow-up visits throughout 6 months. Control-arm patients received a BP wallet card, a pamphlet on diabetes, general diabetes advice, and usual care by their physician. The primary outcome measure was the difference in change in systolic BP between the 2 groups at 6 months. RESULTS: A total of 227 eligible patients were randomized to intervention and control arms between May 5, 2005, and September 1, 2006. The mean (SD) patient age was 64.9 (12.1) years, 59.9% were male, and the mean (SD) baseline systolic/diastolic BP was 141.2 (13.9)/77.3 (8.9) mm Hg at baseline. The intervention group had an adjusted mean (SE) greater reduction in systolic BP at 6 months of 5.6 (2.1) mm Hg compared with controls (P = .008). In the subgroup of patients with a systolic BP greater than 160 mm Hg at baseline, BP was reduced by an adjusted mean (SE) of 24.1 (1.9) mm Hg more in intervention patients than in controls (P < .001). CONCLUSION: Even in patients who have diabetes and hypertension that are relatively well controlled, a pharmacist and nurse team-based intervention resulted in a clinically important improvement in BP. Trial Registration clinicaltrials.gov Identifier: NCT00374270.