eHealth technology use and eHealth literacy after percutaneous coronary intervention.

AIMS: Electronic health (eHealth) sources have great potential to improve patients' access to health information for self-management of secondary prevention after percutaneous coronary intervention (PCI). It remains unclear, however, whether patients are health-related digitally active and whether they have sufficient eHealth literacy. This study aimed to determine the extent to which patients after PCI are health-related digitally active at baseline, 2 and 6 months after PCI, and to determine the association between patients' eHealth literacy and their health-related digital activity. METHODS AND RESULTS: This multicentre cohort study included patients at three large referral PCI centres in Norway (n = 1970). Data were collected from medical records, national registries, and patients' self-reports. The eHealth Literacy Scale (eHEALS) assessed patients' eHealth literacy. At baseline, 67% had used the internet to find health information. The mean eHEALS score was 25.71 (standard deviation 6.22), illustrating a lower level of eHealth literacy. There were substantial associations between eHealth literacy and use of the internet to find health information [coefficient 10.90, 95% confidence interval (CI) 8.05-14.57]. At the 2-month follow-up, there were substantial associations between baseline eHealth literacy and use of the internet to find information about health, prevention, illness, or treatment [odds ratio (OR) 1.19, 95% CI 1.14-1.24] and use of health applications (OR 1.15, 95% CI 1.08-1.22). CONCLUSION: This study provides evidence that patients' level of eHealth literacy after PCI is associated to how patients use, and can make use of, eHealth technology for health information. REGISTRATION: ClinicalTrials.gov (NCT03810612).

Incretins as a novel therapeutic strategy in patients with diabetes and heart failure.

Heart failure (HF) and diabetes mellitus (DM) commonly co-exist, with a prevalence of DM of up to 40 % in HF patients. Treatment of DM in patients with HF is challenging since many of the contemporary therapies used for the treatment of DM are either contraindicated in HF or are limited in their use due to the high prevalence of co-morbidities such as significant renal dysfunction. This article presents an overview of the physiology of the incretin system and how it can be targeted therapeutically, highlighting implications for the management of patients with DM and HF. Receptors for the incretin glucagon-like peptide-1 (GLP-1) are expressed throughout the cardiovascular system and the myocardium and are up-regulated in HF. GLP-1 therapy improves cardiac function in animal models of HF through augmented glucose uptake in the myocardium mediated through a p38 MAP kinase pathway. Small clinical studies have shown that GLP-1 improves ejection fraction, reduces BNP levels and enhances functional capacity in patients with chronic HF. A number of randomized controlled trials are currently underway to define the utility of targeting the incretin system in HF patients with DM. Incretin-based therapy may represent a novel therapeutic strategy in the treatment of HF patients with diabetes, in particular for their cardioprotective effects independent of those attributable to tight glycemic control.

Organic dust exposure increases mast cell tryptase in bronchoalveolar lavage fluid and airway epithelium of heaves horses.

BACKGROUND: Mast cell degranulation is believed to act as a key event in initiating and maintaining airway response to allergen challenge in human asthma. It is hypothesized that the mast cell may play a similar role in equine heaves, which shares many similarities with occupational dust-induced asthma. OBJECTIVE: The aim of this study was to quantify the mast cell proteinase tryptase in bronchoalveolar lavage fluid (BALF) from control and heaves-susceptible horses and to investigate tryptase mRNA and protein expression in pulmonary mast cells. METHODS: Equine BALF tryptase concentrations were determined by ELISA from control and heaves-susceptible horses pre and post 24 h hay/straw challenge (HSC). Tryptase mRNA and protein expression were investigated by quantitative PCR and immunohistochemistry in bronchial and bronchiolar tissue samples of control and heaves-susceptible horses. RESULTS: Both control and heaves-susceptible horses had significantly increased BALF tryptase concentrations following HSC (P=0.003 and 0.034, respectively). Increased numbers of tryptase-expressing intra-epithelial mast cells were demonstrated in heaves horses, but not controls, following challenge (P=0.02). Bronchiolar tissue from heaves horses removed from challenge contained significantly lower tryptase transcripts than that from control horses (P=0.02). CONCLUSION: Mast cell degranulation and tryptase release into the airways occur following HSC of control and heaves-susceptible horses. The greater number of mast cells available in the bronchiolar epithelium of heaves horses may be clinically significant in the pulmonary inflammatory response of heaves.

Comparison of the antioxidant status in tracheal and bronchoalveolar epithelial lining fluids in recurrent airway obstruction.

REASONS FOR PERFORMING STUDY: Following a period of airway inflammation the clearance of inflammatory cells along the mucociliary escalator may impose a considerable oxidant load on the trachea. OBJECTIVES: To determine the degree of oxidative stress in tracheal epithelial lining fluid (ELF) in comparison to that present in peripheral airways after an acute exposure to organic dust. METHODS: Tracheal wash fluid and bronchoalveolar lavage fluid (BALF) were collected for cytology and antioxidant analyses from 6 recurrent airway obstruction (RAO)-affected horses and 6 healthy control horses before and after stabling on straw bedding for 24 h. RESULTS: In RAO-affected horses, organic dust exposure resulted in a significant decrease in ascorbic acid concentration in tracheal ELF (P<0.0001), which was greater than the decrease in bronchoalveolar ELF (P = 0.0003). The percentage decrease in tracheal ELF ascorbic acid correlated with the percentage decrease in bronchoalveolar ELF ascorbic acid (r = 0.76; P = 0.004) following exposure. CONCLUSIONS: Acute organic dust exposure results in significant antioxidant depletion in the trachea, which may reflect inflammation and oxidative processes in peripheral airways. POTENTIAL RELEVANCE: Further work is required to evaluate the role of ascorbic acid depletion in the pathogenesis of RAO.

Changes in selected physiological and laboratory measurements in elite horses competing in a 160 km endurance ride.

REASON FOR PERFORMING STUDY: Limited information exists about the physiological changes and clinical problems that occur in elite horses competing in high-speed 160 km endurance races. OBJECTIVES: To provide initial data describing changes in physiological and laboratory measurements in horses competing in a high-speed, 160 km endurance race under temperate conditions and to compare data between horses that successfully completed the race and those that failed to finish. METHODS: Body mass (BM) was measured, blood samples were collected, and veterinary examinations performed on horses before, during, and at the finish of a CEI*** 160 km endurance race. RESULTS: Of 36 horses participating in the study, 22 (61%) completed the race. Twelve horses were eliminated for lameness and 2 for persistent heart rate elevation. Mean speed of finishers was 15.2 km/h. Mean +/- s.d. BM loss of finishers at the end of the race (5.7 +/- 2.6%) was not different (P = 0.58) from BM loss of nonfinishers at elimination (6.7 +/- 34%). Similarly, there were no significant differences in heart rate or veterinary assessment of hydration at the race end for finishers as compared to the elimination point for nonfinishers. PCV increased while sodium, chloride and potassium concentrations decreased with exercise but differences between finishers and nonfinishers were not detected. In contrast, both total and ionised calcium concentrations decreased in successful horses but remained unchanged in nonfinishers. CONCLUSIONS: Elite endurance horses are more likely to be eliminated from competition for lameness than metabolic problems; however, it remains unclear whether these conditions are entirely distinct. The magnitude of the decrease in sodium concentration in both finishers and nonfinishers was greater than in previous reports of 160 km rides. POTENTIAL RELEVANCE: These data should be of use for both organisers and participants in elite 160 km endurance races. The tendency toward hyponatraemia as well as the difference in calcium concentrations between finishers and nonfinishers warrant further study.

Retrospective study of predictive variables for maximal heart rate (HRmax) in horses undergoing strenuous treadmill exercise.

REASONS FOR PERFORMING STUDY: Heart rate is one of the most commonly measured variables in equine exercise physiology and relative exercise intensity commonly expressed as % of maximal heart rate. A number of influences affect maximal heart rate (HRmax), including age of the horse but other factors have not been described. OBJECTIVES: To determine if fitness, health status, gender, breed, athletic use, body mass, in addition to age, are predictive of HRmax in the horse. METHODS: Maximal heart rate data from 328 horses which underwent treadmill exercise tests at 5 different laboratories were obtained retrospectively. Univariable linear regression analyses were performed on individual variables. Multiple linear regression analysis using a backward elimination modelling procedure was then used to relate the observed HRmax values simultaneously with different predictive variables. Variables were retained in the final regression model if they or any of their categories were significantly predictive of HRmax at P<0.05 and if there was a significant collective contribution to the model from inclusion of each variable, also at P<0.05. RESULTS: Age, fitness status, laboratory, gender and breed/use (combined category) were all statistically significantly predictive of HRmax. Together these variables accounted for 41% of the variance in HRmax. Age alone accounted for only approximately 13% of the variation between horses in HRmax. Neither body mass nor health status were significantly predictive. CONCLUSIONS: HRmax in the horse declines with age but is also influenced by other factors. As the factors investigated accounted for only 41% of the variation between horses, other unidentified variables with a strong influence on HRmax remain to be identified. POTENTIAL RELEVANCE: Factors such as fitness, age, gender, breed and use need to be considered when interpreting estimates or measurements of HRmax.

The effect of inspired gas density on pulmonary artery transmural pressure and exercise induced pulmonary haemorrhage.

REASONS FOR PERFORMING STUDY: Pulmonary capillary stress failure, largely as a result of high pulmonary vascular pressures, has been implicated in the aetiology of EIPH. However, the role of the respiratory system in determining the magnitude of EIPH has received little attention. HYPOTHESIS: Horses breathing a gas of greater density than air will exhibit greater transmural pulmonary arterial pressures (TPAP) and more severe EIPH, and horses breathing a gas of lower density than air will exhibit lower TPAP and less severe EIPH, both compared with horses breathing air. METHODS: Following a warm-up, 8 Thoroughbred horses were exercised for 1 min at 10, 11 and 12 m/sec (5 degrees incline) breathing air or 21% oxygen/79% helium or 21% oxygen/79% argon in a randomised order. Heart rate, respiratory rate, pulmonary arterial pressure and oesophageal pressure were measured during exercise. Bronchoalveolar lavage fluid (BALF) was collected from the dorsocaudal regions of the left and right lungs 40 min post exercise and red blood cell (RBC) counts were performed. RESULTS: The exercise tests induced mild EIPH. Maximum changes in oesophageal pressure were lower on helium-oxygen compared to argon-oxygen (P<0.001). TPAP and median RBC counts did not differ between gas mixtures. BALF RBC counts from the left lung correlated with counts from the right lung (P<0.0001). However BALF RBC counts from the left lung were higher than those from the right lung (P = 0.004). CONCLUSION: As alterations in pulmonary arterial and oesophageal pressure caused by changes in inspired gas density were of similar magnitude, TPAP remained unchanged and there was no significant effect on EIPH severity. POTENTIAL RELEVANCE: Manipulations that decrease swings in intrapleural pressure may only decrease the degree of EIPH in horses severely affected by the condition.

Antioxidant and inflammatory responses of healthy horses and horses affected by recurrent airway obstruction to inhaled ozone.

REASONS FOR PERFORMING STUDY: Inhaled ozone can induce oxidative injury and airway inflammation. Horses affected by recurrent airway obstruction (RAO) have a decreased pulmonary antioxidant capacity, which may render them more susceptible to oxidative challenge. It is currently unknown whether RAO-affected horses are more susceptible to oxidative stress than those unaffected by RAO. OBJECTIVES: To determine whether ozone exposure induces greater oxidative stress and airway inflammation in RAO-affected horses in remission than in healthy horses. METHODS: Seven healthy control horses and 7 RAO-affected horses were exposed to 0.8 ppm ozone for 2 h at rest. RESULTS: At baseline, bronchoalveolar lavage fluid (BALF) ascorbic acid concentrations were lower in RAO-affected horses than healthy controls. Ozone appeared to preferentially oxidise glutathione rather than ascorbic acid 6 h after exposure. Individual healthy and RAO-affected horses demonstrated oxidation of BALF glutathione after ozone exposure. Overall, RAO-affected horses did not demonstrate increased oxidative stress following ozone exposure, compared with healthy horses. Ozone did not induce significant airway inflammation in either group. CONCLUSIONS: RAO-affected horses in remission are not more sensitive to ozone despite a decreased pulmonary antioxidant capacity. Sensitivity to ozone appears to be independent of initial pulmonary antioxidant status. POTENTIAL RELEVANCE: Horses with high susceptibility to oxidative stress may benefit from antioxidant supplementation.

Antioxidant supplementation and pulmonary function at rest and exercise.

Antioxidants have been implicated in the reduction and prevention of oxidative stress during exercise. We hypothesised that a dietary supplement containing a mixture of natural antioxidants together with vitamins E, C and selenium, given for 4 weeks, would increase the systemic and pulmonary antioxidant capacity leading to a reduction in markers of oxidative damage and an improvement in pulmonary function during exercise. In 6 healthy horses studied, the antioxidant supplement significantly increased plasma concentrations of ascorbic acid (from mean +/- s.d. 16 +/- 7 to 23 +/- 4 micromol/l; P = 0.007) and alpha-tocopherol (from 10 +/- 3 to 14 +/- 3 micromol/l; P = 0.02) and increased the bronchoalveolar lavage pulmonary epithelial lining fluid (ELF) concentration of ascorbic acid compared to a placebo, but not significantly (2.0 +/- 0.9 mmol/l and 1.2 +/- 0.9 mmol/l, respectively; P>0.05). Alpha-tocopherol was not detected in ELF either before or after supplementation or exercise. The mean concentration of malondialdehyde (MDA) in ELF was lower following antioxidant supplementation compared to placebo and control periods, but not significantly. An intermittent exercise test consisting of 2 min at 70, 80 and 90% of the horses' individual maximum oxygen uptake, failed to induce significant systemic or pulmonary oxidative stress (based on the glutathione redox ratio (GRR) and the ascorbic acid redox ratio (ARR)) and lipid peroxidation (based on the concentration of thiobarbituric acid reactive substances in plasma and MDA in ELF) either for placebo or antioxidant treatments. There was a strong correlation between GRR and ARR in the pulmonary epithelial lining fluid (r = 0.89; P<0.0001). In healthy horses on a diet containing adequate levels of antioxidants, additional antioxidant supplementation has no apparent beneficial or detrimental effect on pulmonary function during moderate intensity exercise. The importance of antioxidant supplementation may only become apparent if the diet is deficient in antioxidants, if exercise intensity is higher or more prolonged, or if disease or additional stresses are present.

Movements of thoracic and abdominal compartments during ventilation at rest and during exercise.

The present investigation utilised simultaneous measurements of chest (Ch) and abdominal (Ab) circumferences and respiratory airflow to test the hypothesis that Ch circumferential expansion contributes proportionally little to tidal volume in the running Thoroughbred. During exercise, there were only small changes in Ch and Ab circumference and no increase with increasing tidal volume. At rest, walk and trot, the flow, Ch and Ab signals were in phase. However, during canter and gallop, the Ch and Ab changes were 180 degrees out of phase with each other and both were out of phase with airflow. In contrast to exercise, increase in ventilation at rest achieved by administration of lobeline resulted in a 4-6-fold increase in tidal volume; large excursions of the chest were always in phase with airflow. Furthermore, 3 horses showed an increase in chest circumference, demonstrating that chest stiffness per se does not preclude chest circumferential expansion. In conclusion, in the absence of significant increases in either Ch or Ab expansion during running, elongation of the thoracoabdominal segment may be the main determinant of tidal volume.

Heart size estimated by echocardiography correlates with maximal oxygen uptake.

Maximum oxygen uptake also appears to correlate to athletic performance in horses. In the Thoroughbred industry, there has long been an empirical theory that heart size is related to athletic performance, despite a lack of scientific evidence supporting this assertion. To investigate the relationship between peak oxygen consumption (VO2max) and cardiac size measured by echocardiography, guided M-mode and 2-dimensional echocardiography were performed in 17 conditioned Thoroughbreds with a range of VO2max from 126 to 217 ml/min/kg STPD (mean +/- s.d. 158 +/- 28 m/min/kg). Horses were age 2-10 years and weighed 430-510 kg. Echocardiography was performed using a Vingmed System V echocardiograph with a 2.25 MHz phased array ultrasound transducer. All images were obtained from the right hemithorax using a short axis view of the left ventricle (LV) at the level of the chordae tendinae. All horses were free from significant regurgitation at the aortic or mitral valves. Maximal oxygen uptake was measured during a standardised incremental treadmill exercise test to fatigue. Maximal oxygen uptake was correlated significantly with LVIDd (r = 0.71; P = 0.001), MWT (r = 0.72; P = 0.001), LV mass (r = 0.78; P = 0.0002) and LV short-axis area (r = 0.69; P = 0.003). When indices of heart size were indexed to bodyweight, the correlation between VO2max and indices of heart size were LVIDd (r = 0.57; P = 0.01), MWT (r = 0.44; P = 0.07), LV mass (r = 0.78; P = 0.0002) and LV short-axis area (r = 0.69; P = 0.003). The current study suggests there is a strong relationship between VO2max and measurements of left ventricular size in Thoroughbred horses when individuals with a range of VO2max are compared.

Predictors and outcomes associated with early extubation in older adults undergoing coronary artery bypass surgery.

BACKGROUND: Older age has been associated with prolonged mechanical ventilation after coronary artery bypass surgery. Prolonged mechanical ventilation contributes to increased morbidity and mortality and to use of limited financial resources among older adults. OBJECTIVES: To examine selected physiological and pathophysiological variables ofpresurgicalpatients to predict duration of mechanical ventilation in older adults after coronary artery bypass surgery. METHODS: Nonrandomized study of a clinical database of 919 patients (> or =65 years old) who had coronary artery bypass surgery between October 1996 and December 1997. RESULTS: Median elapsed time after coronary artery bypass surgery until extubation was used to sort patients into 2 groups: group 1, 6 hours or fewer (n = 464); and group 2, more than 6 hours (n = 455). With stepwise logistic regression, the physiological model included age (odds ratio, 1.05; P<.001) and female sex (odds ratio, 1.48; P = .005) with weak discrimination by group (concordance statistic = 0.5880). The pathophysiological model, which included renal insufficiency (odds ratio, 3.28; P = .01), previous peripheral vascular surgery (odds ratio, 2.87; P = .03), nonelective preoperative clinical status (odds ratio, 2.8; P = .006), congestive heartfailure (odds ratio, 2.6; P<.001), and reoperation (odds ratio, 2.34; P = .007), showed moderate discrimination bygroup (concordance statistic =0.6755). CONCLUSION: Many older adults were easily extubated and had good outcomes. The variables comorbid conditions and severity of illness provided better discrimination between extubation groups than a physiological model provided. Both predictive models allowed limited discrimination between groups.

Environmental enrichment decreases intravenous self-administration of amphetamine in female and male rats.

RATIONALE: Previous work has shown that environmental enrichment alters amphetamine-induced locomotor activity and conditioned place preference. OBJECTIVE: The present study examined the effect of environmental enrichment on amphetamine self-administration. METHODS: Female and male rats were raised from 21 days of age in one of three different conditions: an enriched condition (EC) containing novel objects and social partners, a social condition (SC) containing social partners only, or an isolated conditioned (IC) without objects or social partners. Beginning at 51 days of age, rats were then tested for operant responding for a sucrose reinforcer using an incremental fixed ratio (FR) requirement across four sessions. Rats were then implanted with a chronic indwelling intravenous catheter and were allowed to self-administer amphetamine (0.03 or 0.1 mg/kg per infusion) for five FR1 sessions, followed by a progressive ratio (PR) session. RESULTS: EC rats initially showed an increase in sucrose-reinforced responding relative to IC rats and this environment-induced difference was greater in females than in males. However, in both sexes, the environment-induced difference in sucrose-reinforced responding dissipated completely across repeated sessions. With amphetamine self-administration, both EC and SC rats earned fewer infusions than IC rats across repeated FRI sessions using the low dose of amphetamine (0.03 mg/kg per infusion), but not using the higher dose of amphetamine (0.1 mg/kg per infusion). EC rats also earned fewer self-infusions of the low amphetamine dose on the PR session relative to IC rats. The effects of environmental enrichment on amphetamine self-administration were similar in both females and males. CONCLUSION: These results suggest that environmental enrichment may serve as a protective factor for reducing amphetamine self-administration.

A collaborative program for cardiovascular patient follow-up.

Transitions from one health care system to another are common, but they can affect coordination of care and measurement of patient outcomes. In this project, a community hospital and a tertiary center collaborated to obtain follow-up information on patients 30 days after they underwent cardiac catheterization and revascularization. Results show that patients experienced similar physical and emotional concerns regardless of diagnosis or procedure. Although the intent was to gather information, nurses also provided education and arranged services for patients. This project has implications for the development of collaborative interventions to improve care for patients after undergoing coronary procedures.

Outcomes measurement and evidence-based nursing practice.

Outcome measurement and evidence-based practice are complementary and iterative efforts; both contribute to quality health care. In this article, hemodynamic monitoring is utilized as an example to discuss outcome measurement and evidence-based practice. The use of technology, medications, and other interventions ideally would be based on sound scientific evidence of efficacy and effectiveness in clinical practice. Outcome measurement can contribute to the evidence and strengthen the process of appropriate technology use and evidence-based practice.

Diagnostic strategies for women with suspected coronary artery disease.

The clinician evaluating a woman with symptoms potentially indicative of coronary heart disease faces the challenge of choosing the appropriate diagnostic test. The use of noninvasive testing in women has been controversial due to a perception of diminished accuracy, limited female representation, and technical limitations that compromise efficacy. Recent meta-analyses and large observational series report marked improvements in accuracy for women undergoing exercise treadmill, echocardiography, and nuclear testing. Electron beam computed tomography is a relatively new technique, and the body of evidence is still developing. An adequate body of evidence supports the use of noninvasive testing for intermediate risk, symptomatic women and may result in improved diagnostic and therapeutic decision making.

Outcome measurement: self-management in heart failure.

Improvement in heart failure outcomes depend on patients' abilities to care for themselves and manage aspects of their condition, and patient self-management has itself become an outcome to be measured. Some behaviors, such as diet and fluid restriction, are prescribed, and self-management is often equated with adherence to the treatment regimen. Self-management has also been defined as cognitive decision making in response to symptoms and conceptualized as a process with stages from novice to expert. Greater understanding and measurement of patient decision making and self-management expertise facilitates the development of effective interventions to improve patient outcomes.

Ethnicity and analgesic practice.

STUDY OBJECTIVE: We previously reported that Hispanic ethnicity was an independent risk factor for inadequate analgesic administration among patients presenting to a single emergency department. We then attempted to generalize these findings to other ethnic groups and EDs. Our current study objective is to determine whether black patients with extremity fractures are less likely to receive ED analgesics than similarly injured white patients. METHODS: We conducted the following retrospective cohort study at an urban ED in Atlanta, GA. All black and white patients presenting with new, isolated long-bone fractures over a 40-month period were studied. After abstracting demographic information from the medical record and subsequently removing ethnic identifiers, we submitted the medical record to a physician who recorded characteristics of the patients' injury and treatment. We then submitted the records to a nurse, again blinded to ethnicity, who recorded analgesic administration. We used multiple logistic regression to determine the independent effect of ethnicity on analgesic use while controlling for multiple potential confounders. Our main outcome measure was the proportion of black versus white patients receiving ED analgesics. RESULTS: The study group consisted of 217 patients, of whom 127 were black and 90 were white. White patients were significantly more likely than black patients to receive ED analgesics (74% versus 57%, P =.01) despite similar records of pain complaints in the medical record. The risk of receiving no analgesic while in the ED was 66% greater for black patients than for white patients (relative risk 1.66, 95% confidence interval, 1.11 to 2.50). This effect persisted after controlling for multiple potential confounders. CONCLUSION: Black patients with isolated long-bone fractures were less likely than white patients to receive analgesics in this ED. No covariate measured in this study could account for this effect. Our findings have implications for efforts to improve analgesic practices for all patients.

Outcomes measurement.

Reductions in hospital lengths of stay (LOS) for patients with cardiovascular conditions can be a cost-effective in-hospital outcome, but the effect of shortened hospital LOS on patient and family outcomes after discharge needs to be evaluated. Suggestions for the use of appropriate data to evaluate LOS and outcomes that need study are presented.