Correlates of online health information-seeking behaviors in a low-income Hispanic community.

OBJECTIVE: The purpose of this study was to explore the correlates of online health information-seeking behaviors among Hispanic residents of a low-income urban neighborhood. METHODS: Data were collected with a community survey from 1045 unique participants at ambulatory care clinics in a largely Hispanic immigrant community in northern Manhattan, New York. A descriptive correlational analysis was conducted using logistic regression. RESULTS: A majority of the participants were born outside the United States (85.7%), and half (50.3%) had completed high school. A logistic regression revealed that five independent variables were significantly correlated with online health information-seeking behaviors: age, education, marital status, primary language, and health literacy. Age and Spanish as preferred language were negatively associated with online health information-seeking (OR = 0.93 and 0.50), whereas education and health literacy were positively associated with online health information-seeking (OR = 4.28 and 1.28). CONCLUSIONS: The findings have implications for designing online health information resources and interventions appropriate for the populations they are likely to reach. Furthermore, the findings highlight the need for special efforts to ensure access to reliable health information for immigrant populations and those with low health literacy.

Value of additional myocardial perfusion imaging during dobutamine stress magnetic resonance for the assessment of intermediate coronary artery disease.

This study was performed to assess the role of additional myocardial perfusion imaging during high dose dobutamine/atropine stress magnetic resonance (DSMR-wall motion) for the evaluation of patients with intermediate (50-70%) coronary artery stenosis. Routine DSMR-wall motion was combined with perfusion imaging (DSMR-perfusion) in 174 consecutive patients with chest pain syndromes who were scheduled for a clinically indicated coronary angiography. When defining CAD as the presence of a ≥ 50% stenosis, the addition of perfusion imaging improved sensitivity (90 vs. 79%, P < 0.001) with a non-significant reduction in specificity (85 vs. 90%, P = 0.13) and an improvement in overall diagnostic accuracy (88 vs. 84%, P = 0.008). Adding perfusion imaging improved sensitivity in patients with intermediate stenosis (87 vs. 72%, P = 0.03), but not in patients with severe (≥70%) stenosis (93 vs. 84%, P = 0.06). In patients with severe stenosis specificity of DSMR-perfusion versus DSMR-wall motion decreased (61 vs 70%, P = 0.001) resulting in a lower overall accuracy (71 vs 74%, P = 0.03). Using a cutoff of ≥50% for the definition of CAD, sensitivity of DSMR-perfusion compared to DSMR-wall motion was significantly higher in patients with single vessel (88 vs. 77%, P = 0.03) and multi vessel disease (93 vs. 79%, P = 0.03), whereas no significant differences were found using a cutoff of ≥70% stenosis for the definition of CAD. The addition of perfusion imaging during DSMR-wall motion improved the sensitivity in patients with intermediate coronary artery stenosis. Overall diagnostic accuracy increased only when defining CAD as ≥50% stenosis. In patients with ≥70% stenosis DSMR-wall motion alone had higher accuracy due to more false-positive cases with DSMR-perfusion.

[Networking and integrated disease management. Advantages and disadvantages from the medical point of view]. / Vernetzung und integrierte Versorgung. Vor- und Nachteile aus medizinischer Sicht.

At the moment the terms "networking", "cost reduction" and "integrated disease management" are frequently discussed in all branches of the German health care system. Unfortunately there are different interpretations of these terms. "Integrated disease management" in the meaning of communication between clinical and outpatient health care has al ready existed for years now. Traditional ways of communication lead to information loss. Losing information is a reason for low cost effectiveness and a prolonged healing process directly harming the patient. A computer network may prevent information loss and may in crease the performance of data transfer. Different sides have al ready started networking, and it is now necessary to bundle the interests. This necessity has been recognized by the German legislative. To lead this project to success it is important to know and to fulfil some medical criteria. Defining and describing these conditions is the topic of this paper. Our special intent is to show that digital technique is necessary to improve cooperation among physicians.

Assessment of weight gain during pregnancy in general prenatal care services in Brazil.

Obesity is an emerging major health risk for women around the world. In this regard, little attention has been given to pregnancy, a moment of risk not only for major weight gain in these women, but also for macrosomia in their offspring. The objective of this study is to evaluate weight gain during pregnancy. Data pertains to a cohort of pregnant women attending general prenatal care clinics in six state capitals in Brazil, from 1991 to 1995. We studied women aged 20 years and over with singleton pregnancies and no diagnosis of diabetes outside pregnancy, enrolled at approximately 20 - 28 weeks of gestation. According to the Institute of Medicine criteria, 38% (95%CI: 36-40%) of the women studied gained less and 29% (95%CI: 28-31%) had more than the recommended total weight gain. These proportions vary according to pre-pregnancy nutritional status. Given the increasing epidemic of obesity, the high prevalence of overweight and obesity in Brazilian women prior to pregnancy, and the lack of achievement of recommended weight gain during pregnancy, more effective means of managing weight gain during pregnancy are necessary.

Improvement of myocardial perfusion reserve early after coronary intervention: assessment with cardiac magnetic resonance imaging.

OBJECTIVES: The purpose of this study was to determine the potential value of magnetic resonance myocardial perfusion in the follow-up of patients after coronary intervention. BACKGROUND: In some patients a residual impairment of myocardial perfusion reserve (MPR) early after successful coronary intervention has been observed. In this study we evaluated an MPR index before and after intervention with magnetic resonance. METHODS: Thirty-five patients with single- and multivessel coronary artery disease were studied before and 24 h after intervention. The signal intensity time curves of the first pass of a gadolinium-diethylene triamine pentacetic acid bolus injected via a central vein catheter were evaluated before and after dipyridamole infusion. The upslope was determined using a linear fit. Myocardial perfusion reserve index was estimated from the alterations of the upslope. RESULTS: The MPR index in segments perfused by the stenotic artery was significantly lower than in the control segments (1.07 +/- 0.24 vs. 2.18 +/- 0.35, p < 0.001) and improved significantly after intervention (1.89 +/- 0.39, p < 0.001) but did not normalize completely (p < 0.01). After intervention the MPR index remained significantly lower in the balloon percutaneous transluminal coronary angioplasty group (1.72 +/- 0.38; n = 13) in comparison with the stent group (1.99 +/- 0.36, n = 18, p < 0.05). In the stent group a complete normalization of the MPR index was found 24 h after stenting. CONCLUSIONS: Magnetic resonance perfusion measurements allow a reliable assessment of MPR index. An improvement of MPR index can be observed after coronary intervention, which is more pronounced after stenting. Magnetic resonance perfusion measurements allow the assessment and may be useful for the follow-up of patients with coronary artery disease after coronary intervention.

Angiographical and Doppler flow-derived parameters for assessment of coronary lesion severity and its relation to the result of exercise electrocardiography. DEBATE study group. Doppler Endpoints Balloon Angioplasty Trial Europe.

AIMS: Evaluation of angiographical and intracoronary Doppler-derived parameters of coronary stenosis severity. METHODS AND RESULTS: A total of 225 patients with one-vessel disease were studied before PTCA and at 6 months follow-up. Exercise electrocardiography was performed to document presence (n = 157) or absence (n = 138) of an ST segment shift (> or =0.1 mV). Intracoronary blood flow velocity analysis was performed to determine the proximal/distal flow velocity ratio, the distal diastolic/systolic flow velocity ratio and coronary flow velocity reserve. Receiver operator characteristic curves were calculated to assess the predictive value of these variables compared with the exercise test. The distal coronary flow velocity reserve demonstrated the best linear correlation for both percentage diameter stenosis and minimum lumen diameter (r = 0.67 and r = 0.66; P<0.01), compared to the diastolic/systolic flow velocity ratio (r = 0.19 and r = 0.14; P<0.01) and the proximal/distal flow velocity ratio (r = 0.03 and r = 0.07; not significant). The areas under the curve were 0. 84+/-0.02; 0.82+/-0.03 and 0.83+/-0.03 for diameter stenosis, minimum lumen diameter and coronary flow velocity reserve, respectively. Logistic regression analysis revealed that the percentage diameter stenosis or minimum lumen diameter and coronary flow velocity reserve were independent predictors for the result of stress testing. CONCLUSIONS: The distal coronary flow velocity reserve is the best intracoronary Doppler parameter for evaluation of coronary narrowings. Angiographical estimates of coronary lesion severity and distal coronary flow velocity reserve are good and independent predictors for the assessment of functional severity of coronary stenosis, emphasizing the complementary role of these parameters for clinical decision making.

Validation of an accurate method for three-dimensional reconstruction and quantitative assessment of volumes, lengths and diameters of coronary vascular branches and segments from biplane angiographic projections.

UNLABELLED: The goal of the study was the validation of an accurate method for three-dimensional reconstruction and quantitative assessment of volumes, lengths and diameters of coronary vascular branches and segments from biplane angiographic projections. METHODS: The accuracy was tested in a complex phantom. In vivo, inter- and intraobserver agreement were assessed by analysis of routine angiograms. The sensitivity was evaluated using angiograms of patients having diagnostic vasoactive pharmacological intervention. Two-dimensional quantitative coronary angiography (2-D QCA) and 3-D QCA were compared concerning the accuracy of diameter evaluation. RESULTS: 3-D QCA yields accurate results (< 3% error) even based on nonorthogonal views, provided that projections parallel to the object are avoided. The inter- and intraobserver variability is < or = 5%. Significant (p < 0.01) changes of the volume (36-39%) and the diameter (19-21%) are detected following pharmacological intervention. 2-D QCA and 3-D QCA agree in short matched segments without foreshortening. 2-D QCA is rather sensitive to foreshortening and not suitable for evaluation of diameters of longer branches or total coronaries. CONCLUSION: 3-D QCA permits an accurate, reproducible and sensitive comprehensive three-dimensional geometric analysis of the coronaries and is superior to 2-D QCA with respect to extended diameter evaluation.

Intravascular ultrasound assessment of direct percutaneous transluminal coronary angioplasty in patients with acute myocardial infarction.

BACKGROUND: Acute myocardial infarction is caused by sudden thrombotic occlusion of the coronary artery due to a previous rupture of atherosclerotic plaque. OBJECTIVE: To use intracoronary ultrasound measurements to evaluate lumen and plaque changes in patients with acute myocardial infarction. METHODS: Patients (n = 103) with acute myocardial infarction who had been scheduled to undergo primary percutaneous transluminal coronary angioplasty (PTCA) were selected. Both before and after successful coronary angioplasty, intracoronary 30 MHz ultrasound studies were performed using a 3.5F monorail catheter. The ultrasound catheter was successfully advanced into the occluded vessel segment without major complications prior to PTCA in 79 of 103 (76.7%) patients and after PTCA in 88 of 103 (85.3%) patients. RESULTS: The plaques were eccentric in 66 patients (83.5%). The plaque morphology was purely low echogenic in 14 (17.7%), highly echogenic in six (7.6%) and mixed in 59 (74.7%) patients. Partial (59 of 79, 74.7%) or ring-like calcification (3 of 79, 3.8%) was observed in 62 patients (78.5%). Plaque fissuring or dissection was detected prior to PTCA in 25 patients (31.7%). Coronary angioplasty successfully enlarged the inner luminal area from 2.1 +/- 0.7 to 7.4 +/- 1.9 mm2 (P < 0.01), whereas the plaque-thrombus area decreased significantly (13.8 +/- 1.7 mm2 before and 9.0 +/- 1.9 mm2 after PTCA; P < 0.01). The total vessel area remained virtually constant (15.9 +/- 1.9 mm2 before and 16.4 +/- 2.5 mm2 after PTCA, NS). PTCA-induced plaque rupture or dissection was observed in only 13 (16.5%) patients. CONCLUSION: Intracoronary ultrasound imaging can be performed safely and successfully prior and subsequent to PTCA in selected patients with acute myocardial infarction. Early reperfusion via PTCA seems to be attributable to a significant reduction in the amount of low-echogenic plaque and thrombus material, whereas factors like balloon-induced dissection and stretching of vessels play only a minor role.

Improved assessment of intravascular Doppler coronary flow velocity profile.

Easy and safe in-vivo flow velocity studies in small coronary arteries have become feasible using a 0.014 'or 0.018' guidewire with an integrated Doppler probe in its tip (FloWire, Cardiometrics). Assessment of the flow velocity profile by the ratio of diastolic to systolic flow velocity (DSVR) is used as a diagnostic parameter. However, DSVR is a coarse quantifier of the flow velocity profile, and is subject to large physiologic variance and depends crucially on the quality of the Doppler signal. The aim of our study was to test parameters derived from statistical time series analysis for monitoring the quality of the instantaneous peak velocity (IPV) signal. Improvement of quantification of changes in quality and shape of flow velocity profiles by these parameters as compared to DSVR was a second goal. We investigated analog-digital converted IPV-signals and video registrations of corresponding greyscale spectra of intracoronary Doppler flow velocity signals. The signals were analyzed by using the autocorrelation function (ACF) in the time domain and a fast Fourier transform (FFT) in the frequency domain (standard time series statistics). The first minimum of autocorrelation function turned out to be very sensitive to signal quality, and Fisher's g of the periodogram was the parameter of choice for shape analysis. In 11 patients with coronary artery disease, pre and post PTCA, the sensitivity of DSVR and signal to noise ratio to changes in shape and quality of the flow velocity signals was compared to that of the new parameters. Nineteen Doppler flow velocity samples of good quality from measurements in nonstenotic vessels and 7 flow velocity tracings with visible artefacts were used to assess the value of these parameters in monitoring signal quality. By comparison with corresponding parameters in use (SNR and DSVR) a significantly improved performance of the new statistical parameters was observed with respect to sensitivity to changes in signal quality and flow profile. In view of these results and because of the short calculation time of these variables they should be used for on-line quality control and analysis of flow velocity profiles.

Reduced atrial angiotensin receptor type 1 mRNA content in end-stage human heart failure: assessment by a novel quantitative PCR-ELISA technique.

The number of atrial angiotensin II binding sites is reduced in end-stage human heart failure. The goals of our study were the development of a quantitative polymerase chain reaction for angiotensin II receptor type 1 mRNA to determine the angiotensin receptor type 1 (AT1) mRNA content in the atria of patients with end-stage heart failure. We established a quantitative PCR based on coamplification of AT1 wild-type and an internal standard in the same PCR, followed by liquid-phase hybridization of PCR products in microtiter plates and quantitation by ELISA. Glyceraldehyde phosphate dehydrogenase mRNA in the same samples was used to relate the AT1 mRNA content to a stably expressed reference gene. Atrial samples from 11 patients with end-stage heart failure obtained at cardiac transplantation were compared with atrial samples from 11 patients with normal cardiac function undergoing routine cardiac surgery. A PCR/ELISA system with a variance of about 6% after reverse transcription and a linear measuring range was established. In the samples from 11 patients with end-stage heart failure a 58% decrease in AT1 mRNA content was found in comparison with 11 controls (heart failure: 185,680 +/- 196,912 AT1 mRNA copies/microgram RNA, controls: 440,555 +/- 268,456, P < 0.02). When AT1 mRNA content was related to glyceraldehyde phosphate dehydrogenase mRNA, a 65% decrease was detected (AT1/glyceraldehyde phosphate dehydrogenase: heart failure: 4.84 +/- 5.18; controls: 13.74 +/- 7.77; P < 0.005). Standardization of PCR resulting in a low coefficient of variance, high reproducibility, and large sample capacity is possible using optimal internal standardization and the liquid-phase hybridization/ELISA system for detection. The optimized PCR procedure indicated downregulation of atrial AT1 in end-stage human heart failure, suggesting a reduced capacity of the atria to respond to angiotensin II stimulation in end-stage heart failure.

Assessment of diffuse coronary artery disease by quantitative analysis of coronary morphology based upon 3-D reconstruction from biplane angiograms.

Quantitative evaluations on coronary vessel systems are of increasing importance in cardiovascular diagnosis, therapy planning, and surgical verification. Whereas local evaluations, such as stenosis analysis, are already available with sufficient accuracy, global evaluations of vessel segments or vessel subsystems are not yet common. Especially for the diagnosis of diffuse coronary artery diseases, the authors combined a 3D reconstruction system operating on biplane angiograms with a length/volume calculation. The 3D reconstruction results in a 3D model of the coronary vessel system, consisting of the vessel skeleton and a discrete number of contours. To obtain an utmost accurate model, the authors focussed on exact geometry determination. Several algorithms for calculating missing geometric parameters and correcting remaining geometry errors were implemented and verified. The length/volume evaluation can be performed either on single vessel segments, on a set of segments, or on subtrees. A volume model based on generalized elliptical conic sections is created for the selected segments. Volumes and lengths (measured along the vessel course) of those elements are summed up. In this way, the morphological parameters of a vessel subsystem can be set in relation to the parameters of the proximal segment supplying it. These relations allow objective assessments of diffuse coronary artery diseases.

[The technetium-99-m-pyrophosphate scintigram in the assessment of the size of acute myocardial infarction: comparison with CK-(MB) curves mortality (author's transl)]. / Grössenbestimmung akuter Myokardinfarkte mit Technetium-99m-Pyrophosphat. Vergleich zu CK(MC)-Verlauf und Letalität.

While the technetium-99m-pyrophosphate scintigram enables diagnostic proof of acute myocardial infarction, its use in the evaluation of the extent of infarction has not been clearly established. This study, in 30 patients with acute myocardial infarction was, thus, undertaken to assess the relationship between the findings of the technetium-99m-pyrophosphate scintigram, with respect to infarct area and uptake pattern, the infarct size, as determined from the total CK an CK-MB curves, and the mortality. The scintigraphically determined infarct areas ranged between 1.7 and 29.3 cm2; the 20.2 plus or minus 6.0 cm2 average for anterior wall infarction (n=18, range 7.4 to 29.3 cm2) was significantly greater (p smaller than 0.005) than the 8.3 plus or minus 5.3 cm2 average for inferior infarction (n=12, range 1.7 to 15.8 cm2). Correlation coefficients between the scintigraphically and enzymatically determined infarct sizes for the entire patient population ranged from 0.71 to 0.80. Anterior infarctions correlated more closely (0.66 to 0.84) than inferior infarctions (0.46 to 0.66). The technetium-99m-pyrophosphate uptake pattern was focal in 20 patients and ring-shaped (doughnut) in ten. Infarcts with focal uptake patterns were significantly smaller than those displaying a doughnut pattern (12.2 plus or minus 6.4 vs. 24 plus or minus 4.0 cm2, p smaller than 0.005). The infarct weight calculated from the CK-MC curve with application of individually determined disappearance rate for those infarcts displaying a focal uptake pattern was 34 plus or minus 29 grams while that associated with a doughnut uptake pattern was significantly greater at 86 plus or minus 25 grams (p smaller than 0.005). During the 18 -month observation period there were six deaths; the average scintigraphic infarct area of 22.8 plus or minus 3.6 cm2 in those who died was significantly greater (p smaller than 0.005) than that of the 13.8 plus or minus 8.2 cm2 of the survivors. Of the non-survivors, five had a doughnut uptake pattern and one displayed focal uptake. In the 24 survivors, a focal uptake pattern was found in 19 and a doughnut pattern in five. Conversely, 19 of the 20 patients with a focal uptake pattern survived while only five of the ten patients with a doughnut pattern were alive after 18 months. Thus, comparison with the enzymatically determined infarct weight as well as the mortality indicate that the technetium-99m-pyrophosphate scintigram yields clinically relevant data with regard to infarct size. Since no patient with an infarct area of less than 17 cm2 died within the 18-month observation period, designation of scintigraphically determined infarct size as small (smaller than 17 cm2) and large (larger than 17 cm2) was enabled. The corresponding cut-off point between large and small infarctions as determined enzymatically has been designated at 65 grams. Accordingly, agreement was found in 70% (14 of 20 patients) with scintigraphically small infarcts and in 80% (8 of 10 patients) with scintigraphically large infarcts...