Improved stenosis geometry by quantitative coronary arteriography after vigorous risk factor modification.

This study is a randomized, controlled, blinded, arteriographic trial to determine the effects of a low-cholesterol, low-fat, vegetarian diet, stress management and moderate aerobic exercise on geometric dimensions, shape and fluid dynamic characteristics of coronary artery stenoses in humans. Complex changes of different primary stenosis dimensions in opposite directions or to different degrees cause stenosis shape change with profound effects on fluid dynamic severity, not accounted for by simple percent narrowing. Accordingly, all stenosis dimensions were analyzed, including proximal, minimal, distal diameter, integrated length, exit angles and exit effects, determining stenosis shape and a single integrated measure of stenosis severity, stenosis flow reserve reflecting functional severity. In the control group, complex shape change and a stenosis-molding characteristic of statistically significant progressing severity occurred with worsening of stenosis flow reserve. In the treated group, complex shape change and stenosis molding characteristic of significant regressing severity was observed with improved stenosis flow reserve, thereby documenting the multidimensional characteristics of regressing coronary artery disease in humans.

Advances in controlling hypertension in low-income patients.

Since hypertension is the foremost problem in minority and low-income populations treated in our community health centers, in 1976 we introduced a protocol that standardized diagnostic criteria and a step-care approach to the treatment of hypertension. In 1980, we modified the original protocol with guidelines for dietary management and an outline for improving physician-patient communication and health education. We hypothesized that implementing the protocol (and later modifications) would be associated with improved identification and control of hypertension. We conducted a cross-sectional study of hypertensive patients' charts in three community health centers in 1973, 1978, and 1982, and determined the status of blood pressure (BP) control of those patients by the end of the year. In 1973 (before protocol), 4 percent of hypertensives were undiagnosed and untreated, and 20 percent were lost to follow-up. Among those who remained under care, only 33 percent were under control (BP less than 160/95 mm Hg). In 1978, two years after the protocol was introduced, there were fewer undiagnosed and untreated patients (2 percent), but the number lost to follow-up increased to 31 percent. The proportion of hypertensives under control increased to 70 percent. In 1982, two years after the modifications to the protocol were introduced, the proportion of patients lost to follow-up decreased to 28 percent, and the proportion of patients with controlled blood pressure increased to 79 percent. The improved level of control was statistically significant at p less than .0001 (chi-square test).(ABSTRACT TRUNCATED AT 250 WORDS)

Patient exposition and provider explanation in routine interviews and hypertensive patients' blood pressure control.

Hypertensive patients' expressing themselves in their own words (Exposition) and providers' giving information (Explanation) during medical interviews were hypothesized to be associated with subsequent blood pressure control. Transcripts of routine return visits to clinics in low-income areas of Houston, TX, were coded using the Verbal Response Modes (VRM) system. VRM indexes of Patient Exposition and Provider Explanation were tested in relation to systolic and diastolic blood pressure obtained during home interviews 2 weeks after the clinic visits. Patient Exposition was significantly correlated with reductions in systolic and diastolic blood pressure from clinic visit to home interview, and Provider Explanation was significantly correlated with lower diastolic blood pressure at home interview. The results suggest that patients' and providers' verbal behavior in medical interviews should be included in predictive models of blood pressure control.

PIP: Analysis of the transcriptions of 217 patients' visits to community health centers in low-income areas of Houston, Texas, for hypertension treatment suggests at least a partial correlation between patients' expressing themselves in their own words (exposition) and providers' giving information on the one hand and subsequent lowered blood pressure on the other hand. Verbal Response Mode indexes of Patient Exposition and Provider Explanation were tested in relation to systolic and diastolic blood pressure obtained during home visits 2 weeks after the medical interview. The patients' amount of talking using their own words in the medical history segment of the health center visit was significantly correlated with reductions in blood pressure from clinic to home visit, but not with blood pressure levels at the clinic or the home interview. Providers' percentage of giving objective information in the conclusion segment of the clinical interview was significantly associated with lower blood pressure at the home interview, but not with clinic levels or with change from clinic to home visit. These trends remained even after controlling for patient age, sex, ethnicity, and for provider differences. This is believed to be the 1st empirical evidence of an association between blood pressure and characteristics of the medical interview. Overall, they suggest that greater attention should be given to patient-provider verbal interaction variables in designing blood pressure control programs.

Physician communication to patients regarding medications.

An analysis of 11 physicians' speech content regarding medications was conducted on 267 encounters with hypertensive patients. Scored were categories for questions, instructions, directions to take and justifications for taking medications. The median inter-auditor agreement was 83%. The results indicate that the physicians asked few questions and gave few instructions for patients on stable drug regimens; however, for newly prescribed drugs and changed regimens the provided information doubled: there were instructions for 77%, medication-taking commands for 31% and justification for taking medications for 21% of all medications. Other results indicate that that physicians did not discriminate by age, sex or race in quantity of speech about medication, but they did ask more questions of patients who saw a different physician on the previous visit. The results suggest that the system of scoring speech was reliable and captured the physicians adjustments to their patients' and their own needs for information.

Wound caring is more than wound care: the provider as a partner.

We all know about the placebo effect, but what is it? When a patient "thinks" that he/she is being treated effectively they can improve. Patients who receive supportive interaction do better than those who are alone. These concepts suggest that the mind influences the body's response. This article will discuss the issues of the mind-body connection and its implications in patient care. The first part of this article will provide an overview of the landmark scientific information that validates this intricate relationship between the body and the mind. The second part of this article will focus on the professional practice of medicine and how improved interaction with the patient leads to better outcomes. When the provider becomes a partner with the patient, the results become synergistic. The third part of this article is written by a pervious cancer patient whose presence today is a testimonial to the success of the body/mind alliance and the provider-as-partner concept. She will present the patient's side of medical care.

A three-dimensional model for teaching about hypertension.

We present a model of the cardiovascular system used to teach patients about the nature, risks, and treatment of hypertension. We designed the model to help providers explain abstract principles of cardiovascular function through graphic representations that patients can see, feel and hear. This article describes the model, discusses the concepts that providers can illustrate to patients, and includes an outline followed by providers of our community health centers in educating hypertensive patients.

Type A behavior, self-involvement, and cardiovascular response.

Coronary-prone Type A and noncoronary-prone Type B students were challenged by a battery of tasks including cold pressor, mental arithmetic, behavior type interview, and the generation and expression of emotions. Measures of blood pressure, heart rate, and digital vasoconstriction were intercorrelated with reported distress, performance, speech characteristics, emotional intensity, and self-references. The major difference between the two behavior types concerned self-references, measured as the frequency of personal pronouns employed in speech. The Type A's who referred to themselves frequently had a markedly higher systolic blood pressure, a slightly higher diastolic blood pressure, a lower heart rate, higher distress ratings to cold water, and more extreme voice emphasis and emotional intensity than Type A's who referred to themselves less frequently. The Type B's have little relationship of self-references to any of the measures taken. The possible role of self-involvement in generating Type A behavior and cardiovascular response is discussed.

Type A assessment and interaction in the behavior pattern interview.

Speech characteristics of both an interviewer and respondents were scored from recorded interviews that were conducted to assess Type A behavior. A stepwise regression analysis indicated that the expressive speech characteristics were the best discriminators of behavior typing by the interview. A similar analysis employing the Jenkins Activity Survey as the criterion for typing showed that only the content of the respondents' answers predicted typing. The Activity Survey and the interview assessment appeared to classify individuals on independent aspects of Type A behavior. Correlations of the interviewer's speech characteristics with the respondents' feeling reports and speech characteristics show stronger associations among these variables for Type A than for Type B subjects. The analysis of speech characteristics id discussed as a method of refining the assessment of behavior type and of identifying the psychological predictors of coronary heart disease.

Cook-Medley Hostility scale and subsets: relationship to demographic and psychosocial characteristics in young adults in the CARDIA study.

This report describes the relationships between scores obtained on the Cook-Medley Hostility (Ho) scale and race, education, gender, and age in a sample of 5115 young adult participants in a prospective study of coronary heart disease (CHD) risk factors. Large differences were observed in total Ho scale scores and in six recently identified subsets according to race, education, gender, and age. Young black males with limited education had the highest Ho scale levels (mean = 26.2) while older white females with more education had the lowest levels (mean = 15.5). In all subgroups, education was inversely associated with hostility. The findings suggest a possible mechanism whereby CHD risk is higher in males than females, in the less educated than the more educated, and in blacks than whites. In all race and gender subgroups, total Ho scale scores and the six subsets were positively correlated with negative life events and negatively correlated with social support, supporting a pattern of psychosocial vulnerability found in other studies.

Speech characteristics and behavior-type assessment in the Multiple Risk Factor Intervention Trial (MRFIT) structured interviews.

Four speech characteristics (SCs) were scored from 626 audiotaped Structured Interviews (SIs) designed to assess behavior type in the Multiple Risk Factor Intervention Trial (MRFIT). Analyses suggested that interviewers relied upon respondents' voice emphasis, speed of speaking, speed of answering, and answer content (in that order) for behavior typing. Across the clinics, there were large differences in the degree that each interviewer and auditor used these SCs for behavior-type judgments, and these differences appear to be related to differences in interauditor reliability. Correlations between the various SCs were very low, suggesting that key operationally defined characteristics of Type A behavior occurred independently in the SI. Analysis of interviewers' SCs indicated that they spoke and asked questions more quickly of Type A than Type B subjects--suggesting that interviewers' behaviors were biased by respondents' behavior type. Overall, the findings indicate the complexity of the behavior-type judgment process and how the criteria for assessment may change depending upon interviewer or population differences.

Speech characteristics and coronary heart disease incidence in the multiple risk factor intervention trial.

To assess whether speech characteristics descriptive of Type A behavior were related to coronary heart disease (CHD) incidence in the Multiple Risk Factor Intervention Trial, we scored voice emphasis, speed of speaking, latency of answering, and answer content from 577 audiotaped structured interviews in a case-control design which included all 193 individuals who incurred CHD during the 7-year follow-up. These were matched with 384 CHD-free controls. Multivariate analyses showed that subjects' voice emphasis [relative risk ratio (RR) = 1.25, p = .02] and latency of answering (RR = .78, p = .02) were significantly associated with CHD incidence when controlled for baseline levels of diastolic blood pressure, serum cholesterol, and cigarette smoking.

Self-reference and coronary heart disease incidence in the Western Collaborative Group Study.

Previous research has indicated that the spoken frequency of the self-references "I," "me," and "my" in a structured interview was prospectively related to coronary heart disease (CHD). To assess whether the findings would replicate in another population, we conducted a case-control analysis of 750 structured interviews from the Western Collaborative Group Study. To measure self-references, auditors counted all first person pronouns (I, me, my) and clauses spoken in the audiotaped baseline structured interviews. Matched multiple logistic regression analyses, with or without adjustment for major CHD risk variables, indicated that those who incurred CHD did not self-reference more frequently or densely than the CHD-free control subjects. Type As spoke more clauses and more total self-references but did not have a higher density of self-references than Type Bs. The results question both the method for measuring self-references and the hypothesis that self-referencing are associated with CHD.

Self-involvement and coronary heart disease incidence in the multiple risk factor intervention trial.

At intake into a multiple coronary heart disease (CHD) risk factor intervention trial, 3110 individuals were interviewed to assess Type A behavior. After an average of 7 years followup, the 193 individuals who manifested their first CHD event were matched with 384 CHD-free individuals. To assess self-involvement, auditors counted all verbal self-references (I, me, my) and clauses spoken in the audiotaped baseline interviews. Self-references were entered into multiple logistic regression analyses that controlled for age, diastolic blood pressure, cholesterol, cigarette smoking, and Type A behavior. Relative to matched controls, those who incurred CHD spoke more self-references at baseline [p = 0.017; relative risk (RR) = 1.20], but did not self-reference more densely. Relative to matched controls, those who died from CHD spoke more self-references (p = 0.008; RR = 1.62) and self-referenced more densely (p = 0.027; RR = 1.54). Neither total self-references nor self-reference density was predictive of angina pectoris or nonfatal myocardial infarction (MI). However, among those who incurred MI, self-reference frequency was the strongest predictor of mortality among all the measured risk factors (p = 0.01, RR = 2.0). The results suggest that self-involvement is related to CHD incidence.

Procedures and discrepancies of blood pressure measurements in two community health centers.

Three studies of blood pressure measurement were conducted in two primary care clinics. In study I, procedures for taking blood pressure were observed for seven nurses, and their readings were compared with readings taken in a standard manner. The results show that the nurses' procedure needed improvement; the systolic/diastolic discrepancies with the standard averaged 10.2/7.5 mmHg. In study II, the nurses were trained to improve their procedure, and readings were again compared. The results show improvement for moderate, but not for large, discrepancies in diastolic readings. In study III, two physicians' procedure for taking blood pressure indicated that their procedures could also be improved. Overall, there was little correlation between potential biases in providers' procedures and discrepancies with the standard. The discrepancies between the nurse and physician readings led to different treatment indicators in 22-26 per cent of the observations.

Selection, training, and quality control of Type A interviewers in a prospective study of young adults.

This paper describes Type A/B interviewer selection, training, and quality control results in a prospective study of coronary artery risk development in young adults (CARDIA). Interviewer behaviors from 152 CARDIA structured interviews were audited and compared with 747 Western Collaborative Group Study (WCGS) interviews and 577 Multiple Risk Factor Intervention Trial (MRFIT) interviews. The results show success in modeling the CARDIA interviewer behaviors on those of the WCGS. CARDIA interviews were very similar to WCGS interviews for interview length, number of questions asked, and speed of speaking; they were similar to MRFIT interviews in latency of asking questions. CARDIA interviewer behaviors remained fairly consistent over the four time periods. Comparing the clinics, there were regional differences in latency of asking and speed of speaking, with the Southern clinic having a longer asking latency and speaking more slowly. There were differences between individual interviewers in most characteristics, particularly those that were more free to vary. The study provides procedures and guidelines designed to maintain quality control of the structured interview process.

[Comprehensive life style changes by coronary patients--an intervention study]. / Umfassende Lebensstiländerung bei Koronarkranken--eine Interventionsstudie.

In an intervention trial 31 coronary patients participated in a comprehensive lifestyle change program and 43 control patients received the usual care of the conventional cardiac rehabilitation system. First preliminary findings show that the patients in the intervention group not only improved their health related lifestyle but also increased their exercise capacity and reduced depression, while there was no substantial improvement in the control group. Up to the present, the existing data indicate that German heart patients are able to make comprehensive lifestyle changes and that these changes have positive effects on biomedical and psychosocial variables.

[Life style changes in patients with myocardial infarct in the framework of intramural and ambulatory rehabilitation--results of a German pilot study]. / Lebensstiländerung bei Herzinfarktpatienten im Rahmen der stationären und ambulanten Rehabilitation--Ergebnisse einer deutschen Pilotstudie.

To assess whether German patients would make comprehensive lifestyle changes as designed and successfully tested in the San Francisco Lifestyle Heart Trial, we recruited 25 patients who received usual care, and 15 patients who made lifestyle changes during a 6-week in-hospital rehabilitation program followed by a 3-month ambulatory period. The intervention program consisted of a low-fat vegetarian diet, stress management techniques, aerobic exercises, and group support meetings. The program was well accepted, and high compliance resulted in significant changes in the patients' diet, stress management, and exercise activity. For instance, fat intake dropped from 36% to 9% of total calories. As patients in both groups received 20 mg/day of Pravastatin, a lipid-lowering drug, lipid levels dropped significantly in both groups (30% in the intervention group and 27% in the control group). Thus, the combined effect of behavioral and drug treatment did not result in a substantial additional lipid-lowering effect. Within the intervention group significant improvement in quality of life occurred. In conclusion, the lifestyle heart program can be successfully implemented in a German rehabilitation setting which combines in-hospital and out-patient activities. However, participation in the current program is limited to highly motivated, well educated coronary patients.

Hostility and health behaviors in young adults: the CARDIA Study. Coronary Artery Risk Development in Young Adults Study.

Hostility has been associated with coronary heart disease mortality. To assess possible mechanisms linking hostility to coronary heart disease risk, the authors conducted analyses in a cross-sectional study from data collected in 1985 and 1986 on 5,115 young adults, aged 18-30 years, black and white, male and female, in four large urban areas of the United States. The results show that higher levels of hostility as determined by the Cook-Medley Hostility Scale were strongly associated with tobacco and marijuana smoking, increased alcohol consumption, and greater caloric intake in both blacks and whites and in both men and women. The increased caloric consumption was evident in the higher waist/hip ratios, particularly in men (p less than 0.05). The associations were particularly strong (p less than 0.001) for tobacco cigarette smoking and marijuana smoking, with roughly a 1.5 times higher prevalence in the top hostility quartile compared with the bottom quartile after adjusting for age and education. Hostility levels were not related to the percentage of calories from fat or from sucrose intake, to plasma cholesterol levels, or to physical fitness (except for a weak association in the latter in white women). The results describe relations between hostility and health behaviors that may be detrimental to health. The findings provide a possible explanation for the association between hostility and coronary heart disease mortality.

Interpersonal Hostility Assessment Technique: description and validation against the criterion of coronary artery disease.

High levels of hostility are associated with adverse health outcomes. The Interpersonal Hostility Assessment Technique (IHAT; Barefoot, 1992) measures hostility from verbal behavior during a standardized interview. Four types of behaviors are scored as hostility: evading the question, irritation, and indirect and direct challenges to the interviewer. The sum of the frequencies of these acts is a Hostile Behavior Index (HBI), which is divided into two components: verbal, scored with speech content in mind, and paraverbal, based on vocal stylistics. This study examined characteristics of IHAT assessments in 129 male coronary patients. Satisfactory interrater reliabilities were obtained. The HBI correlated highly (.58) with coronary artery disease severity after controlling for traditional risk factors. This relation was not affected by question topic or by differential weighting of the four hostile behaviors. Both HBI components were significantly correlated with disease. Results are discussed in terms of their implications for hostility assessment.