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.

Differences in the prognostic relevance of myocardial ischaemia and scar by cardiac magnetic resonance in patients with and without diabetes mellitus.

AIMS: To evaluate the prognostic significance of myocardial ischaemia and scar in patients with and without diabetes mellitus (DM) who undergo dobutamine stress cardiac magnetic resonance (DCMR) and late gadolinium enhancement (LGE) imaging for known and suspected coronary artery diseases (CADs). METHODS AND RESULTS: A total of 1969 consecutive patients [age 63 ± 12 years, 29% female, left ventricular ejection fraction = 59 ± 12%] referred for a cardiac magnetic resonance (CMR) examination including DCMR and LGE with the suspicion of CAD or progression of CAD in three tertiary cardiac centres were analysed. Cardiac death and nonfatal myocardial infarction (MI) were registered as hard cardiac events. Patients with a revascularization procedure within the first 3 months after CMR were censored at the time of 'early' revascularization. Patients were followed for 3.2 ± 1.5 years (median 2.9, interquartile range 2-4.3 years). In total, 90 (4.6%) cardiac deaths and MI were registered. Among them, 328 patients (16.6%) had diabetes. The proportion of dobutamine-induced wall motion abnormalities (DWMA) and LGE was higher in patients with DM when compared with those without DM (27 vs. 19% and 53.6 vs. 41.2%, respectively, P < 0.001 for both for proportions). Both DWMA and LGE were independent predictors of cardiac death and MI in patients without DM (HR for DWMA 8, CI 4.5-14.3, HR for LGE 2.1, CI 1.1-4.1) and with DM (HR for DWMA 8.6, CI 3.5-21, HR for LGE 4.5, CI 1.5-13.1). Tests for interaction showed that LGE more strongly influences prognosis in patients with than in those without DM (P = 0.03 for interaction), whereas the presence of DWMA is related to similarly poor outcomes in patients with and without DM (P = NS). CONCLUSION: Myocardial scar by LGE is a hallmark of markedly poorer outcome in patients with DM, while the presence of inducible myocardial ischaemia seems to be predictive both in patients with and without DM. Both markers surpass the predictive value of conventional atherogenic risk factors both in patients with and without DM.

Targeted ED-B fibronectin SPECT in vivo imaging in experimental atherosclerosis.

AIM: The extracellular matrix protein ED-B fibronectin (ED-B) is upregulated in inflammatory atherosclerotic lesions. However, functional in vivo imaging of ED-B-containing plaques has not been explored. This study evaluated whether [(99m)Tc]-conjugated AP39 ([(99m)Tc]-AP39), a single-chain antibody specific to ED-B, can be used for in vivo detection of atherosclerotic plaques in Western diet (WD)-fed, apolipoprotein E-deficient (apoE-/-) mice as compared to wildtype (WT) control mice. METHODS: Using SPECT, 12-month-old WD-fed apoE-/- and WT mice were studied 4 hours after injecting [(99m)Tc]-AP39 (148 MBq). Subsequently, mice were sacrificed, thoracic aortas measured in a g-counter, and plaques analyzed using histology, immuno-histochemistry, autoradiography, and morphometry. RESULTS: In vivo [(99m)Tc]-AP39-SPECT imaging of apoE-/- mice demonstrated a significant signal activity in the plaque-ridden thoracic aorta (52.236 ± 40.646 cpm/cm³) that co-localized with the aortic arch and the supra-aortic arteries in MRI scans. Low signal activity (9.468 ± 4.976 cpm/cm³) was observed in WT mice. In apoE-/- mice, the strongest signals were detected in the aortic root, aortic arch and along the abdominal aorta. Autoradiography analysis of aortas from apoE-/- mice confirmed the in vivo observation by demonstrating signal localization in atherosclerotic plaques. The size of autoradiography-positive plaque areas correlated significantly with the size of ED-B-positive (r=0.645, P=0.044) or macrophage-infiltrated (r=0.84, P<0.002) plaques. A significant correlation was found between the sizes of ED-B-positive and macrophage-infiltrated plaque areas (r=0.93, P<0.01). CONCLUSION: [(99m)Tc]-AP39-SPECT in vivo imaging detects inflammatory plaque lesions in WD-fed apoE-/- mice.

Outcome of cryoballoon ablation for atrial fibrillation. Medium-term follow-up from a single center.

OBJECTIVE: We analyzed the medium-term follow-up of cryoballoon ablation (CBA) for atrial fibrillation (AF) and the clinical risk factors predicting outcome. METHODS: AF patients treated for the first time with CBA in a 4.5-year period were studied retrospectively. Pulmonary vein isolation (PVI) was achieved via a single cryoballoon with diameter of 28 mm. Left atrial diameter (LAD) was measured by transthoracic echocardiography. Failure of cryoablation treatment was defined as detection of an episode of AF, atrial flutter, or atrial tachycardia lasting more than 30 s during the 3-month follow-up. RESULTS: A total of 212 patients were enrolled and in 87.7 % patients PVI was achieved by CBA. The complication rate was 2.83 %. The mean follow-up was 28 ± 15 months; in 166 patients follow-up was complete. The rate of successful treatment for primary CBA was 45.8 %. The percentage of patients who experienced atrial arrhythmia recurrence in the first 12 months was 84.44 %. Patients in whom treatment failed had a larger LAD (47 ± 6 mm vs. 43 ± 5 mm, p < 0.0001). The Kaplan-Meier curve showed that the patients with LAD < 45 mm had a higher success rate than patients with LAD ≥ 45 mm [57.9 % (44/76) vs. 35.6 % (32/90), log rank = 5.492, p = 0.019]. The LAD [odds ratio, OR = - 0.1053(0.303, 12.2040), p = 0.0005] was shown in logistic regression analysis to be independently predictive of CBA treatment failure. CONCLUSION: The CBA procedure for AF patients is safe and effective. Most atrial arrhythmia recurrences occurred during the first 12 months after CBA. The LAD can independently predict failure of CBA treatment.

Comparison of acquisition time and dose for late gadolinium enhancement imaging at 3.0 T in patients with chronic myocardial infarction using Gd-BOPTA.

OBJECTIVES: To compare contrast doses and acquisition times for late gadolinium enhancement (LGE) imaging at 3.0 T using gadobenate dimeglumine (Gd-BOPTA) in patients with chronic myocardial infarction. METHODS: Thirty-four patients with chronic myocardial infarction were randomised to 0.10, 0.15 and 0.20 mmol/kg of Gd-BOPTA. T1-weighted inversion recovery gradient echo sequences were performed at 5, 10, 15 and 20 min post-administration of contrast in a 3.0-T scanner. Scar-to-myocardium contrast-to-noise ratio (CNR), scar-to-blood CNR, scar size and image quality were assessed. RESULTS: Imaging at 5 min was associated with a lower scar-to-blood CNR in comparison to 10, 15 and 20 min at 0.10 mmol/kg, and in comparison to 15 and 20 min at 0.20 mmol/kg. At 0.10-mmol/kg, imaging at 5 min yielded smaller infarct sizes in comparison to 15 and 20 min. Finally, at 0.20-mmol/kg, imaging at 5 min was associated with poorer image quality in comparison to later times. CONCLUSIONS: In LGE imaging at 3.0 T, low doses of Gd-BOPTA perform equally well as higher doses. Early acquisition (5 min) is associated with lower infarct sizes and image quality. Studies with sufficient diagnostic quality can be obtained after 10 min using 0.10 mmol/kg Gd-BOPTA. KEY POINTS: Good performance of low Gd-BOPTA doses for LGE imaging at 3.0 T. Imaging at 5 min yields lower contrast, infarct sizes and image quality. Diagnostic quality can be obtained after 10 min using 0.10-mmol/kg Gd-BOPTA.

[PCSK9 as new target in hyperlipidemia treatment]. / PCSK9 als neues Target in der Therapie der Hypercholesterinämie.

Proprotein convertase subtilisin/kexin type 9 (PCSK 9) is a key regulator of cholesterol homeostasis acting via degradation of the low density lipoprotein (LDL) receptor. Loss of function PCSK 9 mutations result in very low LDL cholesterol serum levels and protection from cardiovascular disease whereas gain of function mutations increase serum LDL cholesterol. Based on in vitro and in vivo data antibodies targeting PCSK 9 have now emerged as a novel treatment option in patients with cardiovascular disease. This review briefly summarizes the biochemistry and function of PCSK9 and the results from recent phase II trials.

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.

High spatial resolution myocardial perfusion imaging during high dose dobutamine/atropine stress magnetic resonance using k-t SENSE.

PURPOSE: To prospectively evaluate the feasibility and diagnostic accuracy of high spatial resolution myocardial perfusion imaging during high dose dobutamine/atropine stress magnetic resonance (DSMR) for the detection of coronary artery disease (CAD). METHODS AND RESULTS: DSMR-wall motion was combined with perfusion imaging (DSMR-perfusion) in 78 patients prior to clinically indicated invasive coronary angiography. For DSMR-perfusion an in-plane spatial resolution of 1.5 × 1.5mm(2) was attained by using 8 × k-space and time sensitivity encoding (k-t SENSE). Image quality and extent of artifacts during perfusion imaging were evaluated. Wall motion and perfusion data were interpreted sequentially. Significant CAD (stenosis ≥ 70%) was present in 52 patients and involved 86 coronary territories. One patient did not reach target heart rate despite maximum infusion of dobutamine/atropine. Two studies (3%) were non-diagnostic due k-t SENSE related artifacts resulting from insufficient breathhold capability. Overall image quality was good. Dark-rim artifacts were limited to the endocardial border at a mean width of 1.8mm. The addition of DSMR-perfusion to DSMR-wall motion data improved sensitivity for the detection of CAD (92% vs. 81%, P=0.03) and accurate determination of disease extent (85% vs. 66% of territories, P<0.001). There were no significant differences between DSMR-perfusion and DSRM-wall motion regarding overall specificity (83% vs. 87%, P=1) and accuracy (89% vs. 83%, P=0.13). CONCLUSION: High spatial resolution DSMR-perfusion imaging at maximum stress level was feasible, improved sensitivity over DSMR-wall motion for the detection of CAD and allowed an accurate determination of disease extent. Specificity of DSMR-perfusion with k-t SENSE improved compared to prior studies using lower spatial resolution.

Dobutamine stress magnetic resonance imaging for the detection of coronary artery disease in women.

BACKGROUND: Dobutamine stress magnetic resonance (DSMR) imaging represents an excellent imaging approach for the detection of coronary artery disease (CAD). However, most studies have predominantly reported the utility of DSMR in men. OBJECTIVE: To evaluate the diagnostic value of DSMR in men and women. METHODS AND RESULTS: High-dose dobutamine/atropine stress magnetic resonance imaging was performed and new or worsening wall motion abnormalities evaluated in 745 consecutive patients (204 women, 541 men). Invasive coronary angiography was performed within 30 days and served as the reference standard (> or =70% stenosis). DSMR was technically successful and had diagnostic image quality in all patients except one woman and three men (p=NS). In the absence of ischaemia, target heart rate was not reached in 9.3% of women and 8.5% of men (P=NS) despite maximum pharmacological infusion (1% and 2.2%, respectively, p=NS) or owing to limiting side effects (8.3% and 6.3%, respectively, p=NS). Diagnostic values (sensitivity/specificity/accuracy) for the detection of significant coronary stenoses were similar for men (86%/83%/85%) and women (85%/86%/85%). There was no gender-based difference in regional diagnostic accuracy of DSMR for all three coronary vascular territories in patients with single-vessel CAD (81% vs 81%, p=NS, respectively). CONCLUSION: The diagnostic capability of DSMR for the detection of haemodynamically relevant, obstructive CAD is independent of gender.

Novel non-dimensional approach to comparison of wall shear stress distributions in coronary arteries of different groups of patients.

BACKGROUND: Local wall shear stress (WSS) has an impact on local remodelling of the vessel wall. WSS in turn strongly depends on local geometry. Our aim was to characterize patterns of local wall shear stress associated with distinct types of remodelling in coronary arteries. Vessel size and flow rates are different between patients, however. To compare distribution patterns of WSS in analogy to fluid-dynamic modelling, non-dimensional WSS/area functions are calculated. METHODS: Right coronary arteries from seven controls, five patients with coronary artery disease (CAD) and five patients with aneurysmatic CAD (AnCAD) were analyzed. Flow simulations were performed in three-dimensionally reconstructed coronary vessels from biplane angiographic projections. Local WSS was normalized as percentage of maximum value in a histogram (100 classes) and corresponding area was expressed as percentage of total area. RESULTS: The normalized WSS distribution was characterized by a single peak with a large lower tie in controls, a loss of the single peak and a stochastic distribution in AnCAD and a narrowing of the lower tie in CAD. Correct classification of 16/17 coronary arteries was feasible by Fisher's discriminant functions based on median WSS, mean diameter, percentage of area with WSS or=15 Pa. CONCLUSION: Normalized WSS distribution might be an efficient tool in comparing wall shear stress between different patient groups. Whether normalized WSS distribution curves are apt to grade severity of disease remains to be investigated.

Dobutamine stress cardiovascular magnetic resonance at 3 Tesla.

PURPOSE: The assessment of inducible wall motion abnormalities during high-dose dobutamine-stress cardiovascular magnetic resonance (DCMR) is well established for the identification of myocardial ischemia at 1.5 Tesla. Its feasibility at higher field strengths has not been reported. The present study was performed to prospectively determine the feasibility and diagnostic accuracy of DCMR at 3 Tesla for depicting hemodynamically significant coronary artery stenosis (> or = 50% diameter stenosis) in patients with suspected or known coronary artery disease (CAD). MATERIALS AND METHODS: Thirty consecutive patients (6 women) (66 +/- 9.3 years) were scheduled for DCMR between January and May 2007 for detection of coronary artery disease. Patients were examined with a Philips Achieva 3 Tesla system (Philips Healthcare, Best, The Netherlands), using a spoiled gradient echo cine sequence. Technical parameters were: spatial resolution 2 x 2 x 8 mm3, 30 heart phases, spoiled gradient echo TR/TE: 4.5/2.6 msec, flip angle 15 degrees . Images were acquired at rest and stress in accordance with a standardized high-dose dobutamine-atropine protocol during short breath-holds in three short and three long-axis views. Dobutamine was administered using a standard protocol (10 microg increments every 3 minutes up to 40 microg dobutamine/kg body weight/minute plus atropine if required to reach target heart rate). The study protocol included administration of 0.1 mmol/kg/body weight Gd-DTPA before the cine images at rest were acquired to improve the image quality. The examination was terminated if new or worsening wall-motion abnormalities or chest pain occurred or when > 85% of age-predicted maximum heart rate was reached. Myocardial ischemia was defined as new onset of wall-motion abnormality in at least one segment. In addition, late gadolinium enhancement (LGE) was performed. Images were evaluated by two blinded readers. Diagnostic accuracy was determined with coronary angiography as the reference standard. Image quality and wall-motion at rest and maximum stress level were evaluated using a four-point scale. RESULTS: In 27 patients DCMR was performed successfully, no patient had to be excluded due to insufficient image quality. Twenty-two patients were examined by coronary angiography, which depicted significant stenosis in 68.2% of the patients. Patient-based sensitivity and specificity were 80.0% and 85.7% respectively and accuracy was 81.8%. Interobserver variability for assessment of wall motion abnormalities was 88% (kappa = 0.760; p < 0.0001). Negative and positive predictive values were 66.7% and 92.3%, respectively. No significant differences in average image quality at rest versus stress for short or long-axis cine images were found. CONCLUSION: High-dose DCMR at 3T is feasible and an accurate method to depict significant coronary artery stenosis in patients with suspected or known CAD.

Functional capacity and changes in the neurohormonal and cytokine status after long-term CRT in heart failure patients.

BACKGROUND: This study investigated the effects of long-term cardiac resynchronization therapy (CRT) on the neurohormonal and cytokines levels in CHF patients and its correlation with changes in functional capacity (peak VO(2) and VO(2) AT) and left ventricular function (LVEF). METHODS: Brain natriuretic peptide (BNP), norepinephrine (NE), tumor necrosis factor alpha (TNF alpha), tumor necrosis factor alpha receptor 1 (TNF alpha R1) and interleukin 6 (IL-6) were collected from 22 patients of the PATH-CHF II study (LVEF< or =30%, NYHA II-IV and QRS> or =120 ms) at baseline and at the 12-month follow-up. Peak VO(2), VO(2) AT and LVEF were recorded. All patients were implanted with a CRT device using atrioventricular sequential left ventricular pacing. RESULTS: CRT led to a significant improvement of peak VO(2) (from 13+/-2.4 ml/kg/min to 14.8+/-2.8 ml/kg/min, p<0.05) and VO(2) AT (from 9+/-2 ml/kg/min to 10.1+/-1.9 ml/kg/min, p<0.05). LVEF increased significantly from 22.2+/-6.2% at baseline to 32+/-10.1% at 12-month follow-up (p<0.05). A significant reduction of BNP (from 332.9+/-295.2 to 193.4+/-253 pg/ml, p=0.049) and NE (410.6+/-306.0 to 274.4+/-174.3 ng/l, p=0.027) was also observed with CRT. CONCLUSION: Long-term CRT is associated with a significant decrease of BNP and NE levels and a significant improvement in functional capacity and LVEF.

WITHDRAWN: Non-invasive Estimation of Left Ventricular End-diastolic Pressure by Pulmonary Venous Flow Deceleration Time.

The publisher regrets that this was an accidental duplication of an article that has already been published in Eur. J. Echocardiogr., 4 (2003) 162-168, . The duplicate article has therefore been withdrawn.

[Cardiac resynchronization therapy for heart failure - from experimental pacing to evidence-based therapy]. / Kardiale Resynchronisation bei Herzinsuffizienz: Vom experimentellen Pacing zur Evidenz-basierten Therapie.

Within the last decade, cardiac resynchronization therapy (CRT) has become an evidence-based cornerstone for a subset of patients with chronic heart failure. For those, who suffer from ischemic or non-ischemic cardiomyopathies at NYHA III or IV, have sinus rhythm, a left bundle branch block and a left ventricular ejection fraction below 35%, CRT has evolved as an important treatment option with promising results. Numerous studies have shown that in these patients pacemaker-mediated correction of intra- and interventicular conduction disturbances can improve not only clinical symptoms, exercise tolerance and the frequency of hospitalizations, but even more important the overall mortality. These clinical results are due to several functional aspects. In the failing heart characteristic intra- and interventricular alterations in electrical conduction result in mechanical asynchrony that leads to an abnormal contraction of the left ventricle with delayed activation of the lateral wall, a paradoxical septal movement, a reduced diastolic filling and a mitral regurgitation due to dyssynchrony of papillary muscle activation. It is conceivable that these functional changes have fatal consequences for the failing heart. AV-optimized left- or biventricular stimulation by modern pacemakers can correct the pathological dyssynchrony, thereby improving cardiac function and clinical outcome in these patients. Although tremendous progress in cardiac resynchronization therapy has been made during the last decade, a couple of questions still need to be resolved. Critical issues are the identification of patients, who will predictably benefit from CRT, the value of CRT-pacemakers versus CRT-ICDs, and the usefullness of CRT in patients with atrial fibrillation.

[Cardiovascular MRT--replacement of diagnostic invasive coronary angiography?]. / Kardio-MRT. Ersatz für die diagnostische Koronarangiographie?

With cardiovascular magnetic resonance imaging (CMR), the necessity of invasive coronary angiography may be increasingly avoided. CMR provides information about the anatomy of the coronaries themselves (e.g. anomalies, aneurysm), functional information on myocardial blood flow (dobutamine-stress-MR, perfusion measurement) and detailed information on cell-mediated alterations (e.g. fibrosis, necrosis). However, visualization of distal coronary vessels and the small side branches is not yet adequate, so that complete replacement of invasive coronary angiography by CMR is not possible.

MR coronary artery imaging with 3D motion adapted gating (MAG) in comparison to a standard prospective navigator technique.

Magnetic resonance coronary angiography (MRCA) has been proven to be feasible for imaging of the proximal and medial portions of the three main coronary arteries. Free breathing techniques allow for high resolution imaging but prolong scan time. This could potentially be shortened by improving the efficiency, robustness and accuracy of the navigator gating algorithm. Aim of this study was to determine the feasibility, efficiency, and image quality of a new motion compensation algorithm (3D-MAG) for coronary artery imaging with navigator techniques. In 21 patients the coronaries were imaged in plane with a 3D k-space segmented gradient echo sequence. A T2 preparation prepulse was used for suppression of myocardial signal, during free breathing and a navigator technique with using real time slice following and a gating window of 5 mm was applied to suppress breathing motion artefacts. Imaging was performed with standard gating and compared to 3D-MAG. Image quality was visually compared, contrast-to-noise and signal-to-noise ratio were calculated, the length of visualized coronary arteries was measured and scan duration and scan efficiency were calculated. Standard navigator imaging was feasible in 19 of 21 (90.5%) patients 3D-MAG in 21/21 (100%). Scan efficiency and duration was significantly improved with 3D-MAG (p < .05) without change in image quality. 3D-MAG is superior to conventional navigator correction algorithms. It improves feasibility and scan efficiency without reduction of image quality. This approach should be routinely used for MR coronary artery imaging with navigator techniques.

Primary fibrosarcoma of the liver infiltrating the right atrium of the heart.

A rare case of a primary fibrosarcoma of the liver infiltrating the right heart is described in a 72-year-old woman. The patient presented with a history of progressive dyspnea and ascites and her general condition was poor. Preoperative cardiac magnetic resonance (CMR) imaging revealed a large mass, which originated from the liver and had infiltrated the right atrium via the inferior vena cava. The patient underwent tumor resection yet died shortly afterwards. Histologically the mass was classified as a fibrosarcoma with positive immunostaining for vimentin. We report the CMR imaging characteristics in this uncommon case. Preoperative CMR proved to be useful for clinical decision making and the planning of surgery.

[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.