Understanding online health information: Evaluation, tools, and strategies

OBJECTIVE

Considering the status of the Internet as a prominent source of health information, assessing online health material has become a central issue in patient education. We describe the strategies available to evaluate the characteristics of online health information, including readability, emotional content, understandability, usability.

METHODS

Popular tools used in assessment of readability, emotional content and comprehensibility of online health information were reviewed. Tools designed to evaluate both printed and online material were considered.

RESULTS

Readability tools are widely used in online health material evaluation and are highly covariant. Assessment of emotional content of online health-related communications via sentiment analysis tools is becoming more popular. Understandability and usability tools have been developed specifically for health-related material, but each tool has important limitations and has been tested on a limited number of health issues.

CONCLUSION

Despite the availability of numerous assessment tools, their overall reliability differs between readability (high) and understandability (low). Approaches combining multiple assessment tools and involving both quantitative and qualitative observations would optimize assessment strategies.

PRACTICE IMPLICATIONS

Effective assessment of online health information should rely on mixed strategies combining quantitative and qualitative evaluations. Assessment tools should be selected according to their functional properties and compatibility with target material.

Information quality and dynamics of patients' interactions on tonsillectomy web resources

Information technologies have drastically altered the way patients gather health-related information. By analysing web resources on tonsillectomy, we expose information quality and dynamics of patients' interactions in the online continuum. Readability was assessed using Flesch Reading Ease (FRE), Flesch Kincaid Grade Level (FKGL), Simple Measure of Gobbledygook (SMOG), and Gunning Fog Index (GFI). Comprehensibility and actionability were assessed using the Patient Education Materials Assessment Tool (PEMAT). Metrics of forums included author characteristics (level of disclosure, gender, age, avatar image, etc.), posts' motive (community support vs. medical information) and content (word count, emoticon use, number of replies, etc.). Analysis of 6 professional medical websites, of 10 health information portals, and of 3 discussion forums totalizing 1369 posts on 358 threads, from January 1, 2007 to December 31, 2014, reveals that online resources exceed understandability recommendations. Women were more present on online health forums (68.2% of authors disclosing their gender) and invested themselves more in their avatar. Authors replying were significantly older than authors of original posts (39.7 ± 0.8 years vs. 29.2 ± 0.9 years, p < 0.001). The degree of self-disclosure was inversely proportional to the requests for medical information (p < 0.001). Men and women were equally seeking medical information (men: 74.0%, women: 77.0%) and community support (men: 65.7%, women: 70.4%), however women responded more supportively (women 86.2%, men 59.1%, p < 0.001). The dynamics of patients' interactions used to overcome accessibility difficulties encountered is complex. This work outlines the necessity for comprehensible medical information to adequately answer patients' needs.

Pain modulation induced by respiration: phase and frequency effects

The voluntary control of respiration is used as a common means to regulate pain and emotions and is fundamental to various relaxation and meditation techniques. The aim of the present study was to examine how breathing frequency and phase affect pain perception, spinal nociceptive activity (RIII-reflex) and brain activity (scalp somatosensory-evoked potentials - SEP's). In 20 healthy volunteers, painful electric shocks individually adjusted to 120% of the RIII-reflex threshold were delivered to the sural nerve near the end of inspiration or expiration phases, during three cued-breathing conditions: (1) slow breathing (0.1 Hz) with slow (4s) inspiration (0.1Hz-SlowIns), (2) slow breathing (0.1 Hz) with fast (2s) inspiration (0.1 Hz-FastIns), and (3) normal breathing (0.2 Hz) with fast (2s) inspiration (0.2 Hz). Pain ratings were not affected by breathing patterns (p=0.3), but were significantly lower during inspiration compared with expiration (p=0.02). This phase effect was also observed on the N100 component of SEP's, but only in the 0.1-Hz-FastIns condition (p=0.03). In contrast, RIII-reflex amplitude was greater during inspiration compared with expiration (p=0.02). It was also decreased in the 0.1-Hz-SlowIns compared with the 0.2-Hz condition (p=0.01). Slow breathing also increased the amplitude of respiratory sinus arrhythmia (RSA), although these changes were not significantly associated with changes in pain responses. In conclusion, this study shows that pain and pain-related brain activity may be reduced during inspiration but these changes are dissociated from spinal nociceptive transmission. The small amplitude of these effects suggests that factors other than respiration contribute to the analgesic effects of relaxation and meditation techniques.

Dissection of perceptual, motor and autonomic components of brain activity evoked by noxious stimulation

In the past two decades, functional brain imaging has considerably advanced our knowledge of cerebral pain processing. However, many important links are still missing in our understanding of brain activity in relation to the regulation of pain-related physiological responses. This fMRI study investigates the cerebral correlates of pain (rating), motor responses (RIII-reflex) and autonomic activity (skin conductance response; SCR) evoked by noxious electrical stimulation. Stimulus intensity was adjusted individually based on the RIII threshold to control for differences in peripheral processes and baseline spinal activation. Covariance analyses were used to reveal individual differences in brain activity uniquely associated with individual differences in pain, RIII and SCR. Shock-evoked activity in cingulate, medial orbitofrontal and parahippocampal regions predicted pain sensitivity. Moreover, lateral orbitofrontal and cingulate areas showed strong positive associations with individual differences in motor reactivity but negative associations with autonomic reactivity. Notably, individual differences in OFC activation was almost fully accounted by the combination of individual measures of autonomic and motor reactivity (R(2)=0.93). Additionally, trial-to-trial fluctuations of RIII-reflex and SCR (within-subjects) were proportional to shock-evoked responses in subgenual cingulate cortex (RIII), anterior insula (SCR) and midcingulate cortex (SCR and RIII). Together, these results confirm that individual differences in perceptual, motor, and autonomic components of pain reflect robust individual differences in brain activity. Furthermore, the brain correlates of trial-to-trial fluctuations in pain responses provide additional evidence for a partial segregation of sub-systems involved more specifically in the ongoing monitoring, and possibly the regulation, of pain-related motor and autonomic responses.

Widespread hypersensitivity is related to altered pain inhibition processes in irritable bowel syndrome

The mechanisms of chronic pain in irritable bowel syndrome (IBS) have been widely investigated but remain unclear. The present study investigated the relation between visceral hypersensitivity, cutaneous thermal sensitivity, and central pain mechanisms. Rectal sensitivity was assessed with a barostat, and forearm and calf sensitivity with a contact thermode. Central mechanisms were assessed by counterirritation using sustained cold-pain to the hand and painful electric shocks to the ankle. Psychological symptoms were also assessed, using questionnaires. Female volunteers with diarrhea-predominant IBS (n=27) and healthy controls (n=25) participated in the study. IBS patients had lower rectal and calf pain thresholds compared to controls (p's<0.05). IBS patients also reported more pain than controls for rectal distensions, and heat pain on the calf and forearm (all p's<0.001). Cold-pain inhibited shock-pain in controls but not IBS patients (controls: -13.5+/-5.3 vs IBS: +1.9+/-10.5; p<0.01). In addition, visceral hypersensitivity was significantly correlated to cutaneous thermal hypersensitivity and pain inhibition deficits, although effects were only weak and moderate, respectively. Furthermore, covariance analyses indicated that psychological factors accounted for group differences in visceral hypersensitivity and pain inhibition deficits. In conclusion, this study confirms the relation between altered pain inhibition processes and widespread hypersensitivity in IBS. The present results also suggests that psychological symptoms and altered pain processing in IBS patients may reflect at least in part, common underlying mechanisms.

Expression of CD133 and poor outcome in neuroblastoma associated with chemoresistance mediated by AKT pathway

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Background: Neuroblastoma is a frequent childhood cancer with very heterogeneous prognosis. Recent studies showed that CD133 expression is an independent prognostic marker for low survival in several cancers like medulloblastoma. The aim of our study is to determine the prognostic value of CD133 expression in a large population of neuroblastoma and to determine the chemoresistance of neuroblasts expressing CD133. Methods: 280 tumor samples of neuroblastoma were screened for CD133 expression. Patients had a median follow-up of 7.15 years. One hundred eighteen patients were under one year of age with a median age of 27 months. There were 67 stage 1, 46 stage 2, 43 stage 3, 99 stage 4, and 25 stage 4S. The association of CD133 expression with relapse and survival were determined through univariate and multivariate analysis. Sensitivity of purified CD133+ neuroblasts isolated from 2 human neuroblastoma cell lines (SKNSH and NB10) to doxorubicin, vincristine and cisplatin was evaluated in vitro, as single agents or in combination with LY294002, a AKT inhibitor. Results: CD133 was expressed in 95 of 280 tumors (33%). There was a significant association between CD133 expression and the following poor prognosis co-variates: age (p<0.0001), INSS stage (p<0.0001), MYCN amplification (p<0.0001). Patients with a CD133+ tumor had a three year event-free and overall survival of 43±5% and 51±5%, respectively, as compared to patients with a CD133- tumor with 88±2% (P<0.001) and 95±2% (p<0.001). In a multivariate model, CD133 expression was independently associated with a decreased overall survival (p = 0.003) in the entire cohort. In vitro purified CD133+ neuroblasts were significantly resistant to chemotherapy as compared to their CD133- cells counterpart, but not in presence of the AKT inhibitor. In vitro treatment of unsorted neuroblasts with the three anticancer drugs significantly enriched the CD133+ subpopulation but not in presence of the AKT inhibitor. CD133plus; significantly expressed higher levels of activated proteins in the AKT pathway than CD133−. Conclusions: CD133 is independently associated with a worse outcome in patents with neuroblastoma. This prognosis factor is associated with in vitro resistance to chemotherapy involving activation of the AKT pathway.

No significant financial relationships to disclose.

Epinephrine infusion during moderate intensity exercise increases glucose production and uptake

The glucoregulatory response to intense exercise [IE, >80% maximum O(2) uptake (VO(2 max))] comprises a marked increment in glucose production (R(a)) and a lesser increment in glucose uptake (R(d)), resulting in hyperglycemia. The R(a) correlates with plasma catecholamines but not with the glucagon-to-insulin (IRG/IRI) ratio. If epinephrine (Epi) infusion during moderate exercise were able to markedly stimulate R(a), this would support an important role for the catecholamines' response in IE. Seven fit male subjects (26 +/- 2 yr, body mass index 23 +/- 0.5 kg/m(2), VO(2 max) 65 +/- 5 ml x kg(-1) x min(-1)) underwent 40 min of postabsorptive cycle ergometer exercise (145 +/- 14 W) once without [control (CON)] and once with Epi infusion [EPI (0.1 microg x kg(-1) x min(-1))] from 30 to 40 min. Epi levels reached 9.4 +/- 0.8 nM (20x rest, 10x CON). R(a) increased approximately 70% to 3.75 +/- 0.53 in CON but to 8.57 +/- 0.58 mg x kg(-1) x min(-1) in EPI (P < 0.001). Increments in R(a) and Epi correlated (r(2) = 0.923, P </= 0.01). In EPI, peak R(d) (5.55 +/- 0.54 vs. 3.38 +/- 0.46 mg x kg(-1) x min(-1), P = 0.006) and glucose metabolic clearance rate (MCR, P = 0.018) were higher. The R(a)-to-R(d) imbalance in EPI caused hyperglycemia (7.12 +/- 0.22 vs. 5.59 +/- 0.22 mM, P = 0.001) until minute 60 of recovery. A small and late IRG/IRI increase (P = 0.015 vs. CON) could not account for the R(a) increase. Norepinephrine (approximately 4x increase at peak) did not differ between EPI and CON. Thus Epi infusion during moderate exercise led to increments in R(a) and R(d) and caused rises of plasma glucose, lactate, and respiratory exchange ratio in fit individuals, supporting a regulatory role for Epi in IE. Epi's effects on R(d) and MCR during exercise may differ from its effects at rest.

Variation of anatomic valve area during ejection in patients with valvular aortic stenosis evaluated by two-dimensional echocardiographic planimetry: comparison with traditional Doppler data

OBJECTIVES

Flow variations can affect valve-area calculation in aortic stenosis and lead to inaccuracies in the evaluation of the stenosis. Knowing that transvalvular flow varies normally within one beat, we designed this study to assess the response of the valve to intrabeat variation of flow during systole. Results were compared with flow-derived measurements.

BACKGROUND

Technological improvements now allow us to evaluate aortic valve area directly by short axis planimetry. This offers the possibility to perform serial planimetries during one ejection phase and analyze the intrabeat dynamic behavior of the stenotic-aortic valve and compare these measurements with flow-derived measurements.

METHODS

Forty echocardiograms displaying different degrees of aortic stenosis were analyzed by frame-by-frame planimetry of the valve area from onset of opening to complete closure. Maximal-mean area, opening and closing rates and ejection times were obtained and compared with Doppler-derived data.

RESULTS

Valve area varied during ejection. Stenotic valves opened and closed more slowly than normals and remained maximally open for a shorter period. Mean area by Doppler data corresponded more closely to maximal than to mean-planimetered area. Duration of flow was shorter than valve opening in severely stenotic valves. Discrepancies between Doppler-derived and two-dimensional (2D) measurements decreased in less stenotic valves.

CONCLUSIONS

Our observations reveal striking differences between the dynamics of normal and stenotic valves. Surprisingly, Doppler-derived mean-valve area correlated better with maximal-anatomic area than with mean-anatomic area in patients with aortic stenosis. Discrepancies between duration of flow and valve opening could explain this phenomenon.

Echocardiographic analysis of regional and global left ventricular shape in Chagas' cardiomyopathy

Chagas' heart disease is a common form of cardiomyopathy in Latin America and an important cause of cardiac morbidity and mortality there. Left ventricular (LV) apical aneurysm and LV dysfunction are frequent findings in Chagas' cardiomyopathy. Because cardiac shape has important implications for LV function, we sought to characterize regional and global changes in LV geometry in Chagas' heart disease. Quantitative shape analysis was performed on 2-dimensional echocardiograms from 43 patients with Chagas' cardiomyopathy. Regional shape was quantitated by measuring endocardial curvature and global shape was evaluated by Fourier shape analysis of the endocardial contour. Data from 22 age- and sex-matched normal test subjects were used for comparison. Regional shape analysis demonstrated decreased apical curvature (consistent with blunting of normal apical shape) in the group with Chagas' disease compared with controls (apical 2-chamber view: 19 +/- 1 vs 24 +/- 1 [p = 0.0039] at end-diastole and 20 +/- 2 vs 29 +/- 3 [p = 0.0019] at end-systole). Fourier shape power index was decreased in the Chagas' group, consistent with a more spherical ventricle (apical 2-chamber view: 9 +/- 1 vs 17 +/- 2 [p <0.0001] at end-diastole and 12 +/- 1 vs 35 +/- 3 [p <0.0001] at end-systole). Shape changes among the population with Chagas' disease were further evaluated in those with end-diastolic volumes equal to or greater than the median for the group (104 ml) and those < 104 ml. Global shape did not differ between patients with dilated ventricles and those with relatively nondilated ventricles. Diastolic Fourier shape power index = 8 +/- 2 in dilated ventricles compared with 9 +/- 5 in nondilated ventricles (p = 0.53); systolic Fourier shape power index = 10 +/- 2 in dilated versus 14 +/- 2 in nondilated ventricles (p = 0.15) (apical 2-chamber view). In Chagas' cardiomyopathy, LV apical deformation results in disruption of the optimal global prolate-ellipsoid shape, even in patients with relatively preserved LV volumes.

Induction of neuronal functions: acetylcholine-induced acetylcholinesterase activity in mouse neuroblastoma cells

Addition of acetylcholine to growing cultures of mouse neuroblastoma cells induced a 37-fold increase in the specific activity of acetylcholinesterase (EC 3.1.1.7). Morphological changes, consisting of neurite-extensions, were also observed during the logarithmic phase of growth of cells stimulated with acetylcholine. A histochemical procedure for localization of acetylcholinesterase was used with the following results: (a) Cells differentiating by growth inhibition in serum-free medium do not stain positively for acetylcholinesterase, except when they have extended neurites, whereas all cells induced with acetylcholine, with or without neurites, stain positively for the enzyme. (b) The inverse relation between cell growth and induction of enzyme activity was demonstrated in nondividing cells at the center of a colony that do not incorporate thymidine into DNA and that stain positively for acetylcholinesterase, whereas actively dividing cells on the periphery of the colony do not stain for the enzyme. However, by addition of acetylcholine we were able to dissociate inhibition of cell growth from biochemical and morphological differentiation in mouse neuroblastoma cells.