Child-mediated health communication: A conceptual framework for increasing stroke literacy in hard to reach populations

Effectively engaging economically-disadvantaged ethnic minority communities for promoting health has proved to be challenging for a variety of reasons, including factors related to healthcare access, literacy, inadequate or ineffective cultural appropriateness of materials, and the relatively low priority for health due to competing demands related to economic hardship. We have developed a framework of Child-Mediated Health Communication (CMHC), which focuses on children as channels for carrying out health promotion interventions to parents and other caregivers. CMHC is an innovative, alternative strategy for engaging this underserved population, where traditional methods of health promotion have not been successful. We discuss the theoretical foundation, development, and effectiveness of a CMHC framework in our stroke preparedness communication intervention, Hip Hop Stroke

Effect of Anger Provocation on Endothelium-Dependent and -Independent Vasodilation

Anger is an independent predictor of coronary heart disease events, although the mechanisms for this relation are unclear. The effects of an anger-provoking interview compared with a neutral interview on endothelium-dependent and -independent vasodilation assessed by brachial artery ultrasound were examined in 14 healthy subjects without coronary heart disease risk factors. The anger provocation condition, but not the neutral condition, caused a significant impairment in endothelium-dependent vasodilation at 90 minutes compared with baseline (p = 0.004) and 30 minutes (p = 0.013). Similarly, endothelium-independent vasodilation was significantly impaired at 90 minutes after the angry interview compared with baseline (p = 0.003) and 30 minutes (p = 0.001). The decreases in endothelium-dependent and -independent vasodilation were greater after the anger-provoking interview than after the neutral interview, especially between 30 and 90 minutes. In conclusion, preliminary results suggest that an episode of anger is associated with a dysregulation in endothelium-dependent and -independent pathways, suggesting that these mechanisms might contribute to the link between anger and coronary heart disease events. Although anger is associated with increased short- and long-term risk for coronary heart disease (CHD) events, independent of traditional CHD risk factors,1, 2, 3, 4, 5 and 6 the mechanisms that underlie this relation are unknown. Endothelial dysfunction plays a major role in the development of atherosclerosis.7 Traditional CHD risk factors are associated with endothelial dysfunction8 and may also impair arterial vasodilation in response to exogenous nitric oxide (NO), suggesting concomitant vascular smooth muscle dysfunction.8 and 9 Thus, the higher risk for CHD events associated with anger may be similarly mediated through an impairment in endothelium-dependent vasodilation (EDV) with or without an impairment in endothelium-independent vasodilation (EIV). To our knowledge, the effects of anger on EDV and EIV have never previously been examined. To test this hypothesis, we examined the effects of anger induction in humans on EDV and EIV assessed by brachial artery ultrasonography

Preventing misdiagnosis of ambulatory hypertension: algorithm using office and home blood pressures

Objectives—An algorithm for making a differential diagnosis between sustained and white coat hypertension (SH and WCH) has been proposed–patients with office hypertension undergo home blood pressure monitoring (HBPM) and those with normal HBP levels undergo ambulatory blood pressure monitoring (ABPM). We tested whether incorporating an upper office blood pressure (OBP) cutoff in the algorithm, higher than the traditional 140/90 mmHg, reduces the need for HBPM and ABPM. Methods—229 normotensive and untreated mildly hypertensive participants (mean age 52.5 ± 14.6, 54% female) underwent OBP measurements, HBPM, and 24-hour ABPM. Using the algorithm, sensitivity (SN), specificity (SP), and positive and negative predictive values (PPV, NPV) for SH and WCH were assessed. We then modified the algorithm utilizing a systolic and diastolic OBP cutoff at a SP of 95% for ambulatory hypertension –those with office hypertension but OBP levels below the upper cutoff undergo HBPM and subsequent ABPM if appropriate. Results—Using the original algorithm, SN and PPV for SH were 100% and 93.8%. Despite a SP of 44.4%, NPV was 100%. These values correspond to SP, NPV, SN, and PPV for WCH respectively. Using the modified algorithm, the diagnostic accuracy for SH and WCH did not change. However, far fewer participants needed HBPM (29 vs. 84) and ABPM (8 vs. 15). Conclusions—In this sample, the original and modified algorithms are excellent at diagnosing SH and WCH. However, the latter requires far fewer subjects to undergo HBPM and ABPM. These findings have important implications for the cost-effective diagnosis of SH and WCH

What is the optimal interval between successive home blood pressure readings using an automated oscillometric device?

Objectives: To clarify whether a shorter interval between three successive home blood pressure (HBP) readings (10 s vs. 1 min) taken twice a day gives a better prediction of the average 24-h BP and better patient compliance. Design: We enrolled 56 patients from a hypertension clinic (mean age: 60 ± 14 years; 54% female patients). The study consisted of three clinic visits, with two 4-week periods of self-monitoring of HBP between them, and a 24-h ambulatory BP monitoring at the second visit. Using a crossover design, with order randomized, the oscillometric HBP device (HEM-5001) could be programmed to take three consecutive readings at either 10-s or 1-min intervals, each of which was done for 4 weeks. Patients were asked to measure three HBP readings in the morning and evening. All the readings were stored in the memory of the monitors. Results: The analyses were performed using the second–third HBP readings. The average systolic BP/diastolic BP for the 10-s and 1-min intervals at home were 136.1 ± 15.8/77.5 ± 9.5 and 133.2 ± 15.5/76.9 ± 9.3 mmHg (P = 0.001/0.19 for the differences in systolic BP and diastolic BP), respectively. The 1-min BP readings were significantly closer to the average of awake ambulatory BP (131 ± 14/79 ± 10 mmHg) than the 10-s interval readings. There was no significant difference in patients' compliance in taking adequate numbers of readings at the different time intervals. Conclusion: The 1-min interval between HBP readings gave a closer agreement with the daytime average BP than the 10-s interval

Franz Volhard lecture: should doctors still measure blood pressure? The missing patients with masked hypertension

The traditional reliance on blood pressure (BP) measurement in the medical setting misses a significant number of individuals with masked hypertension, who have normal clinic BP but persistently high daytime BP when measured out of the office. We suggest that masked hypertension may be a precursor of clinically recognized sustained hypertension and is associated with increased cardiovascular risk compared with consistent normotension. We discuss factors that may contribute to clinic–daytime BP differences as well as the changing relationship between these two measures over time. Anxiety at the time of BP measurement and having been diagnosed as hypertensive appear to be two possible mechanisms. The identification of individuals with masked hypertension is of great clinical importance and requires out-of-office BP screening. Ambulatory BP monitoring is the best established technique for doing this, but home monitoring may be applicable in the future

The Misdiagnosis of Hypertension: The Role of Patient Anxiety

Background: The white coat effect (defined as the difference between blood pressure [BP] measurements taken at the physician's office and those taken outside the office) is an important determinant of misdiagnosis of hypertension, but little is known about the mechanisms underlying this phenomenon. We tested the hypothesis that the white coat effect may be a conditioned response as opposed to a manifestation of general anxiety. Methods: A total of 238 patients in a hypertension clinic wore ambulatory blood pressure monitors on 3 separate days 1 month apart. At each clinic visit, BP readings were manually triggered in the waiting area and the examination room (in the presence and absence of the physician) and were compared with the mercury sphygmomanometer readings taken by the physician in the examination room. Patients completed trait and state anxiety measures before and after each BP assessment. Results: A total of 35% of the sample was normotensive, and 9%, 37%, and 19% had white coat, sustained, and masked hypertension, respectively. The diagnostic category was associated with the state anxiety measure (F3,237 = 6.4, P < .001) but not with the trait anxiety measure. Patients with white coat hypertension had significantly higher state anxiety scores (t = 2.67, P < .01), with the greatest difference reported during the physician measurement. The same pattern was observed for BP changes, which generally paralleled the changes in state anxiety (t = 4.86, P < .002 for systolic BP; t = 3.51, P < .002 for diastolic BP). Conclusions: These findings support our hypothesis that the white coat effect is a conditioned response. The BP measurements taken by physicians appear to exacerbate the white coat effect more than other means. This problem could be addressed with uniform use of automated BP devices in office settings

Are there consequences of labeling patients with prehypertension? An experimental study of effects on blood pressure and quality of life

Objective The prehypertension classification was introduced to facilitate prevention efforts among patients at increased risk for hypertension. Although patients who have been told that they have hypertension report worse outcomes than unaware hypertensives, little is known about whether or not prehypertension labeling has negative effects. We evaluated the effects of labeling individuals with prehypertension on blood pressure and health-related quality of life three months later. Methods One hundred adults (aged 19 to 82 [mean=40.0] years; 54% women; 64% racial/ethnic minorities) with screening blood pressure in the prehypertensive range (120–139/80–89 mm Hg) and no history of diagnosis or treatment of elevated blood pressure were randomly assigned to either a “Labeled” group in which they were informed of their prehypertension, or an “Unlabeled” group in which they were not informed. Subjects underwent office blood pressure measurement, 24-hour ambulatory blood pressure monitoring and completed self-report questionnaires at baseline and at three months. Results Multilevel mixed effects regression analyses indicated that changes in the white coat effect, office blood pressure, mean daytime ambulatory blood pressure, and physical and mental health did not differ significantly between the two groups. Adjusting for age, sex, race/ethnicity and body mass index did not affect the results. Conclusion These findings suggest that labeling patients with prehypertension does not have negative effects on blood pressure or quality of life. Additional research is needed to develop approaches to communicating with patients about their blood pressure that will maximize the clinical and public health impact of the prehypertension classification

Rumination as a Mediator of Chronic Stress Effects on Hypertension: A Causal Model

Chronic stress has been linked to hypertension, but the underlying mechanisms remain poorly specified. We suggest that chronic stress poses a risk for hypertension through repeated occurrence of acute stressors (often stemming from the chronic stress context) that cause activation of stress-mediating physiological systems. Previous models have often focused on the magnitude of the acute physiological response as a risk factor; we attempt to extend this to address the issue of duration of exposure. Key to our model is the notion that these acute stressors can emerge not only in response to stressors present in the environment, but also to mental representations of those (or other) stressors. Consequently, although the experience of any given stressor may be brief, a stressor often results in a constellation of negative cognitions and emotions that form a mental representation of the stressor. Ruminating about this mental representation of the stressful event can cause autonomic activation similar to that observed in response to the original incident, and may occur and persist long after the event itself has ended. Thus, rumination helps explain how chronic stress causes repeated (acute) activation of one's stress-mediating physiological systems, the effects of which accumulate over time, resulting in hypertension risk

Heart Rate Recovery After Cognitive Challenge Is Preserved With Age

Objective: To investigate the effect of age on heart rate recovery (HRR) from cognitive challenge. Background: Aging is an independent risk factor for the development of cardiovascular disease. HRR from exercise is an established predictor of cardiac morbidity and mortality, and evidence suggests that HRR from cognitive challenge is predictive of cardiac morbidity as well. Aging is associated with delayed HRR from exercise stress, but little is known about the effect of aging on HRR from psychological stress. We tested the hypothesis that age would be related to delayed HRR from psychological stress. Methods: HRR post exposure to cognitive challenge (mental arithmetic and Stroop) was investigated in a sample of 436 participants aged 35 to 84 years in MIDUS II, a national study of health and well-being. HRR was measured as 1) the amount of change from the stress level; 2) time to recover; and 3) the area under the curve. The analyses were controlled for medical comorbidities and medications that influence HR, such as body mass index, smoking, sex, menopausal status, and amount of physical activity/exercise. Results: There was no effect for age on HRR as evaluated by all three recovery assessment methods. Conclusions: Contrary to expectation and in contrast to findings concerning HRR from exercise, HRR from cognitive challenge was preserved with age. These findings require further inquiry into differential mechanism(s) underlying HRR from psychological versus exercise stress, including any role for improved emotion regulation with greater age