Behaviour change strategies for reducing blood pressure-related disease burden: findings from a global implementation research programme

Perceptions of the Doctor-Patient Relationship Among Patients in a Private, Secondary-Level Hospital in Southern India

Introduction

An epidemic of non-communicable diseases (NCDs) in India is fueling a growing demand for primary care and hospitalization services. Difficulties in coordinating inpatient and outpatient care create significant barriers to providing high-quality medical care. In this paper, we describe patient experiences, perceptions, and expectations of doctor-patient relationships in a secondary-level private hospital in Karnataka, India.

Methods

We conducted a cross-sectional, mixed-method needs assessment with surveys and in-depth interviews at Dr. TMA Pai Hospital (TMAPH), a secondary-level, private sector hospital in Karnataka, India. Inclusion criteria included all adults over 18 years old hospitalized at TMAPH in the past year. Patients were consecutively recruited from August 2019-October 2019 and asked to rate aspects of their relationship with their primary care provider (PCP). Descriptive statistics and multivariable logistic regression were used to analyze predictors of the doctor-patient relationship. Patients were interviewed regarding their perceptions of care coordination and doctor-patient relationships. General Thematic Analysis was utilized to analyze qualitative data and develop themes. Quantitative and qualitative findings were then merged to interpret the various dimensions of doctor-patient relationships.

Results

A total of 150 patients (47.3% male) enrolled. Ten patients underwent qualitative interviews. The median patient age was 67 years (IQR 56-76). 112 (74.7%) of patients identified a PCP either at or outside of TMAPH. 89% had diabetes and/or hypertension. Compared to patients without a PCP, having a PCP led to a significantly higher adjusted odds of always spending optimal time with their doctors (aOR 2.7, 95% CI 1.1-6.8, p = 0.04), and always receiving clear instructions on managing their medical conditions (aOR 2.5, 95% CI 1.0-6.1, p = 0.04). The following themes were developed from patient interviews: (1) patients trusted and respected their PCP believing they were receiving high quality care; and (2) despite perceived fragmentation in care, patients spoke favorably of their relationships with their doctors.

Conclusions

Among a sample of recently hospitalized patients, those with a PCP reported more positive doctor-patient relationships, though rates of dissatisfaction with doctors were still high. Further research and strategies are required to optimize continuity of care and doctor-patient relationships across the entire continuum of outpatient and inpatient care.

Effects of the self-management training program on self-management behavior and blood pressure levels among elderly people with hypertension

Objective

To determine the effects of the Self-Management Training Program on self-management behavior and blood pressure (BP) levels among elderly people with hypertension (HT).

Methods

This study was based on a quasi-experimental design using sampling groups composed of elderly residents of Pathum Thani Province with HT. Simple random sampling was applied to two sampling groups, an experimental group and a control group. However, the experimental group had been on the Self-Management Training Program based on the Creer concept. The Program's contents included small-group health-education sessions and the patients’ manual, Self-Management Training Skills for Self-Management Behavior. Small group discussions were held for self-reflection, to stimulate follow-up for self-management behavior training during home visits. The Self-Management Training Program was compared with programs involving the more usual care. Data were collected using the Self-Management Behavior for Hypertension Control Questionnaire and BP assessment tests. Data were analyzed using a descriptive statistic, chi-square test, pair t-test, repeated-measures Analysis of Variance (ANOVA), and repeated-measures Analysis Covariance (ANCOVA).

Results

It was found that at 13 weeks after entering the program, the experimental group demonstrated a significantly lower systolic and diastolic BP with a baseline statistical significance (P < 0.005), and that at the 4th week and the 13th week, there was a decrease in BP in the experimental group. The experimental group also had above-baseline self-management behavior scores that were higher than in the control group (P < 0.01).

Conclusions

Results from this study show that the Self-Management Program was useful for BP control and promoted sustainable self-management behavior.

Barriers and facilitators for treatment and control of high blood pressure among hypertensive patients in Kathmandu, Nepal: a qualitative study informed by COM-B model of behavior change

Background

Nepal has a high prevalence of hypertension which is a major risk factor for cardiovascular diseases globally. It is inadequately controlled even after its diagnosis despite the availability of effective treatment of hypertension. There is a need for an in-depth understanding of the barriers and facilitators using theory to inform interventions to improve the control of hypertension. This formative study was conducted to address this gap by exploring the perceived facilitators and barriers to treatment and control of hypertension in Nepal.

Methods

We conducted in-depth interviews (IDIs) among hypertensive patients, their family members, healthcare providers and key informants at primary (health posts and primary health care center) and tertiary level (Kathmandu Medical College) facilities in Kathmandu, Nepal. Additionally, data were collected using focus group discussions (FGDs) with hypertensive patients. Recordings of IDIs and FGDs were transcribed, coded both inductively and deductively, and subthemes generated. The emerging subthemes were mapped to the Capability, Opportunity, and Motivation-Behaviour (COM-B) model using a deductive approach.

Results

Major uncovered themes as capability barriers were misconceptions about hypertension, its treatment and difficulties in modifying behaviour. Faith in alternative medicine and fear of the consequences of established treatment were identified as motivation barriers. A lack of communication between patients and providers, stigma related to hypertension and fear of its disclosure, and socio-cultural factors shaping health behaviour were identified as opportunity barriers in the COM-B model. The perceived threat of the disease, a reflective motivator, was a facilitator in adhering to treatment.

Conclusions

This formative study, using the COM-B model of behaviour change identified several known and unknown barriers and facilitators that influence poor control of blood pressure among people diagnosed with hypertension in Kathmandu, Nepal. These findings need to be considered when developing targeted interventions to improve treatment adherence and blood pressure control of hypertensive patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11548-4.

Adapting Strategies for Optimal Intervention Implementation in Nursing Homes: A Formative Evaluation

BACKGROUND AND OBJECTIVES

Nursing homes pose unique challenges for implementation of research and quality improvement (QI). We previously demonstrated successful implementation of a nursing home-led intervention to improve relationships between frontline staff and residents in 6 U.S. Department of Veterans Affairs (VA) Community Living Centers (CLCs). This article discusses early adaptations made to the intervention and its implementation to enhance frontline staff participation.

RESEARCH DESIGN AND METHODS

This is a formative evaluation of intervention implementation at the first 2 participating CLCs. Formative evidence-including site visitors' field notes, implementation facilitation records, and semistructured frontline staff interviews-were collected throughout the study period. Data analysis was informed by the Capability, Opportunity, Motivation, and Behavior model of behavior change.

RESULTS

Adaptations were made to 5 a priori intervention implementation strategies: (a) training leaders, (b) training frontline staff, (c) adapting the intervention to meet local needs, (d) auditing and providing feedback, and (e) implementation facilitation. On the basis of a 6-month implementation period at the first CLC, we identified elements of the intervention and aspects of the implementation strategies that could be adapted to facilitate frontline staff participation at the second CLC.

DISCUSSION AND IMPLICATIONS

Incremental implementation, paired with ongoing formative evaluation, proved critical to enhancing capability, opportunity, and motivation among frontline staff. In elucidating what was required to initiate and sustain the nursing home-led intervention, we provide a blueprint for responding to emergent challenges when performing research and QI in the nursing home setting.

Association of -344C/T polymorphism in the aldosterone synthase (CYP11B2) gene with cardiac and cerebrovascular events in Chinese patients with hypertension

Objective

Several recent studies have shown that the aldosterone synthase gene (CYP11B2) −344C/T polymorphism is related to cardiovascular diseases. However, whether the −344C allele influences the incidence of cardiovascular diseases in Chinese patients with hypertension is unclear.

Methods

Chinese patients with essential hypertension were genotyped for the −344C/T polymorphism in CYP11B2 (n = 755; CC, n = 112; CT, n = 361; TT, n = 282) and followed for 11 years for major adverse cardiovascular events (MACEs), including stroke, onset of coronary artery disease (CAD), and CAD-related death. Established cardiovascular risk factors were used to adjust the multivariate Cox analysis.

Results

After a mean follow-up period of 7.60 ± 1.12 years, a significantly higher incidence of MACEs was seen in patients with the CC genotype than in those with the CT and TT genotypes. The CC variant was significantly and independently predictive of MACEs (hazard ratio = 2.049), CAD (hazard ratio = 1.754), and stroke (hazard ratio = 2.588), but not CAD-related stroke or death.

Conclusion

The CYP11B2 −344 CC genotype is a risk factor for CAD and stroke, independent of other established cardiovascular risk factors in Chinese patients with hypertension.

Nursing Home Staff Perceptions of Barriers and Facilitators to Implementing a Quality Improvement Intervention

OBJECTIVES

Quality improvement (QI) may be a promising approach for staff to improve the quality of care in nursing homes. However, little is known about the challenges and facilitators to implementing QI interventions in nursing homes. This study examines staff perspectives on the implementation process.

DESIGN

We conducted semistructured interviews with staff involved in implementing an evidence-based QI intervention ("LOCK") to improve interactions between residents and staff through targeted staff behavior change. The LOCK intervention consists of 4 practices: (1) Learn from the bright spots, (2) Observe, (3) Collaborate in huddles, and (4) Keep it bite sized.

SETTING AND PARTICIPANTS

We interviewed staff members in 6 Veterans Health Administration nursing homes [ie, Community Living Centers (CLCs)] via opportunistic and snowball sampling.

MEASURES

The semistructured interviews were grounded in the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change and covered staff experience, challenges, facilitators, and lessons learned during the implementation process. The interviews were analyzed using thematic content analysis.

RESULTS

Overall, staff accepted the intervention and appreciated the focus on the positives. Challenges fell largely within the categories of capability and opportunity and included difficulty finding time to complete intervention activities, inability to interpret data reports, need for ongoing training, and misunderstanding of study goals. Facilitators were largely within the motivation category, including incentives for participation, reinforcement of desired behavior, feasibility of intervention activities, and use of data to quantify improvements.

CONCLUSIONS/IMPLICATIONS

As QI programs become more common in nursing homes, it is critical that interventions are tailored for this unique setting. We identified barriers and facilitators of our intervention's implementation and learned that no challenge was insurmountable or derailed the implementation of LOCK. This ability of frontline staff to overcome implementation challenges may be attributed to LOCK's inherently motivational features. Future nursing home QI interventions should consider including built-in motivational components.

Teaching patient safety in global health: lessons from the Duke Global Health Patient Safety Fellowship

Health systems in low-income and middle-income countries (LMICs) have a high burden of medical errors and complications, and the training of local experts in patient safety is critical to improve the quality of global healthcare. This analysis explores our experience with the Duke Global Health Patient Safety Fellowship, which is designed to train clinicians from LMICs in patient safety, quality improvement and infection control. This intensive fellowship of 3-4 weeks includes (1) didactic training in patient safety and quality improvement, (2) experiential training in patient safety operations, and (3) mentorship of fellows in their home institution as they lead local safety programmes. We have learnt several lessons from this programme, including the need to contextualise training to local needs and resources, and to focus training on building interdisciplinary patient safety teams. Implementation challenges include a lack of resources and data collection systems, and limited recognition of the role of safety in global health contexts. This report can serve as an operational guide for intensive training in patient safety that is contextualised to global health challenges.

Impact of Intervention to Improve Nursing Home Resident-Staff Interactions and Engagement

Background and Objectives

For nursing home residents, positive interactions with staff and engagement in daily life contribute meaningfully to quality of life. We sought to improve these aspects of person-centered care in an opportunistic snowball sample of six Veterans Health Administration nursing homes (e.g., Community Living Centers-CLCs) using an intervention that targeted staff behavior change, focusing on improving interactions between residents and staff and thereby ultimately aiming to improve resident engagement.

Research Design and Methods

We grounded this mixed-methods study in the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change. We implemented the intervention by (a) using a set of evidence-based practices for implementing quality improvement and (b) combining primarily CLC-based staff facilitation with some researcher-led facilitation. Validated resident and staff surveys and structured observations collected pre and post intervention, as well as semi-structured staff interviews conducted post intervention, helped assess intervention success.

Results

Sixty-two CLC residents and 308 staff members responded to the surveys. Researchers conducted 1,490 discrete observations. Intervention implementation was associated with increased staff communication with residents during the provision of direct care and decreased negative staff interactions with residents. In the 66 interviews, staff consistently credited the intervention with helping them (a) develop awareness of the importance of identifying opportunities for engagement and (b) act to improve the quality of interactions between residents and staff.

Discussion and Implications

The intervention proved feasible and influenced staff to make simple enhancements to their behaviors that improved resident-staff interactions and staff-assessed resident engagement.

Serine hydroxymethyltransferase 1 promoter hypermethylation increases the risk of essential hypertension

BACKGROUND

Serine hydroxymethyltransferase 1 (SHMT1) is an enzyme involved in folic acid metabolism and is known to contribute to the development of hypertension. We evaluated the relationship between SHMT1 promoter methylation and essential hypertension (EH).

METHODS

Quantitative methylation-specific polymerase chain reaction was used to measure the SHMT1 promoter methylation level in 241 EH patients and 288 age- and gender-matched healthy individuals. The diagnostic value of SHMT1 promoter hypermethylation was analyzed using a receiver operating characteristic (ROC) curve. The Gene Expression Omnibus (GEO) database and dual-luciferase reporter assay were used to validate our findings.

RESULTS

Compared with the control group, significant differences in SHMT1 promoter methylation were found in both EH and hyperhomocysteinemia groups (P < 0.001 and P = 0.029, respectively). The area under the curve of the diagnosis of SHMT1 promoter hypermethylation for EH was 0.808, with a sensitivity and specificity of 73.9% and 77.8%, respectively. The risk of SHMT1 promoter hypermethylation was significantly higher in the >65-year group than in the ≤65-year group (odds ratio = 3.925; 95% confidence interval = 2.141-7.196). In addition, GEO database analysis showed that 5-aza-deoxycytidine increased gene expression in several carotid endothelial cell lines. A dual-luciferase reporter assay revealed that the target sequence in the SHMT1 promoter upregulated gene expression.

CONCLUSION

Our findings indicate that SHMT1 promoter hypermethylation increases the risk of EH and may be a promising biomarker for EH.

Enhancing self-care adherence in patients with heart failure: a study protocol for developing a theory-based behaviour change intervention using the COM-B behaviour model (ACHIEVE study)

INTRODUCTION

Although international guidelines recommend self-care as an integral part of routine heart failure management, and despite evidence supporting the positive outcomes related to self-care, patients are frequently unable to adhere. Self-care can be modified through behaviour change interventions (BCIs). However, previous self-care interventions have shown limited success in improving adherence to self-care, because they were neither theory-based nor well defined, which precludes the identification of underlying causal mechanisms as well as reproducibility of the intervention. Thus, our aim is to develop an intervention manual that contains theory-based BCIs that are well-defined using eight descriptors proposed to describe BCIs in a standardised way.

METHODS AND ANALYSIS

BCIs will be based on statements of findings derived through qualitative meta-summary techniques and a quantitative meta-analysis. These reviews will be used to extract factors (target behaviours) associated with self-care adherence/non-adherence. Extracted target behaviours will be mapped onto the 'Capability, Opportunity, Motivation and Behaviour' (COM-B) model to capture the underlying mechanisms involved. To develop approaches for change, the 'Taxonomy of Behaviour Change Techniques' will be used to allow effective mapping of the target behaviours onto established behaviour change techniques. Suggested BCIs will then be translated into locally relevant interventions using the Normalisation Process Theory to overcome the difficulties of implementing theoretically derived interventions into practice. Finally, a consensus development method will be employed to fine-tune the content and acceptability of the intervention manual to increase the likelihood of successfully piloting and implementing future BCIs into the German healthcare system.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the Ethics Committee of the Medical Faculty of the Heinrich Heine University Düsseldorf, Germany (Ref #: 2018-30). The results will be disseminated via peer-reviewed journal publications, conference presentations and stakeholder engagement activities.

TRIAL REGISTRATION NUMBER

DRKS00014855; Pre-results.

Gaps in awareness and control of hypertension: a cross-sectional study in Chinese urban adults

Hypertension is a serious public health threat worldwide. This study sought to explore gaps in urban Chinese adults' awareness and control of hypertension. A cross-sectional study was carried out in eight Chinese cities in 2016. Participants were organized into four groups on the basis of blood pressure (BP) and self-reported disease history: healthy group (63.0%), well-controlled BP group (9.1%), unaware hypertension group (14.0%), and poorly controlled BP group (13.9%). Multinomial logistic regression with the healthy group as the reference group showed that younger age and body mass index <24 kg/m² were negatively associated with lack of awareness of hypertension and poor control of BP. Lower salt intake, but not sodium intake, was associated with poor control of BP. Other factors associated with lack of awareness of hypertension included low fish and seafood intake. Low sodium intake contributed to good control of BP. In conclusion, there are gaps in urban Chinese adults' awareness and control of hypertension. A comprehensive strategy for enhancing awareness of hypertension and changing behaviors associated with the condition should be developed and implemented.

Building a safety culture in global health: lessons from Guatemala

Programmes to modify the safety culture have led to lasting improvements in patient safety and quality of care in high-income settings around the world, although their use in low-income and middle-income countries (LMICs) has been limited. This analysis explores (1) how to measure the safety culture using a health culture survey in an LMIC and (2) how to use survey data to develop targeted safety initiatives using a paediatric nephrology unit in Guatemala as a field test case. We used the Safety, Communication, Operational Reliability, and Engagement survey to assess staff views towards 13 health climate and engagement domains. Domains with low scores included personal burnout, local leadership, teamwork and work–life balance. We held a series of debriefings to implement interventions targeted towards areas of need as defined by the survey. Programmes included the use of morning briefings, expansion of staff break resources and use of teamwork tools. Implementation challenges included the need for education of leadership, limited resources and hierarchical work relationships. This report can serve as an operational guide for providers in LMICs for use of a health culture survey to promote a strong safety culture and to guide their quality improvement and safety programmes.

Process Evaluation and Costing of a Multifaceted Population-Wide Intervention to Reduce Salt Consumption in Fiji

This paper reports the process evaluation and costing of a national salt reduction intervention in Fiji. The population-wide intervention included engaging food industry to reduce salt in foods, strategic health communication and a hospital program. The evaluation showed a 1.4 g/day drop in salt intake from the 11.7 g/day at baseline; however, this was not statistically significant. To better understand intervention implementation, we collated data to assess intervention fidelity, reach, context and costs. Government and management changes affected intervention implementation, meaning fidelity was relatively low. There was no active mechanism for ensuring food companies adhered to the voluntary salt reduction targets. Communication activities had wide reach but most activities were one-off, meaning the overall dose was low and impact on behavior limited. Intervention costs were moderate (FJD $277,410 or $0.31 per person) but the strategy relied on multi-sector action which was not fully operationalised. The cyclone also delayed monitoring and likely impacted the results. However, 73% of people surveyed had heard about the campaign and salt reduction policies have been mainstreamed into government programs. Longer-term monitoring of salt intake is planned through future surveys and lessons from this process evaluation will be used to inform future strategies in the Pacific Islands and globally.

Use of audit, feedback and education increased guideline implementation in a multidisciplinary stroke unit

BACKGROUND

The audit-feedback cycle is a behaviour change intervention used to reduce evidence-practice gaps. In this study, repeat audits, feedback, education and training were used to change practice and increase compliance with Australian guideline recommendations for stroke rehabilitation.

OBJECTIVE

To increase the proportion of patients with stroke receiving best practice screening, assessment and treatment.

METHODS

A before-and-after study design was used. Data were collected from medical records (n=15 files per audit). Four audits were conducted between 2009 and 2013. Consecutive files of patients with stroke admitted to the stroke unit were selected and audited retrospectively. Staff behaviour change interventions included four cycles of audit feedback, and education to assist staff with change. The primary outcome measure was the proportion of eligible patients receiving best practice against target behaviours, based on audit data.

RESULTS

Between the first and fourth audit (2009 and 2013), 20 of the 27 areas targeted (74%) met or exceeded the minimum target of 10% change. Practice areas that showed the most change included sensation screening (+75%) and rehabilitation (+100%); neglect screening (+92%) and assessment (100%). Some target behaviours showed a drop in compliance such as anxiety and depression screening (-27%) or little or no overall improvement such as patient education about stroke (6% change).

CONCLUSIONS

Audit feedback and education increased the proportion of inpatients with stroke receiving best practice rehabilitation in some, but not all practice areas. An ongoing process of quality improvement is needed to help sustain these improvements.

Knowledge of hypertension and its management among hypertensive patients on chronic medicines at primary health care public sector facilities in South Africa; findings and implications

BACKGROUND

There are high growing prevalence rates of hypertension in South Africa. Consequently, there is a need to assess knowledge and management among hypertensive patients receiving chronic medication from primary health care (PHC) facilities in South Africa as a basis for improving future management. This is important as South Africa seeks to improve its management of chronic diseases.

METHODS

Descriptive, quantitative study amongst chronic hypertensive patients in the chronic disease programme. Patients were interviewed face-to-face by trained pharmacists using a structured questionnaire. Data analysis included descriptive and inferential statistics.

RESULTS

Half (53.7%) of the patients had uncontrolled blood pressure (BP). Less than a third of patients (27.7%) knew what hypertension is, the meaning of recorded BP numbers (4.5%), and what normal BP should be (19.9%). All patients who knew the meaning of BP numbers had formal education (p = 0.047). Only 15.6% of the 56.0% patients, who received hypertension information, received it on antihypertensive medicines specifically.

CONCLUSIONS

The majority of the patients lacked hypertension specific knowledge and only half had controlled BP. Interventions to improve the control of high BP should be targeted at closing knowledge gaps as part of the current chronic treatment initiatives in South Africa to ensure the benefits of increased access to care are realized.

Patient-related beliefs and adherence toward their medications among the adult hypertensive outpatients in Tanzania

AIM

Hypertension is a leading global health problem requiring lifelong treatment. However, adherence to antihypertensive medicines is a problem, greater among developing countries. Consequently, there is a need to determine current adherence rates and their associations among developing countries to plan future initiatives.

MATERIALS & METHODS

Cross-sectional study among adult outpatients with essential hypertension in Tanzania. Predesigned questionnaires were used to gather information on adherence rates and patient-related beliefs. The main outcome measure was adherence.

RESULTS

A total of 180 participants were included, with females making up 65%. High-adherence rates were seen in 54% of the patients. Patients' belief about their medication and its necessity was higher in the high adherent group and concerns about their medicines and their necessity were higher in the low adherent group. Conclusion & recommendations: Adherence rates were low compared with a suggested level ≥80%. Educational initiatives are needed to address knowledge and concerns with hypertension to improve future outcomes.

Developing consensus measures for global programs: lessons from the Global Alliance for Chronic Diseases Hypertension research program

BACKGROUND

The imperative to improve global health has prompted transnational research partnerships to investigate common health issues on a larger scale. The Global Alliance for Chronic Diseases (GACD) is an alliance of national research funding agencies. To enhance research funded by GACD members, this study aimed to standardise data collection methods across the 15 GACD hypertension research teams and evaluate the uptake of these standardised measurements. Furthermore we describe concerns and difficulties associated with the data harmonisation process highlighted and debated during annual meetings of the GACD funded investigators. With these concerns and issues in mind, a working group comprising representatives from the 15 studies iteratively identified and proposed a set of common measures for inclusion in each of the teams' data collection plans. One year later all teams were asked which consensus measures had been implemented.

RESULTS

Important issues were identified during the data harmonisation process relating to data ownership, sharing methodologies and ethical concerns. Measures were assessed across eight domains; demographic; dietary; clinical and anthropometric; medical history; hypertension knowledge; physical activity; behavioural (smoking and alcohol); and biochemical domains. Identifying validated measures relevant across a variety of settings presented some difficulties. The resulting GACD hypertension data dictionary comprises 67 consensus measures. Of the 14 responding teams, only two teams were including more than 50 consensus variables, five teams were including between 25 and 50 consensus variables and four teams were including between 6 and 24 consensus variables, one team did not provide details of the variables collected and two teams did not include any of the consensus variables as the project had already commenced or the measures were not relevant to their study.

CONCLUSIONS

Deriving consensus measures across diverse research projects and contexts was challenging. The major barrier to their implementation was related to the time taken to develop and present these measures. Inclusion of consensus measures into future funding announcements would facilitate researchers integrating these measures within application protocols. We suggest that adoption of consensus measures developed here, across the field of hypertension, would help advance the science in this area, allowing for more comparable data sets and generalizable inferences.

Acupuncture with reinforcing and reducing twirling manipulation inhibits hippocampal neuronal apoptosis in spontaneously hypertensive rats

To observe the effects of different acupuncture manipulations on blood pressure and target organ damage in spontaneously hypertensive rats (SHRs), this study used the reinforcing twirling method (1.5–2-mm depth; rotating needle clockwise for 360° and then counter clockwise for 360°, with the thumb moving heavily forward and gently backward, 60 times per minute for 1 minute, and retaining needle for 9 minutes), the reducing twirling method (1.5–2-mm depth; rotating needle counter clockwise for 360° and then clockwise for 360°, with the thumb moving heavily backward and gently forward, 60 times per minute for 1 minute, and retaining needle for 9 minutes), and the needle retaining method (1.5–2-mm depth and retaining the needle for 10 minutes). Bilateral Taichong (LR3) was treated by acupuncture using different manipulations and manual stimulation. Reinforcing twirling, reducing twirling, and needle retaining resulted in a decreased number of apoptotic cells, reduced Bax mRNA and protein expression, and an increased Bcl-2/Bax ratio in the hippocampus compared with the SHR group. Among these groups, the Bcl-2/Bax protein ratio was highest in the reducing twirling group, and the Bcl-2/Bax mRNA ratio was highest in the needle retaining group. These results suggest that reinforcing twirling, reducing twirling, and needle retaining methods all improve blood pressure and prevent target organ damage by increasing the hippocampal Bcl-2/Bax ratio and inhibiting cell apoptosis in the hippocampus in SHR.

Interactions between CYP11B2 Promoter Methylation and Smoking Increase Risk of Essential Hypertension

Aldosterone synthase (CYP11B2) is closely linked to essential hypertension (EH). However, it remains unclear whether the methylation of the CYP11B2 promoter is involved in the development of EH in humans. Our study is aimed at evaluating the contribution of CYP11B2 promoter methylation to the risk of EH. Methylation levels were measured using pyrosequencing technology in 192 participants in a hospital-based case-control study. Logistic regression and multiple linear regression analyses were utilized to adjust for confounding factors and the GMDR method was applied to investigate high-order gene-environment interactions. Although no significant result was observed linking the four analyzed CpG sites to EH, GMDR detected significant interactions among CpG1, CpG3, CpG4, and smoking correlated with an increased risk of EH (OR = 4.62, adjusted P = 0.011). In addition, CpG2 (adjusted P = 0.013) and CpG3 (adjusted P = 0.039) methylation was significantly lower in healthy males than in healthy females. Likewise, after adjusting for confounding factors, CpG2 methylation (adjusted P = 0.007) still showed significant gender-specific differences among the participants of the study. CpG1 (P = 0.009) site was significantly positively correlated with age, and CpG3 (P = 0.007) and CpG4 (P = 0.006) were both inversely linked to smoking. Our findings suggest that gene-environment interactions are associated with the pathogenesis and progression of EH.

Oxidative Stress and Salvia miltiorrhiza in Aging-Associated Cardiovascular Diseases

Aging-associated cardiovascular diseases (CVDs) have some risk factors that are closely related to oxidative stress. Salvia miltiorrhiza (SM) has been used commonly to treat CVDs for hundreds of years in the Chinese community. We aimed to explore the effects of SM on oxidative stress in aging-associated CVDs. Through literature searches using Medicine, PubMed, EMBASE, Cochrane library, CINAHL, and Scopus databases, we found that SM not only possesses antioxidant, antiapoptotic, and anti-inflammatory effects but also exerts angiogenic and cardioprotective activities. SM may reduce the production of reactive oxygen species by inhibiting oxidases, reducing the production of superoxide, inhibiting the oxidative modification of low-density lipoproteins, and ameliorating mitochondrial oxidative stress. SM also increases the activities of catalase, manganese superoxide dismutase, glutathione peroxidase, and coupled endothelial nitric oxide synthase. In addition, SM reduces the impact of ischemia/reperfusion injury, prevents cardiac fibrosis after myocardial infarction, preserves cardiac function in coronary disease, maintains the integrity of the blood-brain barrier, and promotes self-renewal and proliferation of neural stem/progenitor cells in stroke. However, future clinical well-designed and randomized control trials will be necessary to confirm the efficacy of SM in aging-associated CVDs.