Suparna Qanungo

Blood Pressure and Cholesterol Control in Hypertensive Hypercholesterolemic Patients National Health and Nutrition Examination Surveys 1988–2010

Background— Hypertension doubles coronary heart disease (CHD) risk. Treating hypertension only reduces CHD risk ≈25%. Treating hypercholesterolemia in hypertensive patients reduces residual CHD risk >35%. Methods and Results— To assess progress in concurrent hypertension and hypercholesterolemia control, National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2004, and 2005 to 2010 were analyzed. Hypertension was defined by blood pressure ≥140/≥90 mm Hg, current medication treatment, and 2-told hypertension status; blood pressure <140/<90 defined control. Hypercholesterolemia was defined by ATP III criteria based on 10-year CHD risk, low-density lipoprotein cholesterol (LDL-C), and non–high-density lipoprotein cholesterol; values below diagnostic thresholds defined control. Across surveys, 60.7% to 64.3% of hypertensives were hypercholesterolemic. From 1988 to 1994 to 2005 to 2010, control of LDL-C rose (9.2% [95% confidence interval (CI), 6.6%–11.9%] to 45.4% [95% CI, 42.6%–48.3%]), concomitant hypertension and LDL-C (5.0% [95% CI, 3.3%–6.7%] to 30.7% [95% CI, 27.9%–33.4%]), and combined hypertension, LDL-C, and non–high-density lipoprotein cholesterol (1.8% [95% CI, 0.4%–3.2%] to 26.9% [95% CI, 24.4%–29.5%]). By multivariable logistic regression, factors associated with concomitant hypertension, LDL-C, and non–high-density lipoprotein cholesterol control (odds ratio [95% CI]) were statin (10.7 [8.1–14.3]) and antihypertensive (3.32 [2.45–4.50]) medications, age (0.77 [0.69–0.88]/10-year increase), ≥2 healthcare visits/yr (1.90 [1.26-2.87]), black race (0.59 [0.44–0.80]), Hispanic ethnicity (0.62 [0.43–0.90]), cardiovascular disease (0.44 [0.34–0.56]), and diabetes mellitus (0.54 [0.42–0.70]). Conclusions— Despite progress, opportunities for improving concomitant hypertension and hypercholesterolemia control persist. Prescribing antihypertensive and antihyperlipidemic medications to achieve treatment goals, especially for older, minority, diabetic, and cardiovascular disease patients, and accessing healthcare at least biannually could improve concurrent risk factor control and CHD prevention. # Clinical Perspective {#article-title-47}Background— Hypertension doubles coronary heart disease (CHD) risk. Treating hypertension only reduces CHD risk ≈25%. Treating hypercholesterolemia in hypertensive patients reduces residual CHD risk >35%. Methods and Results— To assess progress in concurrent hypertension and hypercholesterolemia control, National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2004, and 2005 to 2010 were analyzed. Hypertension was defined by blood pressure ≥140/≥90 mm Hg, current medication treatment, and 2-told hypertension status; blood pressure <140/<90 defined control. Hypercholesterolemia was defined by ATP III criteria based on 10-year CHD risk, low-density lipoprotein cholesterol (LDL-C), and non–high-density lipoprotein cholesterol; values below diagnostic thresholds defined control. Across surveys, 60.7% to 64.3% of hypertensives were hypercholesterolemic. From 1988 to 1994 to 2005 to 2010, control of LDL-C rose (9.2% [95% confidence interval (CI), 6.6%–11.9%] to 45.4% [95% CI, 42.6%–48.3%]), concomitant hypertension and LDL-C (5.0% [95% CI, 3.3%–6.7%] to 30.7% [95% CI, 27.9%–33.4%]), and combined hypertension, LDL-C, and non–high-density lipoprotein cholesterol (1.8% [95% CI, 0.4%–3.2%] to 26.9% [95% CI, 24.4%–29.5%]). By multivariable logistic regression, factors associated with concomitant hypertension, LDL-C, and non–high-density lipoprotein cholesterol control (odds ratio [95% CI]) were statin (10.7 [8.1–14.3]) and antihypertensive (3.32 [2.45–4.50]) medications, age (0.77 [0.69–0.88]/10-year increase), ≥2 healthcare visits/yr (1.90 [1.26-2.87]), black race (0.59 [0.44–0.80]), Hispanic ethnicity (0.62 [0.43–0.90]), cardiovascular disease (0.44 [0.34–0.56]), and diabetes mellitus (0.54 [0.42–0.70]). Conclusions— Despite progress, opportunities for improving concomitant hypertension and hypercholesterolemia control persist. Prescribing antihypertensive and antihyperlipidemic medications to achieve treatment goals, especially for older, minority, diabetic, and cardiovascular disease patients, and accessing healthcare at least biannually could improve concurrent risk factor control and CHD prevention.

Stroke-related stigma among West Africans: Patterns and predictors

BACKGROUND Disability-adjusted life-years lost after stroke in Low & Middle-Income Countries (LMICs) is almost seven times those lost in High-income countries. Although individuals living with chronic neurological and mental disorders are prone to stigma, there is a striking paucity of literature on stroke-related stigma particularly from LMICs. OBJECTIVE To assess the prevalence, severity, determinants and psycho-social consequences of stigma among LMIC stroke survivors. METHODS Between November 2015 and February 2016, we conducted a cross-sectional survey of 200 consecutive stroke survivors attending a neurology clinic in a tertiary medical center in Ghana. The validated 8-Item Stigma Scale for Chronic Illness (SSCI-8) questionnaire was administered to study participants to assess internalized and enacted domains of stigma at the personal dimension with further adaptation to capture family and community stigma experienced by stroke participants. Responses on the SSCI-8 were scored from 1 to 5 for each item, where 1=never, 2=rarely, 3=sometimes, 4=often and 5=always with a score range of 8-40. Demographic and clinical data on stroke type and severity as well as depression and Health-Related Quality of Life indicators were also collected. Predictors of stroke-related stigma were assessed using Linear Models (GLM) via Proc GENMOD in SAS 9.4. RESULTS 105 (52.5%) subjects recruited were males and the mean±SD age of stroke survivors in this survey was 62.0±14.4years. Mean SSCI-8 score was highest for personal stigma (13.7±5.7), which was significantly higher than family stigma (11.9±4.6; p=0.0005) and social/community stigma (11.4±4.4; p<0.0001). Approximately 80% of the cohort reported experiencing mild-to-moderate degrees of stigma. A graded increase in scores on the Geriatric Depression Scale and Centre for Epidemiological Studies-Depression scale was observed across the three categories. Living in an urban setting was associated with higher SSCI-8 scores. Moreover, stroke subjects with more severe post-stroke residual symptom deficits reported a significantly higher frequency of stigma. CONCLUSION Four out of five stroke survivors in this Ghanaian cohort reported experiencing some form of stigma. Stigmatized individuals were also more likely to be depressed and have lower levels of quality of life. Further studies are required to assess the consequences of stigma from stroke in LMIC.

N-acetyl-L-cysteine sensitizes pancreatic cancers to gemcitabine by targeting the NFκB pathway.

First-line therapy for pancreatic cancer is gemcitabine. Although tumors may initially respond to the gemcitabine treatment, soon tumor resistance develops leading to treatment failure. Previously, we demonstrated in human MIA PaCa-2 pancreatic cancer cells that N-acetyl-l-cysteine (NAC), a glutathione (GSH) precursor, prevents NFκB activation via S-glutathionylation of p65-NFκB, thereby blunting expression of survival genes. In this study, we documented the molecular sites of S-glutathionylation of p65, and we investigated whether NAC can suppress NFκB signaling and augment a therapeutic response to gemcitabine in vivo. Mass spectrometric analysis of S-glutathionylated p65-NFκB protein in vitro showed post-translational modifications of cysteines 38, 105, 120, 160 and 216 following oxidative and nitrosative stress. Circular dichroism revealed that S-glutathionylation of p65-NFκB did not change secondary structure of the protein, but increased tryptophan fluorescence revealed altered tertiary structure. Gemcitabine and NAC individually were not effective in decreasing MIA PaCa-2 tumor growth in vivo. However, combination treatment with NAC and gemcitabine decreased tumor growth by approximately 50%. NAC treatment also markedly enhanced tumor apoptosis in gemcitabine-treated mice. Compared to untreated tumors, gemcitabine treatment alone increased p65-NFκB nuclear translocation (3.7-fold) and DNA binding (2.5-fold), and these effects were blunted by NAC. In addition, NAC plus gemcitabine treatment decreased anti-apoptotic XIAP protein expression compared to gemcitabine alone. None of the treatments, however, affected extent of tumor hypoxia, as assessed by EF5 staining. Together, these results indicate that adjunct therapy with NAC prevents NFκB activation and improves gemcitabine chemotherapeutic efficacy.

Teleconsent: A Novel Approach to Obtain Informed Consent for Research.

Lack of recruitment of qualified research participants continues to be a significant bottleneck in clinical trials, often resulting in costly time extensions, underpowered results, and in some cases early termination. Some of the reasons for suboptimal recruitment include laborious consent processes and access to participants at remote locations. While new electronic consents technologies (eConsent) help overcome challenges related to readability and consent management, they do not adequately address challenges related to remote access. To address this, we have developed an innovative solution called “teleconsent”, which embeds the informed consent process into a telemedicine session. Teleconsent allows a researcher to remotely video conference with a prospective research participant, display and interactively guide participants in real-time through a consent form. When finished, the researcher and participant can electronically sign the consent form and print or download the signed document for archiving. This process can eliminate challenges related to travel and management of personnel at remote sites. Teleconsent has been successfully implemented in several clinical trials. Teleconsent can improve research recruitment by reducing the barriers related to informed consent, while preserving human interaction.

Blood Pressure and Cholesterol Control in Hypertensive Hypercholesterolemic Patients: NHANES 1988–2010

Background— Hypertension doubles coronary heart disease (CHD) risk. Treating hypertension only reduces CHD risk ≈25%. Treating hypercholesterolemia in hypertensive patients reduces residual CHD risk >35%. Methods and Results— To assess progress in concurrent hypertension and hypercholesterolemia control, National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2004, and 2005 to 2010 were analyzed. Hypertension was defined by blood pressure ≥140/≥90 mm Hg, current medication treatment, and 2-told hypertension status; blood pressure <140/<90 defined control. Hypercholesterolemia was defined by ATP III criteria based on 10-year CHD risk, low-density lipoprotein cholesterol (LDL-C), and non–high-density lipoprotein cholesterol; values below diagnostic thresholds defined control. Across surveys, 60.7% to 64.3% of hypertensives were hypercholesterolemic. From 1988 to 1994 to 2005 to 2010, control of LDL-C rose (9.2% [95% confidence interval (CI), 6.6%–11.9%] to 45.4% [95% CI, 42.6%–48.3%]), concomitant hypertension and LDL-C (5.0% [95% CI, 3.3%–6.7%] to 30.7% [95% CI, 27.9%–33.4%]), and combined hypertension, LDL-C, and non–high-density lipoprotein cholesterol (1.8% [95% CI, 0.4%–3.2%] to 26.9% [95% CI, 24.4%–29.5%]). By multivariable logistic regression, factors associated with concomitant hypertension, LDL-C, and non–high-density lipoprotein cholesterol control (odds ratio [95% CI]) were statin (10.7 [8.1–14.3]) and antihypertensive (3.32 [2.45–4.50]) medications, age (0.77 [0.69–0.88]/10-year increase), ≥2 healthcare visits/yr (1.90 [1.26-2.87]), black race (0.59 [0.44–0.80]), Hispanic ethnicity (0.62 [0.43–0.90]), cardiovascular disease (0.44 [0.34–0.56]), and diabetes mellitus (0.54 [0.42–0.70]). Conclusions— Despite progress, opportunities for improving concomitant hypertension and hypercholesterolemia control persist. Prescribing antihypertensive and antihyperlipidemic medications to achieve treatment goals, especially for older, minority, diabetic, and cardiovascular disease patients, and accessing healthcare at least biannually could improve concurrent risk factor control and CHD prevention. # Clinical Perspective {#article-title-47}Background— Hypertension doubles coronary heart disease (CHD) risk. Treating hypertension only reduces CHD risk ≈25%. Treating hypercholesterolemia in hypertensive patients reduces residual CHD risk >35%. Methods and Results— To assess progress in concurrent hypertension and hypercholesterolemia control, National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2004, and 2005 to 2010 were analyzed. Hypertension was defined by blood pressure ≥140/≥90 mm Hg, current medication treatment, and 2-told hypertension status; blood pressure <140/<90 defined control. Hypercholesterolemia was defined by ATP III criteria based on 10-year CHD risk, low-density lipoprotein cholesterol (LDL-C), and non–high-density lipoprotein cholesterol; values below diagnostic thresholds defined control. Across surveys, 60.7% to 64.3% of hypertensives were hypercholesterolemic. From 1988 to 1994 to 2005 to 2010, control of LDL-C rose (9.2% [95% confidence interval (CI), 6.6%–11.9%] to 45.4% [95% CI, 42.6%–48.3%]), concomitant hypertension and LDL-C (5.0% [95% CI, 3.3%–6.7%] to 30.7% [95% CI, 27.9%–33.4%]), and combined hypertension, LDL-C, and non–high-density lipoprotein cholesterol (1.8% [95% CI, 0.4%–3.2%] to 26.9% [95% CI, 24.4%–29.5%]). By multivariable logistic regression, factors associated with concomitant hypertension, LDL-C, and non–high-density lipoprotein cholesterol control (odds ratio [95% CI]) were statin (10.7 [8.1–14.3]) and antihypertensive (3.32 [2.45–4.50]) medications, age (0.77 [0.69–0.88]/10-year increase), ≥2 healthcare visits/yr (1.90 [1.26-2.87]), black race (0.59 [0.44–0.80]), Hispanic ethnicity (0.62 [0.43–0.90]), cardiovascular disease (0.44 [0.34–0.56]), and diabetes mellitus (0.54 [0.42–0.70]). Conclusions— Despite progress, opportunities for improving concomitant hypertension and hypercholesterolemia control persist. Prescribing antihypertensive and antihyperlipidemic medications to achieve treatment goals, especially for older, minority, diabetic, and cardiovascular disease patients, and accessing healthcare at least biannually could improve concurrent risk factor control and CHD prevention.

Assessing Mobile Health Capacity and Task Shifting Strategies to Improve Hypertension Among Ghanaian Stroke Survivors

Background: There has been a tremendous surge in stroke prevalence in sub‐Saharan Africa. Hypertension (HTN), the most potent, modifiable risk factor for stroke, is a particular challenge in sub‐Saharan Africa. Culturally sensitive, efficacious HTN control programs that are timely and sustainable are needed, especially among stroke survivors. Mobile health (mHealth) technology and task‐shifting offer promising approaches to address this need. Methods: Using a concurrent triangulation design, we collected data from stroke survivors, caregivers, community leaders, clinicians and hospital personnel to explore the barriers, facilitators and perceptions toward mHealth related to HTN management among poststroke survivors in Ghana. Exploration included perceptions of a nurse‐led navigational model to facilitate care delivery and willingness of stroke survivors and caregivers to use mHealth technology. Results: Two hundred stroke survivors completed study surveys while focus groups (n = 4) were conducted with stroke survivors, caregivers and community leaders (n = 28). Key informant interviews were completed with clinicians and hospital personnel (n = 10). A total of 93% of survey respondents had HTN (60% uncontrolled). Findings support mHealth strategies for poststroke care delivery and HTN management and for task‐shifting through a nurse‐led model. Of survey and focus group participants, 76% and 78.6%, respectively, have access to mobile phones and 90% express comfort in using mobile phones and conveyed assurance that task‐shifting through a nurse‐led model could facilitate management of HTN. Findings also identified barriers to care delivery and medication adherence across all levels of the social ecological model. Conclusions: Participants strongly supported enhanced care delivery through mobile health and were receptive toward a nurse‐led navigational model.

Prevalence and Predictors of Sleep Apnea Risk among Ghanaian Stroke Survivors

BACKGROUND AND PURPOSE Sleep apnea (SA) has emerged as a potent risk factor for stroke recurrence and mortality. The burden of SA among stroke survivors in sub-Saharan Africa where stroke incidence and mortality are escalating is unknown. We sought to assess the prevalence of SA risk and its clinical correlates and predictors among Ghanaian stroke survivors. METHODS This cross-sectional study involved 200 consecutive stroke survivors attending a neurology clinic in a tertiary medical center in Kumasi, Ghana. The validated Berlin, STOP-BANG, and Epworth Sleepiness Scale questionnaires were administered to all eligible subjects to assess SA risk and daytime somnolence, and their demographic and clinical information, health-related quality of life, and symptoms of depression were collected using the questionnaires. RESULTS The median (interquartile range) age of stroke survivors was 62 (52-72) years and 52.5% were male. Ninety-nine (49.5%) subjects were identified as high risk for SA using the Berlin questionnaire, whereas 26 (13%), 137 (68.5%), and 37 (18.5%) subjects were classified as low, intermediate, and high risk for SA, respectively, using the STOP-BANG questionnaire. Patients at high risk of SA were significantly older, used excess alcohol, and were less able to perform activities of daily living, although their mean National Institutes of Health Stroke Scale scores were significantly lower than those with low risk for SA. None of the stroke survivors had ever been screened for SA. CONCLUSIONS One out of every 2 stroke survivors attending a neurology clinic in Ghana is at high risk for undiagnosed SA. Greater regional awareness about SA presence and outcomes among patients and providers is warranted.

Changes in Urine Microalbumin-to-Creatinine Ratio in Children with Sickle Cell Disease over Time

Background Approximately 20% of children with sickle cell disease (SCD) have microalbuminuria (MA). Very little is known about the progression of MA in children and young adults with SCD. Methods In this study, we analyzed 5-year EMR data of 373 children [with ≥2 microalbumin-to-creatinine (MA/Cr) ratio measurements] followed at the Medical University of South Carolina to determine the rate, direction, magnitude, and predictors of MA/Cr change over time. Results Age range was 1–22 years; mean 10.2 ± 5.2 years, 49.5% were males. Median follow-up duration was 3.12 ± 1.16 years. At baseline, 328 children had normal (<20 mg/L) MA level. Forty-five (12.1%) of children had MA (≥20 mg/L), of which 91% were ≥8 years and 21 (47%) continued to have MA at the end of the study period. On the other hand, during the study period, 24 new patients developed MA and 24 normalized their MA to levels <20 mg/L. In multivariate logistic regression model, age and bilirubin levels were predictive of MA/Cr increase in patients who received at least one blood transfusion during the study period. Baseline MA level was not predictive of the change in MA/Cr. Conclusion In children and young adults, microalbuminuria is considered a marker of early renal injury. Over time, MA/Cr levels may increase or decrease. Further studies are needed to confirm our findings, assess the reliability of MA as marker of long-term renal injury, and identify high risk patients with SCD likely to have worsening of MA over time.

Aldosterone Antagonists or Renin-Guided Therapy for Treatment-Resistant Hypertension: A Comparative Effectiveness Pilot Study in Primary Care.

BACKGROUND Uncontrolled treatment-resistant hypertension (TRH), i.e., blood pressure (BP, mm Hg) ≥140/≥90mm Hg in and out of office on ≥3 different BP medications at optimal doses, is common and has a poor prognosis. Aldosterone antagonist (AA) and renin-guided therapy (RGT) are effective strategies for improving BP control in TRH but have not been compared. METHODS A comparative effectiveness TRH pilot study of AA vs. RGT was conducted in 4 primary care clinics with 2 each randomized to AA or RGT. The primary outcome was change in clinic BP defined by means of 5 automated office BP values. Eighty-nine patients with apparent TRH were screened and 44 met criteria for true TRH. RESULTS Baseline characteristics of 20 patients in the AA (70% Black, 45% female, mean age: 57.4 years) and 24 patients in RGT (79% Black, 50% female, 57.8 years) arms were similar with baseline BP 162±5/90±3 vs. 153±3/84±3, respectively, P = 0.11/0.20. BP declined to 144±5/86±4 in AA vs. 132±4/75±3 in RGT, P = 0.07/0.01; BP was controlled to JNC7 (Seventh Joint National Committee Report) goal in 25% vs. 62.5%, respectively, P < 0.01. Although BP changes from baseline, the primary outcome, were not different (-17.6±5.1/-4.0±3.0 AA vs. -20.4±3.8/-9.7±2.0 RGT, P = 0.65/0.10.), more BP medications were added with AA than RGT (+0.9±0.1 vs. +0.4±0.1 per patient, P < 0.01). CONCLUSIONS In this TRH pilot study, AA and RGT lowered BP similarly, although fewer additional medications were required with RGT. A larger comparative effectiveness study could establish the utility of these treatment strategies for lowering BP of uncontrolled TRH patients in primary care.

Technology as a means to address disparities in mental health research: A guide to “tele-tailoring” your research methods.

We must include rural participants in health-related research if we are to address health-related disparities and inequity, particularly in mental health. However, the first step of the research process in person—witnessed, signed, informed consent—is often a limiting factor and insurmountable barrier to precisely the type of research (e.g., telehealth) designed to overcome barriers of geographic distance and travel time. Telehealth, or the provision of medical care or services to patients by means of audio/video and procedure-specific technology, addresses some barriers to health created by rurality by making health care professionals more accessible to patients. A logical complement to telehealth is “teleconsent.” Teleconsent can be defined as using remote, facial integrated identity verification to allow (a) remote guidance of participants through consent documents, and (b) digital signing by all parties, obviating the need for in-person signed consent. The ability to review and sign consent documents via telehealth with synchronous viewing is a novel, innovative means by which to overcome the initial significant barrier to recruitment of rural participants into health care research. By leveraging the growing capabilities of telehealth, teletailoring studies can improve the efficiency of research recruitment and facilitate the consent process for underrepresented populations in research. Strategies for implementation are clearly relevant to increasing the success of clinical trial recruitment.