There is reasonable evidence to suggest that cardiovascular reactivity can predict the development of some preclinical states (eg, increased left ventricular mass and blood pressure) states and perhaps even new clinical events in some patients with essential hypertension or coronary heart disease. However, much more information is needed concerning moderating and potentially confounding variables before the robustness of the positive relationships can become clinically useful.

BackgroundMobile phone based programs for kidney transplant recipients are promising tools for improving long-term graft outcomes and better managing comorbidities (eg, hypertension, diabetes). These tools provide an easy to use self-management framework allowing optimal medication adherence that is guided by the patients’ physiological data. This technology is also relatively inexpensive, has an intuitive interface, and provides the capability for real-time personalized feedback to help motivate patient self-efficacy. Automated summary reports of patients’ adherence and blood pressure can easily be uploaded to providers’ networks helping reduce clinical inertia by reducing regimen alteration time.ObjectiveThe aim of this study was to assess the feasibility, acceptability, and preliminary outcomes of a prototype mobile health (mHealth) medication and blood pressure (BP) self-management system for kidney transplant patients with uncontrolled hypertension.MethodsA smartphone enabled medication adherence and BP self-management system was developed using a patient and provider centered design. The development framework utilized self-determination theory with iterative stages that were guided and refined based on patient/provider feedback. A 3-month proof-of-concept randomized controlled trial was conducted in 20 hypertensive kidney transplant patients identified as non-adherent to their current medication regimen based on a month long screening using an electronic medication tray. Participants randomized to the mHealth intervention had the reminder functions of their electronic medication tray enabled and received a bluetooth capable BP monitor and a smartphone that received and transmitted encrypted physiological data and delivered reminders to measure BP using text messaging. Controls received standard of care and their adherence continued to be monitored with the medication tray reminders turned off. Providers received weekly summary reports of patient medication adherence and BP readings.ResultsParticipation and retention rates were 41/55 (75%) and 31/34 (91%), respectively. The prototype system appears to be safe, highly acceptable, and useful to patients and providers. Compared to the standard care control group (SC), the mHealth intervention group exhibited significant improvements in medication adherence and significant reductions in clinic-measured systolic blood pressures across the monthly evaluations. Physicians made more anti-hypertensive medication adjustments in the mHealth group versus the standard care group (7 adjustments in 5 patients versus 3 adjustments in 3 patients) during the 3-month trial based on the information provided in the weekly reports.ConclusionsThese data support the acceptability and feasibility of the prototype mHealth system. Further trials with larger sample sizes and additional biomarkers (eg, whole blood medication levels) are needed to examine efficacy and effectiveness of the system for improving medication adherence and blood pressure control after kidney transplantation ov...

BackgroundMobile phone based remote monitoring of medication adherence and physiological parameters has the potential of improving long-term graft outcomes in the recipients of kidney transplants. This technology is promising as it is relatively inexpensive, can include intuitive software and may offer the ability to conduct close patient monitoring in a non-intrusive manner. This includes the optimal management of comorbidities such as hypertension and diabetes. There is, however, a lack of data assessing the attitudes of renal transplant recipients toward this technology, especially among ethnic minorities.ObjectiveTo assess the attitudes of renal transplant recipients toward mobile phone based remote monitoring and management of their medical regimen; and to identify demographic or clinical characteristics that impact on this attitude.MethodsAfter a 10 minute demonstration of a prototype mobile phone based monitoring system, a 10 item questionnaire regarding attitude toward remote monitoring and the technology was administered to the participants, along with the 10 item Perceived Stress Scale and the 7 item Morisky Medication Adherence Scale.ResultsBetween February and April 2012, a total of 99 renal transplant recipients were identified and agreed to participate in the survey. The results of the survey indicate that while 90% (87/97) of respondents own a mobile phone, only 7% (7/98) had any prior knowledge of mobile phone based remote monitoring. Despite this, the majority of respondents, 79% (78/99), reported a positive attitude toward the use of a prototype system if it came at no cost to themselves. Blacks were more likely than whites to own smartphones (43.1%, 28/65 vs 20.6%, 7/34; P=.03) and held a more positive attitude toward free use of the prototype system than whites (4.25±0.88 vs 3.76±1.07; P=.02).ConclusionsThe data demonstrates that kidney transplant recipients have a positive overall attitude toward mobile phone based health technology (mHealth). Additionally, the data demonstrates that most kidney transplant recipients own and are comfortable using mobile phones and that many of these patients already own and use smart mobile phones. The respondents felt that mHealth offers an opportunity for improved self-efficacy and improved provider driven medical management. Respondents were comfortable with the idea of being monitored using mobile technology and are confident that their privacy can be protected. The small subset of kidney transplant recipients who are less interested in mHealth may be less technologically adept as reflected by their lower mobile phone ownership rates. As a whole, kidney transplant recipients are receptive to the technology and believe in its utility.

African Americans and Hispanics have disproportionate rates of uncontrolled essential hypertension (EH) compared to Non-Hispanic Whites. Medication non-adherence (MNA) is the leading modifiable behavior to improved blood pressure (BP) control. The Smartphone Medication Adherence Stops Hypertension (SMASH) program was developed using a patient-centered, theory-guided, iterative design process. Electronic medication trays provided reminder signals, and Short Message Service [SMS] messaging reminded subjects to monitor BP with Bluetooth-enabled monitors. Motivational and reinforcement text messages were sent to participants based upon levels of adherence. Thirty-eight African-American (18) and Hispanic (20) uncontrolled hypertensives completed clinic-based anthropometric and resting BP evaluations prior to randomization, and again at months 1, 3 and 6. Generalized linear mixed modeling (GLMM) revealed statistically significant time-by-treatment interactions (p < 0.0001) indicating significant reductions in resting systolic blood pressure (SBP) and diastolic blood pressure (DBP) for the SMASH group vs. the standard care (SC) control group across all time points. 70.6% of SMASH subjects vs. 15.8% of the SC group reached BP control (< 140/90 mmH) at month 1 (p < 0.001). At month 6, 94.4% of the SMASH vs. 41.2% of the SC group exhibited controlled BP (p < 0.003). Our findings provide encouraging evidence that efficacious mHealth, chronic disease, medical regimen, self-management programs can be developed following principles of patient-centered, theory-guided design.

Background The purpose of this study was to assess the long-term effect of adverse childhood experiences (ACEs) on blood pressure (BP) trajectories from childhood to young adulthood and to examine whether this relation is explained by childhood socioeconomic status (SES) and/or risk behaviors that are associated with ACEs. Methods and Results Systolic and diastolic blood pressure (SBP and DBP) were measured up to 16 times (13 times on average) over a 23-year period in 213 African Americans (AAs) and 181 European Americans (EAs) aged 5 to 38 years. Retrospective data on traumatic experiences prior to age 18 were collected, including abuse, neglect and household dysfunction. Individual growth curve modeling within a multilevel framework was used to examine the relation between exposure to ACEs and BP development. No main effect of ACEs on average BP levels was found. However, a significant interaction of ACE score with age3 was observed (SBP: p=0.033; DBP: p=0.017). Subjects who experienced multiple traumatic events during childhood showed a faster rise of BP levels after age of 30 years than those without ACEs. As expected, a graded association of ACEs with childhood SES and negative health behaviors was observed (p<0.001). The ACE-SBP relation was not explained by these factors, while the ACE-DBP relation was partially mediated by illicit drug use. Conclusions In this novel longitudinal study, we observed that participants who were exposed to multiple ACEs displayed a greater increase of BP levels in young adulthood compared to their counterparts without ACEs.

Background: Uncontrolled hypertension (HTN) and medication nonadherence are more prominent among Hispanics compared to non-Hispanic whites and African Americans. Advances in wireless health technology enable real-time monitoring of medication adherence (MA) and blood pressure (BP), facilitating timely patient–provider communication including tailored reinforcement/motivational feedback to patients and quicker titration changes by providers. The purpose of the current study was to conduct a 9-month smartphone-enabled efficacy trial addressing MA and BP control among Hispanic adults with uncontrolled HTN and poor MA. Methods: The research design was a 9-month, two-arm efficacy trial including an experimental (Smartphone Med Adherence Stops Hypertension, SMASH) group and an enhanced standard care (ESC) group. SMASH participants utilized a SMASH app which interfaced with a Bluetooth-enabled BP monitor for BP self-monitoring and an electronic medication tray. The ESC participants received text messages including links to PDFs and brief video clips containing healthy lifestyle tips for attention control. Results: Participants were 54 Hispanic adults (mean age: 46.5 years) with uncontrolled HTN. They were randomly assigned to either the SMASH (n = 26) or ESC group (n = 28). At baseline, no participants had controlled systolic BP (SBP). Baseline group averages for SBP between the SC and SMASH groups did not differ (150.7 and 152.3 mmHg, respectively; p = 0.53). At the 1, 3, 6, and 9-month time points, SBP averages were significantly lower in the SMASH versus SC groups (month 1: 125.3 vs. 140.6; month 3: 120.4 vs. 137.5, month 6: 121.2 vs. 145.7 mmHg; month 9: 121.8 vs. 145.7, respectively; all p-values <0.01). At months 3, 6, and 9 there was a significant difference between the percentage of participants meeting the 7th Joint National Committee cutoffs for SBP control in the SC and SMASH groups (month 3: 62.5 vs. 92.0%; month 6: 57.9 and 94.4%, month 9: 27.8 and 92.3%, respectively; all p-values ≤0.01). Average medical regimen adherence, as indicated by timestamped medication intake and BP monitoring for the SMASH group, ranged from 89.1 to 95.2% across the 9-month trial. Conclusion: Our findings indicate that our culturally tailored smartphone-enabled medical regimen self-management program may be an effective solution for the promotion of MA, resulting in statistically and clinically significant reductions in SBP among Hispanic adults with uncontrolled HTN.

BackgroundDespite evidence linking obesity to impaired immune function, little is known about the specific mechanisms. Because of emerging evidence that immune responses are epigenetically regulated, we hypothesized that DNA methylation changes are involved in obesity induced immune dysfunction and aimed to identify these changes.MethodWe conducted a genome wide methylation analysis on seven obese cases and seven lean controls aged 14 to 18 years from extreme ends of the obesity distribution and performed further validation of six CpG sites from six genes in 46 obese cases and 46 lean controls aged 14 to 30 years.ResultsIn comparison with the lean controls, we observed one CpG site in the UBASH3A gene showing higher methylation levels and one CpG site in the TRIM3 gene showing lower methylation levels in the obese cases in both the genome wide step (P = 5 × 10-6 and P = 2 × 10-5 for the UBASH3A and the TRIM3 gene respectively) and the validation step (P = 0.008 and P = 0.001 for the UBASH3A and the TRIM3 gene respectively).ConclusionsOur results provide evidence that obesity is associated with methylation changes in blood leukocyte DNA. Further studies are warranted to determine the causal direction of this relationship as well as whether such methylation changes can lead to immune dysfunction.See commentary: http://www.biomedcentral.com/1741-7015/8/88/abstract

We compared, in 9-11-y-old children (n=43), three measures of body composition: dual-energy X-ray absorptiometry (DXA), skinfold thickness, and bioimpedance analysis (BIA). The intraclass correlation coefficient (ICC), Bland-Altman procedure, and Spearman rank correlation were used to determine test-retest reliabilities of the three methods and to compare methods. For DXA measurements, the rank correlation between fat-free soft tissue and fat-free mass (FFM) was > 0.99, indicating that bone mineral content did not provide independent information. Thus, subsequent analyses used the two-compartment model (ie, fat mass and FFM) for all three techniques, focusing especially on values for percentage of fat. The test-retest reliabilities for all methods were high (ICCs > 0.994 and no significant differences between trials 1 and 2). The range of individual differences from trial 1 to trial 2 and Bland-Altman limits of agreement suggested that the reliability was greatest for DXA, followed by BIA and skinfold-thickness measurement. The percentage of fat values for the three methods were highly intercorrelated (all Spearman r values > 0.83). However, there was a systematic tendency (P < 0.01) for DXA values (mean: 23.98) to be higher than those derived from skinfold-thickness measurements (mean: 21.05) and BIA (mean: 21.52). The variance in percentage of fat values for BIA was significantly smaller than that for the other two techniques. These findings, along with rather large limits of agreement derived from the Bland-Altman procedure, suggest that the methods should not be used interchangeably.