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Rationale: Over 1.5 million Americans receive long-term oxygen therapy (LTOT) for the treatment of chronic hypoxemia to optimize functional status and quality of life. However, current portable oxy...

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Background: Evidence-based guidelines recommend strategies for reducing risk factors for secondary prevention of acute coronary syndromes, yet referral to and completion of programs to deliver this advice are poor. Purpose: In this article we describe the complexity of factors that influence referral and delivery of evidence-based cardiac rehabilitation (CR) programs through an Australian context and provide direction for solutions for clinicians and policy makers to consider. The Ecological Approach is used as a framework to synthesize evidence. The approach has 5 categories, the characteristics of which may act as barriers and enablers to the promotion and adoption of health behaviors and includes (a) interpersonal factors, (b) interpersonal factors, (c) institutional factors, (d) community networks, and (e) public policy. Conclusions: Despite the context of strong evidence for efficacy, this review highlights systematic flaws in the implementation of CR, an important intervention that has been shown to improve patient outcomes and prevent cardiac events. Recommendations from this review include standardization of program delivery, improvement of data capture, use of technological innovations and social networks to facilitate delivery of information and support, and establishment of a cohesive, consistent message through interorganizational collaboration involved in CR. Clinical Implications: These avenues provide direction for potential solutions to improve the uptake of CR and secondary prevention.

There is a need and opportunity for China to develop education and practice innovations given that advance practice nurses (APNs) improve health care and outcomes. The China Medical Board (CMB) China Nursing Network (CCNN) began planning for an Advanced Nursing Practice Program for education and career development that will facilitate CCNN's contributions to meeting national nursing policy priorities. This paper presents the discussion, recommendations and action plans developed at the inaugural planning meeting on June 26, 2015 at Fudan University in Shanghai. The recommendations are: Develop standards for advanced nursing practice; Develop Master's level curricula based on the standards; Commence pilot projects across a number of University affiliated hospitals; and Prepare clinical tutors and faculty. The strategic directions and actions are: Develop a clinical career ladder system; Expand the nursing role from hospital to community; and Build a specialty nurse accreditation system. Keywords: Advanced nursing practice, China, Nursing education, Nursing practice, Masters education, Nursing specialists

This paper provides an overview of Advanced Practice Nursing (APN) in the USA, Canada, Australia and Hong Kong. It is based upon documents presented to the China Medical Board (CMB) China Nursing Network (CNN) as background for discussions held by the CNN in Shanghai. It discusses the APN role in these countries and regions according to topics identified by the CNN. These are APN educational preparation; role legitimacy; capacity requirements; scope of practice, domains of activities and limited rights for prescription and referral; professional promotion ladder; accreditation system; and, performance evaluation system. Both Canada and Australia have adapted many aspects of the USA model of APN to fit their specific legislative requirements and local conditions. Hong Kong has taken a different path which may be of interest in the Chinese context.

Background The number of African immigrants in the United States grew 40‐fold between 1960 and 2007, from 35 355 to 1.4 million, with a large majority from West Africa. This study sought to examine the prevalence of cardiovascular disease ( CVD ) risk factors and global CVD risk and to identify independent predictors of increased CVD risk among West African immigrants in the United States. Methods and Results This cross‐sectional study assessed West African (Ghanaian and Nigerian) immigrants aged 35–74 years in the Baltimore–Washington metropolitan area. The mean age of participants was 49.5±9.2 years, and 58% were female. The majority (95%) had ≥1 of the 6 CVD risk factors. Smoking was least prevalent, and overweight or obesity was most prevalent, with 88% having a body mass index (in kg/m 2 ) ≥25; 16% had a prior diagnosis of diabetes or had fasting blood glucose levels ≥126 mg/ dL . In addition, 44% were physically inactive. Among women, employment and health insurance were associated with odds of 0.09 (95% CI 0.033–0.29) and 0.25 (95% CI 0.09–0.67), respectively, of having a Pooled Cohort Equations estimate ≥7.5% in the multivariable logistic regression analysis. Among men, higher social support was associated with 0.90 (95% CI 0.83–0.98) lower odds of having ≥3 CVD risk factors but not with having a Pooled Cohort Equations estimate ≥7.5%. Conclusions The prevalence of CVD risk factors among West African immigrants was particularly high. Being employed and having health insurance were associated with lower CVD risk in women, but only higher social support was associated with lower CVD risk in men.

Black men suffer disproportionately from hypertension. Antihypertensive medication nonadherence is a major contributor to poor blood pressure control, yet few studies consider how psychosocial functioning may impact black men's medication adherence. The authors examined the direct and mediating pathways between depressive symptoms, psychosocial stressors, and substance use on antihypertensive medication nonadherence in 196 black men enrolled in a clinical trial to improve hypertension care and control. The authors found that greater depressive symptoms were associated with more medication nonadherence (β=0.05; standard error [SE], 0.01; P

Background Lower socioeconomic status is associated with excess disease burden from diabetes. Diabetes self-management support interventions are needed that are effective in engaging lower income patients, addressing competing life priorities and barriers to self-care, and facilitating behavior change.

J Clin Hypertens (Greenwich). 2010;12:757‐764. © 2010 Wiley Periodicals, Inc. Nonadherence and poor or no persistence in taking antihypertensive medications results in uncontrolled high blood pressure, poor clinical outcomes, and preventable health care costs. Factors associated with nonadherence are multilevel and relate not only to the patient, but also to the provider, health care system, health care organization, and community. National guideline committees have called for more aggressive approaches to implement strategies known to improve adherence and technologies known to enable changes at the systems level, including improved communication among providers and patients. Improvements in adherence and persistence are likely to be achieved by supporting patient self‐management, a team approach to patient care, technology‐supported office practice systems, better methods to measure adherence, and less clinical inertia. Integrating high blood pressure control into health care policies that emphasize and improve prevention and management of chronic illness remains a challenge. Four strategies are proposed: focusing on clinical outcomes; empowering informed, activated patients; developing prepared proactive practice teams; and advocating for health care policy reform. With hypertension remaining the most common reason for office visits, the time is now.

Despite prevalent low literacy nationally, empirical research on the development and testing of literacy-adapted patient education remains limited.To describe procedures for developing and evaluating usability and acceptability of an adapted diabetes and CVD patient education.Materials adaptation for literacy demand and behavioral activation criteria, and pre-/post-test intervention evaluation design.Pilot sample of 30 urban African-American adults with type 2 diabetes with Below Average literacy (n = 15) and Average literacy (n = 15).Wide Range Achievement Test (WRAT-3, Reading), assessment of diabetes and CVD knowledge, and patient rating scale.Reading grade levels were:12th, 30%; 10th-12th, 20%; 7th-9th, 10%; 4th-6th grade, 10%; andor = 3rd grade or unable to complete WRAT-3, 30%. Education materials were modified to a reading level ofor = 4th grade. Knowledge improved for Below Average (2.7 to 4.7, p = 0.005) and Average (3.8 to 5.7, p = 0.002) literacy groups, with up to a ten-fold increase, at post-education, in the number of participants responding correctly to some content items. The print materials and class received maximum usability and acceptability ratings from patients.Development of patient education meeting very low literacy criteria was feasible, effective for knowledge acquisition, and highly acceptable irrespective of literacy level.

The prevalence of hypertension continues to rise across the world, and most patients who receive medical intervention are not adequately treated to goal. A Working Group including representatives of nine international health-care organizations was convened to review the barriers to more effective blood pressure control and propose actions to address them. The group concluded that tackling the global challenge of hypertension will require partnerships among multiple constituencies, including patients, health-care professionals, industry, media, health-care educators, health planners and governments. Additionally, health-care professionals will need to act locally with renewed impetus to improve blood pressure goal rates. The Working Group identified five core actions, which should be rigorously implemented by practitioners and targeted by health systems throughout the world: (1) detect and prevent high blood pressure; (2) assess total cardiovascular risk; (3) form an active partnership with the patient; (4) treat hypertension to goal and (5) create a supportive environment. These actions should be pursued with vigour in accordance with current clinical guidelines, with the details of implementation adapted to the economic and cultural setting.

© 2016 European Society of Cardiology. Background Despite the compelling evidence of the benefits of cardiac rehabilitation (CR) on risk factor modification, quality of life and mortality reduction, a significant proportion of eligible patients are not referred or do not participate. Factors influencing CR referral and participation are complex and are likely patient, referral system and clinician-related. Little is known about clinician-related factors, which include attitudes, values and beliefs towards CR, or how these factors affect patient referral and attendance. This review examines the current evidence in the literature in relation to clinicians' attitudes, values and beliefs about CR. Methods A review of the literature was conducted on studies in relation to clinicians' attitudes, values and beliefs toward CR. An expert consensus methodology was used to develop the concepts presented in this paper. Results Besides guidelines, a range of other factors influence clinicians' view about CR. This review suggests that clinicians lacking cardiac qualifications may have limited knowledge and awareness of CR and its benefits. Low agreement among clinicians on who is more likely to benefit from CR was also identified. Clinicians' personal lifestyle and health belief, the availability and quality of local the CR programme, and the lack of a standard administrative process of referral can also hinder the referral of patients to CR. Conclusions Clinician-related factors are important to consider in relation to CR referral and participation. Education for clinicians, discussion of local services and the support of an efficacious system at programme and organisation levels are essential.

Background African American men with hypertension in low socioeconomic urban populations achieve poor rates of hypertension control and suffer early from its complications. Methods In a randomized clinical trial with 309 hypertensive urban African American men aged 21 to 54 years, we evaluated the effectiveness of a more intensive comprehensive educational-behavioral-pharmacologic intervention by a nurse practitioner-community health worker-physician (NP/CHW/MD) team and a less intensive education and referral intervention in controlling blood pressure (BP) and minimizing progression of left ventricular hypertrophy (LVH) and renal insufficiency. Changes in BP, left ventricular mass (LVM), and serum creatinine from baseline to 36 months were compared between groups. Results At 36 months, the mean systolic BP/diastolic BP change from baseline was −7.5/−10.1 mm Hg for the more intensive group and +3.4/−3.7 mm Hg for the less intensive group (P = .001 and .005 for between-group differences in systolic BP and diastolic BP, respectively). The proportion of men with controlled BP (

Young, urban, African American men are at particularly high risk of hypertension and its cardiovascular complications. Left ventricular hypertrophy and renal dysfunction are manifestations of target organ damage from hypertension that predict adverse cardiovascular events. The subjects of this study were 309 African American men, age 18–54 years, with hypertension, residing in inner‐city Baltimore. Echocardiograms, electrocardiograms, serum creatinine, and the urinary albumin‐creatinine ratio were obtained to evaluate hypertensive target organ damage. Fifty‐three percent of the men reported use of antihypertensive medications, of whom 80% were on monotherapy. Calcium channel blockers were used most frequently. The mean echocardiographic left ventricular mass was 211±68 g, with a prevalence of echocardiographic left ventricular hypertrophy of 30%. There were 14 men (5%) with extremely high left ventricular mass, >350 grams. Left ventricular systolic dysfunction was seen in 9% of the men with uncontrolled hypertension, and none of the men with controlled hypertension (p=0.02). Renal dysfunction was found in 12% of the subjects, and microalbuminuria or gross proteinuria in 34%. The authors conclude that there is a high prevalence of cardiac and renal abnormalities in inner‐city African American men with hypertension, especially in men on antihypertensive therapy with uncontrolled hypertension. It is imperative that cost‐effective medications and culturally acceptable health care delivery programs be developed, tested, and integrated into health systems, with strategies specifically relevant to this high‐risk population, to decrease the largely preventable morbidity and mortality associated with hypertension.

Cardiovascular disease (CVD) is the leading cause of death and disability in most Western industrialized countries including the U.S., cutting across all ethnic, racial, and gender groups. Despite the tremendous body of research to support the efficacy and cost-effectiveness of CVD prevention

A large number of factors contribute to racial and ethnic disparities in health status. Health care professionals, researchers, and policymakers have believed for some time that access to care is the centerpiece in the elimination of these health disparities. The Institute of Medicine's (IOM) model of access to health services includes personal, financial, and structural barriers, health service utilization, and mediators of care. This model can be used to describe the interactions among these factors and their impact on health outcomes and equity of services among racial and ethnic groups. We present a modified version of the IOM model that incorporates the features of other access models and highlights barriers and mediators that are relevant for interventions designed to eliminate disparities in U.S. health care. We also suggest that interventions to eliminate disparities and achieve equity in health care services be considered within the broader context of improving quality of care. Some health service intervention studies have shown improvements in the health of disadvantaged groups. If properly designed and implemented, these interventions could be used to reduce health disparities. Successful features of interventions include the use of multifaceted, intense approaches, culturally and linguistically appropriate methods, improved access to care, tailoring, the establishment of partnerships with stakeholders, and community involvement. However, in order to be effective in reducing disparities in health care and health status, important limitations of previous studies need to be addressed, including the lack of control groups, nonrandom assignment of subjects to experimental interventions, and use of health outcome measures that are not validated. Interventions might be improved by targeting high-risk populations, focusing on the most important contributing factors, including measures of appropriateness and quality of care and health outcomes, and prioritizing dissemination efforts.

OBJECTIVE: To examine the association of socioeconomic barriers, familial barriers, and clinical variables with health-related quality of life (HRQL). METHODS: A cross-sectional study was conducted of 186 African Americans with type 2 diabetes recruited from 2 primary care clinics in East Baltimore, Maryland. Physical functioning, social functioning, mental health, and general health were measured using the Medical Outcomes Study 36-item short form. Socioeconomic (money, housing, street crime) and familial (family problems, caretaker responsibilities) barriers were assessed by standardized interview. Insulin use, comorbid disease, and measured abnormalities in body mass index, hemoglobin A1c (HbA1c), blood pressure, lipids, and renal function were investigated. RESULTS: Mean HRQL scores were: physical functioning, 61±29; social functioning, 76±26; mental health, 69±21; and general health, 48±21. Linear regression analyses revealed that each barrier to care was significantly associated with lower scores in 1 or more HRQL domain. As number of socioeconomic and familial barriers increased from 0 to 5, HRQL scores decreased by 18 for social functioning, 21 for general health, 23 for physical functioning, and 28 for mental health (all P for trend

Background Oxygen (O 2 ) homeostasis is central to myocardial tissue functioning, and increased O 2 demand is thought to be satisfied by a vasodilatory mechanism that results in increased blood and O 2 delivery. We applied blood oxygenation level–dependent (BOLD) MRI in conjunction with vasodilatory stress to index the ability to augment intramyocardial oxygenation in hypertensive hypertrophy, the primary cause of heart failure. Methods and Results Nine healthy controls and 10 hypertensive subjects with moderate-to-severe hypertrophy underwent imaging on a 1.5 T clinical scanner. The dipyridamole-induced change in the apparent transverse relaxation rate, R2*, which correlates with hemoglobin oxygenation, was −5.4±2.2 s −1 (95% CI, −4.0 to −6.8 s −1 ) in controls compared with −1.7±1.4 s −1 (95% CI, −0.8 to −2.6 s −1 ) in hypertensive patients ( P =0.0003). Conclusions Patients with hypertensive hypertrophy demonstrate an impaired ability to increase intramyocardial oxygenation during vasodilatory stress, as indexed by BOLD MRI. The capacity to image vascular function with BOLD MRI may advance the understanding of the development of ventricular dysfunction in hypertension.

Background and Purpose— This guideline provides an overview of the evidence on various established and potential stroke risk factors and provides recommendations for the reduction of stroke risk. M...

This randomized trial recruited and followed underserved, inner-city, hypertensive (HTN), young black men and investigated whether a nurse-community health worker team in combination with usual medical care (SI) increased entry into care and reduced high blood pressure (HBP), in comparison to usual medical care (UC) alone. Emergency department records, advertising, and BP screenings identified potential participants with HBP. Telephone calls and personal contacts tracked enrollees. Of 1391 potential participants, 803 (58%) responded to an invitation to be screened and scheduled a visit. Of these, 528 (66%) kept an appointment, 207 (35%) were BP eligible, and 204 (99%) consented to enroll. At 12 months 91% of men were accounted for and 85.8% (adjusted for death, in jail, or moved away) were seen. Mean BP changed from 153(16)/98(10) to 152(19)/94(11) mm Hg in the SI group and 151(18)/98(11) to 147(21)/92(14) mm Hg in the UC group (P = NS). High rates of participation are attainable in this population; however, culturally acceptable ways of delivering HBP care are needed.

The objective of this study was to determine the prevalence of symptoms and the morbidity associated with Raynaud’s phenomenon (RP) among African Americans. A total of 2196 randomly selected residents of an inner-city community, in Baltimore, completed a health-assessment survey. Symptoms of RP consisted of cold sensitivity plus cold-induced white or blue digital color change. One third ( n = 703) reported cold sensitivity and 14% ( n = 308) reported digital color change; 84 residents with symptoms of RP were identified, yielding an overall prevalence rate of 3.8% (95% confidence interval [CI] 3.0–4.6). RP was associated with poor or fair health status (odds ratio [OR] = 1.82, CI 1.18–2.81), heart disease (OR = 2.32, CI 1.39–3.87), and stroke (OR = 2.20, CI 1.17–4.15), after adjustment for age, gender, and physician-diagnosed arthritis. The prevalence of symptoms of RP in this African-American community is comparable to published reports from other populations. These community-based data suggest that identification of RP among African Americans should raise consideration of possible comorbidity, particularly cardiovascular disease.

Abstract —To determine the extent to which the Fifth Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC-V) guidelines were implemented in high-risk families with premature coronary heart disease, we examined the prevalence of hypertension and associated coronary risk factors in asymptomatic siblings of persons with documented premature coronary disease (30% of calories from fat; and only 14% were participating in vigorous physical activity three or more times per week. Comparisons with the national reference population revealed siblings to have a significantly higher prevalence of hypertension, along with significantly lower levels of awareness, treatment, and control. These findings demonstrate the intersection of multiple risk factors among hypertensive siblings and emphasize the need for more aggressive screening and treatment in this easily identifiable high-risk population.

It is a privilege and an honor to speak with the scientific community about the need to integrate the behavioral and social sciences with the biomedical sciences and how this relates to the mission of the American Heart Association. My observations and thoughts are influenced by my experiences as a nurse researcher and behavioral scientist at Johns Hopkins, where I have been involved in a research program on high blood pressure control in urban black communities. Tremendous advances in biology are providing new knowledge about genetics, physiology, pathophysiology, and disease, creating exciting opportunities for clinical research. From the laboratory this research evolves into new applications for diagnosis, therapy, and prevention in humans. At the same time, important advances in behavioral science, clinical outcomes, and healthcare delivery have provided needed knowledge about prevention and treatment. This research transitions from the healthcare setting into the community. Individuals’ lifestyles significantly impact their health, with unhealthy habits accounting for about 54%1 of known contributions to heart disease. Behavioral and biological interventions can reduce morbidity, disability, and death due to heart disease and stroke. They can improve quality of life and influence the behavior of policy makers in their decisions, health professionals in their practice, and people in their daily lives. However, there is a gap between the efficacy of interventions in studies and their effectiveness in practice, a gap between potential and reality, intention and action, and information and behavior. This gap illustrates the urgent need to more fully integrate the social and behavioral sciences with the biomedical sciences. Three questions arise: Despite extensive studies of strategies to prevent and treat risk factors for heart disease and stroke, current evidence documents …

Black men suffer disproportionately from hypertension. Antihypertensive medication nonadherence is a major contributor to poor blood pressure control, yet few studies consider how psychosocial functioning may impact black men's medication adherence. The authors examined the direct and mediating pathways between depressive symptoms, psychosocial stressors, and substance use on antihypertensive medication nonadherence in 196 black men enrolled in a clinical trial to improve hypertension care and control. The authors found that greater depressive symptoms were associated with more medication nonadherence (β=0.05; standard error [SE], 0.01; P.001). None of the psychosocial stressor variables were associated with antihypertensive medication nonadherence. Alcohol misuse was associated with increased medication nonadherence (β=0.81; SE, 0.26; P.01), but it did not mediate the association between depressive symptoms and medication nonadherence. Clinicians should consider screening for depressive symptoms and alcohol misuse if patients are found to be nonadherent and should treat or refer patients to appropriate resources to address those issues.

The role of the nurse in improving hypertension control has expanded over the past 50 years, complementing and supplementing that of the physician. Nurses' involvement began with measuring and monitoring blood pressure (BP) and patient education and has expanded to become one of the most effective strategies to improve BP control. Today the roles of nurses and nurse practitioners (NPs) in hypertension management involve all aspects of care, including (1) detection, referral, and follow up; (2) diagnostics and medication management; (3) patient education, counseling, and skill building; (4) coordination of care; (5) clinic or office management; (6) population health management; and (7) performance measurement and quality improvement. The patient-centered, multidisciplinary team is a key feature of effective care models that have been found to improve care processes and control rates. In addition to their clinical roles, nurses lead clinic and community-based research to improve the hypertension quality gap and ethnic disparities by holistically examining social, cultural, economic, and behavioral determinants of hypertension outcomes and designing culturally sensitive interventions to address these determinants.

Adherence to a prescribed medication regimen is influenced not only by characteristics of the individual patient, but also by factors within the patient's environment, or so-called system level factors. Until now, however, health care system factors have received relatively little attention in explaining medication nonadherence. Ecological models might serve as a framework to help explain the influence of health care system factors on patient behavior (e.g., adherence). In an ecological model, different levels of factors influence patients' behavior, i.e. factors at the patient-level, micro- (provider and social support), meso- (health care organization), and macro (health policy) -levels. In order to understand medication adherence and implement interventions to improve medication adherence, factors at these different levels should be taking into consideration. This paper describes an ecological model compromised of the most important factors at the patient-, micro-, meso- and macro-levels. ispartof: Western Journal of Nursing Research vol:34 issue:5 pages:635-653 ispartof: location:United States status: published

Background— Despite well-publicized guidelines on the appropriate management of cardiovascular disease and type 2 diabetes, the implementation of risk-reducing practices remains poor. This report describes the results of a randomized, controlled clinical trial evaluating the effectiveness of a comprehensive program of cardiovascular disease risk reduction delivered by nurse practitioner /community health worker (NP/CHW) teams versus enhanced usual care (EUC) to improve lipids, blood pressure, glycated hemoglobin (HbA1c), and patient perceptions of the quality of their chronic illness care in patients in urban community health centers. Methods and Results— A total of 525 patients with documented cardiovascular disease, type 2 diabetes, hypercholesterolemia, or hypertension and levels of LDL cholesterol, blood pressure, or HbA1c that exceeded goals established by national guidelines were randomly assigned to NP/CHW (n=261) or EUC (n=264) groups. The NP/CHW intervention included aggressive pharmacological management and tailored educational and behavioral counseling for lifestyle modification and problem solving to address barriers to adherence and control. Compared with EUC, patients in the NP/CHW group had significantly greater 12-month improvement in total cholesterol (difference, 19.7 mg/dL), LDL cholesterol (difference,15.9 mg/dL), triglycerides (difference, 16.3 mg/dL), systolic blood pressure (difference, 6.2 mm Hg), diastolic blood pressure (difference, 3.1 mm Hg), HbA1c (difference, 0.5%), and perceptions of the quality of their chronic illness care (difference, 1.2 points). Conclusions— An intervention delivered by an NP/CHW team using individualized treatment regimens based on treat-to-target algorithms can be an effective approach to improve risk factor status and perceptions of chronic illness care in high-risk patients. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00241904.

Background Despite well-publicized guidelines on the appropriate management of cardiovascular disease (CVD) and type 2 diabetes, implementation of risk-reducing practices remains poor. This paper describes the rationale and design of a randomized controlled clinical trial evaluating the effectiveness of a comprehensive program of CVD risk reduction delivered by nurse practitioner (NP)/community health worker (CHW) teams versus enhanced usual care in improving the proportion of patients in urban community health centers who achieve goal levels recommended by national guidelines for lipids, blood pressure, HbA1c and prescription of appropriate medications. Methods The COACH (Community Outreach and Cardiovascular Health) trial is a randomized controlled trial in which patients at federally-qualified community health centers were randomly assigned to one of two groups: comprehensive intensive management of CVD risk factors for one year by a NP/CHW team or an enhanced usual care control group. Results A total of 3899 patients were assessed for eligibility and 525 were randomized. Groups were comparable at baseline on sociodemographic and clinical characteristics with the exception of statistically significant differences in total cholesterol and hemoglobin A1c. Conclusions This study is a novel amalgam of multilevel interdisciplinary strategies to translate highly efficacious therapies to low-income federally-funded health centers that care for patients who carry a disproportionate burden of CVD, type 2 diabetes and uncontrolled CVD risk factors. The impact of such a community clinic-based intervention is potentially enormous.

In November 2013, the Honor Society of Nursing, Sigma Theta Tau International (STTI), announced the creation of the Global Advisory Panel on the Future of Nursing (GAPFON) to establish a voice and vision for the future of nursing and midwifery that will advance global health. The composition of the panel, first convened in March 2014, was purposeful in nature to ensure that the voices at the table represented individual expertise and experience from diverse backgrounds. Key issues identified at this inaugural meeting included the need for reform, advocacy, and innovations in leadership, policy, practice, education, and work environments. While the specific context through which these efforts will be addressed is nursing and midwifery, recognition of the interprofessional and collaborative nature of the world's healthcare needs and systems was kept at the forefront of all discussions. GAPFON intends to demonstrate how nursing and midwifery can contribute to strengthening health systems and attaining global health goals through the exchange of ideas and experiences across the different regions of the world. GAPFON is designed to be a catalyst to stimulate partnerships and collaborations to advance global health outcomes, and is a vehicle for thought leaders to share information, develop and influence policy, and advance interprofessional efforts toward those goals.Health professions from across disciplines have helped direct, define, and advance public health-and the role of health practitioners within public health-around the world for decades, establishing the current model for global health. As a result, health promotion policies and processes have been established, diseases have been mitigated, access to care has been facilitated, and a notion of "shared responsibility" for the world's health has been realized. Nursing and midwifery have played a key role in the innovation and cohesion required to establish, sustain, and implement this model of global health.As healthcare demands predicate the need for enhanced and/or new models of global health, nurses, midwives, and our healthcare colleagues from all professions need to bring a clear voice and vision for the future of global health. This is especially important as we address the United Nation's Millennial Development Goals (MDGs; United Nations, 2014), and also support the emerging Sustainable Development Goals (SDGs; United Nations Department of Economic and Social Affairs, Division for Sustainable Development, 2014) as part of the post-2015 agenda.As with other healthcare professionals, nurses believe in and support the idea that an investment in health results in an enormous payoff, and that in our collective lifetimes, a grand convergence in health is within reach (Jamison et al., 2013). Additionally, globalization, in all its facets-economic, technological, and cultural- has created a world market for the nursing workforce (Shaffer, 2014). Opportunities continue to grow for nurses and midwives to have a strong role in shaping health at the policy and practice levels, even as challenges present themselves: demand for nurses exceeds supply; nursing and midwifery education and regulation differs across borders; and task shifting and sharing are increasing as some traditional nursing work is being undertaken by healthcare generalists that are less costly to employ. GAPFON recognizes all the possibilities for nursing to have an inclusive voice worldwide, to overcome barriers, and to help create a new narrative for nursing and a model for global health.With the support of Pfizer, Inc., our Founding Sponsor, and Johns Hopkins University School of Nursing, in 2015 and 2016, GAPFON will address its core mission by convening a series of meetings in seven global regions:* Middle East (April 2015)* Asia/Oceania (June 2015)* The Caribbean (July 2015)* Central-Latin America (July 2015)* Africa (July 2016)* Europe (2016)* North America (2016)Each meeting will convene thought and action leaders from a variety of disciplines, including ministers of health, representatives from key nursing and midwifery associations, educational institutions, economists, regulatory bodies, other health professionals or health industries, pharmaceutical companies, and governmental leaders that are influential in global health. …

Many Korean American persons have hypertension, but competing life priorities often prevent them from attending health-promotion educational activities. Using principles of community-based participatory research, the authors conducted a prospective clinical trial to determine the effectiveness of a mailed vs an in-class culturally tailored education intervention. A total of 380 hypertensive Korean American persons from the Baltimore/Washington area were assigned to a more intense in-class education group or a less intensive mail education group. Evaluation of postintervention blood pressure (BP) outcomes revealed that significant reductions in systolic BP (13.3 mm Hg and 16.1 mm Hg, respectively) and diastolic BP (9.5 mm Hg and 10.9 mm Hg) and increases in BP control rates (42.3% and 54.3%) were achieved in both groups. No significant differences in BP outcomes between groups, however, were found. In conclusion, education by mail was an effective strategy for improving BP control and may be a viable approach for other immigrant groups if the education materials address their cultural needs.

To describe the HiHi Study and assess cardiovascular disease (CVD) risk profile and comorbid conditions of Black patients receiving hypertension (HTN) care.Cross sectional, descriptive.Public and private primary care sites in three townships near Cape Town, South Africa.403 hypertensive Black patients (183 men, 220 women), ages 35-65 years.Self-reported sociodemographic, lifestyle, and medical history factors were assessed. Height, weight, and blood pressure (BP) were measured and 12-lead electrocardiogram recorded. Blood and urine were collected to assess lipid profile, diabetes, and renal impairment. Type and number of medications were abstracted from medical records.Antihypertensive medication was prescribed for all participants, with HTN controlled (BP140/90 mm Hg) for 36% of public and 51% of private patients. Mean systolic and diastolic BP were higher in the public than private sector (148/90 +/- 28/13 and 138/ 86 +/- 21/13 mm Hg) as was LVH (37% and 30%) but diabetes (18% and 29%) and obesity (55% and 75%) were less common in the public sector. There were no significant differences between public and private settings in use of antihypertensive medications, total cholesterolor =5 mmol/L, daily tobacco use, or total CVD risk. More men than women smoked tobacco daily (30% and 6%) and used alcohol excessively (53% and 15%).Despite attending HTN primary care, CVD risk factors were addressed inadequately. Differences in risk factor prevalence and control were identified by healthcare sector and sex. A critical need exists to improve HTN care and CVD risk management programs for this high risk group.

To examine determinants of hypertension (HTN) care and control among peri-urban hypertensive Black South Africans.Cross-sectional, descriptive.Public and private primary care sites in three townships near Cape Town, South Africa.403 hypertensive Black patients (183 men, 220 women), ages 35-65 years.The Precede-Proceed Model guided the study. Self-report sociodemographics, medical history, health behaviors, health service utilization, quality of life, social support, and exposure to life threats and illness were assessed. Blood pressure (BP) was measured and height and weight recorded.Mean BP (mm Hg) was 151/99 for men, 142/88 for women with BP controlled (140/90 mm Hg) among 33% of men, 44% of women. Patient-related barriers to HTN care included limited HTN-related knowledge, poor quality of life and stressors such as family death. An unhealthy lifestyle involving smoking cigarettes, physical inactivity and using alcohol excessively was common. In regression models of select socioeconomic, lifestyle risk and HTN care variables, significant predictors of lower SBP and DBP or BP control included: fewer antihypertensive medications, better compliance to HTN recommendations, younger age, female, higher education level, not using alcohol excessively, and private sector healthcare.This study identified a high level of barriers to HTN control and the need for comprehensive multilevel interventions to improve HTN care and control in this high-risk population. Furthermore, the data illustrate that the Hill-Bone compliance scale can be a practical tool in primary healthcare settings to identify patient-related factors and guide counseling to improve adherence in HTN care.

Since the recommendations for blood pressure measurement in humans were published,1 questions have been raised regarding the recommendations for cuff sizes in subjects with obese arms and how the width of the cuffs should relate to the length.2 In the 1993 recommendations,3 the largest recommended bladder width was 20 cm, whereas in the latest version it is 16 cm (Table). View this table: 1993 and 2005 Recommendations for Cuff Sizes in Obese and Overweight Subjects The 2005 document stated that, “the ‘ideal’ cuff should have a bladder length that is 80%, and a width that is at least 40% of arm circumference (a length to width ratio of 2:1). A recent study comparing intra-arterial and auscultatory blood pressure concluded that the error is minimized with a cuff width of 46% of the arm circumference.” The study that examined this issue was published by Marks and Groch,4 who measured blood pressure directly from the radial artery and indirectly from the brachial artery in 50 subjects who were in an intensive care unit and had intra-arterial lines as part of their routine care. The average arm circumference of these patients was 29.7 cm, and the published figure show that the highest circumference was 37 cm. Thus, only 2 of their 50 patients had arm circumferences in the 35 to 44 cm range, and none had circumferences …

African American men with hypertension (HTN) in low socioeconomic urban environments continue to achieve poor rates of HTN control.In a 5-year randomized clinical trial with 309 hypertensive urban African American men aged 21 to 54 years, the effectiveness of a more intensive educational/behavioral/pharmacologic intervention provided by a nurse practitioner/community health worker/physician team was compared to less intensive information and referral intervention. Changes in behavioral factors, health care utilization, blood pressure (BP) control, left ventricular hypertrophy (LVH), and renal insufficiency were evaluated.Follow-up rates exceeded 89% of available men. The ranges of mean annual systolic BP/diastolic BP change from the baseline to each year follow-up were -3.7 to -10.1/-4.9 to -12.3 mm Hg for the more intensive group and +3.4 to -3.0/-1.8 to -8.7 mm Hg for the less intensive group. The annual proportion of men with controlled BP (140/90 mm Hg) ranged from 17% to 44% in the more intensive group and 21% to 36% in the less intensive group. At 5 years the more intensive group had less LVH than the less intensive group and 17% of the men were deceased primarily due to narcotic or alcohol intoxication (36%) and cardiovascular causes (19%).An appropriate educational/behavioral intervention significantly improved BP control and reduced some sequelae of HTN in a young African American male population. Improvement in risk factors other than HTN was limited and sustained control of HTN was difficult to maintain during 5 years.

1) To describe stressful life events as experienced by a sample of young Black men with high blood pressure (HBP) living in inner-city Baltimore, Maryland; and 2) to examine the effect of cumulative stressful life events on substance use, depression, and quality of life.Data were obtained over 48 months by interview from 210 men in an HBP management study.Stressors repeatedly occurring over time included death of family member or close friend (65.2%), having a new family member (32.9%), change in residence (31.4%), difficulty finding a job (24.3%), and fired or laid off from work (17.6%). Involvement with crime or legal matters was reported at least twice during the 48 months by 33.3% of men. When a cumulative stressful life events score was calculated by summing the number of events experienced at 6-month points over 48 months and tested for its relationship with the health outcomes, the findings of multivariate analyses revealed significant associations between cumulative life stressors and depression and quality of life. No significant relationship was found between stressful life events and substance use.The results suggest that cumulative stressful life events have a negative effect on mental health and quality of life in young Black men with HBP. Future study should focus on developing interventions to assist individuals in managing distress related to stressful events with necessary community resources.

Accurate measurement of blood pressure is essential to classify individuals, to ascertain blood pressure–related risk, and to guide management. The auscultatory technique with a trained observer and mercury sphygmomanometer continues to be the method of choice for measurement in the office, using the first and fifth phases of the Korotkoff sounds, including in pregnant women. The use of mercury is declining, and alternatives are needed. Aneroid devices are suitable, but they require frequent calibration. Hybrid devices that use electronic transducers instead of mercury have promise. The oscillometric method can be used for office measurement, but only devices independently validated according to standard protocols should be used, and individual calibration is recommended. They have the advantage of being able to take multiple measurements. Proper training of observers, positioning of the patient, and selection of cuff size are all essential. It is increasingly recognized that office measurements correlate poorly with blood pressure measured in other settings, and that they can be supplemented by self-measured readings taken with validated devices at home. There is increasing evidence that home readings predict cardiovascular events and are particularly useful for monitoring the effects of treatment. Twenty-four-hour ambulatory monitoring gives a better prediction of risk than office measurements and is useful for diagnosing white-coat hypertension. There is increasing evidence that a failure of blood pressure to fall during the night may be associated with increased risk. In obese patients and children, the use of an appropriate cuff size is of paramount importance.

Concern about the cost and quality of health care has stimulated an interest in documenting improved patient outcomes. Large multisite clinical trials, such as MRFIT,1 HDFP,2 SHEP,3 and 4S,4 used multidisciplinary educational and behavioral interventions to demonstrate dramatic reductions in cardiovascular morbidity and mortality through the modification of risk factors. Other large multisite clinical trials, such as TOHP I5 and TOMS,6 used similar strategies to demonstrate significant differences in lifestyle modification and quality of life associated with effective risk reduction. But similar outcomes have not been achieved in clinical practice. Why are we not achieving the same results in clinical practice that we see in randomized controlled clinical trials? We believe one major reason is that the multidisciplinary team approach used in clinical trials to reduce risk is insufficiently incorporated into standard clinical practice. In the case of secondary prevention for coronary artery disease, improved outcomes depend on patients’ following appropriate risk reduction plans. The recent American Heart Association consensus statement “Preventing Heart Attack and Death in Patients With Coronary Disease”7 outlines a set of risk reduction recommendations for clinicians and emphasizes the central role of patient compliance (or “adherence”) in achieving improved medical outcomes. The statement says that “attention to enhancing patient compliance is an integral part of any risk reduction program,” adding that the proportion of patients who continue risk factor interventions over the long term “can be significantly increased by a team approach in which healthcare professionals−including physicians, nurses, and dietitians− manage risk reduction therapy by using follow-up techniques that include office or clinic visits and telephone contact. In many healthcare settings, the team approach will be the preferred technique for optimizing risk reduction.” The need for improved patient compliance extends well beyond those with established coronary artery disease. For …

This study investigated the effectiveness of a community-academic health center partnership, utilizing nurse-supervised indigenous community health workers, in decreasing the blood pressure in an urban African-American population. A four-year randomized clinical trial was conducted in the Sandtown-Winchester community, which has an excess prevalence of high blood pressure, in order to test the effectiveness of 2 different levels of intervention intensity on increasing the control of high blood pressure. Community health workers were trained and certified in blood pressure management, monitoring, education and counseling, social support mobilization, and community outreach and follow up. The primary results were a significant decrease in mean systolic and diastolic pressures after both levels of intervention, and a significant increase in the percentage of individuals with controlled high blood pressure. Surprisingly, no differences in results were observed between the 2 levels of intervention intensity. This study supports the use of community-based partnership efforts, and the utilization of indigenous health workers, to enhance the control of high blood pressure in a high-risk, African-American urban population.

The key topics identified by the Clinical Science Subgroup are: ### Introduction, Definition, Content The scope of new biomedical information is rapidly evolving, both in breadth and depth, from multiple research strategies. These sources of data include: (1) major population studies on the epidemiology and results of intervention for disease prevention from clinical trials and epidemiological surveys; (2) new approaches to understanding the pathophysiology of disease, with particular regard to predictors of acute events; and (3) the promise of a major impact on prediction, prevention, and treatment of disease, as well as a much better understanding of the basic biology of cardiovascular disease as a result of genetic insights. Each of these disciplines offers individual analytical challenges in order to understand their meaning and applications, but equally important, the three avenues of study must be integrated to maximize the derived benefits. It will be necessary to construct new methods for complex systems analyses applicable to these biomedical questions. Although this requirement will apply to all phases of large database analysis, it is particularly important for deriving benefits that can be applied to human disease states from molecular genetics. Completion of the draft sequence of the human genome has provided a broad horizon of opportunity for application of genetically based information to our knowledge of pathophysiology and to the diagnosis, prevention, and treatment of clinical states. Technological advances in high-throughput sequencing and various gene expression methods are anticipated to provide ever-increasing volumes of information, with the potential to generate novel approaches to clinical medicine. It was apparent, even before the completion of the draft sequence of the human genome, that …

Hypertensive patients with target organ damage are at increased cardiovascular risk, and should be treated most aggressively. The association between urinary albumin excretion and left ventricular hypertrophy (LVH) in prior studies is inconsistent, and has not been described using a single, random spot urine specimen. Therefore, we evaluated the association between the urinary albumin creatinine ratio (ACR) and left ventricular (LV) mass and also tested the hypothesis that a simple random, single-void urine ACR would identify high risk young, hypertensive, African-American men. We measured echocardiographic LV mass and a random spot urinary ACR in 109 untreated, hypertensive, young, inner city, African-American men. The mean age was 41 +/- 6 years and the mean blood pressure (BP) was 157 +/- 19/107 +/- 13 mm Hg. Microalbuminuria (ACR 30 to 300 mg/g) was present in 22% of subjects. The ACR is higher in the men with LVH than in the men without LVH (P.05). Increased ACR is a predictor of increased LV mass index (P.003) using multiple linear regression. An ACR30 mg/g has a sensitivity of 33% and a specificity of 82% for the diagnosis of echocardiographic LVH. In conclusion, elevated random spot ACR is a marker of increased LV mass, independent of BP, in young urban African-American men with hypertension, and may help to determine the aggressiveness of antihypertensive therapy in this high-risk group.

The Workshop on Sodium and Blood Pressure was convened by the National Heart, Lung, and Blood Institute (NHLBI) in Bethesda, Md, on January 28 and 29, 1999, to update earlier reviews of this topic.1 2 3 Other topics covered were sodium intake in relation to other cardiovascular disease (CVD) and non-CVD conditions, research needs, and public policy considerations. More than 55 invited speakers and other attendees from the United States and abroad reviewed and discussed the scientific information. This review synthesizes the presentations and discussions. Epidemiological studies conducted over the past 50 years have shown a clear curvilinear relation of higher adult blood pressure (BP) levels to higher rates of coronary heart disease (CHD), stroke, heart failure, and kidney failure. A continuous relation is apparent from below the 120/80 mm Hg level. Thus, a significant portion of CVD occurs in persons whose BP has not reached the arbitrary 140/90 mm Hg level defining hypertension. Studies show unequivocally that lowering high BP in hypertensive patients can reduce the likelihood of developing or dying from CVD, including CHD and stroke. Dietary factors in individuals and in the population at large have important effects on BP levels, which are generally assumed to translate to CVD risk. For the nonhypertensive subset, a population-wide approach to lowering BP (an approach based on lifestyle modifications that have been shown to prevent or delay increases in BP) could affect the total CVD burden as much as or more than treating only those with established hypertension. There is an abundance of scientific evidence demonstrating a direct relation between salt intake and BP. Studies in laboratory animals show that high BP can be induced by diet.4 Recent evidence comes from a randomized trial involving 26 chimpanzees that were given a low salt/high potassium diet (preintervention period). Subsequently, …

Writing Group I of Prevention Conference V reviewed the role of medical office assessment in the detection of risk factors and estimation of total cardiovascular risk. The primary focus was on identification of known risk factors for coronary heart disease (CHD). Population screening may identify risk factors that prompt people to seek clinical consultation. Risk factors may also be identified in patients who are seeking medical treatment for other conditions. Physicians have the responsibility to evaluate cardiovascular risk in all their patients. Medical office assessment permits the identification of many high-risk patients without the need for noninvasive testing for atherosclerotic burden or subclinical myocardial ischemia. Techniques for office assessment available to clinicians include history, physical examination, laboratory testing, and electrocardiography (ECG). Routine evaluation and testing provides most of the information needed to estimate risk and make treatment decisions. The essential information required for estimating risk for CHD lies in the known risk factors for coronary disease. These risk factors must first be identified and their severity determined. The relationship between risk factors and development of CHD is strong but variable. When a risk factor is causally and independently related to disease, the physician should make recommendations to the patient about risk factor modification. When risk factors are associated with increased risk for CHD but are not directly causative, the risk factor is considered to be a marker for increased risk . In the following discussion, the major risk factors and risk markers for CHD that can be detected in medical office assessment are reviewed. The different categories of risk are then considered. Finally, the special characteristics of each risk factor in relation to global risk assessment are reviewed. Special groups, including older patients and those with diabetes, are considered, and suggestions are made for modifying the existing guidelines for risk …

Barriers to high blood pressure (HBP) care and control have been reported in the literature for > 30 years. Few reports on barriers, however, have focused on the young black man with HBP, the age/sex/race group with the highest rates of early severe and complicated HBP and the lowest rates of awareness, treatment, and control. In a randomized clinical trial of comprehensive care for hypertensive young urban black men, factors potentially associated with care and control were assessed at baseline for the 309 enrolled men. A majority of the men encountered a variety of barriers including economic, social, and lifestyle obstacles to adequate BP care and control, including no current HBP care (49%), risk of alcoholism (62%), use of illicit drugs (45%), social isolation (47%), unemployment (40%), and lack of health insurance (51%). Having health insurance (odds ratio = 7.20, P = .00) and a negative urine drug screen (odds ratio = .56, P = .04) were significant predictors of being in HBP care. Low alcoholism risk and employment were identified as significant predictors of compliance with HBP medication-taking behavior. Men currently using illicit drugs were 2.64 times less likely to have controlled BP compared with their counterparts who did not use illicit drugs, and men currently taking HBP medication were 63 times more likely have controlled BP compared with men not taking HBP medication. Comprehensive interventions are needed to address socioeconomic and lifestyle issues as well as other barriers to care and treatment, if HBP care is to be salient and effective in this high risk group.

Consensus reports providing guidelines designed to alter clinical practice are being disseminated with increasing frequency by professional associations, the government, and voluntary health agencies. The purpose of this study was to examine nurses' perceptions of consensus reports that contain recommendations designed to alter clinical practice, including the extent to which consensus reports offer relative advantage over other more traditional sources of practice-related information. Strategies for encouraging the use of consensus reports are discussed.