Effect of Antihypertensive Medication Reduction vs Usual Care on Short-term Blood Pressure Control in Patients With Hypertension Aged 80 Years and Older: The OPTIMISE Randomized Clinical Trial.

Importance: Deprescribing of antihypertensive medications is recommended for some older patients with polypharmacy and multimorbidity when the benefits of continued treatment may not outweigh the harms. Objective: This study aimed to establish whether antihypertensive medication reduction is possible without significant changes in systolic blood pressure control or adverse events during 12-week follow-up. Design, Setting, and Participants: The Optimising Treatment for Mild Systolic Hypertension in the Elderly (OPTIMISE) study was a randomized, unblinded, noninferiority trial conducted in 69 primary care sites in England. Participants, whose primary care physician considered them appropriate for medication reduction, were aged 80 years and older, had systolic blood pressure lower than 150 mm Hg, and were receiving at least 2 antihypertensive medications were included. Participants enrolled between April 2017 and September 2018 and underwent follow-up until January 2019. Interventions: Participants were randomized (1:1 ratio) to a strategy of antihypertensive medication reduction (removal of 1 drug [intervention], n = 282) or usual care (control, n = 287), in which no medication changes were mandated. Main Outcomes and Measures: The primary outcome was systolic blood pressure lower than 150 mm Hg at 12-week follow-up. The prespecified noninferiority margin was a relative risk (RR) of 0.90. Secondary outcomes included the proportion of participants maintaining medication reduction and differences in blood pressure, frailty, quality of life, adverse effects, and serious adverse events. Results: Among 569 patients randomized (mean age, 84.8 years; 276 [48.5%] women; median of 2 antihypertensive medications prescribed at baseline), 534 (93.8%) completed the trial. Overall, 229 (86.4%) patients in the intervention group and 236 (87.7%) patients in the control group had a systolic blood pressure lower than 150 mm Hg at 12 weeks (adjusted RR, 0.98 [97.5% 1-sided CI, 0.92 to ∞]). Of 7 prespecified secondary end points, 5 showed no significant difference. Medication reduction was sustained in 187 (66.3%) participants at 12 weeks. Mean change in systolic blood pressure was 3.4 mm Hg (95% CI, 1.1 to 5.8 mm Hg) higher in the intervention group compared with the control group. Twelve (4.3%) participants in the intervention group and 7 (2.4%) in the control group reported at least 1 serious adverse event (adjusted RR, 1.72 [95% CI, 0.7 to 4.3]). Conclusions and Relevance: Among older patients treated with multiple antihypertensive medications, a strategy of medication reduction, compared with usual care, was noninferior with regard to systolic blood pressure control at 12 weeks. The findings suggest antihypertensive medication reduction in some older patients with hypertension is not associated with substantial change in blood pressure control, although further research is needed to understand long-term clinical outcomes. Trial Registration: EudraCT Identifier: 2016-004236-38; ISRCTN identifier: 97503221.

Adhesive capsulitis of the hip: a review.

Adhesive capsulitis of the hip (ACH) is a rare clinical entity. Similar to adhesive capsulitis of the shoulder, ACH is characterized by a painful decrease in active and passive range of motion as synovial inflammation in the acute stages of the disease progresses to capsular fibrosis in the chronic stages. Once other diagnoses have been ruled out, management of ACH is tailored to reduce inflammation in the acute stages with NSAIDs, intra-articular steroid injections, and targeted physical therapy while biomechanical dysfunction in the spine, hip, sacroiliac joint, or lower limb joints is addressed. In chronic stages of the disease, intervention should focus on decreasing the progression of fibrotic changes and regaining range of motion through aggressive physical therapy. Interventions described for chronic ACH include manipulation under anesthesia; pressure dilatation; and open or arthroscopic synovectomy, lysis of adhesions, and capsular release. Surgical intervention should be considered only after failure of a minimum 3-month course of nonsurgical treatment.

Prevalence of hearing loss in college students: a meta-analysis.

Introduction: Hearing loss among college students, specifically noise-induced hearing loss (NIHL), appears to be increasing. This may be particularly challenging for this population as college students are required to listen to lectures in classrooms that may have suboptimal listening environments. College-aged musicians are at a particularly high risk due to repeated and extended exposure to loud noise. Therefore, the purpose of the current study was (1) to examine the prevalence of hearing loss in college students and (2) to emphasize the importance of detecting hearing loss at 6,000 Hz. Methods: A meta-analysis was conducted using the PRISMA model. The literature search yielded 8 studies (1,950 subjects) that tested hearing loss using an audiogram and Distortion Product Otoacoustic Emissions (DPOAEs). All studies used audiologic tests to detect hearing loss among college students between the ages of 17-35 years. Results: Results indicate that the prevalence of hearing loss in college students is 19%. In addition, the prevalence of hearing loss at 6,000 Hz is 85% among student musicians. For this meta-analysis, slight sensorineural hearing loss, or thresholds greater than 20 dB bilaterally or unilaterally, qualified as hearing loss. Discussion: Decreased hearing at 6,000 Hz may lead to an individual's inability to hear important environmental factors and high frequency speech sounds. College students without full auditory function at this frequency may have difficulties performing in class based on decreased attention, comprehension, and memory. Although students may not realize the influence of their 6,000 Hz hearing loss or be unaware of its presence, it could significantly change their likelihood to succeed in college. Therefore, implementing a hearing conservation program may be advised for colleges and universities to help prevent hearing loss in students, particularly for collegiate musicians. In addition, it may be beneficial to screen hearing in college students at 6,000 Hz for better detection of hearing loss overall.

Sleep duration is associated with auditory radiation microstructure.

OBJECTIVES: Although hearing has been shown to interact with sleep, the underlying mechanisms for the interaction remain largely unclear. In the absence of knowledge about the neural pathways that are associated with hearing-sleep interaction, this study aimed to examine whether the auditory radiation, the final portion of the auditory pathway from the cochlea to the cerebral cortex, shows association with sleep duration. METHODS: Using Diffusion Tensor Imaging (DTI) data from enhanced Nathan Kline Institute-Rockland Sample (NKI-RS), we isolated the white matter tracts between the medial geniculate nucleus of the thalamus and Heschl's gyrus in each individual subject (N = 465) using probabilistic tractography. As a measure of the white matter microstructure integrity, the mean fractional anisotropy (FA) of the whole auditory radiation was examined and tested for an association with sleep length in the Pittsburgh Sleep Assessment Index. RESULTS: A significant inverse-U shaped association was found between the auditory radiation FA and sleep duration. DISCUSSION: It is suggested that the auditory radiations are a part of the pathway mediating the sleep-hearing interaction. Although the current study does not resolve the causal relationship between hearing and sleep, it would be the first evidence that the auditory radiation is associated with sleep duration.

Generalizability of Blood Pressure Lowering Trials to Older Patients: Cross-Sectional Analysis.

BACKGROUND/OBJECTIVES: Randomized controlled trials are used to inform clinical guidelines on the management of hypertension in older adults, but it is unclear to what extent these trials represent the general population attending routine clinical practice. This study aimed to define the proportion and characteristics of patients eligible for hypertension trials conducted in older people. DESIGN: Cross-sectional study. SETTING: A total of 24 general practices in England. PARTICIPANTS: Anonymized electronic health record data from all individuals aged 80 and older. MEASUREMENTS: Descriptive statistics were used to define the proportion and characteristics of patients eligible for two previous medication intensification trials (HYVET, SPRINT) and one medication reduction trial (OPTiMISE). A logistic regression model was constructed to estimate predictors of eligibility for each trial. RESULTS: Of 15,376 patients identified, 268 (1.7%; 95% confidence interval [CI] = 1.5-2.0%), 5,290 (34.4%; 95%CI = 33.7-35.2%), and 3,940 (25.6%; 95%CI = 24.9-26.3%) were eligible for the HYVET, SPRINT, and OPTiMISE trials, respectively. Between 5.6% and 30.7% of exclusions from each trial were due to eligibility criteria excluding those with high or uncontrolled blood pressure. Frailty (odds ratio [OR] = .44; 95%CI = .36-.54 [OPTiMISE]), cardiovascular polypharmacy (OR = .61; 95%CI = .55-.68 [SPRINT]) and multimorbidity (OR = .72; 95%CI = .64-.82 [SPRINT]) were associated with a lower likelihood of being eligible for one or more of the trials. CONCLUSION: A possible unintended consequence of blood pressure criteria used by trials attempting to answer different primary questions is that for many older patients, no trial evidence exists to inform treatment decisions in routine practice. Caution should be exercised when applying results from existing trials to patients with frailty or multimorbidity.

Suicide in juveniles and adolescents in the United Kingdom.

BACKGROUND: Suicide is a leading cause of death among youths. Comparatively few studies have studied recent trends over time, or examined rates and characteristics of service contact in well-defined national samples. METHODS: Data on general population suicides and mid-year population estimates were used to calculate suicide rates (per 100,000/year) among youths aged 10-19 years in the United Kingdom. We then determined the proportion of youths who had been in mental health service contact in the year prior to death. Social and clinical data were collected via questionnaires sent to clinicians who had provided care. RESULTS: The general population rate of suicide was higher in males than females, and was higher in 15-19-year-olds compared to 10-14-year-olds. Suicide rates for 10-19-year-olds declined by 28% between 1 January 1997 and 31 December 2003 (compared with an 8% reduction in those aged >19 years); the fall was particularly marked for males. Mental health service contact was low at 14% (compared with 26% for adults), especially for males (12%). Youths in mental health contact were characterised by: diagnosis of affective disorder, mental illness history, residential instability, self-harm, and substance misuse. Over half of youths were living with parents and one-fifth were in full-time education. CONCLUSIONS: The suicide rate for 10-19-year-olds in the UK appeared to fall between 1997 and 2003. Further monitoring of suicide rates is needed to determine whether this trend has continued for the most recent years (e.g., 2004-7). The fall in rates may have been related to socio-economic or clinical factors. The rate of contact with services was low compared to adults, particularly in males. This is concerning because young males have the highest suicide rate in the UK. Suicide prevention in young people is likely to require a multi-agency approach.

Doctor Referral of Overweight People to Low Energy total diet replacement Treatment (DROPLET): pragmatic randomised controlled trial.

OBJECTIVE: To test the effectiveness and safety of a total diet replacement (TDR) programme for routine treatment of obesity in a primary care setting. DESIGN: Pragmatic, two arm, parallel group, open label, individually randomised controlled trial. SETTING: 10 primary care practices in Oxfordshire, UK. PARTICIPANTS: 278 adults who were obese and seeking support to lose weight: 138 were assigned to the TDR programme and 140 to usual care. 73% of participants were re-measured at 12 months. INTERVENTIONS: The TDR programme comprised weekly behavioural support for 12 weeks and monthly support for three months, with formula food products providing 810 kcal/day (3389 kJ/day) as the sole food during the first eight weeks followed by reintroduction of food. Usual care comprised behavioural support for weight loss from a practice nurse and a diet programme with modest energy restriction. MAIN OUTCOME MEASURES: The primary outcome was weight change at 12 months analysed as intention to treat with mixed effects models. Secondary outcomes included biomarkers of cardiovascular and metabolic risk. Adverse events were recorded. RESULTS: Participants in the TDR group lost more weight (-10.7 kg) than those in the usual care group (-3.1 kg): adjusted mean difference -7.2 kg (95% confidence interval -9.4 to -4.9 kg). 45% of participants in the TDR group and 15% in the usual care group experienced weight losses of 10% or more. The TDR group showed greater improvements in biomarkers of cardiovascular and metabolic risk than the usual care group. 11% of participants in the TDR group and 12% in the usual care group experienced adverse events of moderate or greater severity. CONCLUSIONS: Compared with regular weight loss support from a practice nurse, a programme of weekly behavioural support and total diet replacement providing 810 kcal/day seems to be tolerable, and leads to substantially greater weight loss and greater improvements in the risk of cardiometabolic disease. TRIAL REGISTRATION: International Standard Randomised Controlled Trials No ISRCTN75092026.

Adhesive capsulitis of the hip: a case report: an entity in question.

Very little has been discussed in the medical literature concerning adhesive capsulitis of the hip (ACH). There are no articles to date in the physical therapy literature regarding ACH and only a dozen or so in medical journals. Evidence suggests ACH may present in a similar progression through four stages as adhesive capsulitis of the shoulder (ACS) (from synovial inflammation to capsular fibrosis). Consensus does not exist for management of ACS or ACH. However, most clinicians agree that treatment should be guided by the stage of the disorder, whether medically, surgically, or through physical therapy. A large part of the confusion for management of adhesive capsulitis (ACS and ACH) is due to the many studies that have not reported their findings by stage. Arthroscopy and synovial/capsular biopsy can confirm the presence and stage of adhesive capsulitis. Primary (idiopathic) ACH is proposed to be caused by biomechanical dysfunction in the hip or other joints related to the mechanical function of the hip. The treatment for stages 1 and 2 consists of using techniques to reduce inflammation and correct biomechanical faults that affect the hip. In stages 3 and 4 treatment focuses on the biomechanical dysfunction of the spine, hip(s), pelvic ring, and lower limb, if needed. In this case, the 55-year-old female patient presenting with probable stage 3 adhesive capsulitis, responded well to manual therapy and has been able to return to functional activities and maintain them with a home program.