Antihypertensive treatment is effective at reducing the risk of cardiovascular disease, but is associated with adverse events, particularly in older patients with frailty. As a result, deprescribing antihypertensive medications is recommended in some clinical guidelines despite limited evidence from a few small randomised controlled trials. The aim of the OPTIMISE2 trial is to examine the safety, efficacy and cost-effectiveness of deprescribing antihypertensive treatment in older adults with controlled systolic blood pressure, who are at higher risk of adverse events. The OPTIMISE2 trial aims to enrol 3014 participants into the trial and actively follow them up for 1 year. Participants are aged 75 years and above and taking two or more blood pressure lowering drugs, with controlled blood pressure readings (systolic blood pressure < 140 mmHg if aged 75–79 years or < 150 mmHg if aged 80+ years), frail and/or at a higher risk of serious drug-related side effects of hypotension, syncope and falls. The trial randomises (1:1) participants to either step-down medication reduction (withdrawal of one antihypertensive medication at a time, at 4-week intervals with regular monitoring of blood pressure) or usual care (no medication reduction mandated). The choice of medications to withdraw is at the discretion of participating general practitioners or prescribers. The primary outcome is emergency hospitalisation or death within 1 year of randomisation. The primary objective is to determine whether antihypertensive deprescribing is non-inferior to usual care, with up to a 5

Hypertension is a major risk factor for cardiovascular disease, for which the management involves both lifestyle modification (diet, exercise etc) and medication. Digital interventions (mobile applications, websites, and SMS messages) are being developed to facilitate lifestyle change, but their effectiveness remains uncertain. This review aimed to establish whether digital interventions targeting lifestyle factors are effective in reducing blood pressure in individuals with hypertension. A systematic search was run through MEDLINE, EMBASE and the Cochrane Library. 5302 records were screened for eligibility and data on the primary outcome (systolic blood pressure (SBP)) and secondary outcomes (diastolic blood pressure (DBP) and change in lifestyle factors) were extracted from eligible papers. Where sufficient data were available, meta-analysis was undertaken using a random effects model. 17 randomised controlled trials were eligible for inclusion (3040 patients). 12 studies were suitable for meta-analysis. Lifestyle change mediated by digital interventions were associated with a larger SBP reduction than controls (mean difference (MD) −2.91 mmHg; 95% confidence interval (CI) −4.11, −1.71; p value (p) <0.0001). A significant difference was also seen in DBP reduction between groups (MD −1.13 mmHg; CI −1.91, −0.35; p = 0.005). Reporting of other secondary outcomes relating to lifestyle change was too heterogenous for meta-analysis. Digital interventions targeting lifestyle factors were associated with an improvement in blood pressure in patients with hypertension, but interpretation of the results is limited by significant heterogeneity between studies. Further research is required to understand which lifestyle factors, when targeted with digital interventions, result in maximal blood pressure reduction.

Objective: Deprescribing of antihypertensive medications is recommended for some older patients with polypharmacy and frailty. The OPTIMISE trial showed that this can be achieved without affecting blood pressure control at 3-month follow-up. This longer-term follow-up study aimed to examine the impact on serious adverse events (SAEs), mortality and cardiovascular disease (CVD) outcomes after at least 3 years. Design and method: Participants aged 80 years or older, with systolic blood pressure <150 mmHg, and receiving at least 2 antihypertensive medications were randomised (1:1) to a strategy of antihypertensive medication reduction (removal of one antihypertensive) or usual care. Participants were followed-up via their primary and secondary care electronic health records, at least 3 years after randomisation. The primary outcome was SAEs, defined as hospitalisation or death from any cause. Secondary outcomes included mortality, stroke, myocardial infarction and major CVD events. Analyses were undertaken using Cox proportional hazards modelling. Results: Among 569 randomised participants (intervention=282; control=287) with a mean age 85 years (276 [48.5%] women), 564 (99.1%) were followed-up for a median of 3.9 years. Medication reduction was sustained in 109 participants (52.7% of those alive in the intervention group) at 3 years. Participants in the intervention group were prescribed fewer antihypertensives than the control group (mean difference -0.35, 95%CI -0.52 to -0.18). Overall, 202 (72.1%) patients in the intervention group and 218 (76.8%) patients in the control group experienced SAEs during follow-up (adjusted HR 0.93, 95%CI 0.76-1.12). There was no evidence of a difference in mortality (aHR 0.81, 95%CI 0.58-1.13), stroke (aHR 0.91, 95%CI 0.40-2.06), myocardial infarction (aHR 0.86, 95%CI 0.42-1.77) or CVD events (aHR 1.00, 95%CI 0.68-1.46). Conclusions: Medication reduction was sustained in half of those attempting it, with no evidence of harm from SAEs, mortality or CVD after almost four years. These findings suggest that deprescribing antihypertensive medication is safe in older patients living in the community with controlled blood pressure.

• Acknowledging chronic pain as a diagnosis in its own right can help clinicians and patients move on from a mindset of searching for a diagnosis to discussing long term management strategies • Consider non-pain features such as poor sleep, low mood, and reduced physical activity: these can be both a cause and a consequence of chronic primary pain • Consultations where patients feel believed, listened to, and validated can enable a therapeutic relationship that forms the basis for subsequent management strategies, including supported self-management.

Authors’ reply to Bray Anushka Soni, 1 Youngjoo Kang, 2 Louise Trewern, 3 John Jackman, 4 David McCartney5 We thankBray for emphasising the fundamental role of psychological factors in chronic pain.1 2 Thedefinition of pain by the International Association for the Study of Pain has been recently revised from “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” to “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”3 The updated definition reduces the emphasis of pain needing to be associated with tissue damage, and the updated accompanying notes include “Pain is always a personal experience that is influenced to varying degrees by biological, psychological and social factors,” which further embraces the importanceofmind-body interactions that, somemayargue, havebeenpreviously overlooked.3 Although a detailed exploration of psychological factors was beyond the scope of our brief review, we did mention the bidirectional relationship betweenpsychological factors and chronic pain and encourage further exploration of these key features of chronic pain.2 We agree that trying to disentangle the physical aspects of pain from psychological drivers is impossible as the two are closely intertwined, and the main focus should be on supporting a person as a whole and not just their physical health needs. We accept that there are flaws in the current approach to the classification of chronic pain, but our aim was to relay contemporary thinking in the field. This was intended as a backdrop for practical advice to promote early identification and effective communication with people who currently have chronic pain, as the quest for further mechanistic understanding of these incredibly debilitating conditions continues.

AbstractBackgroundUpper respiratory tract infections (URTIs) are common, mostly self-limiting, but result in inappropriate antibiotic prescriptions. Poor sleep is cited as a factor predisposing to URTIs, but the evidence is unclear.ObjectiveTo systematically review whether sleep duration and quality influence the frequency and duration of URTIs.MethodsThree databases and bibliographies of included papers were searched for studies assessing associations between sleep duration or quality and URTIs. We performed dual title and abstract selection, discussed full-text exclusion decisions and completed 50% of data extraction in duplicate. The Newcastle–Ottawa Quality Assessment Scale assessed study quality and we estimated odds ratios (ORs) using random effects meta-analysis.ResultsSearches identified 5146 papers. Eleven met inclusion criteria, with nine included in meta-analyses: four good, two fair and five poor for risk of bias. Compared to study defined ‘normal’ sleep duration, shorter sleep was associated with increased URTIs (OR: 1.30, 95% confidence interval [CI]: 1.19–1.42, I2: 11%, P < 0.001) and longer sleep was not significantly associated (OR: 1.11 95% CI: 0.99–1.23, I2: 0%, P = 0.070). Sensitivity analyses using a 7- to 9-hour baseline found that sleeping shorter than 7–9 hours was associated with increased URTIs (OR: 1.31, 95% CI: 1.22–1.41, I2: 0%, P < 0.001). Sleeping longer than 7–9 hours was non-significantly associated with increased URTIs (OR: 1.15, 95% CI: 1.00–1.33, I2: 0%, P = 0.050, respectively). We were unable to pool sleep quality studies. No studies reported on sleep duration and URTI severity or duration.ConclusionsReduced sleep, particularly shorter than 7–9 hours, is associated with increased URTIs. Strategies improving sleep should be explored to prevent URTIs.

Background and Objectives As teaching technology advances, medical education is increasingly using digital mediums and exploring instructional models such as the flipped classroom and blended learning courses, where the in-class taught sessions are more groups on content delivered before class. Early evidence suggests lectures and foundational material can be equally provided online, but we have low-quality research to be convinced. We aim to test and develop an online evidence-based teaching resource that seeks to improve the availability and scalability of evidence-based medicine (EBM) learning tools. We evaluate the feasibility of a study design that could test for changes in academic performance in EBM skills using an online supplement. Methods Mixed-methods feasibility study of a randomised controlled trial (RCT) in an undergraduate medical student cohort. Results Of a small cohort (n=34), eight participants agreed to randomisation and completed the study. No study participant completed the EBM supplementary course in full. Students report time-management as a significant barrier in participation, and all aspects of the study and communications should be delivered with efficiency a key consideration. Conclusion Randomising students to an online EBM supplement within a medical school programme presents challenges of recruitment and student motivation, but the study design is potentially feasible.

OBJECTIVE:To assess the feasibility of using a blood pressure (BP) self-measurement kiosk-a solid-cuff sphygmomanometer combined with technology to integrate the BP readings into patient electronic medical records- to improve hypertension detection. DESIGN:A concurrent mixed-methods feasibility study incorporating observational and qualitative interview components. SETTING:Two English general practitioner (GP) surgeries. PARTICIPANTS:Adult patients registered at participating surgeries. Staff working at these sites. INTERVENTIONS:BP self-measurement kiosks were placed in the waiting rooms for a 12-month period between 2015 and 2016 and compared with a 12-month control period prior to installation. OUTCOME MEASURES:(1) The number of patients using the kiosk and agreeing to transfer of their data into their electronic medical records; (2) the cost of using a kiosk compared with GP/practice nurse BP screening; (3) qualitative themes regarding use of the equipment. RESULTS:Out of 15 624 eligible patients, only 186 (1.2%, 95% CI 1.0% to 1.4%) successfully used the kiosk to directly transfer a BP reading into their medical record. For a considerable portion of the intervention period, no readings were transferred, possibly indicating technical problems with the transfer link. A comparison of costs suggests that at least 52.6% of eligible patients would need to self-screen in order to bring costs below that of screening by GPs and practice nurses. Qualitative interviews confirmed that both patients and staff experienced technical difficulties, and used alternative methods to enter BP results into the medical record. CONCLUSIONS:While interviewees were generally positive about checking BP in the waiting room, the electronic transfer system as tested was neither robust, effective nor likely to be a cost-effective approach, thus may not be appropriate for a primary care environment. Since most of the cost of a kiosk system lies in the transfer mechanism, a solid-cuff sphygmomanometer and manual entry of results may be a suitable alternative.

Aims  C-reactive protein (CRP) and neutrophil count (NC) are important diagnostic indicators of inflammation. Point-of-care (POC) technologies for these markers are available but rarely used in community settings in the UK. To inform the potential for POC tests, it is necessary to understand the demand for testing. We aimed to describe the frequency of CRP and NC test requests from primary care to central laboratory services, describe variability between practices and assess the relationship between the tests. Methods We described the number of patients with either or both laboratory tests, and the volume of testing per individual and per practice, in a retrospective cohort of all adults in general practices in Oxfordshire, 2014–2016. Results 372 017 CRP and 776 581 NC tests in 160 883 and 275 093 patients, respectively, were requested from 69 practices. CRP was tested mainly in combination with NC, while the latter was more often tested alone. The median (IQR) of CRP and NC tests/person tested was 1 (1–2) and 2 (1–3), respectively. The median (IQR) tests/practice/week was 36 (22–52) and 72 (50–108), and per 1000 persons registered/practice/week was 4 (3–5) and 8 (7–9), respectively. The median (IQR) CRP and NC concentrations were 2.7 (0.9–7.9) mg/dL and 4.1 (3.1–5.5)×109/L, respectively. Conclusions The high demand for CRP and NC testing in the community, and the range of results falling within the reportable range for current POC technologies highlight the opportunity for laboratory testing to be supplemented by POC testing in general practice.

Commentary on: Berlowitz DR, Foy CG, Kazis LE, et al . Effect of intensive blood-pressure treatment on patient-reported outcomes. N Engl J Med 2017;377:733–44. The Systolic Blood Pressure Intervention Trial (SPRINT) was a large, multicentre, randomised controlled trial (RCT) originally reported in 2015.1 The trial randomly assigned 9361 individuals with hypertension at high risk of cardiovascular disease (but without diabetes or stroke) to intensive blood pressure (BP) control (systolic BP less than 120 mm Hg) or standard BP control (systolic BP less than 140 mm Hg). There was a significant reduction in cardiovascular events and mortality in the intensive treatment group and the trial was stopped early. The original trial reported a doubling of treatment-related serious adverse events including symptomatic hypotension, syncope and acute kidney injury in the intensive treatment group.1 This follow-on analysis presents the patient-reported outcomes of physical and mental health, and patient-reported adherence to treatment.2 SPRINT was an open-label RCT and recruited individuals over 50 years of age with a systolic BP between 130 and 180 mm …

It is important in primary care to be able to differentiate between cervical spine disease that can be managed conservatively and that associated with neurological symptoms suggestive of more serious disease, which may require urgent surgery. This article will cover key points in the history, examination, and management of patients with neck and neurological symptoms, with particular reference to cervical myelopathy and radiculopathy. The prevalence of neck pain in the general population is high: it has been estimated that 30–50% of adults will experience neck pain in any given year,1 with the average GP estimated to consult with seven people per week for neck or upper extremity symptoms.2 Neck pain with abnormal neurology (usually cervical radiculopathy) is much less common: it has been estimated to affect around 100 per 100 000 males and 60 per 100 000 females.3 Cervical myelopathy is even rarer but is worthy of discussion given that it requires urgent management and needs to be identified from among the many cases of neck and neurological symptoms that a GP sees on a regular basis — the incidence of cervical myelopathy is poorly quantified but studies have estimated it to be around 4 per 100 000.4 Cervical radiculopathy is due to compression or irritation of either or both of the dorsal (sensory) and ventral (motor) roots of a cervical nerve at one or more vertebral levels. Compression can result from intervertebral disc herniation, osteophyte formation, or other mass effects near the exit foramen of the cervical spine. This results in lower motor neurone symptoms and often presents with arm pain, weakness, and/or sensory loss, with or without associated neck pain. Cervical myelopathy is spinal cord dysfunction due to compression caused by narrowing of the spinal canal. Common causes include disc herniation, spondylosis, and congenital …

People with diabetes have a threefold increased risk of all musculoskeletal conditions, but are particularly vulnerable to tendon conditions, which are more treatment-resistant than in patients without diabetes.1,2 This is important as such problems can limit the opportunity to exercise as part of diabetes management.1 Discriminating between tendonitis and tendinopathy, conflicting evidence on treatment, and slow recovery can make these conditions challenging for GPs to manage. This article highlights key features of tendinopathy within diabetes and current evidence for treatment. Increased awareness may facilitate early diagnosis and improved outcome. Up to 50% of people who drop out of exercise interventions for type 2 diabetes do so due to musculoskeletal symptoms.1 A significant proportion of these will be due to tendinopathy. Common manifestations are Achilles tendinopathy, rotator cuff syndrome, lateral epicondylitis, and trigger finger. Patients with type 1 or type 2 diabetes have an increased risk of developing these conditions, although the mechanism for this is unclear.2 Symptoms can often last several months and cause considerable loss of function. Within the authors’ own practice, 18% of patients with diabetes have been affected in the past 5 years, with a mean symptom duration of 3 months. Approximately 5% of a GP diabetes caseload will develop tendinopathy annually.1 This compares with a background prevalence of approximately 2%.3 The nomenclature of tendon conditions is confusing. Tendonitis relates to acute …

The 90% CI of mean AUC differences between the exploratory sample and the validation sample corresponding to severe AKI. Dotted line are the equivalence margin with Δ = 20% (wider interval) and Δ = 10% (narrower interval)

[This corrects the article DOI: 10.1186/s41512-016-0001-y.].

Background Lactate is measured in hospital settings to identify patients with sepsis and severe infections, and to guide initiation of early treatment. Point-of-care technology could facilitate measurement of lactate by clinicians in the community. However, there has been little research into its utility in these environments. Aim To investigate the effect of using point-of-care lactate at presentation to health care on mortality and other clinical outcomes, in patients presenting with acute infections. Design and setting Studies comparing the use of point-of-care lactate to usual care in initial patient assessment at presentation to health care were identified using a maximally sensitive search strategy of six electronic databases. Method Two independent authors screened 3063 records for eligibility, and extracted data from eligible studies. Quality assessment for observational studies was performed using the ROBINS-I tool. Results Eight studies were eligible for inclusion (3063 patients). Seven studies were recruited from emergency departments, and one from a pre-hospital aeromedical setting. Five studies demonstrated a trend towards reduced mortality with point-of-care lactate; three studies achieved statistical significance. One study demonstrated a significant reduction in length of hospital stay, although another did not find any significant difference. Two studies demonstrated a significant reduction in time to treatment for antibiotics and intravenous fluids. Conclusion This review identifies an evidence gap - there is no high-quality evidence to support the use of point-of-care lactate in community settings. There are no randomised controlled trials (RCTs) and no studies in primary care. RCT evidence from community settings is needed to evaluate this potentially beneficial diagnostic technology.

BackgroundAnaemia is common in older people and the identification of potentially reversible haematinic deficiencies relies on appropriate investigation, often undertaken in primary care.AimTo determine the laboratory prevalence of anaemia, the types of anaemia observed, and the biochemical and haematological investigations undertaken to characterise any associated haematinic abnormality in older primary care patients.Design & settingA retrospective primary care based study of patients aged >65 years undergoing a full blood count in Oxfordshire, UK between 1 January 2012 and 31 December 2013.MethodConsecutive patients aged >65 years with a full blood count were identified retrospectively from a laboratory database. Patient demographics, number of blood tests and additional laboratory investigations requested were recorded. World Health Organisation (WHO) criteria were used to define anaemia.ResultsIn total 151 473 full blood counts from 53 890 participants were included: 29.6% of patients were anaemic. The majority had a normocytic anaemia (82.4%) and 46.0% of participants with anaemia had no additional investigations performed. The mean haemoglobin was lower in the anaemic group that underwent further investigation than those who did not (Hb 10.68 g/dl versus 11.24 g/dl, P<0.05): 33.2 % of patients with a microcytic anaemia (mean cell volume <80) did not have any markers of iron status measured.ConclusionA large proportion of older adults in primary care with a recent blood test are anaemic, the majority with a normocytic anaemia, with evidence of inadequate investigation. Those with lower haemoglobin are more likely to be further investigated. Further work is needed to understand the approach to anaemia in older adults in primary care.

Purpose of reviewThis article reviews recent developments in self-monitoring and self-management of hypertension aimed at the improvement of blood pressure (BP) control. Recent findingsThere is an increasing body of evidence examining the effects of self-monitoring on BP control. Several landmark studies in recent years have demonstrated clinically relevant benefit from self-monitoring based interventions. Self-management of BP with self-titration has shown particular promise, as has self-monitoring combined with intensive health-care led support. There is a lack of evidence on the benefits of self-monitoring for those with important comorbidity such as coronary heart disease, chronic kidney disease, diabetes and previous stroke, and future research should be directed towards this. SummaryThere is a growing body of evidence supporting the use of self-monitoring along with additional intervention including telemonitoring and self-titration in improving BP control. Further research is needed to understand which patients are likely to benefit most and how this is best integrated with routine care.

Previous studies report benefits of exercise for blood pressure control in middle age and older adults, but longer-term effectiveness in younger adults is not well established. We performed a systematic review and meta-analysis of published randomized control trials with meta-regression of potential effect modifiers. An information specialist completed a comprehensive search of available data sources, including studies published up to June 2015. Authors applied strict inclusion and exclusion criteria to screen 9524 titles. Eligible studies recruited younger adults with a cardiovascular risk factor (with at least 25% of cohort aged 18-40 years); the intervention had a defined physical activity strategy and reported blood pressure as primary or secondary outcome. Meta-analysis included 14 studies randomizing 3614 participants, mean age 42.2 +/- 6.3 (SD) years. At 3 to 6 months, exercise was associated with a reduction in systolic blood pressure of -4.40 mm Hg (95% confidence interval, -5.78 to -3.01) and in diastolic blood pressure of -4.17 mm Hg (95% confidence interval, -5.42 to -2.93). Intervention effect was not significantly influenced by baseline blood pressure, body weight, or subsequent weight loss. Observed intervention effect was lost after 12 months of follow-up with no reported benefit over control, mean difference in systolic blood pressure -1.02 mm Hg (95% confidence interval, -2.34 to 0.29), and in diastolic blood pressure -0.91 mm Hg (95% confidence interval, -1.85 to 0.02). Current exercise guidance provided to reduce blood pressure in younger adults is unlikely to benefit long-term cardiovascular risk. There is need for continued research to improve age-specific strategies and recommendations for hypertension prevention and management in young adults.