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Low blood 25(OH)D level is associated with increased cardiovascular disease (CVD) risk. Additionally, individuals with prediabetes are at higher risk for CVD than individuals with normoglycemia. We investigated the effects of vitamin D supplementation on CVD outcomes in the vitamin D and type 2 diabetes (D2d) study, a large trial among adults with prediabetes.2423 participants were randomized to 4000 IU/day of vitamin DMean age was 60 years, 45 % were women, 13 % had history of CVD. Twenty-one participants assigned to vitamin D and 12 participants assigned to placebo met the MACE outcome (HR 1.81, 95%CI 0.89 to 3.69). There were 27 expanded MACE outcomes in each group (HR 1.02, 95%CI, 0.59 to 1.76). There were no significant differences between vitamin D and placebo in individual CVD risk factors, but change in ASCVD risk score favored the vitamin D group (-0.45 %, 95%CI -0.75 to -0.15).In people with prediabetes not selected for vitamin D insufficiency and with intermediate CVD risk, vitamin D supplementation did not decrease MACE but had a small favorable effect on ASCVD risk score.D2d ClinicalTrials.gov number, NCT01942694, prospectively registered September 16, 2013.

Hypertension control is falling in the US yet efficacious interventions exist. Poor patient reach has limited the ability of pragmatic trials to demonstrate effectiveness. This paper uses quantitative and qualitative data to understand factors influencing reach in Hyperlink 3, a pragmatic hypertension trial testing an efficacious pharmacist-led Telehealth Care intervention in comparison to a physician-led Clinic-based Care intervention. Referrals to both interventions were ordered by physicians.A sequential-explanatory mixed methods approach was used to understand barriers and facilitators to reach. Reach was assessed quantitatively using EHR data, defined as the proportion of eligible patients attending intended follow-up hypertension care and qualitatively, via semi-structured interviews with patients who were and were not reached. Quantitative data were analyzed using descriptive and inferential statistics. Qualitative data were analyzed via combined deductive and inductive content analysis.Of those eligible, 27% of Clinic-based (n = 532/1945) and 21% of Telehealth patients (n = 385/1849) were reached. In both arms, the largest drop was between physician-signed orders and patients attending initial intended follow-up care. Qualitative analyses uncovered patient barriers related to motivation, capability, and opportunity to attend follow-up care.Although the proportion of eligible patients with signed orders was high in both arms, the proportion ultimately reached was lower. Patients described barriers related to the influence of one's own personal beliefs or priorities, decision making processes, logistics, and patient perceptions on physician involvement on reach. Addressing these barriers in the design of pragmatic interventions is critical for future effectiveness.NCT02996565.

Importance On the basis of observational studies, the use of thiazide diuretics for the treatment of hypertension is associated with reduced fracture risk compared with nonuse. Data from randomized clinical trials are lacking. Objective To examine whether the use of thiazide diuretics for the treatment of hypertension is associated with reduced fracture risk compared with nonuse. Design, Setting, and Participants Using Veterans Affairs and Medicare claims data, this study examined hip and pelvic fracture hospitalizations in Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial participants randomized to first-step therapy with a thiazide-type diuretic (chlorthalidone), a calcium channel blocker (amlodipine besylate), or an angiotensin-converting enzyme inhibitor (lisinopril). Recruitment was from February 1994 to January 1998; in-trial follow-up ended in March 2002. The mean follow-up was 4.9 years. Posttrial follow-up was conducted through the end of 2006, using passive surveillance via national databases. For this secondary analysis, which used an intention-to-treat approach, data were analyzed from February 1, 1994, through December 31, 2006. Main Outcomes and Measures Hip and pelvic fracture hospitalizations. Results A total of 22 180 participants (mean [SD] age, 70.4 [6.7] years; 43.0% female; and 49.9% white non-Hispanic, 31.2% African American, and 19.1% other ethnic groups) were followed for up to 8 years (mean [SD], 4.9 [1.5] years) during masked therapy. After trial completion, 16 622 participants for whom claims data were available were followed for up to 5 additional years (mean [SD] total follow-up, 7.8 [3.1] years). During the trial, 338 fractures occurred. Participants randomized to receive chlorthalidone vs amlodipine or lisinopril had a lower risk of fracture on adjusted analyses (hazards ratio [HR], 0.79; 95% CI, 0.63-0.98;P = .04). Risk of fracture was significantly lower in participants randomized to receive chlorthalidone vs lisinopril (HR, 0.75; 95% CI, 0.58-0.98;P = .04) but not significantly different compared with those randomized to receive amlodipine (HR, 0.82; 95% CI, 0.63-1.08;P = .17). During the entire trial and posttrial period of follow-up, the cumulative incidence of fractures was nonsignificantly lower in participants randomized to receive chlorthalidone vs lisinopril or amlodipine (HR, 0.87; 95% CI, 0.74-1.03;P = .10) and vs each medication separately. In sensitivity analyses, when 1 year after randomization was used as the baseline (to allow for the effects of medications on bone to take effect), similar results were obtained for in-trial and in-trial plus posttrial follow-up. Conclusions and Relevance These findings from a large randomized clinical trial provide evidence of a beneficial effect of thiazide-type diuretic therapy in reducing hip and pelvic fracture risk compared with treatment with other antihypertensive medications. Trial Registration clinicaltrials.gov Identifier:NCT00000542

Objectives: Control of hypertension has improved nationally with focus on identifying and treating elevated blood pressures (BP) to guideline recommended levels. However, once BP control is achieved, the frequency in which BP falls out of control and the factors associated with BP recidivism is unknown. The objective of this study is to examine rates and predictors of blood pressure recidivism in adults with controlled hypertension. Study Design: A retrospective cohort study in two large, integrated health care systems in Minnesota and Colorado. Methods: Patients with a prior diagnosis of hypertension based on a combination of ICD-9 codes, receipt of anti-hypertensive medications and/or elevated blood pressure readings were eligible to be included. We defined controlled hypertension as normotensive blood pressure (BP) readings (less than 140/90 mmHg or less than 130/80 mmHg if coexistent diabetes or chronic kidney disease present) at 2 consecutive primary care visits. Following these visits among patients with controlled BP, we followed patients for BP recidivism defined by the mean of the last 2 blood pressure readings greater than 140/90 mm Hg or 130/80 mm Hg for those with diabetes or chronic kidney disease during a mean follow-up period of 13.2 months . Results: A total of 22,275 patients with controlled hypertension were included in this study. The proportion of patients with hypertension recidivism was 16.4%. A linear increase in blood pressure recidivism was noted with time between the index visit and last observed blood pressure reading. Major predictors of recidivism included female gender (OR 1.14, p = 0.02), history of diabetes (OR 2.32, p < 0.001) and black race (OR 1.37, p = 0.02). Age 50-64 displayed a protective effect against recidivism (OR 0.80, p = 0.02). Conclusions: Hypertensive recidivism occurs in a significant portion of patients with controlled hypertension. Patient factors associated with recidivism include age, race and prior history of diabetes among other characteristics. Strategies to minimize hypertension recidivism have significant potential to improve overall levels of blood pressure control and hypertension related quality measures from a health care systems perspective.

I wrote this article as an initial response to Beyond the Fragments, by Sheila Rowbotham, Lynne Segal and Hilary Wainwright; and also to Elizabeth Wilson's contribution, Beyond the Ghetto, published in Feminist Review number 4. I wanted to add my personal feelings and doubts to the debate opened by Beyond the Fragments, in the hope that it would develop further than the 'Leninism versus feminism' dichotomy posed by the left groups.