New onset of type 2 diabetes mellitus during antihypertensive therapy: What evidence?

Hypertension is a widely diffused clinical condition in the general population and it is often associated with people who are overweight (i.e. have abdominal adiposity) or obese and with metabolic syndrome. Evidence shows that hypertensive patients are at increased risk of developing type 2 diabetes mellitus (T2DM) since angiotensin II is involved in the pathogenesis of hypertension and insulin resistance, which are both the key components of metabolic syndrome. The preventive effect of renin-angiotensin system (RAS) inhibition on the development of T2DM could reflect the closely linked mechanisms of blood pressure and blood glucose homeostasis. Since hyperglycaemia is a consequence of insulin resistance and β-cell dysfunction, preventing T2DM by RAS inhibition may result from an improvement of β-cell function and/or an enhancement of insulin sensitivity, which are secondary to modifications in microcirculation and changes in ionic status. On the basis of this hypothesis, several trials in treating hypertensive patients have shown a positive effect of drugs inhibiting RAS in reducing the number of hypertensive patients that develop T2DM. We analysed the results of the following clinical studies that found a reduction in the incidence of new-onset T2DM in hypertensive patients using angiotensin II type 1 receptor blockers (ARBs): LIFE (Losartan Intervention For Endpoint reduction in hypertension) [losartan]; SCOPE (Study on COgnition and Prognosis in the Elderly) [candesartan]; ALPINE (Antihypertensive treatment and Lipid Profile In a North of Sweden Efficacy evaluation) [candesartan]; CHARM (Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity) [candesartan]; and VALUE (Valsartan Antihypertensive Long-term Use Evaluation) [valsartan]. Evidence shows that blood pressure reduction, when associated with lifestyle modifications (especially in high-risk patients), is more important than the mechanism of action of the antihypertensive drugs, which is to normalise blood pressure and thus reduce the incidence of cardiovascular events. In this regard, the identification of the potential influence of RAS inhibition in preventing new-onset T2DM in hypertensive subjects is a promising topic for the healthcare system. In the future, data from the ongoing trials, where prevention of diabetes is the primary endpoint, may prove to what extent this class of drugs is actually effective. However, in the previously mentioned clinical trials, the superior effectiveness of ARBs in preventing T2DM is associated with a lower efficacy in preventing cardiovascular events, because of their lesser capacity in lowering blood pressure. Evidence so far suggests the use of ARBs preferably in association with other classes of antihypertensive drugs and under a constant control of blood pressure. In this latter regard, in the recently published ASCOT-BPLA (Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm) study, a combination therapy based on a drug inhibiting RAS (perindopril) and a calcium-channel blocker (amlodipine) significantly reduced the incidence of major cardiovascular events and new onset of diabetes in high-risk hypertensive patients, compared with a combination therapy based on thiazide diuretic and a β-blocker

Fahr's disease detected on a head CT scan in patient with "epileptic syncope" in the Emergency Department.

Fahr’s disease is a rare neurological disorder characterized by diffuse intracranial calcification with a prevalent involvement of the basal ganglia and dentate nucleus of the cerebellum. It has been reported to be an autosomal dominant inheritance in familial cases, although the causal gene is still unknown, and sporadic types have been described. Most cases initially present with a deterioration of motor function. Later in the development of the disease, other symptoms and signs occur, especially extrapyramidal symptoms. We report a case with an unusual presentation and no extrapyramidal signs: An 58-year-old woman was brought to the Emergency Department (ED) because of a sudden loss of consciousness with seizure and urinary incontinence. She denied chest or abdominal pain, nausea vomiting or diarrhea. Upon falling from the seizure, she sustained cranial trauma (frontal skull). She denied any past medication history, allergies to medications, chest or abdominal pain, nausea, vomiting or diarrhea. There was no family history of mental illness, dementia, or major physical illness

Elevated B-type natriuretic peptide blood levels during hypertensive crisis: A novel diagnostic marker of acute coronary and cerebrovascular events?

Objectives: The objectives of this study were: (i) to assess the role of B-type natriuretic peptide (BNP) in the course of hypertensive crisis; (ii) to evaluate the possible role of BNP in the differential diagnosis between hypertensive emergencies (HE) or urgencies (HU); and (iii) to investigate the relationship between BNP concentration and blood pressure (BP) acute burden with consequent myocardial ischaemia or brain damage. Methods: 57 consecutive patients were admitted to the emergency department for acute elevated BP levels (systolic BP [SBP]/diastolic BP [DBP]: 200.7 ± 24.7/121.2 ± 12.4 mmHg) were enrolled. On the basis of clinical data, patients were subdivided into two groups: (i) 25 patients with HE: SBP/DBP 204.16 ± 29.1/123.3 ± 13.0 mmHg with heart (acute coronary syndrome) or brain involvement; (ii) 32 patients with HU: SBP/DBP 198.1 ± 20.7/120 ± 11.7 mmHg, without any acute or ongoing deterioration of target organs. For each patient, a serum dosage of BNP was performed. Results: In the whole population, no significant relationship was found between BP total burden and BNP level. In HE, BNP concentration (113.22 ± 87 pg/mL) was significantly (p < 0.001) higher than in HU (23.5 ± 21.3 pg/ mL) patients. There was a significant increase (p < 0.01) of BNP blood level in HE patients with acute coronary syndrome (162.02 ± 95.7 pg/mL) compared with those with neurological complications (80.7 ± 65.2 pg/mL). Moreover, in HU patients, there was a significant relationship (r = 0.37; p < 0.05) between BNP levels and pulse pressure. Conclusions: During hypertensive crisis, BNP blood level increase seems to have a role as a diagnostic tool for the screening of hypertensive emergencies due to an acute coronary or brain injury, and the BNP elevation is greater in the presence of myocardial ischaemia than brain damage

Clinical Management of Adult Coronavirus Infection Disease 2019 (COVID-19) Positive in the Setting of Low and Medium Intensity of Care: a Short Practical Review

Coronavirus disease 2019 (COVID-2019) is a viral infection which is rapidly spreading on a global scale and causing a severe acute respiratory syndrome that affects today about four and a half million registered cases of people around the world. The aim of this narrative review is to provide an urgent guidance for the doctors who take care of these patients. Recommendations contained in this protocol are based on limited, non-definitive, evidence and experience-based opinions about patients with low and medium intensity of care. A short guidance on the management of COVID-19 is provided for an extensive use in different hospital settings. The evidence-based knowledge of COVID-19 is rapidly evolving, and we hope that, in the near future, a definitive and most efficacious treatment will be available including a specific vaccine for SARS-CoV-

Comparison of Computerized Prescription Support Systems in COVID-19 Patients. INTERCheck and Drug-PIN

The coronavirus disease 19 (COVID-19) infection requires major efforts in healthcare systems, due to the high risk of mortality, particularly in subjects with significant comorbidity (≥ 2 pathologies) and polypharmacy (≥ 5 drugs). The treatment of COVID-19 needs a careful evaluation, to reduce the risk of potentially adverse drug reactions. The aim of the study was to examine the use of computerized prescription support in the management and treatment of the COVID-19 infection. We evaluated n.33 patients (51% females) admitted to the west COVID Low-Medium Intensity of Care of Sant'Andrea Hospital during the period March-April 2020 and n.42 subjects (50% females) admitted to the Internal Medicine ward (as control group), by INTERCheck® and Drug-PIN®. The comorbidity (n. pathologies), polypharmacy (n. drugs), and total INTERCheck score in COVID-19 patients and controls were, respectively (mean ± standard deviation): 5.8 ± 3.8, 7.9 ± 4.5, and 9.2 ± 7.1 and 6.8 ± 2.6, 8.0 ± 2.6, and 4.9 ± 3.8 (statistically significant for comorbidity p &lt; 0.01 and INTERCheck score p &lt; 0.01). The correlation between the scores obtained by the INTERCheck and Drug-PIN software was statistically significant, either at admission (p &lt; 0.0000001) or during hospitalization (p &lt; 0.00000001). Both the computerized prescription support systems, INTERCheck® and Drug-PIN®, are useful to better characterize the patients and to ameliorate the drugs prescriptions in COVID-19 infection, with particular attention to the elderly population