Articles and issues

Background. Hypertensive heart disease (HHD) is a common and preventable consequence of long-standing hypertension, yet comparative data from Southeast Asia remain scarce. This study compared the determinants, clinical patterns, and treatment of HHD at two tertiary centers in Indonesia and Malaysia. Methods. We conducted a retrospective cross-sectional comparative study of 600 adults with HHD (300 per site) managed at tertiary hospitals in Makassar, Indonesia, and Kuala Terengganu, Malaysia, between January 2022 and December 2023. Demographic, clinical, echocardiographic, and prescribing data were extracted from medical records, and determinants of left ventricular hypertrophy (LVH) were assessed with multivariable logistic regression. Results. Mean age was 58.4 ± 10.7 years and 52.3% of patients were male. LVH was present in 72.0%, diastolic dysfunction in 48.7%, and heart failure with preserved ejection fraction (HFpEF) in 28.5%. Diabetes mellitus (36.8%) and dyslipidemia (41.2%) were more frequent in Makassar and were independent determinants of LVH (p < 0.05). Use of renin–angiotensin system (RAS) inhibitors was higher in Kuala Terengganu than in Makassar (68.7% vs 52.3%, p < 0.001), whereas calcium channel blockers were prescribed more often in Makassar. Conclusions. HHD at both sites carried a high burden of LVH and diastolic dysfunction, with diabetes and dyslipidemia as key modifiable determinants. The lower use of RAS inhibitors in Makassar indicates a treatment gap that could be narrowed through better formulary access and guideline-based prescribing.

Background. Point-of-care (POC) HbA1c testing makes results available during the consultation and may support timely treatment decisions in type 2 diabetes, but its effect on glycemic control in primary care remains uncertain. Methods. We searched MEDLINE, Embase, CINAHL, the Cochrane Central Register of Controlled Trials, and Web of Science from inception to January 31, 2026, for randomized and nonrandomized controlled studies comparing POC with laboratory HbA1c testing in adults with type 2 diabetes managed in primary care. Two reviewers independently screened records, extracted data, and assessed risk of bias. Mean differences (MD) in HbA1c were pooled by random-effects meta-analysis, and certainty of evidence was rated with GRADE. Results. Fourteen studies (8 randomized trials and 6 nonrandomized studies; 5,872 participants) were included, and 12 (4,918 participants) contributed to the meta-analysis. POC testing was associated with a greater reduction in HbA1c (MD −0.26 percentage points, 95% CI −0.38 to −0.14; I² = 61%). The effect was smaller in randomized trials (MD −0.21, 95% CI −0.34 to −0.08) and larger when baseline HbA1c was 8.0% or higher (MD −0.41, 95% CI −0.60 to −0.22). POC testing increased the proportion of patients reaching an HbA1c below 7.0% (risk ratio 1.18, 95% CI 1.06–1.31) and treatment intensification at the index visit (risk ratio 1.34, 95% CI 1.12–1.60). Conclusions. Moderate-certainty evidence indicates that POC HbA1c testing in primary care produces a modest improvement in glycemic control, largely through more timely treatment intensification, with the greatest benefit in patients with poorly controlled diabetes.

Background. Population aging in Brazil has been accompanied by growing multimorbidity and medication use, but population-based data on potentially inappropriate medications (PIMs) among community-dwelling older adults remain limited. Methods. We conducted a population-based cross-sectional household survey of adults aged 60 years or older in Belo Horizonte, Brazil, between March and November 2024. All medicines used in the previous 15 days were recorded through a structured interview and inspection of medicine packages. PIMs were identified with the 2023 American Geriatrics Society Beers Criteria and the Brazilian consensus on PIMs, and polypharmacy was defined as the use of five or more medicines. Factors associated with PIM use were examined with Poisson regression with robust variance. Results. Among 1,212 participants (mean age 71.6 ± 7.9 years; 62.4% women), 39.8% met the definition of polypharmacy and 6.1% used ten or more medicines. Overall, 45.3% used at least one PIM, most often long-term proton pump inhibitors (14.2%), benzodiazepines (9.6%), and glibenclamide (7.4%). PIM use was independently associated with polypharmacy (prevalence ratio 2.03, 95% CI 1.78–2.31), female sex (1.21, 95% CI 1.07–1.37), fair or poor self-rated health (1.18, 95% CI 1.04–1.34), and consultation with three or more physicians in the previous year (1.16, 95% CI 1.02–1.32). Conclusions. Nearly half of community-dwelling older adults in Belo Horizonte used at least one PIM, mostly drugs for which safer alternatives exist. Structured medication review in primary care and revision of public formularies, particularly for proton pump inhibitors, benzodiazepines, and glibenclamide, could reduce avoidable medication-related harm.

Introduction. Takotsubo syndrome (TTS) is an acute, usually reversible form of left ventricular dysfunction that is often triggered by emotional or physical stress. Exogenous catecholamines and beta-adrenergic agonists are recognized but uncommon triggers, and the syndrome is easily overlooked in acute asthma, where tachycardia and chest discomfort are readily attributed to the exacerbation itself. Case presentation. A 46-year-old woman with long-standing asthma presented with a severe exacerbation and hypercapnia. She received continuous nebulized albuterol (approximately 105 mg over 12 hours), ipratropium, intravenous methylprednisolone and magnesium sulfate, and two doses of subcutaneous terbutaline. Ten hours after admission she developed new retrosternal pressure and hypotension, with anterior ST-segment elevation and a rise in high-sensitivity troponin I from 9 to 1,840 ng/L. Echocardiography showed apical ballooning with a left ventricular ejection fraction of 35%, and coronary angiography revealed no obstructive disease. Cardiac magnetic resonance imaging showed apical myocardial edema without late gadolinium enhancement. Beta-agonists were withdrawn and the exacerbation was managed with an inhaled anticholinergic and systemic corticosteroids. Ventricular function recovered fully within 6 weeks, with an ejection fraction of 60%. Conclusion. High-dose beta-agonist therapy for acute asthma can precipitate TTS. New chest pain, hypotension, or electrocardiographic changes during intensive bronchodilator treatment warrant prompt cardiac evaluation, and cumulative beta-agonist exposure should be limited once the diagnosis is suspected.

Polypharmacy is common among older adults with multimorbidity and is associated with adverse drug events, falls, hospital admissions, and a substantial burden of treatment. Deprescribing, the supervised process of reducing or stopping medicines whose harms outweigh their benefits, is increasingly recommended but remains inconsistently practiced in primary care. This review summarizes the evidence on structured deprescribing for older adults with multimorbidity and examines the tools and implementation strategies available to general practitioners and pharmacists. Randomized trials show that structured medication reviews reliably reduce the number of potentially inappropriate medicines and can be carried out safely, whereas effects on hospital admission, mortality, and quality of life have been inconsistent, largely because trials were underpowered for these outcomes and many recommendations were never implemented. Explicit criteria such as STOPP/START and the Beers Criteria, implicit approaches such as the Medication Appropriateness Index, drug-specific algorithms, and patient-facing materials each support different stages of the process. Barriers include fragmented prescribing across specialties, limited consultation time, clinician uncertainty about stopping guideline-recommended drugs, and patient concern about withdrawal. Interventions appear most effective when they combine a systematic review of the full medication list with shared decision-making, pharmacist involvement, and planned follow-up of tapering. We propose a practical stepwise approach for primary care and outline research priorities, including trials with patient-relevant outcomes and evaluation of digital decision support.

Background. Night-shift work reduces daytime sun exposure and may predispose healthcare workers to vitamin D deficiency, but comparative data from Turkish hospitals are limited. This study compared vitamin D status between night-shift and day-shift hospital staff. Methods. We conducted a cross-sectional study of 312 healthcare workers at a university hospital in Izmir between February and April 2025, comprising 156 workers with regular night shifts and 156 day-shift workers. Serum 25-hydroxyvitamin D (25(OH)D) was measured by chemiluminescent immunoassay, and deficiency was defined as a concentration below 20 ng/mL. Associated factors were examined with multivariable logistic regression. Results. The median 25(OH)D concentration was 15.8 ng/mL (interquartile range 11.2–21.4), and 216 participants (69.2%) were deficient. Deficiency was more common among night-shift than day-shift workers (79.5% vs 59.0%, p < 0.001), as was severe deficiency below 10 ng/mL (24.4% vs 10.9%, p = 0.002). Night-shift work remained independently associated with deficiency after adjustment for age, sex, body mass index, supplement use, and daily daylight exposure (adjusted odds ratio 2.61, 95% CI 1.49–4.57). Conclusions. Vitamin D deficiency was highly prevalent among hospital staff, particularly those working night shifts. Occupational health services should consider targeted screening or routine supplementation for night-shift workers.