Hypertension in Adults: Initial Evaluation and Management.

Hypertension is a leading modifiable risk factor for cardiovascular disease and the most common chronic condition seen by family physicians. Treatment of hypertension reduces morbidity and mortality due to coronary artery disease, myocardial infarction, heart failure, stroke, and chronic kidney disease. The use of ambulatory and home blood pressure monitoring improves diagnostic accuracy. Assessment of adults with hypertension should focus on identifying complications of the condition and comorbid cardiovascular risk factors. Physicians should counsel all patients with elevated blood pressure about effective lifestyle interventions, including the Dietary Approaches to Stop Hypertension (DASH) diet, dietary sodium restriction, potassium enrichment, regular exercise, weight loss, and moderation of alcohol consumption. First-line antihypertensive medications include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, and thiazide diuretics. Thresholds for pharmacologic intervention and blood pressure goals differ according to various guidelines. Evidence strongly supports reducing blood pressure to less than 140/90 mm Hg to reduce the risk of all-cause and cardiovascular mortality in adults with hypertension. Lowering blood pressure to less than 135/85 mm Hg may further reduce the risk of myocardial infarction. Clinical judgment and shared decision-making should guide treatment of patients with mild hypertension and older adults who may be more susceptible to adverse effects of antihypertensive medications and tight blood pressure control.

Immigrant and refugee health: medical evaluation.

Overseas medical screening by panel physicians for conditions that might jeopardize US public health is required for admission to the United States by immigrant visa or refugee status. According to protocols established by the Centers for Disease Control and Prevention, conditions such as active tuberculosis and substance dependence, when detected, prohibit entry to the United States, whereas close medical follow-up after arrival is required for individuals with other conditions. Refugees and asylees should undergo further medical assessment by a US civil surgeon as soon as possible after arrival. Applicants for legal permanent residence in the United States, whether by immigrant visa or adjustment of status, must receive vaccinations comparable to those recommended for citizens. When immigrants and refugees present to a primary care physician, the vaccination process may not be complete, and documentation of the extent to which it is complete might be lacking. Immigrants and refugees may have a variety of unrecognized or untreated musculoskeletal conditions, mental health conditions, infectious diseases, and chronic conditions.

Immigrant and refugee health: mental health conditions.

Immigrants leave their homes for unfamiliar destinations in search of better lives for themselves and their families. Many immigrants experience profound loss and emotional distress as they adjust to life in different societies. Despite these challenges, the prevalence of mental health conditions among immigrants is low, whereas children of immigrants have rates equal to those of native populations. The prevalence of mental health conditions is high among refugees, who comprise a specific subgroup of immigrants who have been displaced forcibly and often have experienced severe trauma. Cultural factors, such as stigma and somatization of emotional symptoms, make it less likely that immigrants and refugees from certain groups will ever present to mental health subspecialists. Strong therapeutic relationships, cultural sensitivity, involvement of family members, judicious use of medications, and knowledge of available community resources are important tools that can aid clinicians who treat immigrants and refugees with mental health conditions.

Immigrant and refugee health: common infectious diseases.

Immigrants and refugees are at risk of infectious diseases (IDs) that are rare in the United States. Screening and treatment before entry into the United States are required for some of these diseases, whereas quarantine is mandated for others. The Centers for Disease Control and Prevention has published specific recommendations for the evaluation and treatment of immigrants and refugees before and after they arrive in the United States. In addition, immigrants and refugees who return to their home countries are at greater risk of IDs than other travelers. Health care professionals are required to report certain IDs to state or local health departments.

Immigrant and refugee health: cross-cultural communication.

Physicians in the United States increasingly care for culturally, linguistically, and educationally diverse immigrants with limited English proficiency. Language barriers contribute significantly to the health disparities experienced by patients with limited English proficiency. Qualified professional interpreters should be used instead of ad hoc interpreters, such as a patient's friend or family member, an untrained bilingual staff member, or a bilingual stranger. Children should not be used as interpreters. Physicians and other health care professionals must be fluent to communicate with patients in another language. Use of electronic translation systems should be avoided. Cultural competence refers to the attitudes, knowledge, and skills needed to work well in cross-cultural situations and effectively provide care to diverse populations. Stereotypes are perpetuated when members of a group are assumed to share cultural values, beliefs, or attitudes. Attempting to memorize a list of what to do and what to avoid when working with any particular group is ineffective. Every patient's culture is multidimensional and dynamic and is not defined by race or language group.

Cerebrovascular Accident in a High-Risk Patient During the Early Initiation Phase With Canagliflozin.

OBJECTIVE: To report a case of cerebrovascular accident (CVA) in a high-risk patient following initiation of canagliflozin, the first-in-class sodium-glucose-co-transporter 2 inhibitor approved by the Food and Drug Administration for type 2 diabetes mellitus. CASE SUMMARY: We describe a 62-year-old woman, with multiple clinical risk factors for stroke, who began canagliflozin 300 mg daily in addition to basal insulin therapy for diabetes management. The patient developed expressive aphasia 15 days following initiation of canagliflozin. Neuroimaging revealed acute infarcts of the left basal ganglia and temporal and parietal lobes. The patient was diagnosed with a CVA. Canagliflozin therapy was discontinued, metformin therapy was reinitiated in addition to the patient's basal insulin, and the patient was treated with antiplatelet, statin, and speech therapies. DISCUSSION: Assessment of the cardiovascular (CV) safety of canagliflozin is currently being investigated. A numerical increase in CV events, including nonfatal stroke, has been noted in preliminary data from ongoing analyses of canagliflozin in patients with preexisting CV risk factors. Although significant clinical risk factors were present in the patient described, a workup for routine causality came back negative. According to the Naranjo probability score, initiation of canagliflozin had a possible to probable association with the patient's CVA. CONCLUSIONS: This case suggests a potential association between the timing of canagliflozin initiation and development of stroke in patients with multiple clinical risk factors. We advise practitioners to use caution when initiating this new agent in patients at high risk for stroke while long-term CV safety surveillance is ongoing.