Mayo Clinic proceedings
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Mayo Clinic proceedings · Jun 2020
ReviewAngiotensin-Converting Enzyme 2 and Antihypertensives (Angiotensin Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors) in Coronavirus Disease 2019.
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, is being defined as the worst pandemic disease of modern times. Several professional health organizations have published position papers stating that there is no evidence to change the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in the management of elevated blood pressure in the context of avoiding or treating COVID-19 infection. In this article, we review the evidence on the relationship between the renin-angiotensin-aldosterone system and COVID-19 infection. ⋯ No differences generally exist between ARBs and ACEIs in terms of efficacy in decreasing blood pressure and improving other outcomes, such as all-cause mortality, cardiovascular mortality, myocardial infarction, heart failure, stroke, and end-stage renal disease. The ACEIs are associated with cough secondary to accumulation of bradykinin and angioedema, and withdrawal rates due to adverse events are lower with ARBs. Given their equal efficacy but fewer adverse events, ARBs could potentially be a more favorable treatment option in patients with COVID-19 at higher risk for severe forms of disease.
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Mayo Clinic proceedings · Jun 2020
ReviewA Practical Approach for the Management of the Mixed Opioid Agonist-Antagonist Buprenorphine During Acute Pain and Surgery.
The use of buprenorphine, a mixed opioid agonist-antagonist, for the management of chronic pain and/or opioid use disorder is increasing. As such, medical providers will more frequently encounter patients on this therapy. In this paper, we synthesize existing knowledge (derived through keyword searches using MEDLINE databases) in a novel conceptual framework for patients on buprenorphine presenting with acute pain or for those requiring surgical or invasive procedures. ⋯ We discuss important considerations regarding the unique aspects of buprenorphine formulations and dosing, and we describe the importance of multidisciplinary planning and multimodal analgesic strategies. We also highlight important differences in management strategies based upon the presence or absence of opioid use disorder. All medical providers must be prepared to guide the patient on buprenorphine safely through the acute care episode, which includes adequate treatment of acute pain and avoidance of iatrogenic harm, including both short-term complications (eg, respiratory depression) and long-term complications (eg, relapse to opioid use).
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Mayo Clinic proceedings · Jun 2020
ReviewBreast Cancer Risk Assessment: A Step-Wise Approach for Primary Care Providers on the Front Lines of Shared Decision Making.
Breast cancer-screening guidelines increasingly recommend that clinicians perform a risk assessment for breast cancer to inform shared decision making for screening. Precision medicine is quickly becoming the preferred approach to cancer screening, with the aim of increased surveillance in high-risk women, while sparing lower-risk women the burden of unnecessary imaging. Risk assessment also informs clinical care by refining screening recommendations for younger women, identifying women who should be referred to genetic counseling, and identifying candidates for risk-reducing medications. ⋯ However, choosing the appropriate model for a given patient requires a working knowledge of the strengths, weaknesses, and performance characteristics of each. The aim of this article is to provide a stepwise approach for clinicians to assess an individual woman's risk for breast cancer and describe the features, appropriate use, and performance characteristics of commonly encountered risk-prediction models. This approach will help primary care providers engage in shared decision making by efficiently generating an accurate risk assessment and make clear, evidence-based screening and prevention recommendations that are appropriately matched to a woman's risk for breast cancer.
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Dementia affects nearly 50 million people worldwide, translating into one new case every 3 seconds. Dementia syndrome is one of the leading causes of disability among older adults, yet it remains vastly underdiagnosed. ⋯ Comprehensive MEDLINE and PubMed searches were performed to develop an unbiased, practical diagnostic approach to these symptoms. This review guides primary care providers in the workup, diagnosis, delivery, and initial management of patients presenting with new cognitive symptoms.