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Aortic Valve Repair Aortic valve repair is a technique for repairing the existing aortic valve and usually does not require anticoagulant therapy. Early post-operative evaluation is required to assess adequacy of repair and extent of residual aortic regurgitation. Monitoring/Testing Two-dimensional echocardiography with Doppler should be performed prior to discharge. Additional monitoring and testing should be based on aortic regurgitation severity. To review the Aortic Regurgitation Recommendation Table or the Aortic Stenosis Recommendation Table, see Appendix D of this handbook. Mitral Regurgitation Recommendation parameters for mitral regurgitation include the severity of the diagnosis and the presence of signs or symptoms. The development of symptoms, especially dyspnea, fatigue, orthopnea, and/or paroxysmal nocturnal dyspnea, is a marker of a poor prognosis, including an inability to perform driver tasks and increased risk for sudden cardiac death. Surgical mitral valve repair for mitral regurgitation, is asymptomatic, and has clearance from a cardiovascular specialist who understands the functions and demands of commercial driving. Severe mitral regurgitation should have an exercise tolerance test and echocardiography every 6 to 12 months. To review the Mitral Regurgitation Recommendation Table, see Appendix D of this handbook. Mitral Stenosis Recommendations for mitral stenosis are based on valve area size and the presence of signs or symptoms. Inquire about episodes of angina or syncope, fatigue, and the ability to perform tasks that require exertion. Severe mitral stenosis and a clearance from a cardiovascular specialist who understands the functions and demands of commercial driving following: Recommend not to certify if: the driver has severe mitral stenosis, until successfully treated. Two-dimensional echocardiography with Doppler or other mitral stenosis severity assessment. To review the Mitral Stenosis Recommendation Table, see Appendix D of this handbook. Mitral Stenosis Treatment Management of mitral stenosis is based primarily on the development of symptoms and pulmonary hypertension rather than the severity of the stenosis itself. Treatment options for mitral stenosis include enlarging the mitral valve or cutting the band of mitral fibers. Symptomatic improvement occurs almost immediately, but after 9 years, recurrent symptoms are present in approximately 60% of individuals. Has clearance from a cardiovascular specialist who understands the functions and demands of commercial driving. Pulmonary hypertension (pulmonary pressure greater than 50% of systemic blood pressure). Two-dimensional echocardiography with Doppler performed after the procedure and prior to discharge. The frequency of repeat echo-Doppler examinations is variable and depends upon the initial periprocedural outcome and the occurrence of symptoms. Mitral Valve Prolapse the natural history of mitral valve prolapse is extremely variable and depends on the extent of myxomatous degeneration, the degree of mitral regurgitation, and association with other conditions.
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The effects of benzodiazepines on skills performance generally also apply to virtually all nonbenzodiazepines sedative hypnotics, although the impairment is typically less profound. However, barbiturates and other sedative hypnotics related to barbiturates cause greater impairment in performance than benzodiazepines. Epidemiological studies indicate that the use of benzodiazepines and other sedative hypnotics are probably associated with an increased risk of automobile crashes. Waiting Period No recommended time frame You should not certify the driver until the medication has been shown to be adequate/effective, safe, and stable. Clinical experience has shown that acute side effects usually resolve rapidly and almost invariably within a few months. Has a comprehensive evaluation from an appropriate mental health professional who understands the functions and demands of commercial driving. Monitoring/Testing You may on a case-by-case basis obtain additional tests and/or consult with a mental health specialist, such as a psychiatrist or psychologist to adequately assess driver medical fitness for duty. Lithium Therapy Lithium (Eskalith) is used for the treatment of bipolar and depressive disorders. Studies suggest that there is little evidence of lithium interfering with driver skill performance. Monitoring/Testing You may on a case-by-case basis obtain additional tests and/or consult with a mental health specialist, such as a psychiatrist or psychologist, to adequately assess driver medical fitness for duty. Bipolar Mood Disorder Mood disorders are characterized by their pervasiveness and symptoms that interfere with the ability of the individual to function socially and occupationally. Bipolar disorder is characterized by one or more manic episodes and is usually accompanied by one or more depressive episodes. During a manic episode, judgment is frequently diminished, and there is an increased risk of substance abuse. Treatment for bipolar mania may include lithium and/or anticonvulsants to stabilize mood and antipsychotics when psychosis manifests. Symptoms of a depressive episode include loss of interest and motivation, poor sleep, appetite disturbance, fatigue, poor concentration, and indecisiveness. A severe depression is characterized by psychosis, severe psychomotor retardation or agitation, significant cognitive impairment (especially poor concentration and attention), and suicidal thoughts or behavior. In addition to the medication used to treat mania, antidepressants may be used to treat bipolar depression. Other psychiatric disorders, including substance abuse, frequently coexist with bipolar disorder. Monitoring/Testing At least every 2 years the driver with a history of a major mood disorder should have evaluation and clearance from a mental health specialist, such as a psychiatrist or psychologist, who understands the functions and demands of commercial driving. Major Depression Major depression consists of one or more depressive episodes that may alter mood, cognitive functioning, behavior, and physiology. Symptoms may include a depressed or irritable mood, loss of interest or pleasure, social withdrawal, appetite and sleep disturbance that lead to weight change and fatigue, restlessness and agitation or malaise, impaired concentration and memory functioning, poor judgment, and suicidal thoughts or attempts. Hallucinations and delusions may also develop, but they are less common in depression than in manic episodes. Page 197 of 260 Most individuals with major depression will recover; however, some will relapse within 5 years. A significant percentage of individuals with major depression will commit suicide; the risk is the greatest within the first few years following the onset of the disorder. Although precipitating factors for depression are not clear, many patients experience stressful events in the 6 months preceding the onset of the episode.
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Recommended methods for maintenance dosing adjustments are dose reductions, lengthening the dosing interval, or both. Physicians should be familiar with commonly used medications that require dosage adjustments. Resources are available to assist in dosing decisions for patients with chronic kidney disease. In particular, older patients are at a higher risk of developing advanced disease and related adverse events caused by age-related decline in renal function and the use of multiple medications to treat comorbid conditions. Chronic kidney disease can affect glomerular blood flow and filtration, tubular secretion and reabsorption, and renal bioactivation and metabolism. Drug absorption, bioavailability, protein binding, distribution volume, and nonrenal clearance (metabolism) also can be altered in these patients. Physicians should pay careful attention when considering drug therapies with active or toxic metabolites that can accumulate and contribute to exaggerated pharmacologic effects or adverse drug reactions in patients with chronic kidney disease. Table 2 includes resources for more information about dosing adjustments in patients with chronic kidney disease. These calculations are valid only when renal function is stable and the serum creatinine level is constant. Physicians should be aware of drugs with active metabolites that can exaggerate pharmacologic effects in patients with renal impairment. Evidence rating C References 17, 21, 25, 30, 36, 43 25 1, 4 C C A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series. Adjustments Loading doses usually do not need to be adjusted in patients with chronic kidney disease. Published guidelines suggest methods for maintenance dosing adjustments: dose reduction, lengthening the dosing interval, or both. This approach maintains more constant drug concentrations, but it is associated with a higher risk of toxicities if the dosing interval is inadequate to allow for drug elimination. Normal doses are maintained with the extended interval method, but the dosing interval is lengthened to allow time for drug elimination before redosing. Lengthening the dosing interval has been associated with a lower risk of toxicities but a higher risk of subtherapeutic drug table1. Dosing recommendations for individual drugs can be found in Drug Prescribing in Renal Failure: Dosing Guidelines for Adults. Drug dosing requirements for antihypertensives in patients with chronic kidney disease are listed in Table 4. Dosages should be titrated carefully and followed by weekly monitoring of renal function and potassium levels until values return to baseline. Other antihypertensive agents that do not require dosing adjustments include calcium May 15, 2007 channel blockers, clonidine (Catapres), and alpha blockers. A fixed-dose combination with hydrochlorothiazide should not be used in patients with a creatinine clearance less than 30 mL per minute (0. Physicians may be apprehensive to maximize the use of metformin in appropriate patients because of these contraindications. A Cochrane review showed that lactic acidosis did not occur in the more than 20,000 patients with type 2 diabetes studied (patients with standard contraindications 1490 American Family Physician A more common practice is to temporarily discontinue metformin therapy in patients at a higher risk of lactic acidosis, such as patients who become septic. Renal function and drug concentrations should be monitored and dosages adjusted accordingly. Nitrofurantoin (Furadantin) has a toxic metabolite that can accumulate in patients with chronic kidney disease, causing peripheral neuritis. Metabolites of meperidine (Demerol), dextropropoxyphene (propoxyphene [Darvon]), morphine (Duramorph), tramadol (Ultram), and codeine can accumulate in patients with chronic kidney disease, causing central nervous system and respiratory adverse effects. A 50 to 75 percent dose reduction for morphine and codeine is recommended in patients with a creatinine clearance less than 50 mL per minute (0. The dosing interval of tramadol (regular release) may need to be increased to every 12 hours in patients with a creatinine clearance less than 30 mL per minute (0.
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Sexual and reproductive health and rights have profound implications for human development and economic growth. At individual, household and macro levels, access to sexual and reproductive health and rights enables people, particularly women, to participate in social life, to access education and to participate in the formal labour market. They have no chance to decide their lives for themselves and it can have tragic consequences. When women have access to sexual and reproductive health services, and are able to exercise autonomy over their bodies and reproductive health, they are more likely to delay marriage and pregnancy, and to have fewer children. As a direct consequence of delaying the age of marriage and pregnancy, girls are more likely to enter and stay in education. This, in turn, can have a positive impact on their future earnings and participation in the labour market. It is no surprise that denying families the information and services to make sustainable choices about how quickly they grow their own family can result in rapid population growth rates for communities and countries that create environmental pressures. Reducing consumption, particularly by high-income countries, is the most effective way to mitigate the effects of climate change. Yet many countries also identify that improving sexual and reproductive health services and comprehensive sexuality education are two factors that could help their efforts to increase sustainability. However, many aspects of sexual and reproductive health and rights remain under-funded and under-prioritized. This lack of support can be seen by the discussion so far on the sustainable development goals. Delivering social equity and environmental protection reproductive health and rights Sexual and reproductive health and rights also play an important role in delivering social equity and environmental protection. Sexual and reproductive health and rights are enshrined in a number of international declarations and agreements, including the Millennium Development Goals. Sexual and reproductive health and rights were prioritized at the 1994 International Conference on Population and Development (Cairo), and the 1995 World Conference on Women (Beijing). There has been significant progress towards sexual and reproductive health and rights, particularly since 2007, when Goal 5b (the target for universal access to reproductive health) was adopted. However, sexual and reproductive health and rights were not prioritized within the Goals right from the start; of all the Millennium Development Goals, the least progress has been made towards the maternal health goal. Every day, nearly 800 women around the world die because of complications during pregnancy and childbirth; 99 per cent of these deaths occur in developing countries. Some aspects of the sexual and reproductive health and rights agenda are inadequately resourced and sorely neglected, including access to safe and legal abortion, access by adolescents, and access for the poorest and most marginalized groups. Many individuals and groups experience discrimination and stigma based on their sexuality, their gender identity, and their sexual and reproductive choices and behaviours. There is a strong imperative to promote the recognition of sexual rights, beyond access to services. As governments, civil society and private sector actors, we have a collective duty to ensure that the new goals, targets and indicators support progress to date in order to sustain impacts, continue progress towards unfulfilled targets, and address gaps and failures. Today, there remain 222 million women who do not have access to family planning,4 yet demand for family planning is projected to increase to more than 900 million by 2015. If sexual and reproductive health and rights are not established as a centrepiece of the next framework, gains will not be protected, progress towards other sustainable development goals will be compromised, and young people, women and men around the world will be unable to realize a range of basic human rights related to sex, reproduction, family life, and participation in social, economic and public spheres. Sex and reproduction are essentially intimate affairs, played out within personal and familial relationships. However, the consequences of lack of access to sexual and reproductive health services, supplies, information and education are felt across entire populations, social and economic life, and by the planet. When individuals can control their choices about sex and reproduction, and be safe and healthy in their sexual and reproductive lives, they are better able to participate in education and the labour market, to care for their families, and have more capacity to contribute to their communities and social life.
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The actual ability to drive safely and effectively should not be determined solely by diagnosis but instead by an evaluation focused on function and relevant history. Individuals with this condition tend to be severely incapacitated and frequently lack the cognitive skills necessary for steady employment, may have impaired judgment and poor attention, and have a high risk for suicide. Monitoring/Testing At least every 2 years, the driver with a history of mental illness with psychotic features should have evaluation and clearance for commercial driving from a mental health specialist, such as a psychiatrist or psychologist, who understands the functions and demands of commercial driving. Drug Abuse and Alcoholism There is overwhelming evidence that drug and alcohol use and/or abuse interferes with driving ability. Although there are separate standards for alcoholism and other drug problems, in reality much substance abuse is polysubstance abuse, especially among persons with antisocial and some personality disorders. Alcohol and other drugs cause impairment through both intoxication and withdrawal. Episodic abuse of substances by commercial drivers that occurs outside of driving periods may still cause impairment during withdrawal. However, when in remission, alcoholism is not disabling unless transient or permanent neurological changes have occurred. Page 201 of 260 Alcohol and other drug dependencies and abuse are profound risk factors associated with personality disorders that may interfere with safe driving. Even in the absence of abuse, the commercial driver should be made aware of potential effects on driving ability resulting from the interactions of drugs with other prescription and nonprescription drugs and alcohol (e. If a driver has a current drinking problem, clinical alcoholism, or uses a Schedule I drug or other substance such as an amphetamine, a narcotic, or any other habit-forming drug, the effects and/or side effects may interfere with driving performance, thus endangering public safety. Page 202 of 260 Medical certification depends on a comprehensive medical assessment of overall health and informed medical judgment about the impact of single or multiple conditions on the whole person. Key Points for Medical Assessment for Drug Abuse and/or Alcoholism During the physical examination, you should ask the same questions as you would for any individual who is being assessed for psychological or behavior concerns. Have a history of driver and/or family alcohol-related medical and/or behavioral problems? Voluntary, ongoing participation in a self-help program to support recovery is not disqualifying. Necessary steps to correct the condition as soon as possible, particularly if the untreated condition could result in more serious illness that might affect driving. Medical fitness for duty includes the ability to perform strenuous labor and to have good judgment, impulse control, and problem-solving skills. Reasonable suspicion testing is conducted when a trained supervisor or company official observes behavior or appearance that is characteristic of drug and/or alcohol misuse. Random drug and/or alcohol testing is conducted on a random, unannounced basis just before, during, or just after performance of safety-sensitive functions. Return-to-duty and follow-up testing is conducted when an individual who has violated the prohibited drug and/or alcohol conduct standards returns to performing safety-sensitive duties.
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The presence of left ventricular hypertrophy confers a higher risk  as does an elevation in home and ambulatory blood pressure levels in addition to the office values . Current guidelines consider a reduction in body weight by low caloric diet and physical exercise as the first and main treatment strategy in subjects with the metabolic syndrome . Nutritional therapy also calls for low intake of saturated fats, trans-fatty acids, cholesterol, and simple carbohydrates with an increased consumption of fruits, vegetables, and whole grains . Long- term maintenance of weight loss can be best achieved if regular exercise (e. Subjects with the metabolic syndrome also have a higher prevalence of microalbuminuria, left ventricular hypertrophy and arterial stiffness than those without the metabolic syndrome. Their cardiovascular risk is high and the chance of developing diabetes markedly increased. In patients with a metabolic syndrome diagnostic procedures should include a more in-depth assessment of subclinical organ damage. In all individuals with metabolic syndrome, intense lifestyle measures should be adopted. When there is hypertension drug treatment should start with a drug unlikely to facilitate onset to diabetes. Therefore a blocker of the renin-angiotensin system should be used followed, if needed, by the addition of a calcium antagonist or a low-dose thiazide diuretic. There is some evidence that blocking the renin-angiotensin system may also delay incident hypertension. Statins and antidiabetic drugs should be given in the presence of dyslipidemia and diabetes, respectively. Insulin sensitizers have been shown to markedly reduce new onset diabetes, but their advantages and disadvantages in the presence of impaired fasting glucose or glucose intolerance as a metabolic syndrome component remain to be demonstrated. In a secondary analysis of the Diabetes Prevention Program, the prevalence of the metabolic syndrome decreased over 3. In patients with the metabolic syndrome, additional administration of antihypertensive, antidiabetic or lipid lowering drugs is required when there is hypertension, diabetes or frank dyslipidaemia, respectively. Because cardiovascular risk is high in hypertensive patients with the metabolic syndrome it would appear advisable to pursue a rigorous blood pressure control, i. However, the optimal blood pressure values to achieve in these patients have never been investigated. However, these effects appear to be less pronounced or absent with the new vasodilating b-blockers such as carvedilol and nebivolol [572,717]. Diabetogenic and other dysmetabolic actions also characterize thiazide diuretics, especially at high doses , and therefore their use as the first-line treatment is not recommended in subjects with a metabolic syndrome. If blood pressure is not controlled by monotherapy with one of these agents, a dihydropyridine or a non-dihydropyridine calcium antagonist can be added, because calcium antagonists are metabolically neutral and also have favourable effects on organ damage (see Section 4. In addition, the combination of a blocker of the renin-angiotensin system and a calcium antagonist has been shown to be associated with a lower incidence of diabetes than conventional treatment with a diuretic and a b-blocker [330,331]. Because subjects with the metabolic syndrome are frequently obese and have a salt-sensitive blood pressure , a low-dose thiazide diuretic might also represent a reasonable second or third step therapy. Thiazide diuretics at low dose, although they may still have some dysmetabolic effect [331,455,720], reduce serum potassium concentration to a lower degree, which attenuates the adverse effect of hypokalaemia on insulin resistance, carbohydrate tolerance and new onset diabetes . Maintenance of body potassium has been shown to prevent the glucose intolerance induced by thiazides [592,593], which suggests that the combination of thiazide and potassium-sparing diuretics may have a metabolic advantage compared to thiazide diuretics alone. Lack of specific intervention trials in the metabolic syndrome prevents any firm recommendation to be given on whether lifestyle modifications should be associated with antihypertensive drug treatment in non-hypertensive and non-diabetic patients with the metabolic syndrome, although the clustering of various risk factors and the frequent presence of organ damage make the cardiovascular risk of these patients rather high. The pros and cons of administration of a blocker of the renin-angiotensin system when these subjects have blood pressure in the high normal range have been summarized 1156 Journal of Hypertension 2007, Vol 25 No 6 in Section 5. It has been concluded that, for the time being, intense lifestyle measures should remain the main treatment approach, but that, in some cases, consideration might be given to drugs such as blockers of the renin-angiotensin system for their potential ability of preventing new onset hypertension and new onset diabetes, and some of the organ damage that is particularly common in this high risk condition.
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In order assess whether the intervention provides "enough bang for the buck" it is essential to consider all costs involved in the intervention from training costs to participant incentives. There are often intervention inputs that have hidden costs-for example, an after school intervention can be cost-neutral for meeting space, may have "hidden costs" that include costs for staff to work a longer day or the cost to provide electricity to the building. As discussed under scale up, the cost for the same intervention may vary from setting to setting. In addition, collecting detailed cost data can often been burdensome for project staff and needs to be included as part of the evaluation from the beginning of the project. It is important to really understand well-designed interventions and evaluations where the intervention did not succeed and why they failed to change the outcomes of interest. In addition, there are many interventions that were well implemented and either poorly evaluated (lacked a control group, poor measures of intervention impact) or not evaluated at all. Without evidence of impact, the group that supported the intervention cannot determine the impact of the intervention. For example, "early" pregnancy or "early" marriage is subjective and highly contextually based. If we do have a standard definition, consensus is needed in the field as to whether definitions should be based on legal standards, health concerns/risks or simply an age cut-off. When they do interact with health facilities (for delivery or abortion) we have an opportunity for improving their health outcomes. Post-partum (and post-abortion) visits are missed opportunities for intervention, particularly contraception interventions, especially for this age range. We would recommend interventions focusing efforts on contraceptive provision in these populations. It is relative easy to impact knowledge and even attitudes, but effective interventions should show change in behavior (or differences in behavior from a similar comparison group). Interesting it was only for this outcome that we saw the use of mass media approaches. That said, it is an approach worth visiting-especially to improve knowledge about incorrect norms such as fear of contraceptive side effects. While improved knowledge may not cause behavior to change, it may be a necessary before people change their behaviors. In general, behavior change interventions tend to be more time intensive, more expensive and depending on the behavior, may be harder to achieve success. Developing and Piloting Abstraction Form We sought several sources from other systematic literature reviews to develop an appropriate abstraction form for this project. While most systematic reviews focus on the intervention and outcome (how effective the intervention was), we wanted to include an additional set of components that focused on the evaluation itself and the quality of both the evaluation and intervention. We asked our advisory group (Bruce Dick, Jane Ferguson, and Robert Blum) for feedback on the form and modified it accordingly. This group also reviewed our search terms and were asked about additional studies we may have missed in our searches. We initially developed an on-line abstraction form using Google docs, but the online form was problematic for those members of our team with limited Internet connectivity as well as abstractors who wanted to stop and return to the abstraction form before submitting it. Search Strategy We undertook a systematic search of published literature to identify interventions that address each of the outcomes. In building the search, we combined a list of terms that describe young people with a list of terms that describe the outcome of interest. Depending on the outcome, we searched websites of non-governmental organizations (e. In addition to formally searching, we also used a snowball technique to track references mentioned in identified documents. Abstracted studies are those that met the age range (10-24), were interventions, and included information on evaluation. Abstraction Process For each study located, we assigned an abstractor from our team to pull information from that intervention. We abstracted details about both the intervention design and the evaluation design (form available from first author upon request).
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Nephrologist, Endocrinologist, Management of complex hypertension care, especially due to Hypertension Specialist secondary causes, and/or resistant hypertension. Dietician Ongoing patient-centered counseling to assess dietary habits and preferences, set and monitor goals for healthy lifestyle Social Worker Assess for psychosocial, cultural and financial barriers, find solutions to overcome these barriers. Community Health Providers Assess for psychosocial, cultural and financial barriers, identify and promote acceptable community-based resources to overcome these barriers. Online Quality Improvement Resources for Treatment and Control of Hypertension American College of Cardiology/American Heart Association/Centers for Disease Control Science Advisory for the Effective Approach to High Blood Pressure Control i content. Significance of white-coat hypertension in older persons with isolated systolic hypertension: a meta-analysis using the International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes population. Association of all-cause and cardiovascular mortality with prehypertension: a metaanalysis. Prehypertension and the risk of coronary heart disease in Asian and Western populations: a meta-analysis. Incidence of cardiovascular events in white-coat, masked and sustained hypertension versus true normotension: a meta-analysis. Home blood pressure self-monitoring: diagnostic performance in white-coat hypertension. Age-specific differences between conventional and ambulatory daytime blood pressure values. Masked hypertension assessed by ambulatory blood pressure versus home blood pressure monitoring: is it the same phenomenon? Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U. Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis. Hypertension: the clinical management of primary hypertnesion in adults: clincial guidelines: methods, evidence and recommendations. Target Organ Complications and Cardiovascular Events Associated With Masked Hypertension and White-Coat Hypertension: Analysis From the Dallas Heart Study. Meta-analysis of revascularization versus medical therapy for atherosclerotic renal artery stenosis. Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: systematic review and meta-analyses. Long-term effect of continuous positive airway pressure in hypertensive patients with sleep apnea. Continuous positive airway pressure treatment in sleep apnea patients with resistant hypertension: a randomized, controlled trial. Effects of continuous positive airway pressure treatment on clinic and ambulatory blood pressures in patients with obstructive sleep apnea and resistant hypertension: a randomized controlled trial. Effects of dietary fibre type on blood pressure: a systematic review and meta-analysis of randomized controlled trials of healthy individuals. Dietary protein intake and blood pressure: a meta-analysis of randomized controlled trials. The effects of nonpharmacologic interventions on blood pressure of persons with high normal levels. Insufficient evidence to conclude whether or not Transcendental Meditation decreases blood pressure: results of a systematic review of randomized clinical trials. Effects of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial. Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Meta-analysis comparing Mediterranean to low-fat diets for modification of cardiovascular risk factors. Improving hypertension control among excessive alcohol drinkers: a randomised controlled trial in France. Blood pressure response to calcium supplementation: a metaanalysis of randomized controlled trials. The evolution of a Canadian Hypertension Education Program recommendation: the impact of resistance training on resting blood pressure in adults as an example. Effects of exercise on resting blood pressure in obese children: a meta-analysis of randomized controlled trials. Obesity reviews : an official journal of the International Association for the Study of Obesity.