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However, relatively few have been directly compared in randomized 20 Blood Pressure Management controlled trials. A meta-analysis published in 2008 included data from 15 studies evaluating seven drug classes for treating hypertensive emergencies. Only minor differences in blood pressure were seen between select drug classes, with analyses severely limited by a low number of studies, short durations of follow-up, and few included patients (Perez 2008). Clevidipine maintained blood pressure within the prespecified range better than either nitroglycerin (p=0. Pharmacologic management of hypertensive emergencies and urgencies: focus on newer agents. In patients with catecholamine excess, either the nonselective -blocker phentolamine or the -blocker (with -blocking properties) labetalol is recommended. For individuals presenting with acute coronary syndromes, vasodilators such as nitroglycerin, sodium nitroprusside, nicardipine, or clevidipine can be used. Thus, the specific agent for treating patients presenting with a hypertensive emergency depends on both the end-organ dysfunction and the patient comorbidities. Treatment of Hypertensive Urgency Hypertensive urgency has also been called blood pressure elevations without ongoing target organ damage. Of note, however, hypertensive urgency can still be associated with headache, thoracic pain, and dyspnea despite the lack of overt organ damage. The most common cause is either inadequate antihypertensive treatment or drug nonadherence. In 2013, the American College of Emergency Physicians stated that acute treatment of blood pressure without target organ damage may not be required (Wolf 2013). If short-acting agents are desired, commonly used options include captopril, clonidine, and labetalol. Barring contraindications, no specific agent appears to have a major advantage over another. If this occurs, consider tapering therapy unless therapy has benefits beyond blood pressure lowering, such as medications used to treat left ventricular systolic dysfunction. The baroreflex-mediated compensatory sympathetic system activates with a decreased parasympathetic activation, which increases heart rate and vascular resistance to restore cardiac output and blood pressure. Baroreflex sensitivity, heart rate response, and vasoconstriction become blunted as patients age (Shibao 2013). These symptoms are not present in the supine position and should be relieved after sitting or lying down. In older adults, it has been identified as an independent predictor of mortality (Luukinen 1999). This helps determine whether there is an immediate decline in blood pressure, when patient falls are most likely to occur, and if there is delayed onset of blood pressure lowering. Pharmacologic therapy options include fludrocortisone (which increases intravascular volume) and adrenergic agent hypertensives (e. Midodrine can also be used in combination with either fludrocortisone or pseudoephedrine if monotherapy is ineffective. Droxidopa is a newly approved agent that is a structural analog of norepinephrine. In clinical trials, efficacy 22 Blood Pressure Management was measured by a questionnaire describing dizziness, light-headedness, faintness, and symptoms of syncope. Studies showed a treatment effect (decrease in dizziness) at week 1, but no study showed a treatment effect beyond 2 weeks (Biaggioni 2015; Kaufmann 2014). One potential explanation for this variation is genetic polymorphisms that can lead to alterations in either the pharmacokinetic or pharmacodynamic actions of these agents. Although this research is promising, most of the information is not ready for clinical implementation. The following sections highlight the current state of knowledge, organized by major drug class. However, much of these data have not been replicated, and further studies are needed in varying populations before they can be translated to clinical practice. These genes code for the calcium channel, voltage-dependent, L-type, -1C and -2 regulatory subunits, respectively. This finding was consistent across white, African American, and Hispanic populations. Ongoing studies are aimed at further examining and replicating these relationships. The thiazide diuretics are another antihypertensive drug class with a fair amount of pharmacogenomic data. This chapter summarizes some of the more recent changes to guidelines and therapy recommendations. Randomized withdrawal study of patients with symptomatic neurogenic orthostatic hypotension responsive to droxidopa. Effect of spironolactone on blood pressure in subjects with resistant hypertension. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Noninvasive 24-h ambulatory blood pressure and cardiovascular disease: a systematic review and meta-analysis. Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Chlorthalidone reduces cardiovascular events compared with hydrochlorothiazide: a retrospective cohort analysis. Selective aldosterone blockade with eplerenone reduces albuminuria in patients with type 2 diabetes. Comparative antihypertensive effects of hydrochlorothiazide and chlorthalidone on ambulatory and office blood pressure. Refocusing the agenda on cardiovascular guidelines: an announcement from the National Heart, Lung, and Blood Institute. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial. Trends in antihypertensive medication use and blood pressure control among United States adults with hypertension: the National Health and Nutrition Examination Survey, 2001 to 2010. Influence of time of day of blood pressure-lowering treatment on cardiovascular risk in hypertensive patients with type 2 diabetes. Beta 1-adrenergic receptor polymorphisms and antihypertensive response to metoprolol. Cardiovascular pharmacogenomics of adrenergic receptor signaling: clinical implications and future directions. Droxidopa for neurogenic orthostatic hypotension: a randomized, placebo-controlled, phase 3 trial. Concurrent use of diuretics, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers with non-steroidal anti-inflammatory drugs and risk of acute kidney injury: nested case-control study. Antihypertensive therapy increases cerebral blood flow and carotid distensibility in hypertensive elderly subjects. A pharmacist-led, American Heart Association Heart 360 Web-enabled home blood pressure monitoring program. Lay perspectives on hypertension and drug adherence: systematic review of qualitative research. Target blood pressure for treatment of isolated systolic hypertension in the elderly: valsartan in elderly isolated systolic hypertension study. The association between orthostatic hypotension and recurrent falls in nursing home residents. Betaadrenergic receptor gene polymorphisms and beta-blocker treatment outcomes in hypertension. The role of spironolactone in the treatment of patients with refractory hypertension.

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When the aspirations of marginalized groups are encouraged and supported, it contributes simultaneously to social equity and environmental protection. As discussed earlier, when girls and women can access higher education they are less likely to have children early and fertility rates fall. The relationship between education and contraception is reciprocal: access to education results in delayed childbearing, and the ability to delay childbearing (through contraception and other sexual and reproductive health services) also helps girls to achieve higher levels of education. Some four billion people live in areas vulnerable to the impacts of climate change, and over the next decade 500 million people will live in areas of extreme risk, including mass loss of life and livelihood. Tackling inequality and supporting the poorest people to have control over their lives is multi-dimensional and complex, but a forward-looking orientation is fundamental. Exercising sexual and reproductive health and rights is about planning for (safer) sex, planning for pregnancy, planning for parenthood, communication in relationships, and fostering societies that support diverse sexual identities and expressions. For example, only 53 per cent of births in rural areas are attended by skilled health personnel, versus 84 per cent in urban areas. The extent to which development interventions reach the poorest and most vulnerable groups is limited by existing data collection and management systems, as well as the absence of specific targets related to inequality. Similarly, we lack disaggregated data on where the needs are greatest, and among which specific groups. For example, few countries measure unmet need for contraception among sexually active unmarried women, including young women, although access to contraception by this group is particularly important to prevent unwanted adolescent pregnancies. The next framework should include targets related to data collection and management, to ensure that we can assess progress in reaching the poorest and hardest-to-reach. Family planning can enable women to plan their pregnancies, and limit their family size according to the resources available, taking account of the challenges in accessing water and supplying food. Delayed childbearing also extends the time between generations and in doing so slows population growth, which helps to protect the environment. In Madagascar, for example, an integrated conservation and rights-based sexual and reproductive health programme has supported communities to develop sustainable fisheries and to access family planning, in order to plan family size and reduce unsustainable population pressure on the environment. Within populations that face climate change risks, poor and marginalized people, such as women, children and the elderly, are the worst affected, and the risk of conflict increases. Children are disproportionately affected by the consequent health impacts including hunger, diarrhoea and malaria. Girls are likely to be taken out of school in times of hardship to care for sick relatives or to earn extra income. Women are more likely to be displaced due to climate change, including the violence and conflict associated with it. The impact of climate change threatens to stall progress towards gender equality and reducing gender-based violence. Access to sexual and reproductive health and rights promotes environmental sustainability the impacts of climate change are amplified in low-income countries that have rapid population growth, high population density, intense land use, a young age structure and urbanization. For example, climate change in some areas is causing a gradual depletion of natural resources such as arable land and fresh water resources. In order to support themselves and their families, local people therefore have to use their environment more intensively, and travel further afield to find firewood and water. This burden falls disproportionately on girls and women, who are often responsible for agriculture and for supplying water and fuel for their household. In some areas with rapid population growth and high population density, the agricultural land is being cultivated faster and more intensively than it can renew itself, there is a loss of bio-diversity and natural habitats, and there is increased competition for clean water and water sources to grow food. High fertility rates can also lead to a shortage of land per capita and to over-grazing of land, as relatively small plots of land may be sub-divided among several children. Currently, about a third of the global population lives in an environment of medium or high water stress, meaning that water availability is a limiting factor. This makes living conditions increasingly difficult and can lead to poor health and increased poverty, conflict and migration. It also shows that regardless of whether or not they realize the consequences of intensive land use, these households Within populations that face climate change risks, poor and marginalized people, such as women, children and the elderly, are the worst affected, and the risk of conflict increases. Research has found that although many governments recognize that there are strong linkages between high population growth, unmet need for contraception, environmental degradation and low resilience to climate change impacts, there is little coordination and alignment of policies related to sexual and reproductive health and rights services and climate change responses. Sexual and reproductive health and rights are an integral part of supporting sustainable population growth, alongside a rights-based approach, as part of environmental protection that is fair and equitable. Climate change and environmental degradation has a disproportionate impact on girls and women, and is not only resulting in wider inequality, but threatens to undo the gains that have been made. Girls and women, particularly in rural areas, occupy important roles in managing natural resources: the empowerment of girls and women, and efforts to conserve and protect the environment, must therefore be tackled together. What is at stake if sexual and reproductive health and rights are not prioritized? If we do not include sexual and reproductive health and rights as an important element of the post-2015 framework, what is at stake? If unmet need for contraception is not addressed, some 55 million unplanned births will continue to take place each year, 79,000 women will die from pregnancy, childbirth-related complications and from unsafe abortions, and girls will continue to be denied access to education and employment. Environmental degradation, coupled with rapid population growth, will blaze ahead, and we will fail to achieve gender equality goals. If low-income countries with large youth populations fail to invest in social and health care, and to ensure good governance and financial security, they will fail to capture the potential of a large working age population. If we fail to involve civil society, and particularly the most marginalized groups, in important decisions about how development takes place, health and social spending may continue to perpetuate, rather than tackle, inequality and chronic poverty. Social equity, environmental protection and development meet, and the framework to come out of the current global negotiations will shape our collective future. Sexual and reproductive health and rights must be at the heart of this new framework. Central to achieving many of these goals is gaining global support for the principle that universal access to sexual and reproductive health and rights is an essential precondition to ensure sustainable development and realize the human rights of women and girls. The post-2015 development framework, following on from the Millennium Development Goals, will be very influential. This represents a sea-change from the current Millennium Development Goal framework. Despite the strong and convincing links between gender equality, sexual and reproductive health and rights and development, the Millennium Development Goals, which were agreed in 2000, did not initially address reproductive health. Supplemented by an ask for sexual and reproductive health services to be explicitly included in the essential package of services under Universal Health Coverage. These asks set out the areas where political attention, priority and funding are most urgently required, and where they will have the greatest impact on achieving meaningful, sustainable development. It is too early to assess whether we, alongside our partners and supporters, have been able to influence these processes sufficiently to achieve our vision of seeing sexual and reproductive health and rights at the centre of the post-2015 framework. However, we have had some notable successes in the processes leading up to the new framework. Here are some highlights of the post-2015 process and some of the areas where we have seen progress to date. To also ensure that it could reflect the voices and experiences of individuals around the world, the United Nations hosted a series of 11 online consultations on the post-2015 framework. The goal of this Panel was to produce a vision of the post-2015 development agenda, which it released in spring 2013. The Member Association was represented on the High Level Panel steering committee, building the case for sexual and reproductive health to be recognized as a cornerstone of poverty alleviation. Coming out of the United Nations Conference on Sustainable Development (Rio+20), held in Rio de Janeiro in June 2012, the outcome document set out parameters to create an intergovernmental Open Working Group to prepare a proposal on Sustainable Development Goals. International Conference on Population and Development regional conferences A separate, but equally influential process, includes the regional and global consultations on the International Conference on Population and Development Programme of Action. These will also feed into the post-2015 process and include a global survey, looking at progress towards achieving the Programme of Action; five regional population conferences, leading to outcome documents; and four thematic meetings. The International Conference on Population and Development review process has been an overwhelming success for sexual and reproductive health and rights. This positions sexual and reproductive health and rights strongly vis a vis the post-2015 process. In addition, all but one of the outcome documents recognize the need for comprehensive sexuality education. This was supported by a call for governments to prioritize youth-friendly services in most regions.

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Masked and White Coat Hypertension References that support recommendations are summarized in Online Data Supplements 4, 5, and 6. These include masked hypertension and white coat hypertension, in addition to sustained hypertension. The prevalence of masked hypertension varies from 10% to 26% (mean 13%) in population-based surveys and from 14% to 30% in normotensive clinic populations (6, 16, 19-21). The white coat effect and masked uncontrolled hypertension appear to follow the risk profiles of their white coat hypertension and masked hypertension counterparts, respectively (3, 12). There are no data on the risks and benefits of treating white coat and masked hypertension. Figure 1 is an algorithm on the detection of white coat hypertension or masked hypertension in patients not on drug therapy. Figure 2 is an algorithm on detection of white coat effect or masked uncontrolled hypertension in patients on drug therapy. The risk of vascular complications in patients with office-measured uncontrolled hypertension with a white coat effect is similar to the risk in those with controlled hypertension (3, 4, 7, 11, 12). White coat hypertension and white coat effect raise the concern that unnecessary antihypertensive drug therapy may be initiated or intensified. Although the evidence is consistent in identifying the increased risk of masked uncontrolled hypertension, evidence is lacking on whether the treatment of masked hypertension or masked uncontrolled hypertension reduces clinical outcomes. Prognosis of "masked" hypertension and "white-coat" hypertension detected by 24-h ambulatory blood pressure monitoring 10-year follow-up from the Ohasama study. Setting thresholds to varying blood pressure monitoring intervals differentially affects risk estimates associated with white-coat and masked hypertension in the population. Long-term prognostic value of white coat hypertension: an insight from diagnostic use of both ambulatory and home blood pressure measurements. Reproducibility of masked hypertension in adults with untreated borderline office blood pressure: comparison of ambulatory and home monitoring. Prognosis of white-coat and masked hypertension: International Database of Home Blood Pressure in Relation to Cardiovascular Outcome. High prevalence of masked uncontrolled hypertension in people with treated hypertension. Prevalence of white-coat and masked hypertension in national and international registries. Unmasking masked hypertension: prevalence, clinical implications, diagnosis, correlates and future directions. Masked hypertension and prehypertension: diagnostic overlap and interrelationships with left ventricular mass: the Masked Hypertension Study. Target organ complications and cardiovascular events associated with masked hypertension and white-coat hypertension: analysis from the Dallas Heart Study. Prevalence, determinants, and clinical significance of masked hypertension in a population-based sample of African Americans: the Jackson Heart Study. Determinants of masked hypertension in hypertensive patients treated in a primary care setting. Future studies will need to better elucidate genetic expression, epigenetic effects, transcriptomics, and proteomics that link genotypes with underlying pathophysiological mechanisms. Clinical effect of naturally random allocation to lower systolic blood pressure beginning before the development of hypertension. Poor diet, physical inactivity, and excess intake of alcohol, alone or in combination, are the underlying cause of a large proportion of hypertension. The relationship between obesity at a young age and change in obesity status over time is strongly related to future risk of hypertension. In combined data from 4 longitudinal studies begun in adolescence with repeat examination in young adulthood to early middle age, being obese continuously or acquiring obesity was associated with a relative risk of 2. Becoming normal weight reduced the risk of developing hypertension to a level similar to those who had never been obese (10). Current techniques for recognition of salt sensitivity are impractical in routine clinical practice, so salt sensitivity is best considered as a group characteristic. Even modest levels of physical activity have been associated with a decrease in the risk of incident hypertension (41). Estimates of the contribution of alcohol consumption to population incidence and prevalence of hypertension vary according to level of intake. In the United States, it seems likely that alcohol may account for close to 10% of the population burden of hypertension (higher in men than in women). Obesity as an independent risk factor for cardiovascular disease: a 26year follow-up of participants in the Framingham Heart Study. Body mass index and blood pressure in Korean men and women: the Korean National Blood Pressure Survey. Incidence and precursors of hypertension in young adults: the Framingham Offspring Study. The contribution of urinary cations to the blood pressure differences associated with migration. Intersalt revisited: further analyses of 24 hour sodium excretion and blood pressure within and across populations. Dietary sodium consumption predicts future blood pressure and incident hypertension in the Japanese normotensive general population. Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations. Definitions and characteristics of sodium sensitivity and blood pressure resistance. Salt sensitivity of blood pressure is associated with polymorphisms in the sodium-bicarbonate cotransporter. Sodium sensitivity and cardiovascular events in patients with essential hypertension. Association between usual sodium and potassium intake and blood pressure and hypertension among U. Potassium intake, stroke, and cardiovascular disease a meta-analysis of prospective studies. High potassium intake blunts the effect of elevated sodium intake on blood pressure levels. The association between blood pressure, age, and dietary sodium and potassium: a population study. The influence of physical activity on the variability of ambulatory blood pressure. Cardiorespiratory fitness in young adulthood and the development of cardiovascular disease risk factors. Effects of cardiorespiratory fitness on blood pressure trajectory with aging in a cohort of healthy men. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Childhood physical, environmental, and genetic predictors of adult hypertension: the cardiovascular risk in young Finns study. Preterm birth and the metabolic syndrome in adult life: a systematic review and meta-analysis. Systematic review and meta-analysis of preterm birth and later systolic blood pressure. Screening for specific form(s) of secondary hypertension is recommended when the clinical indications and physical examination findings listed in Table 13 are present or in adults with resistant hypertension. If an adult with sustained hypertension screens positive for a form of secondary hypertension, referral to a physician with expertise in that form of hypertension may be reasonable for diagnostic confirmation and treatment. All new patients with hypertension should be screened with a history, physical examination, and laboratory investigations, as recommended in Section 7, before initiation of treatment. Many of the causes of secondary hypertension are strongly associated with clinical findings or groups of findings that suggest a specific disorder. Table 13 is a detailed list of clinical indications and diagnostic screening tests for secondary hypertension, and Table 14 is a list of drugs that can induce secondary hypertension. The causes of secondary hypertension and recommended screening tests are provided in Table 13, and drugs that can induce secondary hypertension are provided in Table 14. Diagnosis of many of these disorders requires a complex set of measurements, specialized technical expertise, and/or experience in data interpretation. Similarly, specific treatment often requires a level of technical training and experience.

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Although this study indicates that these types of analyses are quite valuable, it is the only one that has been done. The results demonstrate significant brand-by-brand variation in the ability to detect pregnancy at various times after ovulation. This study was performed in 1988, and clearly the brands and assay formulation have changed since that time. However, their study was not included in this analysis, because real urine was not used to test the devices. Their group determined the concentration of urine in women at various times after missed menses. This research raises questions about the ability of even modern home pregnancy devices to detect early pregnancy. Recent studies (after 1989) have not been conducted, making a recommendation difficult. Further studies are needed to determine which newer over-the-counter devices are best able to detect early pregnancy. We recommend that manufacturers provide clear concise instructions for use and adequate (easy to interpret) quality-control measures to maximize the proper use and interpretation of these devices. The authors stress the need for rigorous validation of home pregnancy kits and adequate quality-control measures. These data also demonstrate the need for clear concise instructions for laypersons. We can strongly recommend the use of these devices when the purpose of using them is to detect ovulation. The researchers found that the inexperienced persons had significantly more false-positive and false-negative results than both medical technicians with general chemistry knowledge and medical technicians with extensive experience. Urine samples were obtained from women shortly after missed menses and split in half. One half was tested on 3 devices by the investigator and one half was returned to the layperson for testing on the same 3 devices. Unfortunately, the study did not report the accuracy of the layperson specifically. They did examine accuracy in the context of psychological and socioeconomic variables. They found that accuracy in laypersons increased with age and in persons with more education. Anxiety level (based on whether the patient was trying to get pregnant or was unmarried) also had little effect. When the data allowed the calculation of diagnostic specificity, the luteinizing unruptured follicle syndrome was often used to explain false-positive results (20, 24, 25). Although the studies examined for this report defined this time interval from anywhere between 36 and 72 h, most considered the 48-h period before ovulation as the optimal time for detection. This is an appropriate time frame because the window for fertilization is brief, and introduction of sperm into the female genital tract within 2 days before ovulation has the highest probability of conception (26). This is precisely the population to which these devices are marketed, and such studies would be very useful. Although it is logical to assume that the use of these devices would increase conception rates, it is also possible that the devices are not needed by this population for whom infertility may not be a problem. Evidence-Based Practice for Point-of-Care Testing those with partners with male factor infertility (n 50). Cumulative pregnancy rates in each group were 34% (n 545 cycles), 34% (n 236 cycles), 31% (n 405 cycles), and 37% (n 209 cycles), respectively (P 0. Unfortunately, the numbers of studies investigating these other outcomes are also limited. This approach predicted all those women who ovulated (n 20) and detected unfavorable conditions for insemination in the remaining 5 (34). There are limited data available to adequately assess the utility of the test to improve conception rates, clinic visit frequency, or fertility treatment cycles. Although these questions are certainly of considerable interest, clear-cut answers remain elusive and additional studies need to be performed. Strength/consensus of recommendation: I Level of evidence: I (at least 1 randomized controlled trial) Literature Search 102 summarizes the results for our literature search. Although few, these devices offer unique methods of ovulation detection and may have broad appeal, particularly because they are reusable rather than disposable. Studies from only 2 devices that measure electrical admittance or electrical resistance have been reported in the literature: the Ovulon fertility monitor (Conception Technology, Inc. They reported that the monitor produced the expected vaginal nadir signal 2 days before ovulation in 93% of cycles. However, because the signal is a nadir, it can be correctly identified only retrospectively, making daily interpretation of signals for predicting ovulation challenging, if not impossible. The predictive abilities reported by the other 3 studies were 74% (37), 52% (35), and 55% (36). However, the lack of a gold standard method for confirming ovulation seriously limits interpretation of these results. Four studies examined the utility of fern testing performed on saliva or cervical mucus as a predictor of ovulation. Theoretically, a pattern of "ferning" is observed on examination of dried saliva or cervical mucus that coincides with the fertile period in the female. The ferning or crystallization is caused by alterations in the fluid concentrations of sodium and chloride that cyclically increases under the influence of estrogen. Only 2 of the 4 studies used ultrasound of follicular size as the gold standard for confirming ovulation, and one of these did not report the predictive ability of the fern test. They reported that the fern test predicted ovulation 1 day before the event in 21% of cycles and the day after in another 21%. According to this, they concluded that the salivary fern test was a poor method for predicting ovulation. Although the other studies did not include an appropriate gold standard method for confirming ovulation, one report identified ferning patterns throughout the entire menstrual cycle and in salivary specimens collected from men (40). We note that the pH/nitrazine test is sensitive only when used in women for whom membrane status is known. Accordingly, we do not recommend the use of pH/nitrazine testing alone for the detection of premature rupture of membranes. Does the pH/nitrazine test accurately predict preterm premature rupture of membranes? We note that the evidence is insufficient to recommend for or against providing pH/nitrazine tests for the prediction of preterm premature rupture of membranes. However, to be clinically useful, pH must be evaluated prospectively, and in that regard the study found that any single pH result 4. However, all the data were combined for analysis to produce an overall sensitivity of 92% and a specificity of 53% (n 103). Unlike other investigations that noted only marginal specificity, a study of 39 women with intact membranes for whom membrane status was known at the time of testing reported that vaginal pH had excellent specificity (92%) (58). The lower sensitivity was attributed to the prolonged time period ( 12 h) between rupture and specimen collection in 21% of the patients. The test may better be used as a supportive test in conjunction with other clinical findings. When fluid from the vagina is smeared onto a glass slide and allowed to dry, amniotic fluid will produce a ferning pattern. Garite and Gocke (54) reported a sensitivity of 97% and specificity of 100% when they evaluated 23 women with gross pooling of amniotic fluid and 22 with intact membranes. Another study also reported a sensitivity of 62%, with 100% specificity in 48 women with obvious amniotic fluid leakage and 31 with intact membranes (59). When investigating the use of the fern test in 51 women whose membrane status was definitively known, Watanabe et al. Similar to the pH/nitrazine test, the performance of the fern test deteriorates when applied to a population of women in whom membrane integrity status is uncertain (the very population in whom the test would be used). The low sensitivity is particularly concerning because false-negative results might delay appropriate treatments. Similar to the pH/nitrazine test, the data for the fern test suggest it may better be used as a supportive test in conjunction with other clinical findings. Does the fern test accurately identify women with ruptured membranes and/or women whose membranes have not ruptured?

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United Nations, Comprehensive Strategy on Assistance and Support to Victims of Sexual Exploitation and Abuse by United Nations Staff and Related Personnel. United Nations, "Addressing Sexual Exploitation and Abuse," Protection from Sexual Exploitation and Abuse. The provision of psychosocial services can be challenging to implement in the early stages of an emergency. What if the members of the staff have low capacity and lack the basic skills to provide these services? Local staff will likely be able to help identify the most appropriate local persons with nonjudgmental, supportive attitudes and good communication skills for this role. Staff members need to communicate with the survivor in a way that both ensures accurate information and reflects a caring, uncritical attitude. Training programs on psychosocial support can be established once the situation is stable. Even in settings where discussing sexual violence is strongly discouraged, it is important to find innovative ways to address it as it is a life-saving intervention. In this way, the community gained knowledge on sexual violence, including why, where and when to seek medical care if they or someone they know is assaulted. Part One of this series of training modules focuses on how multi-sectoral actors can engage with survivors in a supportive and ethical way. Global Protection Cluster Gender-based Violence Area of Responsibility Working Group, Handbook for Coordinating Gender-based Violence Interventions in Humanitarian Settings, 2010. Available in English and in French from the Protection cluster website at oneresponse. Global Protection Cluster Gender-based Violence Area of Responsibility Working Group, Workshop Package for the Gender-based Violence Standard Operating Procedures Guide. Available in English and in French from the Protection Cluster website at oneresponse. Support multi-sectoral/inter-cluster coordination of actions to prevent (and respond to) sexual violence. Ensure communities are informed about the benefits of seeking clinical care for rape as well as the location and hours of clinical care service. Identify and support the development and functioning of systems to address sexual exploitation and abuse. In this environment, it is necessary to do everything possible to contribute to the efforts to stop new infections. Protective supplies in health centers, such as clean needles, syringes and gloves, may not be available. Staff may feel they are too busy to adhere to, or are not aware of, the importance of standard precautions. Adolescents may begin sexual relations at an earlier age and/or are more likely to take sexual risks, such as having sexual intercourse without using a condom. While the majority of infections are generally a result of unprotected sex, the proportion of transmission routes varies by setting. Blood transfusions must not be undertaken if the facilities, supplies and appropriately qualified staff do not exist. Decreasing unnecessary blood transfusion is also critical to avoid the risks of infection and preventing blood shortages. Unnecessary transfusion can be reduced by ensuring the appropriate clinical use of blood, avoiding the needs for transfusion and use of alternatives to transfusion. Urban Settings: Determine national policies and practices on safe blood transfusion. In collaboration with the health sector/cluster, distribute blood test kits and supplies for safe blood transfusion and the practice of standard precautions to health facilities as needed. Ensure that condoms are available in health facilities, mobile clinics, throughout the urban area in community centers, popular bars, and at food and non-food item distribution points. To minimize the risk of errors, blood transfusion at night should be avoided as much as possible. Standard precautions are infection control measures that reduce the risk of transmission of blood-borne pathogens through exposure of blood or body fluids among patients and health care workers. Under the standard precautions principle, blood and body fluids from all persons should be considered potentially infectious and handled accordingly. Standard precautions are essential in any setting but, in an emergency, infrastructures and supplies may be destroyed or unavailable. Due to high work pressure, among other reasons, health care staff are more likely to have work-related accidents and may resort to taking shortcuts in procedures, which endangers the safety of both patients and staff. Therefore, infection control measures must be enabled and enforced during a crisis. Keep in mind especially that cleaners and other support staff, who are often newly recruited, may not have worked in health setting environments before and therefore may not have received adequate training. Standard precautions are: Frequent hand washing: Wash hands with soap and water before and after all patient contact. Make facilities and supplies for hand washing easily available for all service providers. Wearing gloves: Wear non-sterile single use gloves for all procedures where contact with blood or other potentially infected body fluids is anticipated. Wearing protective clothing: Waterproof gowns or aprons must be worn where blood or other body fluids might splash. Require staff to wear masks and eye shields where there is possible exposure to large amounts of blood. Ensure puncture-resistant containers for sharps disposal are readily available, close at hand and out of reach of children. Disposal of waste materials: Burn all medical waste in a separate area, preferably within the health facility grounds. Bury items that still pose a threat, such as sharp objects, in a covered pit at least 10 meters from a water source. A Distance Lear ning Module 39 Using single-dose vials rather than multi-dose vials and: If multi-dose vials are used, avoid leaving a needle in the stopper. Sterilize (eliminates all pathogens) instruments to minimize the risk of infections during procedures. Housekeeping: Clean up spills of blood or other body fluids promptly and carefully. Post first aid measures in relevant workspaces and inform all staff how to access treatment for exposure. Maintain confidentiality of the exposed health worker and the person who is the source of exposure at all times. Educate on risk reduction through review of sequence of events and advise exposed worker to use condoms to prevent secondary transmission during the next three months. Ensure that protocols for standard precautions are posted in each health facility and that supervisors enforce adherence to these. Organize in-service orientation sessions on standard precautions for health care workers and auxiliary staff where needed. Establish supervisory systems such as simple checklists to ensure compliance with protocols. Review occupational exposure incidence reports regularly to determine when and how exposure occurs, and to identify safety concerns and possible preventive measures. Trainings on standard precautions were held with village midwives, and necessary supplies were distributed, including condoms. Ensure that adolescent-friendly health services are available for adolescents presenting to facilities. Although not all of the population will be knowledgeable about them, condoms should be available in accessible, private areas from the earliest days of an emergency so that anyone who is familiar with them, both the affected populations and humanitarian staff, has access. This is especially important since many women and girls are unable to negotiate male condom use with their partners due to a lack of power in their relationship. Female condoms are typically more expensive and are usually not as well known as male condoms among the population. If, however, the affected community is known to use female condoms, then they can be procured at the onset of an emergency. If the affected community is not familiar with them, explore whether it is possible to secure a stable supply of female condoms; then once a stable phase of the emergency is reached, provide information to the population about this method and provide training for women, girls, boys and men on correct use. In addition to providing condoms upon request in health facilities, humanitarian staff should make sure that condoms are made visible to the displaced population and provide information that condoms are available at various locations.

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It should be noted that both the Bradford assay and urine dipstick methodology are particularly sensitive to albumin and transferrin, whereas the benzethonium chloride assay is sensitive to these proteins and many others (the authors demonstrate this using qualitative gel electrophoresis). According to this information, the authors assert that benzethonium chloride is the preferred gold standard for biochemical assays and that, in comparison to this standard, urine dipsticks produce far too many false-negative results in hypertensive pregnant women to be 130 useful, even when a similar concentration cutoff is used rather than the traditional proteinuria definition of 0. This study was conducted as a prospective observational study, in which 1000 women were enrolled at their first antenatal visit; 913 completed the study. Of the 913 enrollees, 11 did not have dipstick testing performed at their first visit, 35 women demonstrated dipstick proteinuria (1 ), and 867 did not exhibit dipstick proteinuria on the first visit. Of the 867 patients without dipstick proteinuria, only 338 women developed proteinuria at some time during their pregnancy. Statistically, there were no significant differences in the proportion of women with and without dipstick proteinuria on their first visit who developed hypertension during pregnancy. We cannot recommend for or against measurement of lactate at the point of care to assess or correct lactate buffer replacement in hemodialysis patients. There is not sufficient evidence to recommend for or against urine dipstick testing for myoglobinuria at the point of care as an indicator for possible renal complications of muscle injury. We are unable to recommend dipstick testing for microalbuminuria at the point of care to assess nondiabetic nephropathy. We are not able to recommend for or against routine use of urine dipstick pH testing at the point of care to predict renal stone recurrence. Strength/consensus of recommendation: I Of the 4 articles (25, 57, 88, 89) that were selected for fulltext review (from 310 abstracts), none were able to be graded, because they either did not specifically address the clinical question or they did not contain evidence pertaining to patient outcomes. We are unable to recommend for or against dipstick hematuria testing at the point of care to detect intraabdominal trauma. Urea as a marker of adequacy in hemodialysis: lesson from in vivo urea dynamics monitoring. Point-of-care versus central laboratory testing: an economic analysis in an academic medical center. Renal insufficiency and subsequent death resulting from cardiovascular disease in the United States. Evaluation of a new chemical dip strip for detecting ketonemia in the emergency setting. Leukocyte esterase activity in the rapid detection of urinary tract and lower genital tract infections in obstetric patients. Quantitation of proteinuria with urinary protein/creatinine ratios and random testing with dipsticks in nephrotic children. Traumatic rhabdomyolysis from severe beating: experience of volume diuresis in 200 patients. The urine specific gravity dipstick: a useful tool to increase fluid intake in stone forming patients. Laboratory-based quality assurance programme for nearpatient urine dipstick testing, 1990-1997: development, management and results. Prediction of acute renal failure by "bedside formula" in medical and surgical intensive care patients. Assessment of the length of each hemodialysis session by on-line dialysate urea monitoring. Multicenter study of whole-blood creatinine, total carbon dioxide content, and chemistry profiling for laboratory and point-of-care testing in critical care in the United States. Point-of-care testing in an organ procurement organization donor management setting. A "state model" of renal function in systemic lupus erythematosus: its value in the prediction of outcome in 292 patients. Are routine preoperative laboratory screening tests necessary to evaluate ambulatory surgical patients? Albuminuria and proteinuria in hospitalized patients as measured by quantitative and dipstick methods. Comparison of instrument-read dipsticks for albumin and creatinine in urine with visual results and quantitative methods. Evaluation of a dipstick test for microalbuminuria in three different clinical settings, including the correlation with urinary albumin excretion rate. Evaluation of the Chemstrip 9 as a screening test for urinalysis and urine culture in men. Feasibility study of the early detection and treatment of renal disease by mass screening. On the performance and reliability of mechanized urine teststrip measurement in comparison with visual reading. Proteinuria as a risk factor for cardiovascular disease and mortality in older people: a prospective study. Screening for proteinuria in a rheumatology clinic: comparison of dipstick testing, 24 hour urine quantitative protein, and protein/creatinine ratio in random urine samples. Significance of urinalysis for subsequent kidney and urinary tract disorders in mass screening of adults. Urine dipstick as a screening test for serum creatinine elevation in emergency department patients with severe hypertension. Urinary protein and albumin excretion corrected by creatinine and specific gravity. A new automated system for urine analysis: a simple, cost-effective and reliable method for distinguishing between glomerular and nonglomerular sources of haematuria. Childhood post-streptococcal glomerulonephritis as a risk factor for chronic renal disease in later life. Dipstick urinalysis screening of asymptomatic adults for urinary tract disorders, I: hematuria and proteinuria. Emergency physicians versus laboratory technicians: are the urinalysis and microscopy results comparable? Evaluation of an automated urinalysis system for testing urine chemistry, microscopy and culture. Implementation of a point-of-care satellite laboratory in the emergency department of an academic medical center: impact on test turnaround time and patient emergency department length of stay. Prevalence of hematuria among Zuni Indians with and without diabetes: the Zuni Kidney Project. Utility of dipstick urinalysis as a guide to management of adults with suspected infection or hematuria. Comparison of point-of-care versus central laboratory measurement of electrolyte concentrations on calculations of the anion gap and the strong ion difference. A prospective observational study on the accuracy of patient self-testing of urine at an antenatal clinic. Early prediction of pre-eclampsia by measurement of kallikrein and creatinine on a random urine sample. Early risk assessment of severe preeclampsia: admission battery of symptoms and laboratory tests to predict likelihood of subsequent significant maternal morbidity. Effect of concentration and biochemical assay on the accuracy of urine dipsticks in hypertensive pregnancies. Urine protein dipstick measurements: a screen for a standard, 24hour urine collection. Indinavir crystalluria: identification of patients at increased risk of developing nephrotoxicity. Cost savings associated with changes in routine laboratory tests ordered for victims of trauma. Detection and significance of microscopic hematuria in patients with blunt renal trauma. Evaluation of diagnostic peritoneal lavage in suspected penetrating abdominal stab wounds using a dipstick technique.

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Tyrosine kinase inhibitors-a review on pharmacology, metabolism and side effects. Bridging from preclinical to clinical studies for tyrosine kinase inhibitors based on pharmacokinetics/pharmacodynamics and toxicokinetics/toxicodynamics. Pharmacokinetics and safety of sunitinib malate in subjects with impaired renal function. Pharmacokinetic/pharmacodynamic modeling of biomarker response to sunitinib in healthy volunteers. A novel tyrosine-kinase selective inhibitor, sunitinib, induces transient hypothyroidism by blocking iodine uptake. Benefits from pharmacological and pharmacokinetic properties of sunitinib for clinical development. Genetic polymorphisms associated with a prolonged progression-free survival in patients with metastatic renal cell cancer treated with sunitinib. Indianapolis: Lung Rx Subsidiary of United Therapeutics and Eli Lilly and Co; 2011. Tadalafil: a long-acting phosphodiesterase-5 inhibitor for the treatment of pulmonary arterial hypertension. New treatment options for erectile dysfunction in patients with diabetes mellitus. Effects of gender, age, diabetes mellitus and renal and hepatic impairment on tadalafil pharmacokinetics. Long-acting phosphodiesterase-5 inhibitor tadalafil attenuates doxorubicin-induced cardiomyopathy without interfering with chemotherapeutic effect. Medication and dosage considerations in the prophylaxis and treatment of high-altitude illness. The role of pharmacokinetics and pharmacodynamics in phosphodiesterase-5 inhibitor therapy. Patient preference and satisfaction in erectile dysfunction therapy: a comparison of the three phosphodiesterase-5 inhibitors sildenafil, vardenafil and tadalafil. Effect of tadalafil on cytochrome P450 3A4-mediated clearance: studies in vitro and in vivo. Phosphodiesterase 5 inhibitors-drug design and differentiation based on selectivity, pharmacokinetic and efficacy profiles. Sustained benefit of tadalafil in patients with pulmonary arterial hypertension with prior response to sildenafil: a case series of 12 patients [letter]. Pharmacokinetic interaction between tadalafil and bosentan in healthy male subjects. Safety, efficacy, and pharmacokinetic overview of low-dose daily administration of tadalafil. Pharmacokinetics and pharmacodynamics of tamsulosin in its modifiedrelease and oral controlled absorption system formulations. Does tamsulosin increase stone clearance after shockwave lithotripsy of renal stones? Identification of cytochrome P450 isoenzymes involved in metabolism of the a1-adrenoceptor blocker tamsulosin in human liver microsomes. Pharmacokinetics of tamsulosin hydrochloride in patients with renal impairment: effects of a1-acid glycoprotein. Tamsulosin shows a higher unbound drug fraction in human prostate than in plasma: a basis for uroselectivity? Tamsulosin: an update of its role in the management of lower urinary tract symptoms. Plasma protein binding of tamsulosin hydrochloride in renal disease: role of a1-acid glycoprotein and possibility of binding interactions. Pharmacokinetics and plasma protein binding of tamsulosin hydrochloride in rats, dogs, and humans. Combination therapy with dutasteride and tamsulosin for the treatment of symptomatic enlarged prostate. Pharmacokinetics and safety of tamsulosin in subjects with normal and impaired renal or hepatic function. Ex vivo occupancy by tamsulosin of a1-adrenoceptors in rat tissues in relation to the plasma concentration. A placebo-controlled pharmacodynamic and pharmacokinetic interaction study between tamsulosin and acenocoumarol. Behaviour and transit of tamsulosin oral controlled absorption system in the gastrointestinal tract. Modeling of relationships between pharmacokinetics and blockade of agonist-induced elevation of intraurethral pressure and mean arterial pressure in conscious dogs treated with a1-adrenoceptor antagonists. Pharmacokinetics of tamsulosin in subjects with normal and varying degrees of impaired renal function: an open-label single-dose and multiple-dose study. Tamsulosin and doxazosin as adjunctive therapy following shock-wave lithotripsy of renal calculi: randomized controlled trial. Tamsulosin as adjunctive treatment after shockwave lithotripsy in patients with upper urinary tract stones: a systematic review and meta-analysis. Comparable efficacy and superior gastrointestinal tolerability (nausea, vomiting, constipation) of tapentadol compared with oxycodone hydrochloride. Tolerability of tapentadol immediate release in patients with lower back pain or osteoarthritis of the hip or knee over 90 days: a randomized, double-blind study. Single dose analgesic efficacy of tapentadol in postsurgical dental pain: the results of a randomized, double-blind, placebo-controlled study. Investigations into the drug-drug interaction potential of tapentadol in human liver microsomes and fresh human hepatocytes. Cost-effective analysis of tapentadol immediate release for the treatment of acute pain. Synergistic interaction between the two mechanisms of action of tapentadol in analgesia. Effects of acetaminophen, naproxen, and acetylsalicylic acid on tapentadol pharmacokinetics: results of two randomized, open-label, crossover, drug-drug interaction studies. The efficacy and tolerability of multiple-dose tapentadol immediate release for the relief of acute pain following orthopedic (bunionectomy) surgery. In vitro evaluation of the activities of telavancin, cefazolin, and vancomycin against methicillin-susceptible and methicillin-resistant Staphylococcus aureus in peritoneal dialysate. Lack of effect of moderate hepatic impairment on the pharmacokinetics of telavancin. Single-dose pharmacokinetics and tolerability of telavancin in elderly men and women. Intrapulmonary distribution of intravenous telavancin in healthy subjects and effect of pulmonary surfactant on in vitro activities of telavancin and other antibiotics. Activity of telavancin against Staphylococcus aureus strains with various vancomycin susceptibilities in an in vitro pharmacokinetic/pharmacodynamic model with simulated endocardial vegetations. Telavancin penetration into human epithelial lining fluid determined by population pharmacokinetic modeling and Monte Carlo simulation. Fluorescence microscopy demonstrates enhanced targeting of telavancin to the division septum of Staphylococcus aureus. Pharmacodynamics of telavancin studied in an in vitro pharmacokinetic model of infection. Efficacy of telavancin in the treatment of experimental endocarditis due to glycopeptide-intermediate Staphylococcus aureus. Pharmacodynamic effects of telavancin against methicillin-resistant and methicillin-susceptible Staphylococcus aureus strains in the presence of albumin or serum and in an in vitro kinetic model. Telavancin and hydroxypropyl-b-cyclodextrin clearance during continuous renal replacement therapy: an in vitro study. Telavancin versus vancomycin for hospital-acquired pneumonia due to gram-positive pathogens. Mass balance and pharmacokinetics of [14C]telavancin following intravenous administration to healthy male volunteers. Pharmacokinetics, serum inhibitory and bactericidal activity, and safety of telavancin in healthy subjects. Tissue penetration of telavancin after intravenous administration in healthy subjects. Multiple-dose pharmacokinetics of intravenous telavancin in healthy male and female subjects.

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Randomised trial of old and new antihypertensive drugs in elderly patients: Cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension-2 study. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents: Treatment of hypertension in the elderly. Longterm effects on sexual function of five antihypertensive drugs and nutritional hygienic treatment in hypertensive men and women. Why are physicians not prescribing diuretics more frequently in the management of hypertension? Diuretics and beta-blockers do not have adverse effects at 1 year on plasma lipid and lipoprotein profiles in men with hypertension. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Thiazide therapy is not a cause of arrhythmia in patients with systemic hypertension. C 72 the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 128. Time trends in high blood pressure control and the use of antihypertensive medications in older adults: the Cardiovascular Health Study. Rationale for fixed-dose combinations in the treatment of hypertension: the cycle repeats. Value of low dose combination treatment with blood pressure lowering drugs: Analysis of 354 randomised trials. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure): Developed in collaboration with the International Society for Heart and Lung Transplantation; endorsed by the Heart Failure Society of America. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. A calcium antagonist vs a noncalcium antagonist hypertension treatment strategy for patients with coronary artery disease. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. Randomised placebo-controlled trial of effect of ramipril on decline in glomerular filtration rate and risk of terminal renal failure in proteinuric, non-diabetic nephropathy. The role of diastolic blood pressure when treating isolated systolic hypertension. Prevalence of Diabetes and Impaired Fasting Glucose in Adults-United States, 1999-2000. Excerpts from the United States Renal Data System 2001 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Preserving renal function in adults with hypertension and diabetes: A consensus approach. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. Type 2 diabetes mellitus: Greater cardiovascular risks and greater benefits of therapy. Diabetes and cardiovascular disease: A statement for healthcare professionals from the American Heart Association. Primary prevention of ischemic stroke: A statement for healthcare professionals from the Stroke Council of the American Heart Association. Development and progression of renal disease in Pima Indians with non-insulin-dependent diabetes mellitus. United Kingdom Prospective Diabetes Study, 30: Diabetic retinopathy at diagnosis of non-insulin-dependent diabetes mellitus and associated risk factors. Blood pressure and metabolic responses to hydrochlorothiazide, captopril, and the combination in black and white mild-tomoderate hypertensive patients. The effect of nisoldipine as compared with enalapril on cardiovascular outcomes in patients with non-insulin-dependent diabetes and hypertension. Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Level of kidney function as a risk factor for atherosclerotic cardiovascular outcomes in the community. Prevalence of high blood pressure and elevated serum creatinine level in the United States: Findings from the Third National Health and Nutrition Examination Survey (1988-1994). Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. Effects of blood pressure lowering with perindopril and indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease. Guidelines for the early management of patients with ischemic stroke: A scientific statement from the Stroke Council of the American Stroke Association. Hypertension and other cardiovascular disease risk factors among Mexican Americans, Cuban Americans, and Puerto Ricans from the Hispanic Health and Nutrition Examination Survey. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 203. Management of high blood pressure in African Americans: Consensus statement of the Hypertension in African Americans Working Group of the International Society on Hypertension in Blacks. Persistence of reduction in blood pressure and mortality of participants in the Hypertension Detection and Follow-up Program. Regional and racial differences in response to antihypertensive medication use in a randomized controlled trial of men with hypertension in the United States. Black Americans have an increased rate of angiotensin converting enzyme inhibitor-associated angioedema. Higher incidence of discontinuation of angiotensin converting enzyme inhibitors due to cough in Black subjects. Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction. Effect of weight loss and lifestyle changes on vascular inflammatory markers in obese women: A randomized trial. Relationship between plasma plasminogen activator inhibitor 1 and insulin resistance. Hyperinsulinemia: the missing link among oxidative stress and age-related diseases? Heredity and obesity-associated hypertension: Impact of hormonal characteristics and left ventricular mass. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. Metabolic syndrome and development of diabetes mellitus: Application and validation of recently suggested definitions of the metabolic syndrome in a prospective cohort study. The metabolic syndrome as a precursor of cardiovascular disease and type 2 diabetes mellitus. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults-the evidence report. Low levels of leisure-time physical activity and cardiorespiratory fitness predict development of the metabolic syndrome. Impact of overweight on the risk of developing common chronic diseases during a 10-year period. Dietary sodium intake and subsequent risk of cardiovascular disease in overweight adults. Physical activity and coronary heart disease in women: Is "no pain, no gain" passe? Fitness and fatness as predictors of mortality from all causes and from cardiovascular disease in men and women in the lipid research clinics study. Characteristics of inactive primary care patients: Baseline data from the activity counseling trial. Management of hypertensive patients with left ventricular hypertrophy and diastolic dysfunction. Comparison of left ventricular mass and geometry in Black and White patients with essential hypertension. Update on reversal of left ventricular hypertrophy in essential hypertension (a meta-analysis of all randomized double-blind studies until December 1996). Effect of single-drug therapy on reduction of left ventricular mass in mild to moderate hypertension: Comparison of six antihypertensive agents.

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Apo E genotyping is primarily used for the diagnosis of dysbetalipoproteinaemia (apo E2 homozygosity) and is indicated in cases with severe combined hyperlipidaemia. Treatment targets Treatment targets of dyslipidaemia are primarily based on results from clinical trials. Target levels for subjects at high risk are extrapolated from several clinical trials. Secondary targets of therapy in the high risk category are based on data extrapolation; therefore, clinical judgement is required before a final treatment plan is implemented. Clinicians again should exercise judgement to avoid premature or unnecessary implementation of lipid-lowering therapy. Lifestyle interventions will have an important long-term impact on health, and the long-term effects of pharmacotherapy must be weighed against potential side effects. Clinicians should use clinical judgement when considering further treatment intensification in secondary prevention or in high risk primary prevention. In this section, the influence of lifestyle changes and of functional foods on lipoproteins is considered and summarized in Table 9. The greater and more rapid this perturbation is, the more pronounced are the metabolic consequences. Most detrimental effects of a high carbohydrate diet could be minimized if carbohydrate digestion and absorption were slowed down. Sucrose, a disaccharide containing glucose and fructose, represents an important source of fructose in the diet. Trans unsaturated fatty acids can be found in limited amounts (usually,5% of total fat) in dairy products and in meats from ruminants. Several experimental studies on humans have evaluated the effects of dietary cholesterol on cholesterol absorption and lipid metabolism and have revealed marked variability among individuals. Longterm surveillance is also needed to guarantee the safety of the regular use of phytosterol-enriched products. The possible decrease in carotenoid and fat-soluble vitamin levels by sterols/stanols can be prevented with a diet rich in these nutrients. The substantiation of health claims relevant for each food should be based on results from intervention studies in humans that are consistent with the proposed claims. Phytosterols the principal phytosterols are sitosterol, campesterol, and stigmasterol, and they occur naturally in vegetable oils and, in smaller amounts, in vegetables, fresh fruits, chestnuts, grains, and legumes. The dietary intake of plant sterols ranges between an average of 250 mg/day in Northern Europe to 500 mg/day in Mediterranean countries. Phytosterols have been added to spreads and vegetable oils (functional margarine, butter, and cooking oils) as well as yoghurt and other foods; however, food matrices do not significantly influence the cholesterol-lowering efficacy of phytosterols at equivalent doses. Limited consumption of foods made with processed sources of trans fats provides the most effective means of reducing intake of trans fats below 1% of energy. Because the trans fatty acids produced in the partial hydrogenation of vegetable oils account for. Dietary carbohydrate and fibre Carbohydrate intake may range between 45 and 55% of total energy. Consumption of vegetables, legumes, fruits, nuts, and wholegrain cereals should be particularly encouraged, together with all the other foods rich in dietary fibre with a low glycaemic index. Some of these products have been shown to have potentially relevant functional effects but have not been tested in long-term clinical trials, and should therefore be utilized only when the available evidence clearly supports their beneficial effects on plasma lipid values and their safety. Criteria for central obesity as defined by the International Diabetes Federation are given in Table 10. To be effective in the long run, this advice should be incorporated into structured, intensive lifestyle education programmes. In order to facilitate maintenance of body weight close to the target, it is always appropriate to advise people with dyslipidaemia to engage in regular physical exercise of moderate intensity. Physical activity should be encouraged, aiming at regular physical exercise for at least 30 min/day every day. Dietary fat the recommended total fat intake is between 25 and 35% of calories for adults. Fat intakes that exceed 35% of calories are generally associated with increased intakes of both saturated fat and calories. To improve plasma lipid levels, saturated fat intake should be lower than 10% of the total caloric intake. Salt intake should be limited to,5 g/day, not only by reducing the amount of salt used for food seasoning but also by reducing the consumption of foods preserved by the addition of salt; this recommendation should be more stringent in people with hypertension or MetS. High risk subjects, in particular those with dyslipidaemia, should receive specialist dietary advice, if feasible. Table 12 Summary of lifestyle measures and healthy food choices for managing total cardiovascular risk 7. Drugs for treatment of hypercholesterolaemia Cholesterol levels are determined by multiple genetic factors as well as environmental factors, primarily dietary habits. The clinical conditions of the subjects, concomitant treatments, and drug tolerability will play a major role in determining the final choice of drug and dose. Side effects and interactions Statins differ in their absorption, bioavailability, plasma protein binding, excretion and solubility. Lovastatin and simvastatin are prodrugs, whereas the other available statins are administered in their active form. As an example, mild hypothyroidism is rather frequent and associated with cholesterol elevation; the latter will be solved once thyroid function is normalized. The benefits were significant within the first year, but were greater in subsequent years. Information on episodes of increased liver enzymes was not examined in this meta-analysis. Other Muscle Statins are generally well tolerated, and serious adverse events are rare. Over 129 000 patients have been systematically studied in controlled trials with blinded randomized assignment to statin vs. The most serious adverse effect associated with statin therapy is myopathy, which may progress to rhabdomyolysis, and that, in turn, can lead to renal failure and death. Conversely statin therapy may interfere with the catabolism of other drugs that are metabolized by the same enzymatic system. This risk is highest for gemfibrozil, and the association of gemfibrozil with statins should be avoided. The increased risk for myopathy when combining statins with other fibrates such as fenofibrate, bezafibrate, or ciprofibrate seems to be small. The incidence of myopathy is low (,1/1000 patients treated) and the excess risk in comparison with placebotreated patients has been,1/10 000 patients treated in clinical trials. Myopathy is most likely to occur in persons with complex medical problems and/or who are taking multiple medications, or in elderly persons, especially women. Patients should be instructed on promptly reporting unexpected muscle pain or weakness. The possibility of re-challenge to verify the cause of the pain should be discussed with the patient, as well as dose reduction, drug substitution, and/or drug combinations. Potent drugs such as atorvastatin and rosuvastatin can often be used on intermittent days to reduce side effects. Whether transaminase elevation with statins constitutes true hepatotoxicity has not been determined. Reversal of transaminase elevation is frequently noted with reduction of dose; thus, a patient who develops increased transaminase levels should be monitored with a second liver function evaluation to confirm the finding and be followed thereafter with frequent liver function tests until the abnormality returns to normal. The bile acids are released into the intestinal lumen, but most of the bile acid is returned to the liver from the terminal ileum via active absorption. The two older bile acid sequestrants, cholestyramine and colestipol, are both bile acid-binding exchange resins.

References:

  • https://ijmedph.org/sites/default/files/IntJMedPublicHealth_2012_2_3_1_108377.pdf
  • http://gnarusllc.com/wp-content/uploads/2016/07/ASB121615cm.pdf
  • https://reachair.com/wp-content/uploads/ECG-Interpretation-New-Template.pdf
  • https://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf
  • http://www.ucsfcme.com/2015/MOB15001/slides/final/11BlumenfeldTheNewHTNGuidelines.pdf