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Most reports of the decrease in age-adjusted coronary heart disease (CHD) are based on databases with upper age cut-offs that exclude approximately half of the events. We report changes in rates of acute myocardial infarction (AMI) and of out-of-hospital coronary death between 1986 and 1996 among New Jersey residents > or =15 years old. Data on patients discharged with the diagnosis of AMI from nonfederal acute care hospitals in the state (n = 270,091) and all records in the New Jersey death registration files with CHD (n = 172,175) listed as the cause of death from 1986 to 1996 (total study n = 442,266) were analyzed. The rate of hospitalized AMI cases in the state remained essentially unchanged during these 11 years, whereas in-hospital and 30-day case fatality among all age groups and both sexes declined. Age-adjusted CHD rates showed a decrease in fatal events, a smaller decrease in total events, and a slight increase in nonfatal events. The proportion of fatal CHD events occurring out-of-hospital decreased especially among men. The median age at occurrence of events increased by 1 year. Despite a decrease in CHD mortality, the rate of nonfatal events increased, especially among persons > or =75 years old. Thus, the decrease in age-adjusted CHD mortality is not all due to treatment and true prevention of CHD, but the disease simply occurs at an older age. [ABSTRACT FROM AUTHOR]

Introduction: The intersection of sexism with racism and xenophobia disproportionately exposes visible minority women to gender-based violence (GBV) at the community and systemic levels. This study aims to understand the knowledge strengths and gaps on GBV against visible minority women with an intersectional lens, revealing systemic barriers to accessing support and how these barriers intensify GBV and its effects. It will also identify effective and ineffective policies and practices in the literature to develop strategies addressing the root causes of GBV and supporting survivors., Methods and Analysis: We will conduct a mixed-methods systematic review using a convergent integrated approach to examine current literature on community- and systemic-level GBV against visible minority women. We will follow Joanna Briggs Institute's guidelines to converge data from both qualitative and quantitative studies to obtain an integrated qualitative synthesis on GBV in five countries: Canada, the USA, the UK, Australia and New Zealand. This analysis will be conducted following Thomas and Harden's thematic synthesis guidelines. Community members with lived experience of GBV will actively contribute to improving the relevance and interpretation of results, following a community-engaged research approach. Themes are expected to unveil various aspects of community- and systemic-level GBV due to the intersection of racism, xenophobia and sexism, alongside barriers in addressing GBV and research gaps., Ethics and Dissemination: Since this study does not involve primary data collection or the use of identifiable human data, no ethical approval will be needed. Results will be disseminated through integrated knowledge translation, involving collaboration with participants who have lived experience of GBV. The findings will be used to identify specific areas of policy intervention, including adopting culturally sensitive approaches, improving school and workplace policies and promoting rights of visible minority women., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Black or African American (hereinafter, Black) and Hispanic or Latino/a/x (hereinafter, Latinx) adults are disproportionally affected by Alzheimer disease, but most research studies do not enroll adequate numbers of both of these populations. The Alzheimer's Disease Neuroimaging Initiative-3 (ADNI3) launched a diversity taskforce to pilot a multipronged effort to increase the study inclusion of Black and Latinx older adults., Objective: To describe and evaluate the culturally informed and community-engaged inclusion efforts to increase the screening and enrollment of Black and Latinx older adults in ADNI3., Design, Setting, and Participants: This cross-sectional study used baseline data from a longitudinal, multisite, observational study conducted from January 15, 2021, to July 12, 2022, with no follow-up. The study was conducted at 13 ADNI3 sites in the US. Participants included individuals aged 55 to 90 years without cognitive impairment and those with mild cognitive impairment or Alzheimer disease., Exposures: Efforts included (1) launch of an external advisory board, (2) changes to the study protocol, (3) updates to the digital prescreener, (4) selection and deployment of 13 community-engaged research study sites, (5) development and deployment of local and centralized outreach efforts, and (6) development of a community-science partnership board., Main Outcomes and Measures: Screening and enrollment numbers from centralized and local outreach efforts, digital advertisement metrics, and digital prescreener completion., Results: A total of 91 participants enrolled in the trial via centralized and local outreach efforts, of which 22 (24.2%) identified as Latinx and 55 (60.4%) identified as Black (median [IQR] age, 65.6 [IQR, 61.5-72.5] years; 62 women [68.1%]). This represented a 267.6% increase in the monthly rate of enrollment (before: 1.11 per month; during: 4.08 per month) of underrepresented populations. For the centralized effort, social media advertisements were run between June 1, 2021, and July 31, 2022, which resulted in 2079 completed digital prescreeners, of which 1289 met criteria for subsequent site-level screening. Local efforts were run between June 1, 2021, to July 31, 2022. A total of 151 participants underwent site-level screening (100 from local efforts, 41 from centralized efforts, 10 from other sources)., Conclusions and Relevance: In this cross-sectional study of pilot inclusion efforts, a culturally informed, community-engaged approach increased the inclusion of Black and Latinx participants in an Alzheimer disease cohort study.

Objective: To compare the representation of intersectional (ie, racial/ethnic and gender) identities among surgical faculty versus medical students., Background: Health disparities are pervasive in medicine, but diverse physicians may help the medical profession achieve health equity., Methods: Data from the Association of American Medical Colleges for 140 programs (2011/2012-2019/2020) were analyzed for students and full-time surgical faculty. Underrepresented in medicine (URiM) was defined as Black/African American, American Indian/Alaskan Native, Hispanic/Latino/Spanish Origin, or Native Hawaiian/Other Pacific Islander. Non-White included URiM plus Asian, multiracial, and non-citizen permanent residents. Linear regression was used to estimate the association of year and proportions of URiM and non-White female and male faculty with proportions of URiM and non-White students., Results: Medical students were comprised of more White (25.2% vs 14.4%), non-White (18.8% vs 6.6%), and URiM (9.6% vs 2.8%) women and concomitantly fewer men across all groups versus faculty (all P < 0.01). Although the proportion of White and non-White female faculty increased over time (both P ≤ 0.001), there was no significant change among non-White URiM female faculty, nor among non-White male faculty, regardless of whether they were URiM or not. Having more URiM male faculty was associated with having more non-White female students (estimate = +14.5% students/100% increase in faculty, 95% CI: 1.0% to 8.1%, P = 0.04), and this association was especially pronounced for URiM female students (estimate = +46.6% students/100% increase in faculty, 95% CI: 36.9% to 56.3%, P < 0.001)., Conclusions: URiM faculty representation has not improved despite a positive association between having more URiM male faculty and having more diverse students., Competing Interests: O.M.F. is supported by the National Institutes of Health (NIH) under Award Number 7K08CA241390. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Prior studies have focused on the role of the learning environment on students' decisions to pursue surgery, but few have analyzed the impact of the clerkship curriculum. This study assessed surgical clerkship curricula across United States (US) medical schools and their impact on students' likelihood of pursuing a surgical residency., Design: A cross-sectional survey was developed to assess surgery clerkship characteristics. Questions included clerkship duration, number of offered and required surgical services, method of service assignment, and number of advanced clinical electives (e.g., fourth-year sub-internships) and additional surgical clinical opportunities (e.g., surgical elective rotations). Survey results were merged by the Association of American Medical Colleges with the percentages of students who matched into a surgical specialty. Linear regression models estimated the association of covariates with the percentage of students who (1) matched in surgical specialties, (2) were interested in surgery at medical school matriculation and ultimately matched into surgical residency (retention rate), and (3) were not interested in surgery at medical school matriculation but ultimately matched into surgical residency (recruitment rate)., Setting: The survey was distributed to clerkship directors and coordinators at 66 medical schools through the Association for Surgical Education (ASE) from 5/1/2021 to 8/1/2021., Participants: All US medical schools in the ASE., Results: A total of 21 medical schools responded (34.8% response rate). The overall retention rate was 36.4%, and the overall recruitment rate was 25.0%. Clerkships were 4 to 12 weeks. In 81% of programs, students submitted preferences and were assigned services. The percentage of students applying to surgical specialties was not associated with clerkship duration (p=0.79) or the number of required services (p=0.15), subspecialty services offered (p=0.33), or advanced clinical electives (p=0.24) but was associated with a program's having additional surgical clinical opportunities (p=0.02). Most of these factors were not associated with retention or recruitment rates., Conclusions: Offering more extracurricular surgical clinical opportunities was associated with having more students pursue surgical careers. Though limited by a relatively small sample size, our findings suggest that having shorter clerkships or limited subspecialty offerings may not have a significant influence on students' career choices., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective assessment of technical skills of junior residents is essential in implementing competency-based training and providing specific feedback regarding areas for improvement. An innovative assessment that can be easily implemented by training programs nationwide has been developed by expert surgeon educators under the aegis of the American College of Surgeons (ACS) Division of Education. This assessment, ACS Objective Assessment of Skills in Surgery (ACS OASIS) uses eight stations to address technical skills important for junior residents within the domains of laparoscopic appendectomy, excision of lipoma, central line placement, laparoscopic cholecystectomy, trocar placement, exploratory laparotomy, repair of enterotomy, and tube thoracostomy. The purpose of this study was to implement ACS OASIS at a number of sites to study its psychometric rigor., Design: The ACS OASIS was pre-piloted at two programs to establish feasibility and to gather information regarding implementation. Each skills station was 12 minutes long, and the faculty completed a checklist with 5 to 15 items, and a global assessment scale. The study was then repeated at three pilot sites and included 29 junior residents who were assessed by a total of 44 faculty. Psychometric data for the stations and checklists were collected and analyzed., Setting: The pre-pilot sites were Geisinger and University of Tennessee Knoxville.Data were gathered from pilot sites that included Wellspan Health, Duke University, and University of California Los Angeles., Results: The mean checklist score for all learners was 76% (IQR of 66%-85%). The average global rating was 3.36 on a 5-point scale with a standard deviation of 0.56. The overall cut score derived using the borderline group method was at 68% with 34% of performances requiring remediation. Using this criterion, the average number of stations that were completed by each learner without need for remediation was five.The station discrimination index ranged from 0.27 to 0.65 (all above the threshold of 0.25), demonstrating solid psychometric characteristics at the station level. The internal-consistency reliability was 0.76 with SEM of 5.8%. The inter-rater reliability (intraclass correlation) was high at 0.73 with general agreement of 79% between the two raters. The station discrimination was at 0.45 (range of 0.27 to 0.65) indicating a high level of differentiation between high and low performers. Using the generalizability theory, the G-coefficient reliability was at 0.72 with the reliability projection flattening after 8 stations. Overall, 75% to 82% the faculty and learners rated ACS OASIS as realistic and beneficial., Conclusions: ACS OASIS is a psychometrically sound technical skills assessment tool that can provide useful information for feedback to junior residents and support efforts to remediate gaps in performance., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

The effect of acculturation on cognition was examined among 142 older Hispanics: cognitively normal [CN; n  = 70], Mild Cognitive Impairment, amnestic [aMCI; n  = 27], and Dementia [D; n  = 45]. Acculturation levels (high vs. low) were determined using the Short Acculturation Scale for Hispanics (SASH). ANCOVAs used a wide variety of neuropsychological tests as independent variables controlling for age and education. Among CN subjects, the highly acculturated group performed better on Logical Memory delayed recall (LM-II) [ F (1, 56) = 9.26, p  < .001, η p 2 = 0.14], Digit Span Forward [ F (1, 56) = 4.37, p  < .05, η p 2 = 0.07], Trail Making Test A [ F (1, 56) = 7.74, p  < .05, η p 2 = 0.12], and Trail Making Test B [ F (1, 56) = 4.66, p = .03, η p 2 = 0.08], indicating that high acculturation was associated with a better performance on tests of episodic memory, auditory attention, working memory, cognitive flexibility, and processing speed among CN Hispanics. ANCOVA analyses were not significant among the other groups. In the absence of acculturation scales in clinical practice, caution should be exerted when interpreting neurocognitive results.

Pancreatic ductal adenocarcinoma (PDAC) is a lethal aggressive cancer, in part due to elements of the microenvironment (hypoxia, hypoglycemia) that cause metabolic network alterations. The FDA-approved antihelminthic pyrvinium pamoate (PP) has previously been shown to cause PDAC cell death, although the mechanism has not been fully determined. We demonstrated that PP effectively inhibited PDAC cell viability with nanomolar IC50 values (9-93 nmol/L) against a panel of PDAC, patient-derived, and murine organoid cell lines. In vivo , we demonstrated that PP inhibited PDAC xenograft tumor growth with both intraperitoneal (IP; P < 0.0001) and oral administration (PO; P = 0.0023) of human-grade drug. Metabolomic and phosphoproteomic data identified that PP potently inhibited PDAC mitochondrial pathways including oxidative phosphorylation and fatty acid metabolism. As PP treatment reduced oxidative phosphorylation ( P < 0.001), leading to an increase in glycolysis ( P < 0.001), PP was 16.2-fold more effective in hypoglycemic conditions similar to those seen in PDAC tumors. RNA sequencing demonstrated that PP caused a decrease in mitochondrial RNA expression, an effect that was not observed with established mitochondrial inhibitors rotenone and oligomycin. Mechanistically, we determined that PP selectively bound mitochondrial G-quadruplexes and inhibited mitochondrial RNA transcription in a G-quadruplex-dependent manner. This subsequently led to a 90% reduction in mitochondrial encoded gene expression. We are preparing to evaluate the efficacy of PP in PDAC in an IRB-approved window-of-opportunity trial (IND:144822)., (©2021 American Association for Cancer Research.)

Objective: To analyze (1) whether there are ethnic differences in the severity of depressive symptoms between groups of elders classified as cognitively normal (CN) or amnestic mild cognitive impairment (aMCI) and (2) the influence of depressive symptoms on specific cognitive performance by ethnicity across diagnoses, controlling for covariates., Methods: 164 Hispanics residing in the United States (HAs) and European Americans (EAs) (100 women; Mage = 72.1, SD = 8.0) were diagnosed as either CN or aMCI. Depressive symptoms were measured with the Geriatric Depression Scale (GDS-15). Cognition was assessed using the Loewenstein-Acevedo Scales for Semantic Interference and Learning (semantic memory), Multilingual Naming Test (confrontation naming), and the Stroop Test (Color-Word condition; executive function). A 2 × 2 univariate ANCOVA as well as linear and logistic regressions explored differences in depressive symptoms among diagnostic and ethnic groups., Results: Higher depression was seen in aMCI compared to the CN group for both ethnicities, after controlling for age, education, gender, and Mini-Mental State Examination score. Greater levels of depression also predicted lower scores in confrontation naming and semantic memory for only the EA group and marginally in scores of executive function for HA participants. GDS-15 scores of ≤ 4 also predicted less likelihood of aMCI diagnosis., Conclusions: Severity of depressive symptoms was associated with greater cognitive impairment, independent of ethnicity. Significant results suggest detrimental effects of depression on clinical diagnoses most evidently for subjects from the EA group., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Mitral stenosis is classically caused by rheumatic disease (RMS). However, degenerative mitral stenosis (DMS) is increasingly encountered, particularly in developed countries with aging populations. The aim of this study was to compare clinical and echocardiographic characteristics between the 2 entities. One hundred fifteen patients with DMS were identified from an echocardiographic database in the United States and compared with 510 patients with RMS from Seoul, Korea. All subjects had a mitral valve area (MVA) ≤2.5 cm 2 by continuity equation but were otherwise unselected. Patients with DMS were older and had more hypertension, diabetes, chronic kidney disease, and chronic obstructive pulmonary disease than those with RMS. Atrial fibrillation was more common in RMS patients. Mean mitral valve gradient was slightly lower in DMS versus RMS (7.63 ± 3.67 vs 8.50 ± 4.23 mm Hg, p = 0.04) but MVA was strikingly higher in the DMS group (1.35 ± 0.41 vs 0.95 ± 0.38 cm 2 , p <0.0001). This appeared to be due to greater stroke volume in the DMS patients (70.4 ± 19.7 vs 55.7 ± 15.5 ml, p <0.0001). Indexed left atrial volume was greater in RMS (82.1 ± 40.3 vs 57.9 ± 21.4 ml, p <0.0001) while estimated pulmonary artery systolic pressure was greater in DMS (49.3 ± 16.5 vs 39.4 ± 13.6 mm Hg, p <0.0001). In conclusion, DMS patients are older and have more comorbidities than RMS patients. DMS presents with greater MVA relative to mean mitral valve gradient than RMS. This appears due to a higher stroke volume in DMS patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Implantable cardiac sensors have shown promise in reducing rehospitalization for heart failure (HF), but the efficacy of noninvasive approaches has not been determined. The objective of this study was to determine the accuracy of noninvasive remote monitoring in predicting HF rehospitalization., Methods: The LINK-HF study (Multisensor Non-invasive Remote Monitoring for Prediction of Heart Failure Exacerbation) examined the performance of a personalized analytical platform using continuous data streams to predict rehospitalization after HF admission. Study subjects were monitored for up to 3 months using a disposable multisensor patch placed on the chest that recorded physiological data. Data were uploaded continuously via smartphone to a cloud analytics platform. Machine learning was used to design a prognostic algorithm to detect HF exacerbation. Clinical events were formally adjudicated., Results: One hundred subjects aged 68.4±10.2 years (98% male) were enrolled. After discharge, the analytical platform derived a personalized baseline model of expected physiological values. Differences between baseline model estimated vital signs and actual monitored values were used to trigger a clinical alert. There were 35 unplanned nontrauma hospitalization events, including 24 worsening HF events. The platform was able to detect precursors of hospitalization for HF exacerbation with 76% to 88% sensitivity and 85% specificity. Median time between initial alert and readmission was 6.5 (4.2-13.7) days., Conclusions: Multivariate physiological telemetry from a wearable sensor can provide accurate early detection of impending rehospitalization with a predictive accuracy comparable to implanted devices. The clinical efficacy and generalizability of this low-cost noninvasive approach to rehospitalization mitigation should be further tested. Registration: URL: https://www.clinicaltrials.gov. Unique Identifier: NCT03037710.

Background: Child maltreatment, trauma symptoms, and alpha electroencephalography (EEG) asymmetry have been linked to problem behaviors and alcohol use disorders., Objective: The goal of this pilot study was to clarify the role of alpha EEG asymmetry in the relation of maltreatment and problem behaviors. It was hypothesized that adolescents with more maltreatment, trauma symptoms, and right alpha EEG asymmetry would have more problem behaviors and alcohol use. It was also hypothesized that alpha EEG asymmetry would moderate the association between maltreatment/trauma symptoms and problem behaviors., Participants and Setting: Participants were 52 adolescents aged 12-14 years. Resting-state alpha EEG asymmetry was measured in this home-based study as a potential moderator in the association of child maltreatment and trauma symptoms to problem behaviors including alcohol use., Results: Child maltreatment reports and trauma symptoms were significantly associated with problem behaviors (β = 0.259, p = 0.037 and β = 0.594, p < 0.001, respectively). Trauma symptoms were associated with alcohol-use (Incidence Rate Ratio = 1.048, p = 0.032). Right alpha EEG asymmetry moderated the positive association of trauma symptoms and problem behaviors (β = -0.383, p = 0.024). However, this was not the case for left alpha EEG asymmetry., Conclusions: Neural correlates associated with individuals' affective-behavioral profiles may play a role in the susceptibility for problem behaviors among adolescents exposed to higher levels of childhood trauma. This could be useful in developing targeted assessments and interventions to prevent or treat these problems in adolescents., Competing Interests: Declaration of Competing Interest There are no conflicts of interest., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Abuse of opioids has had and continues to have a devastating impact on public health and safety in the United States, and the use of opioids has increased dramatically in the last two decades. The purpose of this chapter is to examine the roots of this tragic state of affairs and what may be done about it moving forward. The authors review the medical-legal risks physicians face when prescribing pain relieving medications for their patients. Strategies are offered for staying out of trouble while providing quality pain management for patients.

Background & Aims: The efficacy of prophylactic placement of hemoclips to prevent delayed bleeding after removal of large colonic polyps has not been established. We conducted a randomized equivalence study to determine whether prophylactic placement of hemoclips affects incidence of delayed post-polypectomy bleeding (PPB)., Methods: During elective colonoscopy performed at 4 Veterans Affairs Medical Centers, 1098 patients who had polyps ≥1 cm removed were randomly assigned to groups that received prophylactic hemoclips (n = 547) or no hemoclips (n = 551), from September 2011 through September 2018. Data on PPB (rectal bleeding resulting in hemoglobin decreases ≥2 g/dL, hemodynamic instability, colonoscopy, angiography, or surgery) within 30 days of colonoscopy (called delayed PPB) were collected during telephone interviews or hospital visits 7 and 30 days after colonoscopy. The primary outcome was the incidence of important post-polypectomy bleeding., Results: Twelve patients in the hemoclip group (2.3%) and 15 patients in the no hemoclip group (2.9%) had important delayed PPB. There were no deaths, and no patients in either group required angiography or surgery. In intention-to-treat analysis, two 1-sided test's lower and upper confidence interval limits were -2.07 and 1.01, indicating that the data approached but did not meet equivalence criteria. On multiple logistic regression analysis, significant predictors of PPB included use of warfarin with bridging, thienopyridines, polyp size, and polyp location, but hemoclip placement did not associate with important delayed PPB., Conclusions: In a randomized trial, we found that prophylactic placement of hemoclips after removal of large colon polyps does not affect the proportion of important delayed PPB events, compared with no hemoclip placement. These findings call into question the widespread, expensive practice of routinely placing prophylactic hemoclips after polypectomy. ClinicalTrials.gov ID: NCT01647581., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: While the number of research publications related to bariatric surgery have increased remarkably in the past decade, research efforts remain uncoordinated and have limited focus, and numerous important questions remain unanswered., Objective: To generate a research agenda in bariatric surgery., Setting: National survey., Methods: The membership of the American Society of Metabolic and Bariatric Surgery (ASMBS) was asked to submit research questions needed to advance the field of bariatric surgery. An expert panel grouped and collated submitted questions and redistributed them back to the membership to rate their importance on a 5-point Likert scale using a 3-round modified Delphi methodology. The top research questions were determined based on provided rankings., Results: Two hundred ninety-two research questions were initially submitted that were collapsed to 59 unique questions. The ratings for the top 40 questions ranged from 2.67-4.33 (overall mean, 3.46). The highest-ranked questions centered on the mechanisms of effectiveness of bariatric surgery for weight loss and diabetes resolution, the underlying etiology of weight recidivism, and predictors of success., Conclusions: A research agenda for bariatric surgery was developed using the Delphi methodology. This research agenda may enhance the ability of investigators and funding organizations, including the ASMBS, to focus attention to areas most likely to advance the field, and by editors and reviewers to assess the merit and relevance of scientific contributions., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Arthroscopy is one of the most challenging surgical skills to assess and teach. Although basic psychomotor arthroscopic skills, such as triangulation and object manipulation, are incorporated into many simulation exercises, they are not always individually taught or objectively evaluated. In addition, arthroscopic instruments, arthroscopy cameras, and the cadaver or joint models necessary for practice are costly., Methods: A low-cost arthroscopic simulator was created to practice triangulation, probing, horizon changes, suture management, and object manipulation. The simulator materials were purchased exclusively from national hardware stores with a total cost averaging $79. The universal serial bus (USB) camera is included in the total cost. Three residency programs accredited by the Accreditation Council for Graduate Medical Education were tested on the simulator. Replica boards were created at each institution. Participants included medical students (20), residents (46), and attending physicians (9)., Results: Construct validity-the ability to differentiate between novice, intermediate, and senior level participants-was obtained. On all tasks, junior residents scored at a statistically significant lower rate than senior residents and attending physicians., Conclusions: This cost-effective arthroscopic surgical simulator objectively demonstrated that attending physicians and senior residents performed at a higher level than junior residents and novice medical students. The results of this study demonstrate that this simulator could be an important training tool for resident education.

Impaired physicians are unable to manage professional activities safely. Impairment can be the result of physical or mental disorders, but impaired physicians commonly refers to those suffering from substance use disorders. These disorders are at least as common in physicians as they are in the general population, and physician health programs have been established in each state to provide expeditious and detailed evaluation, referral to treatment facilities, and post-treatment monitoring to ensure compliance. These programs protect participants against sanctions and safeguard patients. The prognosis for participants is excellent, with more than 70% able to practice medicine at 5 years., (Copyright © 2016 Elsevier Inc. All rights reserved.)

For the past 24 years, most developed countries have used the International Classification of Diseases, Tenth Revision (ICD-10) to report physician services. In the United States, physicians have continued to use the American Medical Association Current Procedural Terminology, Fourth Edition and the Healthcare Common Procedure Coding System. The ICD-10-Clinical Modification (CM) has approximately 4.9 times more codes than the International Classification of Diseases, Ninth Revision. ICD-10-CM allows for more specific descriptors of a procedure and is broken down by category, etiology, anatomic site, severity, and extension. ICD-10-CM is scheduled to be implemented by Medicare and commercial payers on October 1, 2015. In addition to ICD-10 implementation, physicians have to meet the requirements of the Meaningful Use Electronic Health Record Incentive Program. The Meaningful Use program is designed to promote the use of certified electronic health technology by providing eligible professionals with incentive payments if they meet the defined core and menu objectives of each stage of the program. All core measures must be met; however, providers can choose to meet a preset number of menu measures. Meaningful Use Stage 1 required eligible professionals to meet core and menu objectives that focused on data capture and sharing. Meaningful Use Stage 2 requires eligible professionals to meet core and menu objects that focus on advanced clinical processes for a full year in 2015. Stage 3 has been delayed until 2017, and core and menu measures that will focus on improving outcomes have not yet been defined. It is important for orthopaedic surgeons to understand the history of and techniques for the use of ICD-10-CM in clinical practice. Orthopaedic surgeons also should understand the requirements for Meaningful Use Stages 1 and 2, including the core objectives that must be met to achieve satisfactory attestation.

The use of radiation (RT) in primary mediastinal large B-cell lymphoma (PMBCL) may predispose young patients to the risk of cardiopulmonary toxicities and secondary malignancies. We used Surveillance, Epidemiology and End Results (SEER) 18 database to compare the overall survival (OS) differences among adult patients treated with and without RT after rituximab approval in the US. Multivariate analyses were performed using Cox proportional hazards regression to compare OS based on the use of RT while adjusting for age, year of diagnosis, race, stage and gender. PMBCL patients (n = 258), who received RT (48%), were similar in terms of age, gender, race, and stage at diagnosis to patients who did not receive RT. The five year OS was similar between patients treated with versus without RT (82.5% vs. 78.6%, P = 0.47). In a multivariate analysis, the use of RT did not influence OS in the rituximab era (HR 0.83; 95% CI 0.43-1.59; P = 0.56). Rituximab may reduce the benefit of RT in select patients such as those who achieve a metabolic complete remission at the end of chemotherapy., (© 2015 Wiley Periodicals, Inc.)

Background: Several studies have reported excellent long-term overall survival (OS) of patients with hairy cell leukemia (HCL) without racial disparity. Studies in other cancers have demonstrated worse mortality among African American (AA) individuals., Patients and Methods: We used the Surveillance, Epidemiology, and End Results 18 database to identify HCL patients diagnosed between 1978 and 2011. Kaplan-Meier curves were plotted to estimate OS. Univariate analysis using the life table method and multivariate Cox regression model were used to determine the independent effect of race on OS., Results: The study population included 78% men and had a median age of 56 years. Race included 93% white, 3.5% Asian/Pacific Islander, and 3.5% AA. The 10-year OS was significantly less for AA as compared with white and Asian/Pacific Islander individuals (54% vs. 72% vs. 75%; P < .001). A Kaplan-Meier survival curve showed a significantly worse OS for AA versus other races (P < .001). In a multivariate analysis, AA race remained an independent predictor for a worse OS (hazard ratio 1.77; 95% confidence interval, 1.30-2.40; P < .001) after adjusting for age, sex, year of diagnosis, and marital status., Conclusion: In this population-based study, only half of AA patients but more than two-thirds of HCL patients from other racial groups were alive at 10 years. Such drastic racial differences in OS of HCL patients at the population level mandates further evaluation of the contributory biological, socioeconomic, health system, and other factors. Understanding and overcoming such racial disparities might close the racial differences in OS of this potentially curable disease., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Psychomotor testing has been recently incorporated into residency training programs not only to objectively assess a surgeon's abilities but also to address current patient-safety advocacy and medicolegal trends. The purpose of this study was to develop and test a cost-effective psychomotor training and assessment tool-The Fundamentals of Orthopaedic Surgery (FORS)-for junior-level orthopaedic surgery resident education., Methods: An orthopaedic skills board was made from supplies purchased at a local hardware store with a total cost of less than $350 so as to assess six different psychomotor skills. The six skills included fracture reduction, three-dimensional drill accuracy, simulated fluoroscopy-guided drill accuracy, depth-of-plunge minimization, drill-by-feel accuracy, and suture speed and quality. Medical students, residents, and attending physicians from three orthopaedic surgery residency programs accredited by the Accreditation Council for Graduate Medical Education participated in the study. Twenty-five medical students were retained for longitudinal training and testing for four weeks. Each training session involved an initial examination followed by thirty minutes of board training. The time to perform each task was measured with accuracy measurements for the appropriate tasks. Statistical analysis was done with one-way analysis of variance, with significance set at p < 0.05., Results: Forty-seven medical students, twenty-nine attending physicians, and fifty-eight orthopaedic surgery residents participated in the study. Stratification among medical students, junior residents, and senior residents and/or attending physicians was found in all tasks. The twenty-five medical students who were retained for longitudinal training improved significantly above junior resident level in four of the six tasks., Conclusions: The FORS is an effective simulator of basic motor skills that translates across a wide variety of operations and has the potential to advance junior-level participants to senior resident skill level., Clinical Relevance: The FORS simulator may serve as a valuable tool for resident education., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

Importance: Recently, a rare variant in the amyloid precursor protein gene (APP) was described in a population from Iceland. This variant, in which alanine is replaced by threonine at position 673 (A673T), appears to protect against late-onset Alzheimer disease (AD). We evaluated the frequency of this variant in AD cases and cognitively normal controls to determine whether this variant will significantly contribute to risk assessment in individuals in the United States., Objective: To determine the frequency of the APP A673T variant in a large group of elderly cognitively normal controls and AD cases from the United States and in 2 case-control cohorts from Sweden., Design, Setting, and Participants: Case-control association analysis of variant APP A673T in US and Swedish white individuals comparing AD cases with cognitively intact elderly controls. Participants were ascertained at multiple university-associated medical centers and clinics across the United States and Sweden by study-specific sampling methods. They were from case-control studies, community-based prospective cohort studies, and studies that ascertained multiplex families from multiple sources., Main Outcomes and Measures: Genotypes for the APP A673T variant were determined using the Infinium HumanExome V1 Beadchip (Illumina, Inc) and by TaqMan genotyping (Life Technologies)., Results: The A673T variant genotypes were evaluated in 8943 US AD cases, 10 480 US cognitively normal controls, 862 Swedish AD cases, and 707 Swedish cognitively normal controls. We identified 3 US individuals heterozygous for A673T, including 1 AD case (age at onset, 89 years) and 2 controls (age at last examination, 82 and 77 years). The remaining US samples were homozygous for the alanine (A673) allele. In the Swedish samples, 3 controls were heterozygous for A673T and all AD cases were homozygous for the A673 allele. We also genotyped a US family previously reported to harbor the A673T variant and found a mother-daughter pair, both cognitively normal at ages 72 and 84 years, respectively, who were both heterozygous for A673T; however, all individuals with AD in the family were homozygous for A673., Conclusions and Relevance: The A673T variant is extremely rare in US cohorts and does not play a substantial role in risk for AD in this population. This variant may be primarily restricted to Icelandic and Scandinavian populations.

Background: Dyslipidemia and overweight are common issues in children. Identifying genetic markers of risk could lead to targeted interventions. A polymorphism of SNP rs7566605 near insulin-induced gene 2 (INSIG2) has been identified as a strong candidate gene for obesity, through its feedback control of lipid synthesis., Objective: To identify polymorphisms in INSIG2 which are associated with overweight (BMI ≥ 85% for age) and dyslipidemia in children., Hypothesis: The C allele of rs7566605 would be significantly associated with BMI and LDL., Design/methods: We genotyped 15 SNPs in/near INSIG2 in 1,058 healthy children (53% non-Hispanic white (NHW), 37% overweight) participating in a school based study. Genotype was compared with BMI and lipid markers, adjusting for age, gender, and puberty., Results: We found a significant association between the SNP rs12464355 and LDL in NHW children, p < 0.001. The G allele is protective (lower LDL). A different SNP was associated with overweight in NHW: rs17047757. SNP rs7566605 was not associated with overweight or lipid levels., Conclusions: We identified novel genetic associations between INSIG2 and both overweight and LDL in NHW children. Polymorphisms in INSIG2 may be important in the development of obesity through its effects on lipid regulation.

Background: E-learning is increasingly common in undergraduate medical education. Internet-based multimedia materials should be designed with millennial learner utilization preferences in mind for maximal impact., Methods: Medical students used all 20 Web Initiative for Surgical Education of Medical Doctors modules from July 1, 2013 to October 1, 2013. Data were analyzed for topic frequency, time and week day, and access to questions., Results: Three thousand five hundred eighty-seven students completed 35,848 modules. Students accessed modules for average of 51 minutes. Most frequent use occurred on Sunday (23.1%), Saturday (15.4%), and Monday (14.3%). Friday had the least use (8.2%). A predominance of students accessed the modules between 7 and 10 PM (34.4%). About 80.4% of students accessed questions for at least one module. They completed an average of 40 ± 30 of the questions. Only 827 students (2.3%) repeated the questions., Conclusions: Web Initiative for Surgical Education of Medical Doctors has peak usage during the weekend and evenings. Most frequently used modules reflect core surgical problems. Multiple factors influence the manner module questions are accessed., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The American College of Surgeons has developed a reliable and valid OSCE (objective structured clinical examination) to assess the clinical skills of incoming postgraduate year 1 surgery residents, but the cost and logistics of implementation have not been described., Methods: Fixed costs included staff time, medical supplies, facility fee, standardized patient (SP) training time, and one OSCE session. Variable costs were incurred for additional OSCE sessions. Costs per resident were calculated and modeled for increasing the number of test takers., Results: American College of Surgeons OSCE materials and examination facilities were free. Fixed costs included training 11 SPs for 4 hours ($1,540), moulage and simulation material ($469), and administrative effort for 44 hours ($2,200). Variable cost for each session was $1,540 (SP time). Total cost for the first session was $6,649 ($664/resident), decreased to $324/resident for 3 sessions, and projected to further decline to $239/resident for 6 sessions., Conclusions: The cost decreased as the number of residents tested increased. To manage costs, testing more trainees by regional collaboration is recommended., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The Association for Surgical Education established the Center for Excellence in Surgical Education Research and Training (CESERT) program in 1999 to support innovative research and education projects and programs that will advance surgical education. We sought to examine scholarly outcomes of the projects during the first 15 years of the program., Methods: E-mail surveys were sent to the 24 researchers who were awarded CESERT grants. Data collection focused on recipient professional experiences, publications, and presentations stemming from CESERT-funded research and impact on career development. For grant recipients who were unable to complete the survey, we obtained publication information on studies authored by the grant recipients that described the same grant-funded topic, described similar methods, and fell within the study timeline., Results: Complete survey data were obtained from 18 of the 24 grant recipients. Grants were most commonly awarded to General Surgeons (40%) and Education and Psychology PhDs (24%). Overall, 23 of the 25 projects had reached completion at the time of contact, and from these, 70 articles were published or in press. Abstract presentations were more common, with respondents documenting 84 projects locally, nationally, and internationally. Grant awards ranged from $8,122 to $97,000, with an average of $39,026. In total, the Association for Surgical Education Foundation distributed $988,000 in grant funding from 1999 to 2013. Respondents reported that CESERT funding was critical to their career as it legitimized their pursuit of educational research, helped them establish multidisciplinary and multi-institutional collaborations, provided greater visibility for their research, and helped them develop an understanding of educational principles and grant writing skills., Conclusions: Overall, the CESERT program has produced remarkable results. The careful review process and monitoring protocol have ensured that high-potential studies are funded and successful. These data support continued efforts to garner resources such that CESERT grants may be awarded to fund high-quality, high-impact projects., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The American Board of Surgery In-Training Examination (ABSITE) is a predictor of resident performance on the general surgery-qualifying examination and plays a role in obtaining competitive fellowships. A learning management system (LMS) permits the delivery of a structured curriculum that appeals to the modern resident owing to the ease of accessibility and all-in-one organization. This study hypothesizes that trainees using a structured surgeon-directed LMS will achieve improved ABSITE scores compared with those using an unstructured approach to the examination., Study Design: A multidisciplinary print and digital review course with practice questions, review textbooks, weekly reading assignments, and slide and audio reviews integrated within an online LMS was made available to postgraduate year (PGY)-3 and PGY-4 residents in 2008 and 2009. Surveys were emailed requesting ABSITE scores to compare outcomes in those trainees that used the course with those who used an unstructured approach. Statistical analysis was conducted via descriptive statistics and Pearson chi-square with p < 0.05 deemed statistically significant., Results: Surveys were mailed to 508 trainees. There was an 80% (408) response rate. Residents who used structured approaches in both the years achieved the highest scores, followed by those who adopted a structured approach in PGY-4. The residents using an unstructured approach in both the years showed no significant improvement., Conclusion: Residents who used a structured LMS performed significantly better than their counterparts who used an unstructured approach. A properly constructed online education curriculum has the potential to improve ABSITE scores., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Rectal cancer management has evolved into a complex multimodality approach with survival, local recurrence, and quality of life parameters being the relevant endpoints. Surgical treatment for low rectal cancer has changed dramatically over the past 100 years., Discussion: Abdominoperineal resection, once the standard of care for all rectal cancers, has become much less frequently utilized as surgeons devise and test new techniques for preserving the sphincters, maintaining continuity, and performing oncologically sound ultra-low anterior or local resections. Progress in rectal cancer surgery has been driven by improved understanding of the anatomy and pathophysiology of the disease, innovative surgical technique, improved technology, multimodality approaches, and increased appreciation of the patient's quality of life. The patient with a low rectal cancer, once almost universally destined for impotence and a colostomy, now has the real potential for improved survival, avoidance of a permanent stoma, and preservation of the normal route of defecation.

Objective: This report describes the development, initial implementation, and reliability of American College of Surgeons Resident Objective Structured Clinical Examination (ACS OSCE)., Background: Variability in clinical knowledge and skills of entering surgery residents has been demonstrated. The ACS OSCE was developed to evaluate and help remediate residents' knowledge and skills in managing patients with life-threatening conditions., Methods: A task force of surgeons and professional educators developed 10 standardized clinical case stations, evaluation checklists, and rating scales. Standardized patients (SPs) evaluated each resident's clinical skills (history taking, physical examination, communication, and SP-global scores). Residents completed checklists on diagnosis and management. Coefficient alpha and item-total correlations were used, respectively, to assess internal consistency of metrics and station validity. The resident's overall performance for each station was calculated by combining scores of the individual skills. Analysis of variance compared performance across different institutions., Results: A total of 103 postgraduate year 1 residents from 7 institutions completed the OSCE. Reliability coefficients of skills ranged from 0.38 for diagnosis to 0.68 for global scores. For overall performance on individual stations, the reliability coefficients ranged from 0.51 to 0.82. Using total percent correct scores from highly reliable stations (α > 0.8), wide variability in resident performance was demonstrated within and between the 7 institutions., Conclusions: The ACS OSCE was successfully implemented across diverse institutions. It had moderate reliability and demonstrated variability among entering surgery residents. The ACS OSCE is now available for broader implementation. It should help reduce resident variability and address the requirements of Accreditation Council for Graduate Medical Education for resident supervision.

In this report, we emphasize the importance of public monographs with reference materials, coupled with careful process and change control and attention to GMPs, as a means of advancing access to good quality, safe, and effective medicines, with emphasis on available and incoming biologic medicines. With adequate control of articles covered by a monograph, these public standards can form the basis for a global public quality platform that covers reference products, non-interchangeable reference products, biosimilars, and interchangeable biosimilars. Working collaboratively with all stakeholders, new approaches allow these public standards to emerge nationally and globally in a timely way. Yet, there are increasing limitations in the availability of public standards for biologic medicines, which may reverse many decades of progress. Solutions are considered in this report.

Background: The cost and logistics of deploying the American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) National Technical Skills Curriculum across all training years are not known. This information is essential for residency programs choosing to adopt similar curricula., Methods: A task force evaluated the authors' institution's existing simulation curriculum and enhanced it by implementing the ACS/APDS modules. A 35-module curriculum was administered to 35 general surgery residents across all 5 clinical years. The costs and logistics were noted, and resident satisfaction was assessed., Results: The annual operational cost was $110,300 ($3,150 per resident). Cost per module, per resident was $940 for the cadaveric module compared with $220 and $240 for dry simulation and animal tissue-based modules, respectively. Resident satisfaction improved from 2.45 to 4.78 on a 5-point, Likert-type scale after implementing the ACS/APDS modules., Conclusions: The ACS/APDS skills curriculum was implemented successfully across all clinical years. Cadaveric modules were the most expensive. Animal and dry simulation modules were equivalent in cost. The addition of tissue-based modules was associated with high satisfaction., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Ethnic disparities in patterns of utilization and outcomes after Roux-en-Y gastric bypass surgery (RYGB) were examined from Bariatric Outcomes Longitudinal Database., Methods: Descriptive statistics were used for demographics of Whites, Blacks, or Hispanics undergoing RYGB with 1 year of follow-up, between June 2007 and October 2011. Multivariate logistic and normal regression models, controlling for baseline characteristics, examined relationships between race and outcomes. T tests were used for continuous variables and Pearson chi-square test for categorical variables., Results: Study patients (108,333) were79 % White, 12 % Black, and 9 % Hispanic. Fewer Black males underwent surgery (15 %) compared to Whites or Hispanics (∼22 %). Blacks compared to Whites were younger (42.7 ± 10.6 vs. 46.4 ± 11.6 years), heavier BMI (50 ± 9.1 vs. 47.4 ± 8.0 kg/m(2)), and more often hypertensive (57 vs. 52 %). Other comorbidities were higher in Whites. Thirty-day mortality rate was equivalent (0.23-0.26 %), but serious adverse events were higher for Blacks (3.65 %) versus Whites (3.19 %) and Hispanics (2.01 %). At 1 year, weight and comorbidity burden declined significantly but less in Blacks despite adjustment for baseline characteristics., Conclusions: Fewer Black males underwent RYGB. Despite a smaller percent decline in BMI and comorbidities in Blacks, all races benefitted significantly from RYGB. Influence of other factors such as diet, culture, and genetics needs to be investigated further.

There has been a substantial shift in the assessment of outcomes in medicine, including orthopaedic surgery. The quality movement is redefining the delivery of health care. The effect of these changes on orthopaedic surgery and orthopaedic surgeons has been significant and will become increasingly important. Orthopaedic surgeons must become active participants in the quality movement by understanding the basic principles of the movement and how they apply to patient care. A clear understanding of the different agencies (governmental and private) that are leading these initiatives is also essential. Ultimately, active participation in the quality movement will enhance the care provided to patients with musculoskeletal disorders.

Introduction: The growth of bariatric surgery has resulted in varying types of procedures with increasing complexity. Robotic digital platforms are employed in bariatric surgery to address this increasing complexity in the high-risk obese patient population with difficult anatomy., Materials and Methods: This review explores the literature and examines the reported outcomes and complications in using robotics for bariatric surgery. Robotic approaches to adjustable gastric banding, sleeve gastrectomy, gastric bypass, and biliopancreatic diversion with duodenal switch are examined. Revisional cases, learning curves, and cost effectiveness are reviewed, with an eye toward the future of bariatric surgery as the use of robotics is adopted., Conclusion: Digital platforms are showing great promise as enabling technology which advance bariatric outcomes. With increasingly complex bariatric cases being performed and revised, the insertion of digital information between the surgeon and the patient leads to better operations for the patient and the surgeon.

Background: Previously, Midwestern veteran patients had limited bariatric surgery access because they lived long distances from a bariatric surgery center (BSC). The creation and outcomes of a network to increase bariatric surgery access and patient satisfaction with teleconsultation are discussed., Methods: Several referring Midwestern Veterans Affairs Medical Centers (VAMCs) performed pre- and postoperative management and were linked by teleconferencing and a computerized patient record system to a single BSC., Results: Twenty-eight high-risk patients (older, male) residing an average distance of 324.5 miles from the BSC underwent gastric bypass. Eighty-two percent used teleconferencing for the initial surgical consultation with excellent patient satisfaction saving at least 19,000 miles and 69 travel days. Surgical outcomes were equivalent and follow-up was excellent (96.6%) compared with non-Veterans Affairs patients., Conclusions: A cooperative network using teleconference and computerized records facilitated bariatric surgery in high-risk, remotely located VA patients with high patient satisfaction and without compromising surgical outcomes., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Establishing methods for ascertainment of dementia and cognitive impairment that are accurate and also cost-effective is a challenging enterprise. Large population-based studies often using administrative data sets offer relatively inexpensive and reliable estimates of severe conditions including moderate to advanced dementia that are useful for public health planning, but they can miss less severe cognitive impairment which may be the most effective point for intervention. Clinical and epidemiological cohorts, intensively assessed, provide more sensitive detection of less severe cognitive impairment but are often costly. In this article, several approaches to ascertainment are evaluated for validity, reliability, and cost. In particular, the methods of ascertainment from the Health and Retirement Study are described briefly, along with those of the Aging, Demographics, and Memory Study (ADAMS). ADAMS, a resource-intense sub-study of the Health and Retirement Study, was designed to provide diagnostic accuracy among persons with more advanced dementia. A proposal to streamline future ADAMS assessments is offered. Also considered are algorithmic and Web-based approaches to diagnosis that can reduce the expense of clinical expertise and, in some contexts, can reduce the extent of data collection. These approaches are intended for intensively assessed epidemiological cohorts where goal is valid and reliable case detection with efficient and cost-effective tools., (Copyright © 2011 The Alzheimer's Association. Published by Elsevier Inc. All rights reserved.)

Objective: This study examined the association between a history of heavy alcohol use and smoking, presence of the apolipoprotein-E epsilon 4 allele (APOE epsilon4), and age of disease onset in a community dwelling sample of 685 Alzheimer's disease (AD) patients spanning three ethnic groups., Design: Cross-sectional study of AD patients evaluated at a University-affiliated outpatient memory disorders clinic., Subjects: A clinic-based cohort of white non-Hispanic (WNH; n = 397), white Hispanic (WH; n = 264), and African-American (AA; n = 24) patients diagnosed with possible or probable AD according to NINCDS-ADRDA diagnostic criteria., Measurements: The age of onset of AD was obtained from a knowledgeable family member. All patients were assessed for APOE genotype. History of alcohol and tobacco consumption prior to the onset of dementia was obtained via an interview with the patient and the primary caregiver. A history of heavy drinking was defined as >2 drinks per day and a history of heavy smoking was defined as > or =1 pack per day., Results: Presence of an APOE epsilon4 allele, a history of heavy drinking, or a history of heavy smoking were each associated with an earlier onset of AD by 2-3 years. Patients with all three risk factors were likely to be diagnosed with AD nearly 10 years earlier than those with none of the risk factors., Conclusion: The results suggest that APOE epsilon4 and heavy drinking and heavy smoking lower the age of onset for AD in an additive fashion.

Hypertension is very common in patients with chronic kidney disease (CKD); it causes early loss of kidney function and accelerated cardiovascular morbidity and mortality. African American patients with hypertension and genetic disposition are at an even higher risk for renal disease and ultimately renal failure. Hypertensive patients with CKD should aim for stringent blood pressure (BP) control (target < 130/80 mm Hg) requiring more than one drug with renin-angiotensin-aldosterone system blockade as a component of therapy targeting both hyper-tension and proteinuria. Management of hypertension in the dialysis population should focus on ambulatory measurements of BP and the use of longer-acting antihypertensive drugs, with their dosage and timing adjusted according to their dialytic clearances. Hypertension is also common among kidney transplant recipients and contributes to graft loss and premature death. The target BP in transplant recipients is the same as in the CKD population, with no preference for one drug group over another. Unless contraindicated, angiotensin-converting enzyme inhibitors remain the drugs of choice for hypertension in patients with autosomal-dominant polycystic kidney disease, in whom diastolic cardiac dysfunction is a prominent feature.