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BackgroundDue to the recent COVID-19 pandemic, patient care and medical education have faced many significant changes. The Association of American Medical Colleges and the American Council of Academic Plastic Surgery officially recommended halting all student rotations and interviews for the year. This change has unfortunately fallen squarely at the onset of a vital season for education and recruitment of plastic surgery subinterns. This article presents a curriculum for a single institution's virtual surgical subinternship to help inspire ideas and inspiration for programs developing their own virtual subinternships.MethodsThe goals for the virtual surgical subinternship are focused on student preparation for residency and remain similar to those outlined by the core competencies for in-person rotations. The first virtual subinternship in plastic surgery modeled after the curriculum presented was offered as a 2-week course starting May of 2020.ResultsThe components of the curriculum include a self-study syllabus, virtual case reviews, virtual suture laboratory, educational teleconferences, participation in research, and mentorship meetings. The 2-week course has approximately 25 hours of conferences and teaching, involving direct interaction with residents and faculty, and approximately 15 hours of self-directed learning.ConclusionsTo the authors' knowledge, this was the first virtual subinternship offered for rising fourth-year medical students. They strongly encourage other residency training programs to offer similar virtual learning opportunities for medical students, particularly for those without access to a home plastic surgery training program. The curriculum presented in this article is simply to provide ideas, inspiration, and a potential framework for programs wishing to create similar virtual learning opportunities.

Background and Purpose: Polygenic risk scores (PRSs) can be used to predict ischemic stroke (IS). However, further validation of PRS performance is required in independent populations, particularly older adults in whom the majority of strokes occur. Methods: We predicted risk of incident IS events in a population of 12 792 healthy older individuals enrolled in the ASPREE trial (Aspirin in Reducing Events in the Elderly). The PRS was calculated using 3.6 million genetic variants. Participants had no previous history of cardiovascular events, dementia, or persistent physical disability at enrollment. The primary outcome was IS over 5 years, with stroke subtypes as secondary outcomes. A multivariable model including conventional risk factors was applied and reevaluated after adding PRS. Area under the curve and net reclassification were evaluated. Results: At baseline, mean population age was 75 years. In total, 173 incident IS events occurred over a median follow-up of 4.7 years. When PRS was added to the multivariable model as a continuous variable, it was independently associated with IS (hazard ratio, 1.41 [95% CI, 1.20–1.65] per SD of the PRS; P P =0.004) compared with the lowest. The area under the curve of the conventional model was 66.6% (95% CI, 62.2–71.1) and after inclusion of the PRS, improved to 68.5 ([95% CI, 64.0–73.0] P =0.095). In subgroup analysis, the continuous PRS remained an independent predictor for large vessel and cardioembolic stroke subtypes but not for small vessel stroke. Reclassification was improved, as the continuous net reclassification index after adding PRS to the conventional model was 0.25 (95% CI, 0.17–0.43). Conclusions: PRS predicts incident IS in a healthy older population but only moderately improves prediction over conventional risk factors. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01038583.

Digital, Background and Purpose: The HOPE-3 trial (Heart Outcomes Prevention Evaluation–3) found that antihypertensive therapy combined with a statin reduced first stroke among people at intermediate cardiovascular risk. We report secondary analyses of stroke outcomes by stroke subtype, predictors, treatment effects in key subgroups. Methods: Using a 2-by-2 factorial design, 12 705 participants from 21 countries with vascular risk factors but without overt cardiovascular disease were randomized to candesartan 16 mg plus hydrochlorothiazide 12.5 mg daily or placebo and to rosuvastatin 10 mg daily or placebo. The effect of the interventions on stroke subtypes was assessed. Results: Participants were 66 years old and 46% were women. Baseline blood pressure (138/82 mm Hg) was reduced by 6.0/3.0 mm Hg and LDL-C (low-density lipoprotein cholesterol; 3.3 mmol/L) was reduced by 0.90 mmol/L on active treatment. During 5.6 years of follow-up, 169 strokes occurred (117 ischemic, 29 hemorrhagic, 23 undetermined). Blood pressure lowering did not significantly reduce stroke (hazard ratio [HR], 0.80 [95% CI, 0.59–1.08]), ischemic stroke (HR, 0.80 [95% CI, 0.55–1.15]), hemorrhagic stroke (HR, 0.71 [95% CI, 0.34–1.48]), or strokes of undetermined origin (HR, 0.92 [95% CI, 0.41–2.08]). Rosuvastatin significantly reduced strokes (HR, 0.70 [95% CI, 0.52–0.95]), with reductions mainly in ischemic stroke (HR, 0.53 [95% CI, 0.37–0.78]) but did not significantly affect hemorrhagic (HR, 1.22 [95% CI, 0.59–2.54]) or strokes of undetermined origin (HR, 1.29 [95% CI, 0.57–2.95]). The combination of both interventions compared with double placebo substantially and significantly reduced strokes (HR, 0.56 [95% CI, 0.36–0.87]) and ischemic strokes (HR, 0.41 [95% CI, 0.23–0.72]). Conclusions: Among people at intermediate cardiovascular risk but without overt cardiovascular disease, rosuvastatin 10 mg daily significantly reduced first stroke. Blood pressure lowering combined with rosuvastatin reduced ischemic stroke by 59%. Both therapies are safe and generally well tolerated., Correction to: Antihypertensives and Statin Therapy for Primary Stroke Prevention: A Secondary Analysis of the HOPE-3 Trial, Ciencias Médicas y de la Salud

OBJECTIVE: The aim of the review was to assess whether CHA2DS2-VASc score is predictive of mortality in patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI). BACKGROUND: The CHA2DS2-VASc score is validated in predicting stroke risk in atrial fibrillation. The optimum management strategy for these patients undergoing PCI is still debated. METHODS: The CHA2DS2-VASc score was calculated in consecutive patients with atrial fibrillation undergoing PCI in a large Australian registry between 2007 and 2013. Patients were divided into low (1-2), intermediate (3-4) and high (≥5) groups. Clinical and procedural data, 30-day, 1-year and long-term outcomes were compared between the groups. RESULTS: A total of 564 patients were included in our analysis. Patients with high CHA2DS2-VASc scores had higher mortality rates at 1-year (2, 8, 15; P = 0.002) and long-term (6, 20, 37; P

High office blood pressure variability (OBPV) in midlife increases the risk of cardiovascular disease (CVD), but the impact of OBPV in older adults without previous CVD is unknown. We conducted a post hoc analysis of ASPREE trial (Aspirin in Reducing Events in the Elderly) participants aged 70-years and older (65 for US minorities) without history of CVD events at baseline, to examine risk of incident CVD associated with long-term, visit-to-visit OBPV. CVD was a prespecified, adjudicated secondary end point in ASPREE. We estimated OBPV using within-individual SD of mean systolic BP from baseline and first 2 annual visits. Cox proportional hazards regression was used to calculate hazard ratios (HR) and 95% CI for associations with CVD events. In 16 475 participants who survived to year 2 without events, those in the highest tertile of OBPV had increased risk of CVD events after adjustment for multiple covariates, when compared with participants in the lowest tertile (HR, 1.36 [95% CI, 1.08–1.70]; P =0.01). Similar increased risk was observed for ischemic stroke (HR, 1.56 [95% CI, 1.04–2.33]; P =0.03), heart failure hospitalization, or death (HR, 1.73 [95% CI, 1.07–2.79]; P =0.02), and all-cause mortality (HR, 1.27 [95% CI, 1.04–1.54]; P =0.02). Findings were consistent when stratifying participants by use of antihypertensive drugs, while sensitivity analyses suggested the increased risk was especially for individuals whose BP was uncontrolled during the OBPV estimation period. Our findings support increased OBPV as a risk factor for CVD events in healthy older adults with, or without hypertension, who have not had such events previously. Registration— URL: https://www.clinicaltrials.gov ; Unique identifiers: NCT01038583; URL: https://www.isrctn.com ; Unique identifiers: ISRCTN83772183.

OBJECTIVES: The AHA/ACC-2017 hypertension guideline recommends an age-independent target blood pressure (BP) of less than 130/80 mmHg. In an elderly cohort without established cardiovascular disease (CVD) at baseline, we determined the impact of this guideline on the prevalence of hypertension and associated CVD risk. METHODS: Nineteen thousand, one hundred and fourteen participants aged at least 65 years from the ASPirin in Reducing Events in the Elderly (ASPREE) study were grouped by baseline BP: ‘pre-2017 hypertensive’ (BP ≥140/90 mmHg and/or on antihypertensive drugs); ‘reclassified hypertensive’ (normotensive by pre-2017 guidelines; hypertensive by AHA/ACC-2017 guideline), and ‘normotensive’ (BP

ObjectiveTo determine the effect of low-dose aspirin vs placebo on incident all-cause dementia, incident Alzheimer disease (AD), mild cognitive impairment (MCI), and cognitive decline in older individuals.MethodsAspirin in Reducing Events in the Elderly (ASPREE) was a double-blind, placebo-controlled trial of low-dose aspirin. In the United States and Australia, community-dwelling individuals aged ≥70 years (US minorities ≥65 years) and free of cardiovascular disease, physical disability, and diagnosed dementia were enrolled. Participants were randomized 1:1–100 mg daily aspirin or placebo. The Modified Mini-Mental State Examination, Hopkins Verbal Learning Test–Revised, Symbol Digit Modalities Test, and Controlled Oral Word Association Test assessed cognition at baseline and over follow-up. Additional cognitive testing was performed in participants with suspected dementia (“trigger”) based on within-study assessments or clinical history. Dementia was adjudicated according to DSM-IV criteria. National Institute on Aging–Alzheimer’s Association criteria were used for AD and MCI subclassification.ResultsA total of 19,114 participants were followed over a median 4.7 years and 964 triggered further dementia assessments. There were 575 adjudicated dementia cases, and 41% were classified as clinically probable AD. There was no substantial difference in the risk of all dementia triggers (hazard ratio [HR], 1.03; 95% confidence interval [CI], 0.91–1.17), probable AD (HR, 0.96; 95% CI, 0.74–1.24), or MCI (HR, 1.12; 95% CI, 0.92–1.37) between aspirin and placebo. Cognitive change over time was similar in the aspirin and placebo groups.ConclusionsThere was no evidence that aspirin was effective in reducing risk of dementia, MCI, or cognitive decline. Follow-up of these outcomes after initial exposure is ongoing.Classification of evidenceThis study provides Class II evidence that for healthy older individuals, low-dose aspirin does not significantly reduce the incidence of dementia, probable AD, MCI, or cognitive decline.Clinicaltrials.gov identifierNCT01038583.

Objectives: To investigate legacy effects at 14-year follow-up of all-cause and cardiovascular disease (CVD) mortality in 'treatment-naive' or 'previous treatment' groups based on blood pressure (BP)-lowering treatment status at baseline. Methods: A post-hoc observational study of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. We excluded participants with a previous history of CVD events. Cox proportional hazard model and 95% confidence interval were used to estimate the effects of treatment naive on mortality outcomes. Moreover, a subgroup analysis by estimated 10-year Framingham risk score was performed. Results: In multivariable models adjusting for baseline and in-trial characteristics (BP values and number of BP medications as time-dependent variables), there was no statistically significant difference in 5 and 14-year all-cause mortality with a hazard ratio of 0.93 (95% confidence interval 0.80-1.09) and hazard ratio 0.95 (0.88-1.03) and in 5 and 14-year CVD mortality hazard ratio 0.94 (0.72-1.23) and hazard ratio 0.93 (0.80-1.08). In subgroup by absolute CVD risk, no heterogeneity of the association between treatment naive and short-term or long-term all-cause or CVD mortality were found. All comparisons are between the treatment-naive and previous treatment groups. Conclusion: Physicians are concerned about 'legacy effects' of not treating individuals with a BP of 140 mmHg or over and low absolute risk. When treatment intensification was taken into consideration in the primary prevention population in this study, no adverse legacy effect as a result of baseline BP 'treatment naivety' was evident in 14 years of follow-up. The nonsignificant associations were consistent across the CVD risk subgroups. However, the results may be biased due to unobserved residual confounding and therefore should be interpreted with caution.

Current cardiovascular pharmacotherapy targets maladaptive overactivation of the renin-angiotensin-aldosterone system (RAAS), which occurs throughout the continuum of cardiovascular disease spanning from hypertension to heart failure with reduced ejection fraction. Over the past 16 years, 4 prospective, randomized, placebo-controlled clinical trials using candesartan, perindopril, irbesartan, and spironolactone in patients with heart failure with preserved ejection fraction (HFpEF) failed to demonstrate increased efficacy of RAAS blockade added to guideline-directed medical therapy. We reappraise these trials and their weaknesses, which precluded statistically significant findings. Recently, dual-acting RAAS blockade with sacubitril-valsartan relative to stand-alone valsartan failed to improve outcome in the PARAGON-HF trial (Efficacy and Safety of LCZ696 Compared with Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction). The majority of patients with HFpEF experience hypertension, frequently with subclinical left ventricular dysfunction, contributed to by comorbidities such as coronary disease, diabetes mellitus, overweight, and atrial fibrillation. Contrasting the findings in HFpEF, trials evaluating RAAS blockade on either side of HFpEF on the cardiovascular continuum in patients with high-risk hypertension and heart failure with reduced ejection fraction, respectively, showed positive outcomes. We do not have a biologically plausible explanation for such divergent efficacy of RAAS blockade. Based on considerations of well-established clinical efficacy in hypertension and heart failure with reduced ejection fraction and the shortcomings of aforementioned clinical trials in HFpEF, we argue that RAAS blockers including MRAs (mineralocorticoid receptor antagonists; aldosterone antagonists) should be used in the treatment of patients with HFpEF.

Background: The use of a polygenic risk score (PRS) to improve risk prediction of coronary heart disease (CHD) events has been demonstrated to have clinical utility in the general adult population. However, the prognostic value of a PRS for CHD has not been examined specifically in older populations of individuals aged ≥70 years, who comprise a distinct high-risk subgroup. The objective of this study was to evaluate the predictive value of a PRS for incident CHD events in a prospective cohort of older individuals without a history of cardiovascular events. Methods: We used data from 12 792 genotyped, healthy older individuals enrolled into the ASPREE trial (Aspirin in Reducing Events in the Elderly), a randomized double-blind placebo-controlled clinical trial investigating the effect of daily 100 mg aspirin on disability-free survival. Participants had no previous history of diagnosed atherothrombotic cardiovascular events, dementia, or persistent physical disability at enrollment. We calculated a PRS (meta-genomic risk score) consisting of 1.7 million genetic variants. The primary outcome was a composite of incident myocardial infarction or CHD death over 5 years. Results: At baseline, the median population age was 73.9 years, and 54.9% were female. In total, 254 incident CHD events occurred. When the PRS was added to conventional risk factors, it was independently associated with CHD (hazard ratio, 1.24 [95% CI, 1.08–1.42], P =0.002). The area under the curve of the conventional model was 70.53 (95% CI, 67.00–74.06), and after inclusion of the PRS increased to 71.78 (95% CI, 68.32–75.24, P =0.019), demonstrating improved prediction. Reclassification was also improved, as the continuous net reclassification index after adding PRS to the conventional model was 0.25 (95% CI, 0.15–0.28). Conclusion: A PRS for CHD performs well in older people and improves prediction over conventional cardiovascular risk factors. Our study provides evidence that genomic risk prediction for CHD has clinical utility in individuals aged 70 years and older. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01038583

Background: National cardiac registries are increasingly used for informing health policy, improving the quality and cost-effectiveness of patient care, clinical research, and monitoring the safety of novel treatments. However, the quality of registries is variable. We aimed to assess the characteristics and quality of national cardiac registries across all subspecialties of cardiac care. Methods: Publications relating to national cardiac registries across six cardiac subspecialty domains were identified by searching MEDLINE and the Google advanced search function with 26 438 citations and 4812 full-text articles reviewed. Results: A total of 155 registries, representing 49 countries, were included in the study. Of these, 45 related to coronary disease or percutaneous coronary intervention, 28 related to devices, arrhythmia, and electrophysiology, 24 related to heart failure, transplant, and mechanical support, 21 related to structural heart disease, 21 related to congenital heart disease, and 16 related to cardiac surgery. Enrollment was procedure-based in 60% and disease-based in 40%. A total of 73.10 million patients were estimated to have been enrolled in cardiac registries. Quality scoring was performed using a validated registry grading system, with registries performing best in the use of explicit variable definitions and worst in assessment of data reliability. Higher quality scores were associated with government funding, mandated enrollment, linkage to other registries, and outcome risk adjustment. Quality scores and number of registries within a country were positively correlated with each other and with measures of national economic output, health expenditure, and urbanization. Conclusions: There has been remarkable growth in the uptake of national cardiac registries across the last few decades. However, the quality of processes used to ensure data completeness and accuracy remain variable and few countries have integrated registries covering multiple subspecialty domains. Clinicians, funders, and health policymakers should be encouraged to focus on the range, quality, and integration of these registries. Registration: URL: https://www.crd.york.ac.uk/prospero ; Unique identifier: CRD42020204224.

BACKGROUND The authors sought to identify factors associated with current chiefs and chairpersons in academic plastic surgery to encourage and shape future leaders of tomorrow. METHODS Academic chairpersons in plastic surgery (n = 94) were identified through an Internet-based search of all Accreditation Council for Graduate Medical Education-accredited residency training programs during the year 2015. Sex, ethnicity, academic rank, board certification, time since certification, medical school attended, residency program attended, fellowships training, advanced degrees, obtaining leadership roles at trainee's institution, and h-index were analyzed. RESULTS Of the 94 chiefs and chairpersons, 96 percent were male and 81 percent obtained full professor status, and 98 percent were certified by the American Board of Plastic Surgery. Mean time since certification was 22 years (range, 7 to 45 years). Fifty-one percent graduated from 20 medical schools, whereas 42 percent graduated from only nine plastic surgery training programs. Fifty-six percent had pursued fellowship beyond their primary plastic surgery training. Eighteen percent had obtained advanced degrees. Twenty-nine percent of chiefs and chairpersons obtained leadership roles at the institution where they had completed plastic surgery training. The mean h-index was 17.6 (range, 1 to 63). Graduates of the nine most represented residency programs had a mean h-index of 21 versus 15 when compared with the remaining chief/chairpersons (p < 0.0062). CONCLUSION Leaders in plastic surgery are more likely to be male, hold academic rank of professor, and have completed a fellowship after residency.

PURPOSE For many types of surgical cases, there is an increase in length with the participation of a resident physician. The lost operative time productivity is not necessarily mitigated in any fashion other than to benefit the experience of the trainee. Moreover, increasing pressures to maximize productivity, coupled with diminishing reimbursements serve to disincentive resident involvement. The aim of this study was to examine the opportunity cost in the academic setting for intraoperative resident participation during specific hand surgery cases. METHODS Retrospective analysis was performed on the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database from 2006 to 2015. Cases were identified by Current Procedural Terminology code to isolate distal radius fracture repairs, carpal tunnel releases, scaphoid fractures repairs, and metacarpal fracture repairs. Variables collected included operation time, presence or absence of resident physician, and postgraduate year level. Statistical analysis was performed using the statistical computing software R 3.4.2 (R Foundation for Statistical Computing, Vienna, Austria). Cost analysis was performed to quantify the effect of operative times in terms of relative value units (RVUs) lost. RESULTS A total of 3727 cases were identified. Of those, 1264 cases were performed with a resident present. Residents participated in cases with higher total RVU (14.91 vs 13.16, P < 0.001). There was a statistically significant increase of 24.3 minutes (P < 0.001) in the mean operation time with a resident present as compared with those without. Moreover, RVU per hour in resident cases was significantly lower by 2.97 RVU per hour or 21% (P < 0.001). Using the late 2018 Medicare physician conversion factor of US $33.9996, the opportunity cost to attending physicians is US $159.20 per case. CONCLUSIONS Resident participation in surgical cases is paramount to the education of future trainees, particularly in the era of trainee duty hour reform. Because residents are participating in higher total RVU cases, this selection bias may be playing a role in explaining our result. Nonetheless, resident involvement for certain procedures comes at an opportunity cost to faculty surgeons. How to balance the cost to train residents in the emerging value-based health systems will prove to be challenging but requires consideration.

Background The limitations of the soft-tissue envelope, devascularized bone grafts, and relapse of the deformity are important considerations in the surgical treatment of unicoronal craniosynostosis. The authors report their technique evolution of distraction osteogenesis for treatment of patients with unicoronal craniosynostosis. Methods Open anterior cranial vault reconstruction combined with internal distraction was used, with the aid of virtual surgical planning. Technique evolution included maximizing bone flap perfusion by means of limited rotational flap osteotomies, and preservation of dural attachments. Clinical and procedural characteristics including distraction protocol, intracranial volume change, efficiency of distraction, transfusion, operative time, length of hospitalization, complications, and postoperative outcomes were analyzed. Results Sixteen patients with nonsyndromic unicoronal craniosynostosis underwent repair between August of 2013 and December of 2016. Mean age was 9.0 months. Distractors were advanced a mean of 27.1 mm and achieved a cranial volume change of 29.5 percent, with a mean efficiency of 1.3 percent increase per millimeter of distraction. Mean operating time was 169.3 minutes. Complications were predominately related to infections at the distractor site. At most recent follow-up, all patients had a Whitaker grade I result. Conclusions Distraction osteogenesis can be a safe and effective method of achieving satisfactory aesthetic outcomes and volume expansion for patients with unicoronal craniosynostosis. The technique presented is proposed to maximize bone flap viability and limit relapse of deformity. Further long-term follow-up is needed for definitive comparison with traditional anterior cranial vault reconstruction. Clinical question/level of evidence Therapeutic, IV.

Introduction: Cardiovascular disease (CVD) risk management is suboptimal in Australian primary healthcare. Following trials demonstrating efficacy of individual components, we developed a complex intervention comprised primarily of electronic point-of-care decision support, availability of cardiovascular polypills and a pharmacy-based adherence program. We sought to determine whether this combined multifaceted intervention, compared with usual care, would improve control of CVD risk factors in the Australian primary care setting. Methods and Results: In a parallel-arm cluster randomized trial, 71 general practices were allocated 1:1 either to the intervention or usual care. The primary outcome was the proportion of patients at high CVD risk and not on optimal preventive treatments at baseline (“high-risk under-treated”) achieving both blood pressure (BP) and low density lipoprotein (LDL) cholesterol targets at study end (BP ≤140/90 mmHg, or ≤130/80 mmHg in people with diabetes or albuminuria; LDL Conclusions: Despite the proven efficacy of individual components, this complex multifaceted intervention was poorly adopted and did not lead to relevant improvements in cardiovascular risk factor outcomes.

Blood pressure (BP) increases with age and is a major risk factor for cardiovascular disease (CVD). We examined change in BP level over a median of 4.7 years in ASPirin in Reducing Events in the Elderly trial participants, and its association with CVD events. Participants with baseline and at least one in-trial BP measurement were included. Since CVD event can affect BP (before and after), participants having a non-fatal CVD event in between in-trial BP records were excluded. Participants were classified according to baseline BP level, irrespective of antihypertensive use, into three groups (A) normal (SBP

Greater blood pressure variability (BPV) in midlife increases risk of future cardiovascular disease (CVD) events, but the impact of BPV in adults who have reached older ages while remaining free of CVD is unknown. We examined risk of overall incident CVD, ischemic stroke subgroup, and all-cause mortality associated with long-term, visit-to-visit BPV in participants of the ASPirin in Reducing Events in the Elderly study, a randomized primary prevention trial of daily low-dose aspirin in community-dwelling adults in Australia and the United States (US) aged 70 and older (65 if US minority) without evidence of CVD. The mean of three blood pressures (BP) using an automated cuff was recorded at baseline and annually. CVD was a prespecified composite secondary endpoint of ASPREE, and included fatal coronary heart disease, nonfatal MI, fatal or nonfatal stroke, or hospitalization for heart failure. All CVD events were adjudicated as part of the main trial. This analysis included participants who survived without CVD to the second annual visit and had BP recorded at baseline, years 1 and 2 (n=16,482). BPV was defined as within-individual standard deviation of mean systolic BP across these visits. Cox proportional hazards regression adjusting for confounders was used to calculate hazard ratios (HR) according to tertile of estimated BPV, with year 2 as time zero to minimize immortal time bias. Our results (Table) show that higher visit-to-visit BPV in older adults without previous CVD is associated with increased risk of future CVD events, ischemic stroke, and all-cause mortality, suggesting that BPV in older ages should be considered a potential therapeutic target for CVD risk-lowering.

Greater blood pressure variability (BPV) in midlife increases the risk of dementia, but the impact of BPV in cognitively intact older adults is unknown. We examined the risk of incident dementia and cognitive decline associated with long-term, visit-to-visit BPV in participants of the ASPirin in Reducing Events in the Elderly (ASPREE) study, a randomized primary prevention trial of daily low-dose aspirin in community-dwelling adults in Australia and the US aged 70 and older (65 if US minority), who were free of dementia or evidence of cognitive impairment at enrollment. The mean of three BPs using an automated cuff was recorded at baseline and annually; participants also underwent baseline and biennial standardized assessments of global cognition, delayed episodic memory, verbal fluency, processing speed and attention. Cognitive decline was pre-specified as a >1.5 standard deviation (SD) decline in score from baseline on any of the cognitive tests, while incident dementia was a pre-specified secondary endpoint of ASPREE which was adjudicated using DSM-IV criteria. BPV was estimated using within-individual SD of mean systolic BP across baseline and the first two annual visits, and participants with cognitive decline or incident dementia during this period were excluded from the analysis to avoid immortal time bias. After adjustment for key covariates, Cox proportional hazards regression revealed increased risks for dementia and cognitive decline during follow-up for individuals in the highest SD tertile of BPV (Table). Our findings suggest that high BPV in older ages should be considered a potential therapeutic target to preserve cognitive function.

Complex abdominal wall defects remain a common problem, though there has been significant advancement in technique and biomaterials over the last decade. The newly developed hybrid meshes are targeted to address several shortcomings of other meshes. Specifically, the marriage of biosynthetic or biologic materials with permanent prosthetic material is designed so that each will counteract the other's negative attributes. There are reports of permanent meshes having been associated with chronic pain, stiffness, and inflammation. However, their utility in maintaining biomechanical strength, thus limiting recurrence, makes them of value. In hybrid meshes, biosynthetic or biologic materials are coupled with permanent prosthetics, potentially protecting them from exhibiting deleterious effects by promoting and hastening tissue ingrowth. The various hybrid meshes currently available and investigational data are reviewed.

INTRODUCTION Methods of reporting quantitative results for distraction osteogenesis (DO) of craniosynostosis have been inconsistent. Therefore, the efficacy of differing techniques and timing in regard to volume change is not well established, with no uniform metric for comparisons. Given that cranial vault remodeling with DO may be completed with different approaches, analysis was made to determine (1) the relative efficiency of different approaches in expanding intracranial volume (ICV) and (2) the impact of adjusting for ICV growth on measured DO efficiency. METHODS Patients with craniosynostosis were treated with open cranial vault reconstruction combined with internal distraction. Preoperative and postoperative computed tomography scans were used to quantify ICV change. The metric was determined by dividing percent ICV change by total distraction length. The metric was used as a proxy for efficiency to compare posterior and anterior distraction between groups using the Mann-Whitney U test and within a subgroup of patients who underwent 2-stage distraction using the Wilcoxon matched-pairs signed rank test. RESULTS Twenty patients underwent cranial vault remodeling with DO: 14 unicoronal, 3 bicoronal, 2 multisutural, and 1 lambdoid. Results are reported in medians. Distraction efficiency was 0.99%/mm for primary anterior, unilateral distraction for unicoronal patients (n = 13, aged 9.1 months) and 4.28%/mm for posterior distraction using multiple distractors (n = 4, aged 6.3 months). In terms of the metric, primary posterior distraction was significantly more efficient than primary anterior distraction (P = 0.007). Three patients who had undergone primary posterior distraction later underwent secondary anterior distraction. Again, posterior distraction was shown to be significantly more efficient (5.16 vs 0.62, P = 0.050). For the unicoronal patients who received anterior unilateral distraction, an adjusted metric was calculated to account for normal intracranial growth. This was found to be 0.39%/mm, which was significantly different from the unadjusted metric (P = 0.0001). CONCLUSIONS Posterior distraction is more efficient for ICV expansion than anterior distraction, which may have implications for the choice of approach for craniosynostosis repair. In addition, this is the first report of a novel standardized metric for analyzing ICV change achieved by DO. This tool allows for adjusting the efficiency metric for expected ICV growth, which significantly impacts its value.

INTRODUCTION Timing of intervention and complication profiles in surgical repair of craniosynostosis have been widely debated. Early intervention is frequently promoted as a means of decreasing morbidity while maintaining favorable outcomes via minimally invasive techniques such as endoscopic strip craniectomy. Immediate postoperative morbidity due to complications of early vs late intervention remains a key element in comparing timing and technique for craniosynostosis repair. In addition, concurrent fronto-orbital advancement with open cranial vault remodeling may increase the risk of postoperative complications. We present an evaluation of surgical timing and the presence of fronto-orbital advancement as independent predictors of in-hospital complications after craniosynostosis repair. METHODS Retrospective analysis was performed in the National Inpatient Sample database from 1998 to 2009. Patients younger than 3 years having undergone elective surgical repair for craniosynostosis were identified. Comorbidities, demographics, transfusion status, and syndromic diagnosis were included as covariates. A multivariate regression model was used to characterize the association between age at the time of surgery and in-hospital complications. A subgroup analysis using the variable of concurrent fronto-orbital advancement was restricted to patients 8 to 24 months of age to exclude endoscopic craniosynostosis repair, which is traditionally repaired less than 6 months of age. Multivariate logistic regression was used to assess the impact of concurrent fronto-orbital advancement on postoperative complications. RESULTS A total of 6010 craniosynostosis surgery cases (42.9%, age 0-7 months; 29.5%, age 8-12 months; and 27.6%, age 13-36 months) were included. Patients in the 7-to 12-month age group were more likely to experience complications when compared with the 0- to 6-month age group (odds ratio [OR],1.32; P < 0.05) and 13-to 36-month age group (OR, 1.32; P = 0.056). Syndromic patients (OR, 1.92; P < 0.001) and patients receiving an intraoperative blood transfusion (OR, 1.60; P < 0.05) demonstrated an increased risk for complications. In the subanalysis of 2936 patients aged 8 to 24 months, 15.1% of patients received frontoorbital advancement, which was associated with a significantly increased risk of complications (OR, 1.43; P < 0.05). CONCLUSIONS Intermediate age (7-12 months) and concurrent fronto-orbital repair were independent risk factors for immediate postoperative complications. These findings may better inform the decision-making process for craniosynostosis repair in terms of timing and need for concurrent fronto-orbital reconstruction.

There is a critical need for blood pressure–lowering strategies that have greater efficacy and minimal side effects. Low-dose combinations hold promise in this regard, but there are few data on very-low-dose therapy. We, therefore, conducted a systematic review and meta-analysis of randomized controlled trials with at least one quarter-dose and one placebo and standard-dose monotherapy arm. A search was conducted of Medline, Embase, Cochrane Registry, Food and Drug Administration, and European Medicinal Agency websites. Data on blood pressure and adverse events were pooled using a fixed-effect model, and bias was assessed using Cochrane risk of bias. The review included 42 trials involving 20 284 participants. Thirty-six comparisons evaluated quarter-dose with placebo and indicated a blood pressure reduction of −4.7/−2.4 mm Hg ( P P P P P

Introduction Truly informed consent is an elusive goal, seldom attained in medical or surgical practice. Patients often do not fully understand procedures and therapies they undergo or the associated sequelae. Historically, informed consent and patient education have been limited to physician discussions, sometimes with the addition of simple visual aids. More recently, there is a growing body of decision aids available, including interactive multimedia patient educational modules that review preoperative through postoperative care, risks, benefits, alternatives, different surgical options, as well as commonly asked questions. We hypothesized that the addition of a Web-based educational tool would positively impact attainment of informed consent and satisfaction in plastic surgery patients. Methods We performed a prospective randomized controlled study comparing patients who presented in consultation for breast reconstruction, breast reduction, and abdominoplasty. Patients received standard patient education along with a procedure-specific (study) or general patient safety (control) Web-based educational module. Informed consent was measured using a surgical-focused, modified version of the Shared Decision-making 25 index tool. Patient demographic information as well as surrogate markers of familiarity with technology were recorded preoperatively and postoperatively. Comparisons were made between study and control groups, procedure subgroups, and preoperative and postoperative time points. Demographic factors and consent variables were compared among experimental and procedure groups. Results Data were collected from 65 patients preoperatively and 48 patients postoperatively. Thirty patients competed both surveys. Overall, no differences in patient characteristics or familiarity with technology were observed between experimental groups. Demographic characteristics were also similar between groups. No meaningful differences were identified in comparisons between experimental groups on either cross-sectional or longitudinal analyses. Nearly all patient responses were consistent with being well informed and satisfied with the educational process. Conclusions Overall, patients undergoing plastic surgery procedures are adequately informed and have a high degree of satisfaction regarding their patient education. The addition of a Web-based informed consent tool did not make a demonstrable difference in informed consent.

Background Information is scarce regarding effects of antihypertensive medication on blood pressure variability ( BPV ) and associated clinical outcomes. We examined whether antihypertensive treatment changes BPV over time and whether such change (decline or increase) has any association with long‐term mortality in an elderly hypertensive population. Methods and Results We used data from a subset of participants in the Second Australian National Blood Pressure study (n=496) aged ≥65 years who had 24‐hour ambulatory blood pressure recordings at study entry (baseline) and then after a median of 2 years while on treatment (follow‐up). Weighted day‐night systolic BPV was calculated for both baseline and follow‐up as a weighted mean of daytime and nighttime blood pressure standard deviations. The annual rate of change in BPV over time was calculated from these BPV estimates. Furthermore, we classified both BPV estimates as high and low based on the baseline median BPV value and then classified BPV changes into stable: low BPV , stable: high BPV , decline: high to low , and increase: low to high . We observed an annual decline (mean± SD : −0.37±1.95; 95% CI, −0.54 to −0.19; P BPV between baseline and follow‐up. Having constant stable: high BPV was associated with an increase in all‐cause mortality (hazard ratio: 3.03; 95% CI, 1.67–5.52) and cardiovascular mortality (hazard ratio: 3.70; 95% CI, 1.62–8.47) in relation to the stable: low BPV group over a median 8.6 years after the follow‐up ambulatory blood pressure monitoring. Similarly, higher risk was observed in the decline: high to low group. Conclusions Our results demonstrate that in elderly hypertensive patients, average BPV declined over 2 years of follow‐up after initiation of antihypertensive therapy, and having higher BPV (regardless of any change) was associated with increased long‐term mortality.

BACKGROUND The optimal timing of angiography and percutaneous coronary intervention (PCI) in patients with non-ST elevation acute coronary syndromes (NSTEACS) remains uncertain. We sought to assess clinical characteristics and outcomes of patients in real-world contemporary practice who have early versus delayed PCI for NSTEACS. METHODS We analyzed baseline clinical and procedural characteristics of 4307 patients with NSTEACS who underwent PCI from the Melbourne Interventional Group registry. Patients were assigned to the early PCI group if intervention was performed within a calendar day of presentation. The delayed PCI group received an intervention after one calendar day, but within the index admission. We assessed 30 days and 12-month mortality, myocardial infarction, target vessel revascularization, and major adverse cardiovascular events. The safety endpoint was in-hospital bleeding. RESULTS Of the 4307 patients, 2210 (51%) received early PCI. The delayed PCI group were older (67±12 vs. 64±12, P

Background The transition to the Next Accreditation System is well underway, and a shift toward competency-based assessment in the form of milestones is now the standard. A significant effort has been completed by the Plastic Surgery Milestones Working Group to develop specific milestones and assessment tools for plastic surgery training. Methods The history of the development toward competency-based assessment was reviewed. Data regarding the trends and regulations associated with board certification and the role of maintenance of certification were reviewed. Results The work of the Plastic Surgery Milestones Working Group has sparked interest in assessment and created an opportunity for further development. The efforts toward validating assessment tools by our colleagues working in other surgical specialties serve as a suitable roadmap for further progress. Board certification is an integral part of successful practice and should be regarded as an expectation. Despite the burdens associated with maintenance of certification, it serves a valuable function in ensuring optimal patient care and is often retrospectively seen as an important component of practice. Conclusions The competency-based milestones are the new standard, and work on this new methodology of assessing plastic surgery trainees is expected to continue. Accurate assessment is critical to the pathways for board certification and maintenance of certification, which serve important roles for all parties involved in the delivery of medical care.

Objectives: Current blood pressure (BP) management guidelines recommend that treatment thresholds for BP be based on absolute cardiovascular disease (CVD) risk rather than on elevated BP levels alone. Clinicians are concerned that delayed pharmacotherapy in individuals with high BP, but low CVD risk, may increase long-term CVD events. To investigate this, we examined differences in CVD events within the Second Australian National BP study (ANBP2) for those previously on pharmacotherapy and those who were not, as well as fatal events in the 6-year post-trial period. Methods: Population consisted of ANBP2 participants without a prior CVD event. Adjusted Cox-regression hazard models were used to assess the effects of prior BP pharmacotherapy use on cardiovascular endpoints within ANBP2. An extended 6-year follow-up analysis for cardiovascular and all-cause mortality was also conducted. Results: We found a higher in-trial CVD and all-cause mortality rate and incidence of new-onset diabetes for those on previous treatment versus those who were treatment-naive. We investigated whether this was an effect of the in-trial protocol, but this did not explain the observed differences. No difference in CVD or all-cause mortality at 10 years was observed between 'treatment-naive' and 'previous treatment' groups. Conclusion: We found no long-term adverse mortality associated with treatment naivety of elevated BP in an elderly hypertensive cohort, but this finding is likely to be confounded as seen by the lower in-trial mortality in the 'treatment-naive' group. Legacy effects need to be explored in randomized trials of middle-aged populations where the clinical concern lies.

Objective:To examine the cost-effectiveness of angiotensin-converting enzyme inhibitor-based (ACEI) treatment compared to thiazide diuretic-based treatment for hypertension in elderly Australians considering diabetes as an outcome along with cardiovascular outcomes from the Australian government per

Background There is debate whether the J-curve relationship between cardiac event risk and DBP is because of inherent cardiac risk or is a consequence of blood pressure (BP) lowering therapy. Methods We examined the association between the cardiovascular risk marker amino-terminal-pro-B-type natriuretic peptide (NT-proBNP) and DBP in 1781 women and 2211 men aged at least 60 years with one or more cardiovascular risk factors; exclusion criteria were known heart failure or cardiac abnormality on a cardiac imaging study. Results The lowest median serum NT-proBNP levels were for DBP 85-89 mmHg for both women and men. DBP less than 70 mmHg in women and less than 80 mmHg in men was associated with higher NT-proBNP levels than the levels at DBP 85-89 mmHg, and this relationship was present for those with SBP equal to or less than 140 and SBP greater than 140 mmHg. In conditional logistic regression models, the association of elevated NT-proBNP levels with low DBP in women was no longer statistically significant after adjustment for age, ischaemic heart disease (IHD), pulse rate, atrial fibrillation, haemoglobin and glomerular filtration rate, whereas the association in men was no longer statistically significant after adjustment for age and IHD. By contrast, the association between elevated NT-proBNP levels and low DBP remained statistically significant after adjustment for the number of antihypertensive drug classes alone or together with all antihypertensive drugs, including β-blocker therapy. Conclusion There was a J-curve relationship between the cardiovascular risk marker NT-proBNP and DBP that was explained by the clinical variables and not by the BP-lowering therapy.

Obectives: In hypertensive persons aged 60 years or below, visit-to-visit SBP variability is directly associated with cardiovascular events, especially stroke. It is unclear whether such a relationship exists for older persons. We investigated whether there is a relationship between visit-to-visit SBP variability and cardiovascular events in an elderly population, and identified the factors associated with increased SBP variability. Methods: Information from 49771 visits of 5880 patients aged at least 65 years being treated for hypertension in the Second Australian National Blood Pressure study was used. Patients were followed for 4.1 (median) years and had eight (median) doctor visits during the study. SBP variability was defined as within-individual SD of SBP across study follow-up visits. Results: Increased visit-to-visit SBP variability was found to be a strong predictor for future cardiovascular events in this elderly population. The hazard ratio (95% confidence interval) for any first fatal/nonfatal cardiovascular event for highest decile compared with lowest decile of SBP variability was 2.18 (1.52-3.13) after adjusting for sex, age, treatment including other baseline variables, and average on-treatment SBP. A similar effect was observed for stroke (hazard ratio 2.78, 1.28-6.05), myocardial infarction (hazard ratio 4.11, 1.87-9.06), and heart failure (hazard ratio 4.79, 1.82-12.62). Highest SBP variability was also a predictor of post-trial fatal cardiovascular events. Increased visit-to-visit SBP variability was related to age, pulse pressure, changing physicians, smoking, treatment allocation, and the use of multiple BP-lowering drugs. Conclusion: These findings suggest that reducing visit-to-visit SBP variability might be an important objective in addition to conventional blood pressure-lowering in elderly hypertensive patients.

ObjectiveTo examine the genotype to phenotype connection in glucose transporter type 1 (GLUT1) deficiency and whether a simple functional assay can predict disease outcome from genetic sequence alone.MethodsGLUT1 deficiency, due to mutations in SLC2A1, causes a wide range of epilepsies. One possible mechanism for this is variable impact of mutations on GLUT1 function. To test this, we measured glucose transport by GLUT1 variants identified in population controls and patients with mild to severe epilepsies. Controls were reference sequence from the NCBI and 4 population missense variants chosen from public reference control databases. Nine variants associated with epilepsies or movement disorders, with normal intellect in all individuals, formed the mild group. The severe group included 5 missense variants associated with classical GLUT1 encephalopathy. GLUT1 variants were expressed in Xenopus laevis oocytes, and glucose uptake was measured to determine kinetics (Vmax) and affinity (Km).ResultsDisease severity inversely correlated with rate of glucose transport between control (Vmax = 28 ± 5), mild (Vmax = 16 ± 3), and severe (Vmax = 3 ± 1) groups, respectively. Affinities of glucose binding in control (Km = 55 ± 18) and mild (Km = 43 ± 10) groups were not significantly different, whereas affinity was indeterminate in the severe group because of low transport rates. Simplified analysis of glucose transport at high concentration (100 mM) was equally effective at separating the groups.ConclusionsDisease severity can be partly explained by the extent of GLUT1 dysfunction. This simple Xenopus oocyte assay complements genetic and clinical assessments. In prenatal diagnosis, this simple oocyte glucose uptake assay could be useful because standard clinical assessments are not available.

Objective: To understand the molecular basis and differential penetrance of febrile seizures and absence seizures in patients with the γ2(R43Q) GABA A receptor mutation. Methods: Spike-and-wave discharges and thermal seizure susceptibility were measured in heterozygous GABA A γ2 knock-out and GABA A γ2(R43Q) knock-in mice models crossed to different mouse strains. Results: By comparing the GABA A γ2 knock-out with the GABA A γ2(R43Q) knock-in mouse model we show that haploinsufficiency underlies the genesis of absence seizures but cannot account for the thermal seizure susceptibility. Additionally, while the expression of the absence seizure phenotype was very sensitive to mouse background genetics, the thermal seizure phenotype was not. Conclusions: Our results show that a single gene mutation can cause distinct seizure phenotypes through independent molecular mechanisms. A lack of effect of genetic background on thermal seizure susceptibility is consistent with the higher penetrance of febrile seizures compared to absence seizures seen in family members with the mutation. These mouse studies help to provide a conceptual framework within which clinical heterogeneity seen in genetic epilepsy can be explained.

Estimating absolute risk rather than measurement of blood pressure alone is considered the best way to identify those who would most likely benefit from medical intervention. Risk calculators used to estimate risk in those without previous cardiovascular disease (CVD) events are based on the Framingham Heart Study, which had no person >74 years of age at baseline. This needs to be addressed, because age is the most important determinant of risk. We estimated the predictive value of 3 risk equations for CVD end points in the Second Australian National Blood Pressure study cohort (mean age: 71.9 years at baseline). Observed and predicted 5-year incidence rates, χ 2 goodness-of-fit tests, and Harrell C statistic and area under the receiver operator characteristic curve were used to assess the ability of the equations to predict CVD outcomes over 5 years. A recalibration analysis was undertaken. Significant ( P 2 goodness-of-fit statistics were observed using each of the risk equations for myocardial infarction, coronary heart disease, stroke, or CVD morbidity or mortality across age groups and both sex. All of the overall C statistics or the area under the receiver operator characteristic curve indicated modest discrimination of the algorithms for prediction of the outcomes for coronary heart disease and CVD morbidity and mortality, myocardial infarction, or stroke (Framingham); cardiac death (Pocock); and CVD events (Dubbo). Recalibration analyses showed that it would be inappropriate to apply the risk equations to the Second Australian National Blood Pressure study population. New risk equations for CVD events in the hypertensive aged are needed.

Central arterial waveforms and related indices of large artery properties can be determined with relative ease. This would make them an attractive adjunct in the risk stratification for cardiovascular disease. Although they have been associated with some classical risk factors and the presence of coronary disease, their prospective value in predicting cardiovascular outcomes is unknown. The present study determined the relative predictive value for cardiovascular disease-free survival of large artery properties as compared with noninvasive brachial blood pressure alone in a population of elderly female hypertensive subjects. We measured systemic arterial compliance, central systolic pressure, and carotid augmentation index in a subset of female participants in the Second Australian National Blood Pressure Study (untreated blood pressure 169/88±12/8 mm Hg). There were a total of 53 defined events during a median of 4.1 years of follow-up in 484 women with complete measurements. Although baseline blood pressures at the brachial artery predicted cardiovascular disease-free survival (hazard ratio [HR], 2.3; 95% CI, 1.3 to 4.1 for pulse pressure ≥81 versus P =0.01), no such relation was found for carotid augmentation index (HR, 0.80; 95% CI, 0.44 to 1.44; P value not significant) or systemic arterial compliance (HR, 1.25; 95% CI, 0.72 to 2.16; P value not significant). Blood pressure, but not noninvasively measured central arterial waveforms, predict outcome in the older female hypertensive patient. Thus, blood pressure measurement alone is superior to measurement of arterial waveforms in predicting outcome in this group.

Continuous venovenous hemofiltration (CVVH) is used for renal replacement and fluid management in critically ill children. A previous small study suggested that survival was associated with less percent fluid overload (%FO) in the intensive care unit (ICU) before hemofiltration. We reviewed our experience with a large series of pediatric CVVH patients to evaluate factors associated with outcome.Retrospective chart review.Tertiary children's hospital.CVVH pediatric ICU patients from November 1997 to January 2003.None.%FO was defined as total fluid input minus output (up to 7 days before CVVH for both hospital stay and ICU stay) divided by body weight. One hundred thirteen patients received CVVH; 69 survived (61%). Multiple organ dysfunction syndrome (MODS) was present in 103 patients; 59 survived (57%). Median patient age was 9.6 yrs (25th, 75th percentile: 2.5, 14.3). Median %FO was significantly lower in survivors vs. nonsurvivors for all patients (7.8% [2.0, 16.7] vs. 15.1% [4.9, 25.9]; p =.02] and in patients withor =3-organ MODS (9.2% [5.1,16.7] vs. 15.5% [8.3, 28.6]; p =.01). The Pediatric Risk of Mortality Score III at CVVH initiation also was associated with survival in these groups, but by multivariate analysis, %FO was independently associated with survival in patients withor =3-organ MODS (p =.01).Survival in critically ill children receiving CVVH in this large series was higher than in previous reports. CVVH survival may be associated with less %FO in patients withor =3-organ MODS. Prospective studies are necessary to determine whether earlier use of CVVH to control fluid overload in critically ill children can improve survival.

Objectives The role of ambulatory blood pressure monitoring (ABPM) in the elderly is unclear. This study has examined differences between clinic and ambulatory blood pressure (BP) in a large cohort of older hypertensives, with particular respect to the factors influencing the direction and magnitude of this difference. Design The Second Australian National Blood Pressure Study (ANBP2) is a general practice-based randomized-outcome trial in 6083 older hypertensives treated with an angiotensin-converting enzyme (ACE) inhibitor or diuretic-based regimen. Before starting treatment a subset of 713 patients (age range 65-83 years) had a 'successful' 26-hour ambulatory blood pressure recording with a SpaceLabs 90207 (TM) recorder. Results Average clinic BP (+/- SD) was 167 +/- 12/ 90 +/- 8 mmHg. Average daytime ambulatory BP was 157 +/- 15*/89 +/- 10* mmHg and night ambulatory BP was 137 +/- 16(+)/74 +/- 10(+) mmHg (different from clinic BP: *P < 0.01;from daytime ambulatory BP: P+ < 0.001). Twenty-one to 45% of all patients had higher daytime systolic or diastolic ambulatory BP than clinic readings, with smoking, previous treatment for hypertension and lower clinic BP being the main predictors of this 'reverse white-coat effect. Conclusions Although mean daytime ambulatory blood pressures were lower than clinic readings in this large cohort of untreated older hypertensives, a substantial proportion showed the reverse of the so-called 'white-coat effect'. These findings identify the important role for ABPM in the elderly, not only for avoiding overtreatment in those with typical 'white-coat hypertension' but also for ensuring adequate treatment is given to those with the reverse of this phenomenon. J Hypertens 20:639-644 (C) 2002 Lippincott Williams Wilkins.

OBJECTIVES The timing of arterial wave reflection affects the shape of the arterial waveform and thus is a major determinant of pulse pressure. This study assessed differences in wave reflection between genders beyond the effect of body height. METHODS From 1123 elderly (aged 71 +/- 5 years) currently untreated hypertensives, we selected 104 pairs of men and women with identical body height (average 164 +/- 4 cm). All subjects underwent echocardiography, including measurement of aortic arch expansion, automated blood pressure measurements, measurement of ascending aortic blood flow and simultaneous carotid artery tonometry. RESULTS Women had higher pulse (80 +/- 17 versus 74 +/- 17 mmHg, P < 0.05) and lower diastolic pressure (79 +/- 11 versus 82 +/- 10 mmHg, P < 0.05). Whilst heart rate was similar, women had a longer time to the systolic peak (210 +/- 28 versus 199 +/- 34 ms, P < 0.01) and a longer ejection time (304 +/- 21 versus 299 +/- 25 ms, P < 0.001). Wave reflection occurred earlier in women (time between maxima 116 +/- 55 versus 132 +/- 47 ms, P < 0.05) and augmentation index was higher (36 +/- 11 versus 28 +/- 12%, P < 0.001). Aortic diameter was smaller in women and the aortic arch was stiffer (median Ep 386 versus 302 kN/m2, P < 0.05). Hence, systemic arterial compliance was less in women (0.8 +/- 0.2 versus 1.0 +/- 0.3 ml/mmHg). CONCLUSIONS We conclude that elderly hypertensive men and women have a different timing of both left ventricular ejection and arterial wave reflection when both genders are matched for body height. Women have smaller and stiffer blood vessels resulting in an earlier return of the reflected wave, which is likely due to an increased pulse wave velocity in women.