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Hypertension is one of the leading causes of death and disability worldwide. Blood pressure reduction and control are associated with reduced risk of stroke and cardiovascular disease. To achieve optimal reduction and control, reliable and valid methods for blood pressure measurement are needed. Office based measurements can result in 'white coat' hypertension, which is when a patient's blood pressure in a clinical setting is higher than in other settings, or 'masked' hypertension, which occurs when a patient's blood pressure is normal in a clinical setting, but elevated outside the clinical setting. In 2015, the US Preventative Services Task Force recommended Ambulatory Blood Pressure Monitoring (ABPM) as the "best method" for measuring blood pressure, endorsing its use both for confirming the diagnosis of hypertension and for excluding 'white coat' hypertension. ABPM is a safe, painless and non-invasive test wherein patients wear a small digital blood pressure machine attached to a belt around their body and connected to a cuff around their upper arm that enables multiple automated blood pressure measurements at designated intervals (typically every 15 to 30 minutes) throughout the day and night for a specified period (eg, 24 hours). Patients can go about their typical daily activities wearing the device as much as possible, except when they are bathing, showering, or engaging in heavy exercise. Given the importance of blood pressure monitoring and control to population public health, this article provides details on the relevance and challenges of blood pressure measurement broadly then describes ABPM generally and specifically in the Hawai'i context.

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OBJECTIVES: The scientific literature demonstrates a cost-benefit associated with early access to physical therapy. The purpose of this case study is to report the results of an orthopedic performance improvement initiative (OPII) at a small military treatment facility (approximately 4.5K active duty beneficiaries). The OPII was introduced to (1) limit variation by ensuring that all active duty orthopedic consults were audited ensuring proper timing of appropriate services and (2) establish contractual agreement for shared resources with the U.S. Naval Jacksonville Orthopedic Department. METHODS: OPII was accomplished through consensus development and strong leadership support. All orthopedic referrals (n = 260) were audited for 6 months. Appropriate recommendations were provided to either continue with orthopedic care or to redirect to a physical therapy first approach. RESULTS: Orthopedic referrals decreased 27% with concomitant 32% increase in physical therapy referrals producing overall savings of $462K (33%). Meanwhile, surgical throughput improved 45%. Seventy percent of the savings were attributed to improved utilization translating to a relative value unit savings per beneficiary of $17.64 (23.7%). CONCLUSION: Our results support the value of a conservative physical therapy first approach for musculoskeletal conditions and shared mil-to-mil resourcing agreements. Success requires an iterative audit/feedback process balanced with stakeholder consensus.

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Marine aquaculture is expanding into deeper offshore environments in response to growing consumer demand for seafood, improved technology, and limited potential to increase wild fisheries catches. Sustainable development of aquaculture will require quantification and minimization of its impacts on other ocean-based activities and the environment through scientifically informed spatial planning. However, the scientific literature currently provides limited direct guidance for such planning. Here, we employ an ecological lens and synthesize a broad multidisciplinary literature to provide insight into the interactions between offshore aquaculture and the surrounding environment across a spectrum of spatial scales. While important information gaps remain, we find that there is sufficient research for informed decisions about the effects of aquaculture siting to achieve a sustainable offshore aquaculture industry that complements other uses of the marine environment.

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The scope and limitations of the tandem conjugate addition-Dieckmann condensation for the construction of 1,2,3-trisubstituted naphthalenes is defined. Viable nucleophilic partners in this methodology include organocuprates, active methylenes, and a variety of heteroatom initiators.