Young-IFSO Bariatric/Metabolic Surgery Training and Education Survey.

BACKGROUND: This international Young-IFSO survey aims to address variations, trends, and obstacles in bariatric/metabolic surgery (BMS) training globally, since expectations and resources differ among young surgeons. METHODS: The Young-IFSO scientific team designed an online confidential questionnaire with 50 questions analyzing the individual BMS training. The survey link was sent to all IFSO/ASMBS members and was shared in social media. All Young-IFSO members (age up to 45 years) were invited to participate between 16 December 2022 and 4 February 2023. RESULTS: A total of 240 respondents from 61 countries took the survey. Most respondents (70.24%) described their current position as a consultant surgeon with an average of 5.43 years' experience working in BMS, and 55% are working in a bariatric center of excellence. More than 50% of the respondents performed none or less than 10 BMS during residency. Preparation of the stomach and stapling during sleeve gastrectomy (SG) were the first steps performed, and SG was the first BMS completed as a first operating surgeon by most of the respondents (74%). In total, 201 (84.45%) surgeons reported to perform scientific work. Most respondents (90.13%) reported that surgical mentorship had improved their surgical skills. CONCLUSION: This international experts' survey underlines the lack of a standardized global surgical curriculum of BMS during residency. It shows that SG is the single most performed procedure by young surgeons. These data might underline the importance of advancing surgical education in BMS, and accredited fellowship programs should be offered globally to maintain and raise quality of BMS.

A rare occurrence of a poorly differentiated large cell neuroendocrine carcinoma of the gallbladder: A case report and review of the literature.

INTRODUCTION: Neuroendocrine carcinoma (NEC) of the gallbladder is a rare entity with much of the surgical strategy and management mirroring that of adenocarcinoma of the gallbladder. In contrast to gallbladder adenocarcinoma, however, it tends to be a more aggressive and lethal malignancy associated with a short survival after the time of diagnosis. Furthermore, due to its rarity, there are no consensus guidelines for its management. PRESENTATION OF CASE: We present the case of a 73-year-old female who presented with acute cholecystitis and was found to have a poorly differentiated large cell NEC of the gallbladder after laparoscopic cholecystectomy. She was treated with adjuvant chemotherapy and has shown no evidence of cancer recurrence on three-year follow up. DISCUSSION: Surgical resection is the cornerstone of curative treatment for gallbladder NEC. Management may include simple cholecystectomy, extended cholecystectomy, radical cholecystectomy, or palliative cholecystectomy. It is unclear whether lymphadenectomy confers a survival benefit. Adjuvant chemotherapy with platinum-based regimens, on the other hand, has been associated with increased survival rates. Radiation, immunotherapy, somatostatin analogs and targeted therapy have also been used for treatment. CONCLUSION: NEC of the gallbladder is extremely rare, aggressive, and carries a dismal prognosis. Further studies are needed to develop the optimal treatment approach to increase survival rates and establish best practices to manage these patients.

Histopathologic findings in laparoscopic sleeve gastrectomy: is routine full pathologic evaluation indicated?

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) is the most commonly performed bariatric surgery. The resected gastric segment is routinely sent for pathology evaluation. No formal national recommendation exists that mandates pathology review. We proposed to study the largest histopathologic series in SG patients yet reported. OBJECTIVE: The primary objective of our study was to determine whether a subgroup of patients who underwent bariatric surgery in the northeastern Unites States is more susceptible to having clinically significant pathologic findings that may benefit from routine histopathologic evaluation of the gastric sleeve specimen. SETTING: University hospital. METHODS: A retrospective electronic chart review of patients who underwent SG at a single large academic institution was performed. Patient demographics, body mass index, and histopathologic reports of the gastric specimens obtained during SG were analyzed. RESULTS: The records of 3543 patients were reviewed. A total of 1076 patients had abnormal pathologies, including gastritis (938), follicular gastritis (98), intestinal metaplasia (25), gastrointestinal stromal tumor (12), leiomyoma (1), lymphoma (1), and other malignancy (1). Black and Hispanic patients had a higher incidence of developing gastrointestinal stromal tumor and intestinal metaplasia. A higher incidence of Helicobacter pylori infection among specimens with abnormal pathologies was noted. CONCLUSIONS: The findings of this study call into question the routine use of pathology workup in gastric specimens after SG. Our data suggest that such analysis may be warranted in certain subtypes of patients such as older Black and Hispanic patients in the northeastern United States.

Combined pantaloon and femoral hernia: a common pathology in medicine occurring simultaneously.

Inguinal hernias are typically classified based on their location and can be divided into two types. The most commonly seen inguinal hernias are direct and indirect, which can both potentially require surgical intervention. When both types of hernias are seen simultaneously, it is classified as a pantaloon hernia. This case describes an instance of a femoral hernia being found along with a pantaloon hernia. We present a case of what was projected to be a common inguinal hernia repair but progressed to a rare presentation of a femoral hernia superimposed on a pantaloon hernia. Pantaloon hernias plus a femoral hernia is a rare defect that does not present as often as the different types of isolated hernias.

Morgagni hernia: an uncommon pathology in adults.

Typically, diaphragmatic hernias occur as congenital defects and are considered a rare presentation when seen in adults. They occur as developmental defects and stem from embryonic components of the diaphragm not fusing completely. There are two types of diaphragmatic hernias, classified based on the location of herniation through the diaphragmatic defect. Bochdalek hernias present as defects in the left postero-lateral diaphragm, whereas Morgagni hernias present as anterior defects of the diaphragm. The more common defect of the two are Bochdalek hernias making Morgagni hernias a rare presentation. This case describes the presentation of a hernia through an anterior defect in the diaphragm, otherwise classified as a Morgagni hernia.

Robotic Abdominal Wall Repair with Endoscopic Adductor Lengthening: A Minimally Invasive Approach for Core Muscle Injuries.

Groin pain is a common complaint in sports medicine practices but can be a challenge to accurately diagnose given the expanse of differentials. In the athlete, groin pain may be caused by a core muscle injury, also known as sports hernia or athletic pubalgia. These injuries most frequently occur in young males who participate in explosive and rotationally demanding activities such as soccer, football, and ice hockey, which generate large forces across the trunk and hip joint. These injuries are becoming more frequently diagnosed, in part, due to the utilization of diagnostic modalities, such as dynamic ultrasound and magnetic resonance imaging (MRI) and sensitive physical examination tests, such as the cross-body sit-up and squeeze test. When conservative management fails, surgical intervention is a good option for the athletes who desire to return to play. Surgical options include both open and laparoscopic techniques to repair abdominopelvic defects with or without attention to adductor pathology. The purpose of this article is to present a technique for minimally invasive robotic abdominal wall repair with endoscopic adductor lengthening for core muscle injuries.

Portomesenteric Vein Thrombosis after Bariatric Surgery: An Online Survey.

Portomesenteric vein thrombosis (PMVT) is a rare post-operative complication of bariatric procedures, occurring in between 0.3% and 1% of cases. A structured questionnaire consisting of 27 items was available online to members of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) to investigate the occurrence of PMVT. A total of 89 bariatric surgeons from 61 countries participated. Twenty-six (29.21%) reported at least one case of PMVT (46.15% males; 53.84% females). The surgery most associated with PMVT occurrence was sleeve gastrectomy (84.6%), followed by Roux-en-Y gastric bypass (RYGB) (7.69%), and laparoscopic adjustable gastric banding (LAGB) (7.69%). The time gap between surgery and PMVT was 19.28 ± 8.72 days. The predominant symptom was abdominal pain in 96.15% of patients, followed by fever in 26.9%. Complete occlusion of the portal vein was reported in 34.6% of cases, with involvement of the portal system in 69%, extension to the superior mesenteric district in 23%, and extension to the splenic vein in two patients (7.7%). Our survey, which is the largest regarding PMVT to date, revealed a diffuse lack of standardization in the choice, duration, and dosing of prophylaxis regimens as well as treatment modalities, reflecting the literature gap on the topic.

Depletion of Omega-3 Fatty Acids in RBCs and Changes of Inflammation Markers in Patients With Morbid Obesity Undergoing Gastric Bypass.

BACKGROUND: Bariatric surgery is considered the most effective treatment for severe obesity. Despite this wide success, bariatric surgery is associated with increased risks of nutritional deficiencies. OBJECTIVES: To examine whether Roux-en-Y-gastric bypass (RYGB) alters essential fatty acid (FA) status and inflammation markers. METHODS: Subjects with obesity (n = 28; BMI > 40 kg/m2; mean age 48 years) were studied before and 1 year after RYGB. We collected blood samples before and 12 months after RYGB, and analyzed FA in RBCs and peripheral blood mononuclear cells (PBMC), and measured inflammation parameters in plasma. The proportion of total n-3 FAs was the primary outcome, while parameters related to other FAs and inflammation factors were the secondary parameters. In addition, PBMCs from 15 of the participants were cultured alone or with 100 and 200 µM DHA, and the production of IL-6, IL-1ß, PGE2, and prostaglandin F2-alpha (PGF2α) was assayed after endotoxin (LPS) stimulation. RESULTS: RYGB induced a significant reduction of BMI (-30%) and improvement of insulin resistance (-49%). While the proportion of arachidonic acid was 15% higher after RYGB, the proportions of total and individual n-3 FAs were 50%-75% lower (P < 0.01). Consequently, the RBC omega-3 index and n-3:n-6 fatty acid ratio were 45% and 50% lower after surgery, respectively. In isolated PBMCs, LPS induced the production of IL-6, IL-1ß, PGE2, and PGF2α in both pre- and post-RYGB cells, but the effects were 34%-65% higher (P < 0.05) after RYGB. This effect was abrogated by DHA supplementation. CONCLUSIONS: This study presents evidence that RBC and PBMC n-3 FAs are severely reduced in patients with obesity after RYGB. DHA supplementation in PBMC moderates the production of inflammation markers, suggesting that n-3 FA supplementation would merit a trial in bariatric patients.

Use of Preoperative Magnetic Resonance Imaging to Predict Clinical Outcomes After Core Muscle Injury Repair.

BACKGROUND: Core muscle injury (CMI), often referred to as a sports hernia or athletic pubalgia, is a common cause of groin pain in athletes. Imaging modalities used to assist in the diagnosis of CMI include ultrasound (US) and magnetic resonance imaging (MRI). PURPOSE: To determine if preoperative MRI findings predict clinical outcomes after surgery for CMI. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective cohort study was performed on a consecutive series of patients who were operatively treated for CMI by a single surgeon. CMI was diagnosed based on history, physical examination, and a positive US. In addition, all patients underwent a preoperative MRI. Patients were divided into 2 groups based on whether the MRI was interpreted as positive or negative for CMI. All patients underwent mini-open CMI repair. Patient-reported outcomes (PROs) were collected both pre- and postoperatively and included a visual analog scale (VAS) for pain, the University of California, Los Angeles (UCLA) activity score, and the modified Harris Hip Score. RESULTS: A total of 39 hips were included in this study, of which 17 had a positive MRI interpretation for CMI (44%) and 22 had a negative MRI interpretation (56%). Mean age at the time of surgery was 35 years (range, 17-56 years), and mean follow-up was 21 months (range, 12-35 months). No significant difference was found between groups in mean age or time to follow-up. Patients in both groups demonstrated significant improvement from preoperative to most recent follow-up in terms of the UCLA activity score (P < .05). VAS scores significantly improved for patients with a positive MRI interpretation (P = .001) but not for those with a negative MRI interpretation (P = .094). No significant difference on any PROs was found between groups at the most recent follow-up. CONCLUSION: Successful clinical outcomes can be expected in patients undergoing surgery for CMI diagnosed based on history, physical examination, and US. Patients with a preoperative MRI consistent with CMI may experience greater improvement in pain postoperatively, although MRI does not predict postoperative activity level in these patients.

A Systematic Review Shows High Variation in Terminology, Surgical Techniques, Preoperative Diagnostic Measures, and Geographic Differences in the Treatment of Athletic Pubalgia/Sports Hernia/Core Muscle Injury/Inguinal Disruption.

PURPOSE: To perform a systematic review of reported terminologies, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of core muscle injury (CMI)/athletic pubalgia/inguinal disruption. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies or articles that described a surgical technique to treat CMI refractory to nonoperative treatment. The search phrase used was "core muscle injury" OR "sports hernia" OR "athletic pubalgia" OR "inguinal disruption." The diagnostic terminology, country of publication, preoperative diagnostic measures, surgical technique, and subspecialty of the operating surgeons described in each article were extracted and reported. RESULTS: Thirty-one studies met the inclusion and exclusion criteria, including 3 surgical technique articles and 28 clinical articles (2 Level I evidence, 1 Level II, 4 Level III, and 21 Level IV). A total of 1,571 patients were included. The most common terminology used to describe the diagnosis was "athletic pubalgia," followed by "sports hernia." Plain radiographs and magnetic resonance imaging of the pelvis were the most common imaging modalities used in the preoperative evaluation of CMI/athletic pubalgia/inguinal disruption. Tenderness-to-palpation testing was the most common technique performed during physical examination, although the specific locations assessed with this technique varied substantially. The operating surgeons were general surgeons (16 articles), a combination of orthopaedic and general surgeons (7 articles), or orthopaedic surgeons (5 articles). The most common procedures performed were open or laparoscopic mesh repair, adductor tenotomy, primary tissue (hernia) repair, and rectus abdominis repair. The procedures performed differed on the basis of surgeon subspecialty, geographic location, and year of publication. CONCLUSIONS: A variety of diagnostic methods and surgical procedures have been used in the treatment of a CMI/athletic pubalgia/sports hernia/inguinal disruption. These procedures are performed by orthopaedic and/or general surgeons, with the procedures performed differing on the basis of surgeon subspecialty and geographic location. LEVEL OF EVIDENCE: Level V, systematic review of Level I to V studies.

A proposed algorithm for the treatment of core muscle injuries.

In recent years, there has been increased awareness and treatment of groin injuries in athletes. These injuries have been associated with various terminologies including sports hernia, core muscle injury (CMI), athletic pubalgia and inguinal disruption, among others. Treatment of these injuries has been performed by both orthopaedic and general surgeons and may include a variety of procedures such as rectus abdominis repair, adductor lengthening, abdominal wall repair with or without mesh, and hip arthroscopy for the treatment of concomitant femoroacetabular impingement. Despite our increased knowledge of these injuries, there is still no universal terminology, diagnostic methodology or treatment for a CMI. The purpose of this review is to present a detailed treatment algorithm for physicians treating patients with signs and symptoms of a CMI. In doing so, we aim to clarify the various pathologies involved in CMI, eliminate vague terminology, and present a clear, stepwise approach for both diagnosis and treatment of these injuries.

Diagnostic Accuracy of Physical Examination Tests in Core Muscle Injury.

BACKGROUND: Core muscle injury (CMI), often referred to as a sports hernia, is a common cause of groin pain in athletes characterized by concomitant injury to the insertion of the adductor longus and the rectus abdominis muscles. Currently, the literature on CMI is sparse with no standardized physical examination tests used in the diagnosis of this type of injury. PURPOSE: To determine the diagnostic accuracy of various physical examination tests in the diagnosis of CMI. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: A consecutive series of patients evaluated by the senior author with symptoms consistent with CMI were included. Four physical examination tests were routinely performed in these patients by the senior author and were noted in each patient's chart as positive or negative: (1) pain with resisted cross-body sit-up in figure-of-4 position, (2) pain with straight-leg sit-up, (3) pain with resisted hip flexion in external rotation (external rotation Stinchfield test), and (4) the presence of an adductor contracture. CMI was independently diagnosed by a reference standard (magnetic resonance imaging [MRI]). All MRI scans were read by a musculoskeletal fellowship-trained radiologist. The sensitivity and specificity of each physical examination test alone and in combination were calculated based on this reference standard. RESULTS: A total of 81 patients were included in this study. MRI was positive for a CMI in 39 patients (48%) overall. Both the cross-body sit-up test and the presence of an adductor contracture were found to have a sensitivity of 100% (specificity, 3% for both). The external rotation Stinchfield test was found to have the highest specificity of 60% (sensitivity, 15%). The sensitivity of all 4 physical examination tests in combination was found to be 100% (specificity, 0%). CONCLUSION: Certain physical examination maneuvers can be used to assist in the diagnosis of a CMI. The cross-body sit-up test and the presence of an adductor contracture are highly sensitive but nonspecific tests for CMI and therefore should be used in conjunction with diagnostic imaging before deciding on an appropriate treatment course.

Insurance-Mandated Medical Weight Management Programs in Sleeve Gastrectomy Patients Do Not Improve Postoperative Weight Loss Outcomes at 1 Year.

BACKGROUND/INTRODUCTION: Qualification for bariatric surgery is based upon strict medical guidelines, but individual insurance companies may introduce additional requirements for approval and coverage as they deem necessary. A mandatory preoperative medical weight loss management (MWM) program is commonly such a requirement. OBJECTIVE: The primary objective of this study is to assess the effect of MWM programs on weight loss outcomes. METHODS: A retrospective review of all sleeve gastrectomies performed between 2012 and 2016 at our institution was conducted. Patients were divided into two groups: those who required a preoperative MWM program, and those who did not. A 1:1 greedy nearest-neighbor method matching algorithm was used to match patients based on age, BMI, smoking, gender, race, sleep apnea, and diabetes. Total weight loss and percent excess weight loss at 1 year for each group were compared. RESULTS: A total of 3059 sleeve gastrectomy patients were reviewed. Of these, 941 patients had adequate data points to be evaluated. The matching algorithm resulted in 530 patients for the final analysis, 265 patients in each group. There were no significant differences between the groups in terms of age, BMI, smoking, gender, race, sleep apnea, or diabetes. A paired t test found no significant differences between the MWM group and the control group at 1 year in both total weight loss (36.7 kg vs 36.2 kg) and in percent excess weight loss (56.5% vs 55.8%, p = 0.24). CONCLUSION: There was no significant difference in weight loss outcomes after 1 year in patients required by insurance to participate in MWM programs compared to those who were not. The necessity of these programs should be questioned.

Large series examining laparoscopic adjustable gastric banding as a salvage solution for failed gastric bypass.

BACKGROUND: The Roux-en-Y gastric bypass (RYGB) has long been considered the gold standard of weight loss procedures. However, there is limited evidence on revisional options with both minimal risk and long-term weight loss results. OBJECTIVE: To examine percent excess weight loss, change in body mass index (BMI), and complications in patients who underwent laparoscopic adjustable gastric banding (LAGB) over prior RYGB. SETTING: Academic hospital. METHODS: Retrospective analysis of a single-center prospectively maintained database. Three thousand ninety-four LAGB placements were reviewed; 139 were placed in patients with prior RYGB. RESULTS: At the time of LAGB, the median BMI was 41.3. After LAGB, we observed weight loss or stabilization in 135 patients (97%). The median maximal weight loss after LAGB was 37.7% excess weight loss and -7.1 change in BMI (P < .0001). At last follow-up visit, the median weight loss was 27.5% excess weight loss and -5.3 change in BMI (P < .0001). Median follow-up was 2.48 years (.01-11.48): 68 of 132 eligible (52%) with 3-year follow-up, 12 of 26 eligible (44%) with 6-year eligible follow-up, and 3 of 3 eligible (100%) with >10-year follow-up. Eleven bands required removal, 4 for erosion, 4 for dysphagia, and 3 for nonband-related issues. CONCLUSIONS: LAGB over prior RYGB is a safe operation, which reduces the surgical risks and nutritional deficiencies often seen in other accepted revisional operations. Complication rates were consistent with primary LAGB. Weight loss is both reliable and lasting, and it can be considered as the initial salvage procedure in patients with failed gastric bypass surgery.

Factors associated with failure of nonoperative treatment of complicated appendicitis in children.

UNLABELLED: Appendicitis remains the most common cause for emergency abdominal surgery in children. Immediate appendectomy in complicated, perforated appendicitis can be hazardous and nonoperative therapy has been gaining use as an initial therapy in children. Previous studies have reported failure rates in nonoperative therapy in such cases ranging from 10% to 41%. Factors leading to treatment failures have been studied with various and disparate results. We reviewed our institutional experience in treated complicated appendicitis, with focus on those initially managed nonoperatively. METHODS: Records of all children admitted with the diagnosis of perforated appendicitis to NYU Langone Medical Center and Bellevue Hospital Center from January 1, 2003 to December 31, 2013 were reviewed. The diagnosis was made with ultrasound and/or computed tomography scan. Those with abscesses amenable to drainage underwent aspiration and drain placement by an interventional radiologist. Broad spectrum intravenous (IV) antibiotics were given until the patient became afebrile, pain free and tolerating a regular diet. Oral antibiotics were continued for an additional week and interval appendectomy was done eight weeks later. The primary outcome measure was treatment response with failure defined as those who did not improve or required readmission for additional IV antibiotics and/or early appendectomy. Multiple patient and treatment related variables, including those previously reported as predicting failure in nonoperative therapy, were studied. Continuous variables were reported as means ± standard error and compared using 2-tailed unpaired t tests; nonparametric variables were analyzed by Mann-Whitney U tests. Categorical variables were reported as medians ± interquartile ranges and compared using Chi-square testing. Statistical significance was accepted for p<.05. RESULTS: Sixty-four patients were identified as undergoing initial nonoperative therapy. Fifty-two (81%) were categorized as treatment successes being treated nonoperatively and 12 (19%) were failures. Variables showing no significance in predicting treatment failures included duration of symptoms, presence of appendicolith, presence of phlegmon, presence of abscess, initial white blood cell count, and SIRS (Systemic Inflammatory Response Syndrome) positive. The variables that predicted failure of nonoperative therapy vs. successes were presence of bandemia (75% vs. 40%, p=0.052) and small bowel obstruction on imaging (42% vs. 15%, p=0.052) and presence of bandemia ≥15% which was highly predictive of failure (67% vs. 4%, p<0.01). CONCLUSIONS: Predicting which patients with complicated perforated appendicitis will respond well to nonoperative therapy may allow us to more effectively treat patients with complicated perforated appendicitis. In our study the presence of small bowel obstruction and bandemia, especially ≥15% correlated with treatment failure; this suggests that these select patients may need a modified treatment strategy.

Spontaneous Regression of Thoracic and Extraperitoneal Glial Implants in Child With Gliomatosis Peritonei After Resection of Ovarian Teratoma.

Gliomatosis peritonei is a rare condition associated with ovarian teratomas. Even rarer is extraperitoneal gliomatosis. We present a case of extraperitoneal gliomatosis with pleural implants and implants within the flank muscles, which regressed after resection of the primary tumor.

The prevalence of carotid artery stenosis varies significantly by race.

OBJECTIVE: Certain races are known to be at increased risk for stroke, and the prevalence of carotid artery stenosis (CAS) is thought to vary by race. The goal of this report was to study the prevalence of CAS in different races by analyzing a population of subjects who underwent vascular screening examinations. METHODS: The study data were provided by Life Line Screening. The cohort consists of self-referred individuals who paid for vascular screening tests. Subjects <40 and >100 years of age and those who reported a prior stroke or carotid artery intervention were excluded. Of the remaining 3,291,382 subjects, 3.7% did not self-identify a race. CAS was defined as stenosis in either internal carotid artery ≥50% by duplex ultrasound velocity criteria. RESULTS: The 3,291,382 subjects available for analysis consisted of Caucasian (2,845,936 [90%]), African American (97,502 [3.1%]), Hispanic (75,240 [2.4%]), Asian (60,982 [1.9%]), and Native American (87,757 [2.8%]) individuals. The prevalence of CAS was 3.4% in females and 4.2% in males (P ≤ .001). Controlling for gender and age, there was marked variation in the prevalence of CAS (P < .001) by race. Native American subjects had the highest prevalence of CAS across all age categories and in both sexes. Caucasian subjects had the second highest prevalence of CAS across most age decades and in both sexes. Among males, African American individuals had the lowest prevalence of CAS in nearly all age categories. In contrast to males, Asian females had the lowest prevalence of CAS compared with females of other races in most age groups. Multivariate analysis adjusting for atherosclerotic risk factors in addition to age confirmed race as a significant independent predictor of CAS. Compared with Caucasian subjects, African American (odds ratio [OR], 0.65), Asian (OR, 0.69), and Hispanic (OR, 0.74) subjects had a significantly lower risk of CAS, whereas Native American (OR, 1.3) subjects had a significantly higher risk of CAS. CONCLUSIONS: The prevalence of clinically significant CAS varies significantly by race. Native American and Caucasian individuals have the highest prevalence of CAS, whereas African American males and Asian females appear to have the lowest prevalence. This information adds evidence to the hypothesis that the increased stroke rate in African American subjects is likely not related to extracranial cerebrovascular disease. Furthermore, this is a novel report of an extremely high prevalence of CAS in the Native American population.