Systemic thrombolytic and ultrasound-assisted catheter-directed thrombolysis for treatment of acute pulmonary embolism: a 7-year, multicenter experience.

Treatment of acute pulmonary embolism (PE) varies based upon risk stratification and ranges from outpatient oral anticoagulation to emergency surgical embolectomy. Patients with high-risk PE can be considered for systemic thrombolytic (ST) based upon guideline recommendations, but intermediate-risk PE does not currently have strong evidence to guide primary reperfusion strategies via thrombolytic administration. Ultrasound-assisted catheter-directed thrombolysis (USAT) is an alternative reperfusion option to ST but is not currently recommended as first line in any key guidelines due to limited available evidence. This retrospective, multicenter, observational study compares 210 patients treated with USAT (n = 105) or ST (n = 105) for acute high- or intermediate-risk PE in three hospitals. Baseline characteristics were significant in that severity of illness was higher in those that received ST, which limited comparisons of outcomes. The primary outcome of major bleeding in patients receiving USAT was 15.2% and 22.9% in those that received ST. Efficacy of reperfusion strategy was observed to be 86.7% of patients in USAT group and 65.7% in ST group. Reperfusion strategies had no difference in in-hospital death, intensive care length of stay, or hospital length of stay. Predefined subgroup analysis found that high-risk PE had higher mortality (14.7%) than intermediate-risk PE (0%) regardless of reperfusion strategy. Upon multivariate analysis, high-risk PE was the only independent risk factor for major bleeding while USAT therapy and intermediate-risk PE were independent predictors of efficacy. Due to the difference in baseline severity of illness, direct comparisons in primary outcomes to each group was not performed. We have described real world usage of both USAT and ST and which patients were likely to receive each therapy at these institutions.

Extracorporeal Cardiopulmonary Resuscitation: A Narrative Review and Establishment of a Sustainable Program.

The rates of survival with functional recovery for out of hospital cardiac arrest remain unacceptably low. Extracorporeal cardiopulmonary resuscitation (ECPR) quickly resolves the low-flow state of conventional cardiopulmonary resuscitation (CCPR) providing valuable perfusion to end organs. Observational studies have shown an association with the use of ECPR and improved survivability. Two recent randomized controlled studies have demonstrated improved survival with functional neurologic recovery when compared to CCPR. Substantial resources and coordination amongst different specialties and departments are crucial for the successful implementation of ECPR. Standardized protocols, simulation based training, and constant communication are invaluable to the sustainability of a program. Currently there is no standardized protocol for the post-cannulation management of these ECPR patients and, ideally, upcoming studies should aim to evaluate these protocols.

The Influence of Organized Physical Activity (Including Gymnastics) on Young Adult Skeletal Traits: Is Maturity Phase Important?

We prospectively evaluated adolescent organized physical activity (PA) as a factor in adult female bone traits. Annual DXA scans accompanied semiannual records of anthropometry, maturity, and PA for 42 participants in this preliminary analysis (criteria: appropriately timed DXA scans at ~1 year premenarche [predictor] and ~5 years postmenarche [dependent variable]). Regression analysis evaluated total adolescent interscan PA and PA over 3 maturity subphases as predictors of young adult bone outcomes: 1) bone mineral content (BMC), geometry, and strength indices at nondominant distal radius and femoral neck; 2) subhead BMC; 3) lumbar spine BMC. Analyses accounted for baseline gynecological age (years pre- or postmenarche), baseline bone status, adult body size and interscan body size change. Gymnastics training was evaluated as a potentially independent predictor, but did not improve models for any outcomes (p > .07). Premenarcheal bone traits were strong predictors of most adult outcomes (semipartial r2 = .21-0.59, p ≤ .001). Adult 1/3 radius and subhead BMC were predicted by both total PA and PA 1-3 years postmenarche (p < .03). PA 3-5 years postmenarche predicted femoral narrow neck width, endosteal diameter, and buckling ratio (p < .05). Thus, participation in organized physical activity programs throughout middle and high school may reduce lifetime fracture risk in females.

Site-specific, adult bone benefits attributed to loading during youth: A preliminary longitudinal analysis.

We examined site-specific bone development in relation to childhood and adolescent artistic gymnastics exposure, comparing up to 10years of prospectively acquired longitudinal data in 44 subjects, including 31 non-gymnasts (NON) and 13 gymnasts (GYM) who participated in gymnastics from pre-menarche to ≥1.9years post-menarche. Subjects underwent annual regional and whole-body DXA scans; indices of bone geometry and strength were calculated. Anthropometrics, physical activity, and maturity were assessed annually, coincident with DXA scans. Non-linear mixed effect models centered growth in bone outcomes at menarche and adjusted for menarcheal age, height, and non-bone fat-free mass to evaluate GYM-NON differences. A POST-QUIT variable assessed the withdrawal effect of quitting gymnastics. Curves for bone area, mass (BMC), and strength indices were higher in GYM than NON at both distal radius metaphysis and diaphysis (p<0.0001). At the femoral neck, greater GYM BMC (p<0.01), narrower GYM endosteal diameter (p<0.02), and similar periosteal width (p=0.09) yielded GYM advantages in narrow neck cortical thickness and buckling ratio (both p<0.001; lower BR indicates lower fracture risk). Lumbar spine and sub-head BMC were greater in GYM than NON (p<0.036). Following gymnastics cessation, GYM slopes increased for distal radius diaphysis parameters (p≤0.01) and for narrow neck BR (p=0.02). At the distal radius metaphysis, GYM BMC and compressive strength slopes decreased, as did slopes for lumbar spine BMC, femoral neck BMC, and narrow neck cortical thickness (p<0.02). In conclusion, advantages in bone mass, geometry, and strength at multiple skeletal sites were noted across growth and into young adulthood in girls who participated in gymnastics loading to at least 1.9years post-menarche. Following gymnastics cessation, advantages at cortical bone sites improved or stabilized, while advantages at corticocancellous sites stabilized or diminished. Additional longitudinal observation is necessary to determine whether residual loading benefits enhance lifelong skeletal strength.

Effects of different meal compositions after exercise on fat and carbohydrate oxidation in women with different levels of body fat.

We investigated the effects of consuming a high-carbohydrate meal (HC), high-fat meal (HF), or no meal (CON) following exercise on fat and carbohydrate oxidation (FAT-OX, CHO-OX) in women with differing levels of body fat. Healthy, physically active females were divided into a Lower Fat (<25% fat, n = 10) or Higher Fat (>25% fat, n = 9) group and tested on 4 occasions. During session 1, body composition and maximal oxygen consumption were determined. During 3 treatment sessions, subjects preformed treadmill exercise at 55% of maximal oxygen consumption until 350 kcal were expended. At 10 min postexercise subjects consumed a liquid meal standardized to provide energy equal to 20% of 24-h energy expenditure plus the 350 kcal of exercise. The HC meal comprised 64% carbohydrate, 21.6% fat, and 14.4% protein. The HF meal comprised 24% carbohydrate, 62% fat, and 14% protein. CON consisted of water equal to the meal volume. During exercise and 2 h postexercise, expired gases were collected to determine FAT-OX and CHO-OX. During exercise CHO-OX was a significantly higher for the Lower Fat group and FAT-OX was significantly higher for the Lower Fat group for each of the meal conditions. A significant difference was observed across meals (p < 0.05) for CHO-OX (first hour) and for CHO-OX and FAT-OX (second hour) postexercise. There were no significant differences (p > 0.05) between the Lower Fat and Higher Fat groups for either recovery period. In physically active females, the macronutrient composition of the postexercise meal affects substrate oxidation, but the level of body fat does not.

Effects of carbohydrate ingestion during exercise on substrate oxidation in physically active women with different body compositions.

We examined the effects of consuming a 6% carbohydrate (CHO) beverage during exercise on substrate oxidation in active, young Caucasian women with higher body fat (HF) (>25%) and lower body fat (LF) (<25%). The HF group (n = 9) had 32.4% ± 5.6% fat and the LF group (n = 8) had 20.0% ± 3.0% fat. Subjects completed 2 sessions of 45 min of treadmill exercise at 55% of maximal oxygen consumption. Immediately prior to and at 15-min intervals during exercise, subjects consumed 25% of a total volume of a CHO beverage (1 g CHO·kg(-1)) or a placebo (PLC). During exercise and for 2 h after exercise, expired gases were analyzed to determine oxidation rates for CHO (CHO-OX) and fat (FAT-OX). During exercise, significant differences (p < 0.05) in CHO-OX (mg·kg fat-free mass(-1)·min(-1)) were found between groups for the CHO trial (LF, 35.4 ± 4.7 vs. HF, 29.8 ± 3.6) and the PLC trial (LF, 33.7 ± 6.4 vs. HF, 26.3 ± 4.3). CHO-OX was significantly higher during the first hour of recovery in both the LF group (CHO, 9.3 ± 2.1 vs. PLC, 5.3 ± 2.4) and the HF group (CHO, 8.7 ± 2.0 vs. PLC, 4.2 ± 1.0), but during the second hour of recovery, only the HF group had a higher CHO-OX (CHO, 5.3 ± 1.8 vs. PLC, 3.9 ± 1.1). FAT-OX was significantly lower during the first hour of recovery in both the LF group (CHO, 0.6 ± 0.4 vs. PLC, 1.0 ± 0.4) and the HF group (CHO, 0.4 ± 0.4 vs. PLC, 1.4 ± 0.4), as well as during the second hour of recovery in both the LF group (CHO, 0.8 ± 0.4 vs. PLC, 1.3 ± 0.5) and the HF group (CHO, 0.9 ± 0.6 vs. PLC, 1.6 ± 0). CHO ingestion promotes CHO-OX and suppresses FAT-OX during and following exercise in physically active women with low and high levels of body fat.