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Obstructive bioprosthetic valve thrombosis is associated with hemodynamic compromise, and evidence on management with fibrinolysis is limited. Echocardiography is required to assess thrombus size and its effects on valve gradients, area, and leaflet motion. This case demonstrates use of echocardiography guided slow-infusion low-dose fibrinolytic therapy in a patient with obstructive bioprosthetic valve thrombosis. (Level of Difficulty: Intermediate.).

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Our goal was to assess adherence to American College of Cardiology/American Heart Association guideline-based medical therapy in patients admitted with type I non-ST elevation myocardial infarction (NSTEMI) and to determine factors associated with medication administration delay. We performed a retrospective analysis using data from the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry. Baseline patient demographics, 12-lead electrocardiogram (ECG) findings, laboratory values, medications administered and the time they were administered, and in-hospital clinical outcomes were collected. Global Registry of Acute Coronary Events risk scores were calculated for all patients. We included 1002 patients admitted from the emergency department with a type I NSTEMI. A total of 802 (80%) patients received appropriate initial therapy consisting of therapeutic anticoagulation with heparin and dual antiplatelet therapy. Of the 200 (20%) patients who did not receive therapy, documentation in the chart regarding possible contraindications for administration of the medications was missing in up to half. Female sex, older age, a normal initial ECG, and prolonged time spent in the emergency department were predictors of significant delay in receiving guideline-based medications, while an elevated initial troponin was a predictor of faster medication administration. Global Registry of Acute Coronary Events risk scores had no association with the timing of medication administration. In conclusion, 20% of NSTEMI patients did not receive American College of Cardiology/American Heart Association guideline-based medical therapy. Delay in medication administration was significant for women, older individuals, and patients who did not have ischemic findings on the initial ECG.

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Phyllodes tumor is an uncommon breast lesion with characteristic histologic appearance when examined by hematoxylin and eosin staining: leaf-like fronds projecting into cystic spaces on low-power microscopy, and biphasic (epithelial and stromal) components on high-power microscopy. We report a rare primary case of this tumor arising within the vulva. A 34-year old African American female presented with a 3 cm slow-growing vulvar mass initially thought to be an inclusion cyst. The lesion was excised and histologic examination demonstrated this lesion to be a rare case of benign phyllodes tumor with morphologic features similar to those arising from breast tissue. Patient received no further treatment and did not exhibit any recurrence or metastasis. Nearly two years after excision, the patient died due to an unrelated medical cause. This rare tumor should be considered in the differential diagnosis for women presenting with a slow-growing vulvar mass.

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OBJECTIVES: This study aimed to evaluate the feasibility of using a compact elliptical device to increase energy expenditure during sedentary activities. A secondary aim was to evaluate if two accelerometers attached to the elliptical device could provide reliable and valid assessments of participants' frequency and duration of elliptical device use. DESIGN: Physically inactive adults (n=32, age range=25-65) were recruited through local advertisements and selected using stratified random sampling based on sex, body mass index (BMI), and age. METHODS: Indirect calorimetry was used to assess participants' energy expenditure while seated and while using the elliptical device at a self-selected intensity level. Participants also self-reported their interest in using the elliptical device during sedentary activities. Two Actigraph GT3X accelerometers were attached to the elliptical device to record time-use patterns. RESULTS: Participants expended a median of 179.1 kilocalories per hour while using the elliptical device (range=108.2-269.0), or a median of 87.9 more kilocalories (range=19.7-178.6) than they would expend per hour of sedentary sitting. Participants reported high interest in using the elliptical device during TV watching and computer work, but relatively low interest in using the device during office meetings. Women reported greater interest in using the elliptical device than men. The two accelerometers recorded identical time-use patterns on the elliptical device and demonstrated concurrent validity with time-stamped computer records. CONCLUSIONS: Compact elliptical devices could increase energy expenditure during sedentary activities, and may provide proximal environmental cues for increasing energy expenditure across multiple life domains.

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