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An excerpt from the concluding chapter of the 4th edition of this standard textbook.

Objectives. To characterize the association between pulmonary embolism (PE) severity and bleeding risk with treatment approaches, outcomes, and complications. Methods. Secondary analysis of an 11-hospital registry of adult ED patients treated by a PE response team (August 2016–November 2022). Predictors were PE severity and bleeding risk. The primary outcome was treatment approach: anticoagulation monotherapy vs. advanced intervention (categorized as "immediate" or "delayed" based on whether the intervention was received within 12 hours of PE diagnosis or not). Secondary outcomes were death, clinical deterioration, and major bleeding. Results. Of the 1832 patients, 139 (7.6%), 977 (53.3%), and 9 (0.5%) were classified as high-risk, intermediate-high, intermediate-low, and low-risk severity, respectively. There were 94 deaths (5.1%) and 218 patients (11.9%) had one or more clinical deterioration events. Advanced interventions were administered to 86 (61.9%), 195 (27.6%), and 109 (11.2%) patients with high-risk, intermediate-high, and intermediate-low severity, respectively.Major bleeding occurred in 61/1440 (4.2%) on ACm versus 169/392 (7.6%) with advanced interventions (p <0.001): bleeding withcatheter-directed thrombolysiswas 19/145 (13.1%) versus 33/154(21.4%) with systemic thrombolysis,p= 0.07. High risk was twice as strong as intermediate-high risk for association with advanced intervention (OR: 5.3 (4.2 and 6.9) vs. 1.9 (1.6 and 2.2)). High risk (OR: 56.3 (32.0 and 99.2) and intermediate-high risk (OR: 2.6 (1.7 and 4.0)) were strong predictors of clinical deterioration. Major bleeding was significantly associated with advanced interventions (OR: 5.2 (3.5 and 7.8) for immediate, 3.3 (1.8 and 6.2)) for delayed, and high-risk PE severity (OR: 3.4 (1.9 and 5.8)). Conclusions. Advanced intervention use was associated with high-acuity patients experiencing death, clinical deterioration, and major bleeding with a trend towards less bleeding with catheter-directed interventions versus systemic thrombolysis. [ABSTRACT FROM AUTHOR]

This study investigates the visitors' satisfaction levels to find out if satisfaction levels were decreasing due to the increased visitation levels at southern Utah national parks, which had experienced double digit visitation increases the past two years. The parks included in this study are Arches National Park, Bryce Canyon National Park, and Zion National Park. Surveys were collected from visitors to these three parks on September 15, 2015 (the Saturday of Labor Day weekend) and on September 19, 2015 (a Saturday two weeks later) to examine the different satisfaction levels of very busy and less busy time frames. The results of this study revealed that the percent of visitors that were either satisfied or very satisfied were comparable for the two dates, but the percent of very satisfied visitors was lower for the holiday time frame. Common park features that drive visitor satisfaction were identified. Steps that can be taken to assist visitor satisfaction were also identified. [ABSTRACT FROM AUTHOR]

The article discusses the use of science in managing Northern Forest Tourism and Recreation in Adirondack Mountains in New York. The state's outdoor recreation and tourism continues to grow, however, outdoor recreation is said to be sustainable to protect natural resources in the area and provide a high quality experience to visitors. Furthermore, managing tourism and recreation in a sustainable manner requires informed decisions based on a strong scientific foundation that calls for formulating indicators and standards of quality for natural resource conditions. Moreover, indicators of quality are manageable, measurable variables that define the quality of natural resources and visitor experiences and standard of quality define the minimum acceptable condition of indicator variables.

Objective: To examine recent trends in racial and ethnic disparities in cardiac catheterization for acute myocardial infarction (AMI) to determine whether disparities documented from the 1980s through mid-1990s persist, and evaluate whether patient and hospital characteristics are associated with any observed disparities, Methods: Cross-sectional analyses of 585,710 white, 51,369 black and 31,923 Hispanic discharges from hospitals in the Nationwide Inpatient Sample (which includes data on all discharges from 951 representative hospitals in 23 states) that had performed cardiac catheterization from 1995--2001 with a primary diagnosis of AMI. Adjusted procedure rates and prevalence ratios (PR) were computed to compare catheterization rates by race and ethnicity., Measurements and Main Results: Catheterization rates were higher for whites than blacks for all years examined; rates among Hispanics increased during this period and approached the rate among whites. After adjustment for age, demographics, comorbidity, year and hospital characteristics, rates (per 100 discharges) were 58.4 for whites, 50.1 for blacks (PR 0.87; 95% CI 0.84-0.91) and 55.2 for Hispanics (PR 0.95; 95% CI 0.90-0.99)., Conclusions: These nationwide data suggest blacks remain less likely than whites and Hispanics to undergo catheterization during a hospitalization for AMI. Whether this disparity stems from patient or provider factors remains to be determined.