Maximizing Participant and Staff Safety During Assessment of Physical Function in the COVID-19 Era.

Physical performance measures, including cardiopulmonary exercise testing (CPXT), are widely used in geriatric practice and aging research. Theoretically, research participants and study personnel could get infected in the closed environment of the exercise laboratory by contact with respiratory droplets from an infected person, by breathing virus-laden aerosols, or by touching fomites. Older adults are at increased risk of developing more severe disease and of dying from SARS-CoV-2 infection. This special article offers guidance-informed by a synthesis of scientific data and recommendations of the CDC and WHO-on procedures that can be implemented in exercise laboratories to minimize risk of SARS-CoV-2 and other respiratory infections. Most tests of physical function (e.g., gait speed, Short Physical Performance Battery) are not aerosol-generating and are associated with only a small increase in minute ventilation; in contrast, CPXT markedly increases minute ventilation and is potentially aerosol-generating. Researchers should evaluate the benefit-to-risk ratio of information gained from the laboratory assessment versus the risk of SARS-CoV2 infection. Risk mitigation strategies described here fall into four categories: personal hygiene and the use of personal protective equipment; standardized screening; reconfiguration of laboratory space; and optimization of laboratory ventilation. The proposed safety measures are not intended to replace institutional policy, state, or federal guidelines; they may not apply to all settings and are expected to evolve as more definitive information becomes available. These practical measures to maximize protection against SARS-CoV2 infection can help maximize participant and staff safety, reduce anxiety, and facilitate protocol adherence, and study integrity.

[Assessment of muscular toxicity due to chemotherapy by cardio-pulmonary exercise testing]. / Évaluation de la toxicité musculaire de la chimiothérapie lors d'une épreuve fonctionnelle à l'exercice.

INTRODUCTION: Cardio-pulmonary exercise testing (CPET) is frequently used to assess aerobic capacity, to evaluate respiratory tolerance and to provide prognostic information. Therefore, CPET is often incorporated in the preoperative assessment of cancer patients. This clinical case report presents the preoperative assessment of a patient before thoracic surgery, in whom an important decrease of aerobic capacity was noted, possibly because of muscular toxicity linked to chemotherapy. CASE REPORT: This clinical case concerns a fit, 66-year-old man with a large cell carcinoma of the bronchus. He had received 2 cycles of adjuvant chemotherapy. Subsequently, a left pneumonectomy had been proposed and preoperative assessment performed. CPET showed no further increase in oxygen uptake after the first ventilatory threshold, in spite of increases in carbon dioxide output, minute ventilation and heart rate. Moreover, maximal oxygen uptake was low and there was a decrease of oxygen pulse at maximal effort. CONCLUSION: We suggest that the limitation of effort was due to a limitation of muscular oxygen extraction, which could be explained by possible muscular toxicity due to chemotherapy.

Comparison between two assessment methods for exercise-induced laryngeal obstructions.

Exercise-induced laryngeal obstructions (E-ILOs) are important differential diagnoses to exercise-induced asthma and are diagnosed by the continuous laryngoscopy exercise (CLE) test. There are two different methods for evaluating the severity of E-ILOs using recordings from the CLE test; the CLE score and EILOMEA. The aim of this study was to investigate the consistency between these methods. Using their respective method, the developers of each method evaluated 60 laryngoscopic recordings from patients with different subtypes and various levels of severity of E-ILOs. The CLE score evaluates glottic and supraglottic obstructions on a 4-grade scale. EILOMEA uses software to calculate the obstruction severity on continuous scales from a still frame of the larynx during maximal obstruction giving three parameters reflecting glottic and supraglottic obstruction. The means of the EILOMEA measures differed significantly for CLE score 1 vs. 2 and 2 vs. 3, but not for 0 vs. 1 for glottic as well as supraglottic obstructions. The EILOMEA method does not distinguish between CLE score 0 and 1, but otherwise the methods correlate. Since previous studies have suggested that only CLE scores of 2 and 3 reflect a severity of E-ILOs of clinical importance, this lack of the EILOMEA method is not crucial for a correct medical evaluation.

Triple Rule Out versus CT Angiogram Plus Stress Test for Evaluation of Chest Pain in the Emergency Department.

INTRODUCTION: Undifferentiated chest pain in the emergency department (ED) is a diagnostic challenge. One approach includes a dedicated chest computed tomography (CT) for pulmonary embolism or dissection followed by a cardiac stress test (TRAD). An alternative strategy is a coronary CT angiogram with concurrent chest CT (Triple Rule Out, TRO). The objective of this study was to describe the ED patient course and short-term safety for these evaluation methods. METHODS: This was a retrospective observational study of adult patients presenting to a large, community ED for acute chest pain who had non-diagnostic electrocardiograms (ECGs) and normal biomarkers. We collected demographics, ED length of stay, hospital costs, and estimated radiation exposures. We evaluated 30-day return visits for major adverse cardiac events. RESULTS: A total of 829 patients underwent TRAD, and 642 patients had TRO. Patients undergoing TRO tended to be younger (mean 52.3 vs 56.5 years) and were more likely to be male (42.4% vs. 30.4%). TRO patients tended to have a shorter ED length of stay (mean 14.45 vs. 21.86 hours), to incur less cost (median $449.83 vs. $1147.70), and to be exposed to less radiation (median 7.18 vs. 16.6 mSv). No patient in either group had a related 30-day revisit. CONCLUSION: Use of TRO is feasible for assessment of chest pain in the ED. Both TRAD and TRO safely evaluated patients. Prospective studies investigating this diagnostic strategy are needed to further assess this approach to ED chest pain evaluation.

Desafio do diagnóstico da doença coronária aterosclerótica coronária subclínica / Challenge in diagnosis of subclinical coronary disease

A doenças aterosclerótica coronariana (DAC) continua sendo a principal causa de morte. Consequentemente, há interesse crescente no diagnóstico de DAC em assintomáticos. Entretanto, existem alguns questionamentos acerca da indicação e custo-benefício de tal rastreamento, bem como qual ferramenta diagnóstica seria a mais adequada. A DAC obstrutiva pode ocorrer em pacientes pouco sintomáticos ou mesmo assintomáticos, o pode ocorrer progredir rapidamente. A primeira manifestação clínica pode ser angina instável, infarto do miocárdio, ou mesmo morte súbita. A justificativa para a detecção precoce da DAC é que seu diagnóstico nos estágios subclínicos pode permitir a identificação dos indivíduos com risco aumentado de eventos cardíacos adversos e a instituição de tratamento adequado nos indivíduos de alto risco pode melhorar o prognóstico. De acordo com as diretrizes atuais, em pacientes assintomáticos, o teste ergométrico é recomendado apenas em pacientes de alto risco cardiovascular com ECG interpretável e paciente capas de se exercitar. Outros testes diagnósticos não invasivos como ecocardiografia de estresse, ressonância cardíaca de estresse, cintilografia miocárdica, escore de cálcio, angiotomografia coronária só são recomendados em casos selecionados após julgamento clínico. Esses exames são mais adequados em pacientes com ECG não passível de interpretação adequada no teste ergométrico convencional e em pacientes não capazes de se exercitar, com alto risco cardiovascular. Não é recomendado o rastreamento de rotina de DAC em assintomáticos com baixo risco cardiovascular. Naqueles com risco intermediário, os exames mais adequados, levando em consideração o julgamento clínico e o riso-benefício do exame, são o teste ergométrico convencional e o escore de risco.

Coronary heart disease (CHD) remains the leading cause of mortality. There is na increasing interest in the diagnosis of CHD when patients are still asymptomatic. However, questions remaing regarding the appropriateness and cost effectiveness of screening and the best test. Obstructive CHD can exist with few or no symptoms, and can progress rapidly. The The first clinical manifestations can be: acute myocardial infarction (MI), unstable angina, or sudden cardiac death. The explanation for early detection of CHD is that detection during the subclinical stages of disease might permit the identification of patients at increased risk of na acute cardiac event and that appropriate therapy might improve the prognosis of those at high risk. Based on last guidelines, exercise testing in recommended in asymptomatic adults with high cardiovascular risk, able to exercise, and with interpretable ECG. Other non-invasive tests such as stress echocardiography, cardiac resonance, nuclear imaging, coronary tomography, calcium quantification, are only recommended in selected cases after clinical assessment. These tests are more adequate in patients with no interpretable ECG or not able recommended routine screening of CHD in asymptomatic adults with low cardiovascular risk. In those with moderate risk, exercise testing and calcium coronary quatification may be recommended, after clinical assessment.

Non-physician-led exercise stress testing is a safe and effective practice.

Exercise stress testing is a non-invasive procedure that provides diagnostic and prognostic information for the evaluation of several pathologies, including arrhythmia provocation, assessment of exercise capacity, and coronary heart disease. Historically, exercise tests were directly supervised by physicians; however, cost-containment issues and time constraints on physicians have encouraged the use of health professionals with specific training and experience to supervise selected exercise stress tests. Evidence suggests that non-physician-led exercise stress testing is a safe and effective practice with similar morbidity and mortality rates as those performed or supervised by a physician.

Dobutamine stress MRI for the assessment of coronary artery disease: initial clinical experience in Israel.

BACKGROUND: Over the past few years dobutamine stress magnetic resonance (DSMR) has proven its efficacy as an integral part of the diagnosis of coronary artery disease (CAD). OBJECTIVES: To present the feasibility and safety of DSMR in Israel. METHODS: Thirty patients with suspected or known CAD were studied. DSMR images were acquired during short breath-holds in three short axis views and four-, two-, and three-chamber views. Patients were examined at rest and during a standard dobutamine-atropine protocol. Regional wall motion was assessed in a 16-segment model and the image quality was evaluated using a four-point scale for the visibility of the endocardial border. RESULTS: In 28 patients (93.4%) DSMR was successfully performed and completed within an average of 55 +/- 6 minutes. One patient could not be examined because of claustrophobia and another patient, who was on beta-blockers, did not reach the target heart rate. Image quality was excellent and there was no difference between the rest and stress images in short axis (3.91 +/- 0.29 vs. 3.88 +/- 0.34, P = 0.13, respectively) and long axis (3.83 +/- 0.38 vs. 3.70 +/- 0.49, P = 0.09, respectively) views. Segmental intra-observer agreement for wall motion contractility at rest and stress cine images was almost perfect (K = 0.88, 95% confidence interval = 0.93-0.84, and K = 0.82, 95% CI = 0.88-0.76) respectively. No serious side effects were observed during DSMR. CONCLUSION: The present study confirms the feasibility, safety and excellent image quality of DSMR for the diagnosis of coronary artery diseases.

Are oxygen-conserving devices effective for correcting exercise hypoxemia?

BACKGROUND: Correction of exercise hypoxemia in advanced lung diseases is crucial and often challenging. However, oxygen-conserving devices have been introduced in the market with limited evidence of effectiveness. In the present study the efficacy of 2 oxygen-conserving devices, a pulse demand oxygen delivery (DOD) system and pendant reservoir cannula (PRC), were evaluated in subjects with COPD and interstitial lung disease (ILD). METHODS: A cross-sectional, crossover study included 28 COPD and 31 ILD subjects with oxygen desaturation on the 6-min walk test (average S(pO2) < 88%). Each subject underwent 3 walk tests with DOD, PRC, and continuous oxygen flow by standard nasal cannula (CFNC), in random order, taking average S(pO2) ≥ 90% as the resaturation criterion. RESULTS: Exercise desaturation was corrected in 79%, 79%, and 86% of COPD subjects with CFNC, DOD, and PRC, respectively, and in 77%, 61%, and 81% of ILD subjects with CFNC, DOD, and PRC, respectively. When compared to CFNC, the oxygen-conserving devices showed similar efficacy, except a lower performance for the DOD in the ILD subjects (P = .01). CONCLUSIONS: Although these oxygen-conserving devices corrected exercise hypoxemia in most COPD and ILD subjects, correction was not achieved in about 20% of the severe COPD subjects, regardless of the device, and in nearly 40% of the ILD subjects with the DOD device. These findings underscore that individualized adjustment of oxygen flow is needed for optimal correction of exercise hypoxemia, especially with a DOD in an ILD patient. (ClinicalTrials.gov NCT01086891).

Cost burden of non-specific chest pain admissions.

BACKGROUND: Non-cardiac aetiologies are common among patients presenting with chest pain. AIM: To determine the cost of non-specific chest pain admissions to a tertiary referral, teaching hospital. METHODS: Thrombolysis in myocardial infarction risk (TIMI) risk score, lengths of stay (LOS), investigations and diagnoses were recorded for patients admitted with chest pain. Non-specific chest pain was defined as chest pain where cardiac, pulmonary and gastroesophageal aetiologies were excluded. Costs of admissions were calculated. RESULTS: Of 80 patients, 34 (4%) and 22 (28%) were diagnosed with non-specific chest pain and acute coronary syndrome, respectively. Non-specific chest pain admissions had a mean age of 54 (11; 35-74) years, LOS of 3.8 (2.6; 1-11) days and TIMI risk score of 1.4 (1.5; 0-5). Acute coronary syndrome admissions had a mean age of 67 (14; 43-94) years, LOS of 7.7 (4.3; 2-16) days and TIMI risk score of 3.1 (1.2; 0-5). The mean cost per non-specific chest pain admission was €3,729 (2,378; 1,034-10,468), or 48% of the mean cost per acute coronary syndrome admission of €7,667 (4,279; 1,963-16,071). Bed day costs account for >90% of overall costs. Only 7% of patients were weekend discharges. The mean interval to exercise stress test was 2.7(1.5; 1-7) days. CONCLUSIONS: The mean costs of admission and LOS for patients with non-specific chest pain are significant. Extrapolating findings, annual national cost is estimated at approximately €71 million for this cohort, with 73,000 bed days consumed nationally. Delays from admission to tests and low percentage of weekend discharges prolong LOS.

Relation of the utility of exercise testing for risk assessment in pediatric patients with ventricular preexcitation to pathway location.

The gradual loss of ventricular preexcitation during exercise stress testing (EST) has an unclear risk of an association with life-threatening arrhythmia and could be related to the accessory pathway (AP) location. We compared the loss of preexcitation during EST with the risk assessment during invasive electrophysiology testing and determined whether the loss of preexcitation correlates with the AP location. We retrospectively reviewed patients aged ≤21 years with ventricular preexcitation who had undergone both EST and an electrophysiology study. The patients were divided into 3 groups: sudden loss (SL), gradual loss (GL), or no loss (NL) of preexcitation during EST. A total of 76 patients were included, with 11 (14%) in the SL group, 18 (24%) in the GL group, and 47 (62%) in the NL group. The SL group demonstrated a longer cycle length with 1-to-1 conduction by way of the AP during incremental atrial pacing compared with the NL group (375 ± 135 ms vs 296 ± 52 ms, p = 0.002), with no difference between the GL and NL groups (325 ± 96 vs 296 ± 52 ms, p = NS). Of the patients with 1-to-1 AP conduction of <270 ms, none (0 of 11) were in the SL group compared to 18 of 47 in the NL group (p = 0.0017), with no significant difference in the GL group (5 of 18) compared to the NL group (p = NS). The patients in the GL group were more likely to have a left-sided AP (14 of 18) than the NL group (17 of 47, p = 0.002) and the SL group (3 of 11, p = 0.002). In conclusion, a sudden loss of preexcitation during an EST predicted a long cycle length with 1-to-1 conduction by way of the AP. Also, the AP conduction characteristics in patients with GL compared to those with NL did not differ, and the GL of preexcitation was more frequently seen in patients with a left-sided AP.

Evaluation of osteoarthritis induced by treadmill-running exercise using the modified Mankin and the new OARSI assessment system.

To apply the Osteoarthritis Research Society International (OARSI) assessment system to an osteoarthritis model, 44 Wistar rats were randomized into treadmill-running exercise or control group. At 6, 8, and 10 weeks, medial knee joints were histopathologically evaluated, and aggrecan neoepitope and TUNEL staining were performed. Cartilage changes in exercise group were histopathologically and histochemically compatible with early OA. Total modified Mankin system (MMS) scores were significantly higher at all time points (each P ≤ 0.01) in exercise than in control group. However, only tibial OARSI scores of runners were higher at 10 weeks (P < 0.05), although OARSI scores were found to be significantly correlated with MMS scores. Both total MMS (Spearman's coefficient ρ = 0.786) and OARSI scores (ρ = 0.443 for femoral; ρ = 0.604 for tibial) were significantly associated with the exercise duration. In conclusion, the OARSI system may not be sensitive to early OA changes induced by treadmill exercise.

Audiovisual assessment of exercise-induced laryngeal obstruction: reliability and validity of observations.

Variable obstruction to airflow at the laryngeal level may cause respiratory distress during exercise. The Continuous Laryngoscopy Exercise (CLE)-test enables direct visualization of the larynx during ongoing exercise. The aims of this study were to establish a scoring system for laryngeal obstruction as visualized during the CLE-test as well as to assess reliability and validity of this scoring system. Continuous video recording of the larynx was performed in parallel with continuous video recording of the upper part of the body, and recording of breath sounds in 80 patients and 20 symptom-negative volunteers, running on a treadmill to respiratory maximal tolerable distress or exhaustion. Each participant scored the degree of symptoms during exercise. The scoring system contains four sub-scores, each graded from 0 to 3. Two independent laryngologists, blinded to clinical data, scored the video recordings of the larynx twice. The proportion of inter- and intra-observer agreement (equal scores) for each sub-score through these four sessions varied between 70 and 100% (weighted kappa values varied from 0.49 to 1.00 correspondingly). A positive correlation was found between CLE-test sum score and symptom score (rho = 0.75, P < 0.001). There was a significant difference in CLE-test sum score between patients (3.34 +/- 1.34) and volunteers (0.65 +/- 0.66) (P < 0.001). The single CLE-test sub-score that correlated most strongly with symptom score was glottic adduction at maximal effort (rho = 0.75, P < 0.001). The presented scoring system is reliable and valid, and we suggest that it can be used when laryngeal function during exercise is evaluated.

Assessment of a new non-invasive index of cardiac performance for detection of dobutamine-induced myocardial ischemia.

BACKGROUND: Electrocardiography has a very low sensitivity in detecting dobutamine-induced myocardial ischemia. OBJECTIVES: To assess the added diagnostic value of a new cardiac performance index (dP/dtejc) measurement, based on brachial artery flow changes, as compared to standard 12-lead ECG, for detecting dobutamine-induced myocardial ischemia, using Tc99m-Sestamibi single-photon emission computed tomography as the gold standard of comparison to assess the presence or absence of ischemia. METHODS: The study group comprised 40 patients undergoing Sestamibi-SPECT/dobutamine stress test. Simultaneous measurements of ECG and brachial artery dP/dtejc were performed at each dobutamine level. In 19 of the 40 patients perfusion defects compatible with ischemia were detected on SPECT. The increase in dP/dtejc during infusion of dobutamine in this group was severely impaired as compared to the non-ischemic group. dP/dtejc outcome was combined with the ECG results, giving an ECG-enhanced value, and compared to ECG alone. RESULTS: The sensitivity improved dramatically from 16% to 79%, positive predictive value increased from 60% to 68% and negative predictive value from 54% to 78%, and specificity decreased from 90% to 67%. CONCLUSIONS: If ECG alone is used for specificity, the combination with dP/dtejc improved the sensitivity of the test and could be a cost-savings alternative to cardiac imaging or perfusion studies to detect myocardial ischemia, especially in patients unable to exercise.

Energetic cost of locomotion on different equine treadmills.

REASON FOR PERFORMING STUDY: Human athletes run faster and experience fewer injuries when running on surfaces with a stiffness 'tuned' to their bodies. We questioned if the same might be true for horses, and if so, would running on surfaces of different stiffness cause a measurable change in the amount of energy required to move at a given speed? HYPOTHESIS: Different brands of commercial treadmills have pans of unequal stiffness, and this difference would result in different metabolic power requirements to locomote at a given speed. METHODS: We tested for differences in stiffness between a Mustang 2200 and a Säto I commercial treadmill by incrementally loading each treadmill near the centre of the pan with fixed weights and measuring the displacement of the pan as weights were added or removed from the pan. We trained six 3-year-old Thoroughbreds to run on the 2 treadmills. After 4 months the horses ran with reproducible specific maximum rates of O2 consumption (VO2max/kg bwt, 2.62 +/- 0.23 (s.d.) mlO2 STPD/sec/kg) at 14.2 +/- 0.7 (s.d.) m/sec. They were alternately run on the 2 treadmills at identical grade (0.40 +/- 0.02%) and speeds (1.83 (walk), 4.0 (trot) and 8.0 (canter) m/sec, all +/- 0.03 m/sec) while wearing an open-flow mask for measurement of VO2. RESULTS: The Mustang treadmill was over 6 times stiffer than the Säto. The VO2/kg bwt increased by approximately 4-fold over the range of speeds studied on both treadmills. Oxygen consumption was significantly lower at all speeds for the Mustang treadmill compared to the Säto. The fractional difference in energy cost decreased by a factor of 6 with increasing speed, although absolute difference in cost was relatively constant. CONCLUSIONS: We suggest it costs less energy for horses to walk, trot or canter on a stiffer treadmill than on a more compliant treadmill, at least within the ranges of stiffness evaluated. POTENTIAL RELEVANCE: It may be possible to define a substrate stiffness 'tuned' to a horse's body enabling maximal energetic economy when running. The differences between treadmills allows more accurate comparisons between physiological studies conducted on treadmills of different stiffness, and might help to identify an ideal track stiffness to reduce locomotor injuries in equine athletes.

Is nurse-supervised exercise stress testing safe practice?

OBJECTIVE: Nurses have been performing exercise stress tests (EST) without medical supervision since 1978 in our hospital-based cardiac rehabilitation unit. This study was conducted to examine the incidence of cardiovascular complications and to describe the competency-based training program for the nurses performing the EST. DESIGN: Descriptive, retrospective audit of prospective data. SETTING: Single comprehensive cardiac rehabilitation center in a large tertiary referral hospital in western Sydney, Australia. SUBJECTS: Seventeen thousand, four hundred and sixty-seven patients were included in this study over a 12-year period. METHOD: Data were collected on all ESTs performed by the cardiac rehabilitation nurses from January 1986 to December 1997 in relation to serious cardiovascular complications and other EST parameters. RESULTS: In this study, 17,467 ESTs were performed on 5054 patients who had 6273 separate presentations. The most common entry diagnosis was after an acute myocardial infarction (50%). The mean age was 58 +/- 10.5 years (range 15 to 87 years; 80% male). The left ventricular ejection fraction (n = 2822) was 49% +/- 14%. In a subgroup analysis of 14,454 patients, 14% had a positive EST (ST segment >1.9 mm depression). There were no deaths associated with the EST, and there were 13 major complications in 12 patients. This figure included no cardiac arrests, 11 episodes of conscious sustained ventricular tachycardia, 1 reinfarction, and 1 mitral valve rupture, representing a 0% mortality rate and a 0.075% major morbidity rate. CONCLUSION: This study shows that nurse-supervised EST of higher risk patients in the hospital-based cardiac rehabilitation setting has been a safe practice from a mortality and morbidity rate perspective. This finding may be accounted for by the high training standard and reaccreditation of the nurses on the advanced practice of performing EST.

Weekend and holiday exercise testing in patients with chest pain.

OBJECTIVE: To determine the outcome, safety, and possible cost savings of patients undergoing weekend or holiday exercise treadmill testing. DESIGN: Medical records of all 195 patients scheduled for weekend and holiday exercise testing were reviewed, and 77.9% of patients were contacted by telephone to ascertain medical outcomes and need for further emergency department or inpatient care. Costs were calculated from estimates of days of hospitalization saved and incremental costs incurred in conjunction with weekend or holiday testing. SETTING: Urban tertiary care academic medical center. PATIENTS: A total of 195 patients were scheduled for testing, and 181 tests were performed. Over three quarters (75.1%) of patients underwent testing for assessment of chest pain. Other indications included risk stratification after myocardial infarction or coronary angioplasty or prior to noncardiac surgery, or evaluation for arrhythmias, dyspnea, or syncope. MEASUREMENTS AND MAIN RESULTS: Outcomes included results and complications of testing, hospital course after testing, subsequent emergency department visits and readmissions, myocardial infarction, need for cardiac catheterization or revascularization, and mortality. No complications were noted during testing. In 136 patients tested for the indication of chest pain, 90 (66.2%) had negative tests, 39 (28. 7%) were intermediate, and 6 (4.4%) were positive for ischemia. Same day discharge occurred in 115 (84.6%) of the patients, saving an estimated 185 days of hospitalization ($316.83 per patient tested). Event rates over the 6 months following discharge were low. CONCLUSIONS: Weekend and holiday exercise testing is a safe and effective means of risk stratification prior to hospital discharge for patients with chest pain. It also reduces length of stay and is cost saving.

Injuries during the one repetition maximum assessment in the elderly.

PURPOSE: A decrease in strength, and its associated loss of functional ability is common among the elderly. Although resistance training can reverse this decline, associated injuries with frequently used strength assessments may present a greater risk. METHODS: To evaluate the injuries associated with maximal strength evaluations, 83 relatively healthy elderly subjects (40 men and 43 women, 65.8 +/- 6.2 years) with and without prior weight training experience performed 1 repetition maximum testing (1 RM) involving 5 different exercises: chest press, leg extension, abdominal curl, arm curl, and seated calf raise. Subjects were separated into three groups depending on weight training experience, Group 1 had no weight training experience (n = 32), Group 2 had < 6 months of training (n = 24), and Group 3 had > 6 months of training (n = 27). Injury assessment was made 30 minutes, 2 days, and 7 days posttesting. RESULTS: Two Group 1 subjects sustained an injury (2.4% of total subjects, 8% of Group 1). Eighty-one subjects safely completed the 1 RM assessment without injury (97.6% of total). Forty-eight of the 83 subjects complained of muscle soreness after testing (58% of total). This complaint alone was not sufficient to be categorized as an injury. CONCLUSIONS: These results indicate that 1 RM testing is an acceptable tool in strength evaluations in the elderly. Additional precautions may be needed in inexperienced, elderly individuals to prevent injury.

[Difficulties and limits in the evaluation of the cost of coronary disease in France]. / Difficultés et limites de l'évaluation du coût des affections coronariennes en France.

Evaluating the cost of coronary artery disease is difficult because it must take into account not only the cost of the disease process itself, but also that of prevention and research. 1. The cost of the disease process itself may be assessed by: a) an analytical study of the real cost of diagnostic and therapeutic procedures; b) a synthetic study of the procedures according to the clinical forms of the disease. Although this task is simple for a given patient, extrapolation of the results to a whole group of patients is more aleatory; c) an epidemiological study of the different forms of coronary artery disease: although global data is available the absence of a coronary artery disease register makes this a difficult problem; d) an evaluation of the socio-professional repercussions of coronary artery disease with integration of the cost and loss in gross national product. 2 The cost of prevention can be assessed by taking the following factors into consideration: a) cost of individual primary prevention which poses the problems of check-up examinations; b) cost of community primary prevention; c) cost of research including fundamental research on the atheromatous process and myocardial ischemia plus clinical research such as secondary prevention enquiries. In conclusion, it appears that: --it is difficult to determine the cost of coronary artery disease without a specialist register; --the cost of coronary artery disease should be considered from positive (source of economic activity) and negative points of view (socio-professional repercussions); --a reduction in the cost of coronary artery disease requires a deeper understanding of the disease, better prophylaxis and socio-professional rehabilitation, and improved organisation of exciting health structures.

Treadmill stress testing in the evaluation of patients with valvular heart disease. Possible role in the assessment of functional capacity and severity of the lesion.

A series of 123 patients with valvular heart disease underwent treadmill stress testing (Bruce's protocol). Neither mortality nor serious complications were observed. The incidence of exercise-induced ventricular ectopy was 35% and that of complex ventricular ectopy 19%. Patients with pure left ventricular volume overload had a significantly higher incidence of exercise-induced ventricular ectopy than did patients with other valvular diseases. A significant relation was found between functional class (NYHA) and either duration of exertion or functional aerobic impairment. The NYHA classification was found to coincide in 62% of the instances with another based on the results obtained from stress testing. In patients with mitral stenosis a significant although slight correlation was found to exist between mitral valve area and duration of exercise. The inability to reach stage III of Bruce's protocol was associated with a critical mitral stenosis. A hypotensive response to exercise was frequent both in mitral stenosis and aortic stenosis. But whereas in aortic stenosis it was characteristic of the most severe lesions, in mitral stenosis it bore no relation whatsoever to severity. Thus, treadmill stress testing in valvular heart disease is safe, can be helpful in quantifying functional disability and may provide a clue as to the severity of the lesion in specific subsets.