Should patients with heart disease exercise in the morning or afternoon?

OBJECTIVE: To compare the cardiovascular risk of exercise in the morning and afternoon in patients with established heart disease. DESIGN: Retrospective cohort study. PATIENTS: Patients with established heart disease referred for participation in a comprehensive cardiac rehabilitation program. INTERVENTION: Supervised, submaximal exercise (1 hour three times per week) performed either in the morning (7:30 AM) or the afternoon (3 PM). MAIN OUTCOME: Documented cardiac events that occurred while patients were exercising in the rehabilitation programs. RESULTS: There were five cardiac events in 168,111 patient-hours of exercise in the morning, with an incidence of 3.0 +/- 1.3 events per 100,000 patient-hours. There were two events during the 84,491 patient-hours of exercise in the afternoon, for an incidence of 2.4 +/- 1.5 events per 100,000 patient-hours (not significant). The risk ratio of cardiac events during exercise in the morning compared with the afternoon was 1.27 (95% confidence interval, 0.25 to 6.55). CONCLUSION: In patients with coronary artery disease, the incidence of cardiac events is low during regular, submaximal exercise whether performed in the morning or the afternoon.

Current management of severe exercise-related cardiac events.

Severe cardiac events during either exercise testing or cardiac rehabilitation are described in five patients. The three events related to exercise testing involved patients with atypical chest pain which, in retrospect, probably reflected unstable angina pectoris or coronary vasospasm (or both). Prompt coronary angiography with subsequent percutaneous transluminal coronary angioplasty was performed. Two cardiac arrests (one fatal) occurred during participation in cardiac rehabilitation programs. One was caused by primary ventricular fibrillation. Electrophysiologic testing was used in determining the efficacy of the drug. The fatality was due to an acute myocardial infarction. On-site intravenous thrombolytic therapy might prove useful in similar events in the future. Comparisons of surveys published in the 1970s with those in the 1980s show that the mortality and morbidity during exercise testing remain low and that similar rates during cardiac rehabilitation are even lower; however, these cases exemplify that emergency situations can and do arise, necessitating prompt intervention and aggressive subsequent management.

Babesiosis: problems in diagnosis using autoanalyzers.

A 76-year-old white man previous diagnosed as having Waldenstrom's macroglobulinemia continued with persistent fevers and sweats for two and a half years. Recently, repeated automated differentials during 11 days of hospitalization failed to note any intracellular inclusions in the RBCs. Blood sent to the Microbiology Laboratory was noted to contain Babesia species. A review of the hematology slides revealed that Babesia species was present on all the slides the analyzer had screened. This failure to note infected RBCs may pose serious diagnostic problems.

The results of treatment of synovitis of the wrist induced by particles of silicone debris.

Synovitis of the wrist induced by particles of silicone debris is a destructive inflammatory process. Many silicone-rubber carpal implants remain in place, and there are few reports regarding the treatment of this condition. The purpose of the present study was to examine the results of treatment of synovitis induced by particles of silicone debris. Twenty-eight patients were identified, with use of computerized indexing, as having been evaluated for silicone-induced synovitis between 1972 and 1992. Seventeen of the twenty-eight patients were included in the study. At the time of the latest follow-up, twelve of the seventeen patients had pain, thirteen of the fourteen patients for whom radiographs were available had evidence of osteolysis typical of that associated with debris-induced synovitis, and eight of the seventeen patients reported difficulty with activities of daily living because of problems with the wrist. Seven patients had been treated non-operatively, and ten had been treated operatively. With the small number of patients available for study, we could not detect a significant difference between the two groups with respect to pain, perceived limitation of motion, difficulty with activities of daily living, grip strength, or the total range of motion of the wrist. There was no significant difference between the two groups with regard to the age at the time of the initial procedure, the time to the diagnosis of the synovitis, and the duration of follow-up after treatment. There was no clear advantage to removal of the implant and débridement with or without arthrodesis of the wrist or other reconstructive procedures. We recommend caution when a reconstructive or salvage procedure in the wrist is selected for a patient who has synovitis induced by particles of silicone debris.

The natural history and long-term follow-up of Scheuermann kyphosis.

Sixty-seven patients who had a diagnosis of Scheuermann kyphosis and a mean angle of kyphosis of 71 degrees were evaluated after an average follow-up of thirty-two years (range, ten to forty-eight years) after the diagnosis. All sixty-seven patients completed a questionnaire; fifty-four had a physical examination and radiographs; fifty-two, pulmonary function testing; and forty-five, strength-testing of the trunk muscles. The results were compared with those in a control group of thirty-four subjects who were matched for age and sex. The patients who had Scheuermann kyphosis had more intense back pain, jobs that tended to have lower requirements for activity, less range of motion of extension of the trunk and less-strong extension of the trunk, and different localization of the pain. No significant differences between the patients and the control subjects were demonstrated for level of education, number of days absent from work because of low-back pain, extent that the pain interfered with activities of daily living, presence of numbness in the lower extremities, self-consciousness, self-esteem, social limitations, use of medication for back pain, or level of recreational activities. Also, the patients reported little preoccupation with their physical appearance. Normal or above-normal averages for pulmonary function were found in patients in whom the kyphosis was less than 100 degrees. Patients in whom the kyphosis was more than 100 degrees and the apex of the curve was in the first to eighth thoracic segments had restrictive lung disease. Five patients had an unexplained, mildly abnormal neurological examination. Mild scoliosis was common; spondylolisthesis was not observed.

Current status of wrist arthrodesis and wrist arthroplasty.

A variety of techniques are available for reconstruction of the wrist. The efficacy of wrist arthroplasty, however, is met with narrowed indications and does not enjoy the success that total joint replacement in other joints, such as the hip and knee, has enjoyed. With design improvements during the last decade, good short-term results from total wrist arthroplasty can be expected in the low-demand patient with rheumatoid arthritis. Wrist arthrodesis, either pancarpal or limited, is considered the primary surgical alternative in patients with most arthritic conditions of the wrist. The pancarpal arthrodesis is a predictable, durable alternative to a variety of post-traumatic, degenerative, or neoplastic conditions of the wrist; however, some authors report that complications may be prevalent. This procedure also may be modified and applied to the destroyed rheumatoid wrist. Overall, selection of fixation mode depends on bone quality. In an attempt to preserve motion, various limited arthrodeses of the carpus have been described. Although technically demanding, successful results may be expected, especially in conditions of carpal instability. With the current wide array of surgical alternatives, the surgeon must consider each case carefully and select the procedure that best applies to each particular situation. Furthermore, it is extremely important that the surgeon educate the patient on the limitations of each procedure.

Current status of metacarpophalangeal arthroplasty and basilar joint arthroplasty of the thumb.

MP joint arthroplasty finds its widest application in the patient with rheumatoid arthritis. With only minor design modification over the years, the Silastic MP joint space is a predictable, durable device with reasonable longevity. In contrast, reconstruction of the CMC joint of the thumb relies primarily on soft tissue reconstruction with arthroplasty techniques having limited applications.

Golf-induced injuries of the wrist.

Golf injuries of the wrist are rare, but when they occur they can be devastating for the avid golfer, competitive amateur golfer, or the professional golfer, as the hand and wrist are so integral to the game. The majority of golf injuries are overuse injuries of the wrist flexor or extensor tendons. The left wrist (in the right-handed golfer) is the most common location. Analysis of the golf swing finds excessive motion of the left wrist (in the right-handed golfer), along with a catapulting function, accounting for vulnerability of the left wrist to injury. Hyperextension and radial deviation of the right wrist may cause impingement syndrome and injury may also occur during impact of the swing phase. The majority of golf-induced overuse syndromes of the wrist are successfully treated nonoperatively, but may require restriction from golf for an extended period of time. Many of the wrist problems that we see can often be related to a strong grip (left hand positioned clockwise on the golf club handle), overgripping (too tight a grip) golf club grips in poor repair, or poor swing techniques. The most common bony injury of the wrist is fracture of the hook of the hamate. This injury is a source of chronic ulnar-sided wrist pain in the golfer and is often diagnosed late or left undiagnosed. Proper-fitting golf clubs, proper swing technique, and avoidance of obstacles may prevent this injury. Like any other sport, golf requires the use of proper equipment, proper technique, and conditioning to prevent injury.

Respiratory protection in occupational health-update.

Respiratory protection is a complex field involving industrial hygiene, physics, physiology, toxicology, medicine, anthropology, engineering, law, and worksite administration. Although the use of respirators is widespread, they are the least effective and often the most costly method of protecting workers. Preferred methods of protection are engineering controls that eliminate exposure and substitution of the agent for one of lesser toxicity. However, in work situations where alternative methods are not available, a well-designed and well-monitored respiratory protection program can still provide a safe environment for the soldier and civilian worker. With the enactment and enforcement of the Occupational Health and Safety Act, worker protection has gained a much higher priority among employers and health officials. The field is dynamic and some of the medical screening procedures outlined in TB MED 502 (Respiratory Protection) are outdated. Industrial processes and state-of-the-art protective equipment change rapidly. Because certified occupational health physicians and nurses are not always available, health care workers need a fundamental understanding of respiratory protection.

Septic arthritis of the hand and wrist.

Septic arthritis of the hand and wrist is relatively uncommon. The most common cause is penetrating trauma such as a human or animal bite. The most common causative organism is Staphylococcus aureus. Septic arthritis caused by Streptococcal species. Haemophilus influenzae, Pseudomonas aeruginosa, Serratia species, Neisseria gonorrhoeae, Pasteurella multocida, Eikenella corrodens, and Mycobacterium marinum also may occur in specific clinical settings. The best clinical results occur following an accurate diagnosis, prompt surgical drainage, and debridement in concert with appropriate antibiotics and early postoperative range of motion. A delay in diagnosis or treatment is associated with an unsatisfactory outcome.

Prevalence of False-Positive Exercise Tests in Apparently Normal Women.

In brief: Some experts believe that exercise testing in women elicits an unacceptably high false-positive rate. The authors studied the results of exercise testing in 192 apparently healthy women (mean age, 38.2 years) to assess the false-positive rate in ST-segment response. Based on the tests and a five-year follow-up, only seven women (3.7%) showed false-positive results. The authors suggest that varying methods of testing and interpretation may account for the high rate of false positivity in some testing centers.

ECG Quiz: Dizziness in a Cardiac Rehabilitation Patient.

A 62-year-old woman entered a cardiac rehabilitation program for help with weight loss and fitness, and also for monitoring of episodic atrial fibrillation, which had begun in 1992. She was able to exercise without triggering atrial fibrillation. Additional past medical problems included glucose intolerance (treated with diet), hyperlipidemia, hypertension, migraine headaches, degenerative disease of the spine, and a duodenal ulcer.

Avulsion fractures of the volar aspect of triquetral bone of the wrist: a subtle sign of carpal ligament injury.

OBJECTIVE: We report five examples of a triquetral fracture pattern not previously described to our knowledge. These fractures from the volar aspect of the triquetral bone are important because they are easily missed with conventional wrist radiographs and yet are associated with significant ligament injuries and carpal instability. MATERIALS AND METHODS: Five volar triquetral avulsion fractures occurred in young men (20-28 years old) during falls while playing sports. The initial evaluation consisted of a three-view radiographic series. Subsequently, an instability series was obtained in each case. Four patients were also evaluated by stress videofluoroscopy and arthrography, one by CT, and four by MR imaging. RESULTS: None of the five fractures was recognized on radiographs obtained in the emergency room. Each fracture was identified on an instability series and involved the radial aspect of the volar surface of the triquetral bone. All four wrists evaluated by stress videofluoroscopy showed lunatotriquetral joint instability. One also showed instability of the scapholunate joint. All four wrists evaluated by arthrography showed tears of the lunatotriquetral ligament and three had an associated tear of the scapholunate ligament. MR examination of four wrists showed a volar capsular ligament attached to the avulsion fracture fragment in each wrist. Two of the patients were treated by arthroscopic debridement and three were treated by prolonged splinting. All five patients had persistent pain and carpal instability of variable severity at least 1 year after injury. CONCLUSION: This avulsion fracture of the radial aspect of the volar triquetral bone is a subtle, easily missed sign of a significant injury of the perilunate ligaments. When this fracture is identified, we recommend further evaluation for associated ligament injury and carpal instability.

Indications, types, results, and complications of valvular surgery.

Results of long-term follow-up of new mechanical valves introduced in the 1980s and innovative new surgical techniques complementing repair of the mitral apparatus are discussed here. In addition, recent reports highlighting new information about the indications, types, results, and applications of valve surgery are described.

Anaerobic mediastinitis.

Anaerobic bacteria often are neglected in discussions of the bacteriology of mediastinitis. Two cases of anaerobic mediastinitis are reported and the literature in this field is reviewed. Anaerobes are important pathogens in the etiology of mediastinitis secondary to perforation of the esophagus, extension of a retropharyngeal abscess, or extension of cellulitis or abscess of dental origin from the neck. Although anaerobes indigenous to the oral cavity predominate in these cases, there are also a few cases reported involving Bacteroides fragilis. The source of the mediastinitis should be considered when antimicrobial therapy is initiated so that appropriate anaerobic coverage can be included when indicated.

Anaerobes in burn-wound infections.

Anaerobic bacteria are not routinely considered in discussions of the etiology of burn-wound infection. However, this review of the literature reveals that there are numerous case reports that document clinically significant anaerobic burn-wound infection and some prospective data that suggest a possible role of anaerobes in the clinical setting of burn-wound sepsis. Further studies are needed to answer the questions of how often anaerobes colonize burn wounds and how often anaerobes invade the wounds to cause clinically significant burn-wound sepsis.

Primary neoplasms of the carpal bones.

Primary neoplasms of the carpal bones are rare. We found 44 primary tumors of the carpal bones of 26,800 bone neoplasms (prevalence, 0.16%). Original histologic slides and original radiographs were reviewed in 36 and 29 cases, respectively. Thirty-eight tumors (86%) were benign; 6 (14%) were malignant. The average patient age was 35 years. Benign lesions were diagnosed at a younger age (32 years) than malignant lesions (58 years). Benign tumors occurred more frequently in males (23 of 38 patients); the 6 malignant lesions were equally distributed by gender (3 males and 3 females; 95% confidence interval, 11.8-88.2). The most common tumor was osteoid osteoma (11 cases); the most common malignant neoplasm was hemangioendothelial sarcoma (3). The most common locations were the scaphoid (13 cases) and capitate (10), which together accounted for 52% of all neoplasms. Tumors were identified in every carpal bone except the trapezium. The diagnosis of tumor in a carpal bone should be considered in the undiagnosed painful wrist, especially in younger patients without imaging abnormalities.