C Ronald MacKenzie

Supervised fitness walking in patients with osteoarthritis of the knee. A randomized, controlled trial.

OBJECTIVE To assess the effect of a program of supervised fitness walking and patient education on functional status, pain, and use of medication in patients with osteoarthritis of the knee. DESIGN An 8-week randomized, controlled trial. SETTING Inpatient and outpatient services of an orthopedic hospital in an academic medical center. PATIENTS A total of 102 patients with a documented diagnosis of primary osteoarthritis of one or both knees participated in the study. Data were obtained on 47 of 51 intervention patients and 45 of 51 control patients. INTERVENTIONS An 8-week program of supervised fitness walking and patient education or standard routine medical care. MEASUREMENTS Patients were evaluated and outcomes assessed before and after the intervention using a 6-minute test of walking distance and scores on the physical activity, arthritis impact, pain, and medication subscales of the Arthritis Impact Measurement Scale (AIMS). RESULTS Patients randomly assigned to the walking program had a 70-meter increase in walking distance relative to their baseline assessment, which represents an improvement of 18.4% (95% Cl, 9.8% to 27.0%). In contrast, controls showed a 17-meter decrease in walking distance relative to their baseline assessment (P less than 0.001). Improvements in functional status as measured by the AIMS physical activity subscale were also observed in the walking group but not in the control group (P less than 0.001); patients assigned to the walking program improved 39% (Cl, 15.6% to 60.4%). Although changes in scores on the arthritis impact subscale were similar in the two groups (P = 0.093), the walking group experienced a decrease in arthritis pain of 27% (Cl, 9.6% to 41.4%) (P = 0.003). Medication use was less frequent in the walking group than in the control group at the post-test (P = 0.08). CONCLUSIONS A program of supervised fitness walking and patient education can improve functional status without worsening pain or exacerbating arthritis-related symptoms in patients with osteoarthritis of the knee.

Perioperative outcomes after unilateral and bilateral total knee arthroplasty

Background:The safety of bilateral total knee arthroplasties (BTKAs) during the same hospitalization remains controversial. The authors sought to study differences in perioperative outcomes between unilateral and BTKA and to further compare BTKAs performed during the same versus different operations during the same hospitalization. Methods:Nationwide Inpatient Sample data from 1998 to 2006 were analyzed. Entries for unilateral and BTKA procedures performed on the same day (simultaneous) and separate days (staged) during the same hospitalization were identified. Patient and healthcare system–related demographics were determined. The incidences of in-hospital mortality and procedure-related complications were estimated and compared between groups. Multivariate regression was used to identify independent risk factors for morbidity and mortality. Results:Despite younger average age and lower comorbidity burden, procedure-related complications and in-hospital mortality were more frequent after BTKA than after unilateral procedures (9.45% vs. 7.07% and 0.30% vs. 0.14%; P < 0.0001 each). An increased rate of complications was associated with a staged versus simultaneous approach with no difference in mortality (10.30% vs. 9.15%; P < 0.0001 and 0.29% vs. 0.26%; P = 0.2875). Independent predictors for in-hospital mortality included BTKA (simultaneous: odds ratio, 2.23 [95% confidence interval, 1.69–2.95]; P < 0.0001; staged: odds ratio, 2.01 [confidence interval, 1.28–3.41]; P = 0.0031), male sex (odds ratio, 2.02 [confidence interval, 1.75–2.34]; P < 0.0001), age older than 75 yr (odds ratio, 3.96 [confidence interval, 2.77–5.66]; P < 0.0001), and the presence of a number of comorbidities and complications. Conclusion:BTKAs carry increased risk of perioperative morbidity and mortality compared with unilateral procedures. Staging BTKA procedures during the same hospitalization offers no mortality benefit and may even expose patients to increased morbidity.

Preoperative Characteristics Predicting Intraoperative Hypotension and Hypertension Among Hypertensives and Diabetics Undergoing Noncardiac Surgery

We prospectively studied patients with hypertension and diabetes undergoing elective noncardiac surgery with general anesthesia to test the hypothesis that patients at high risk for prognostically significant intraoperative hemodynamic instability could be identified by their preoperative characteristics. Specifically we hypothesized that patients with a low functional capacity, decreased plasma volume, or significant cardiac comorbidity would be at high risk for intraoperative hypotension and those with a history of severe hypertension would be at risk for intraoperative hypertension. Patients who had a preoperative mean arterial pressure (MAP) ≥110, a walking distance of less than 400 m, or a plasma volume less than 3000 cc were at increased risk of intraoperative hypotension (i.e., more than 1 hour of ≥20 mmHg decreases in the MAP). Hypotension was also more common among patients having intra-abdominal or vascular surgery, and among those who had operations longer than 2 hours. Patients older than 70 years or with a decreased plasma volume were at increased risk of having more than 15 minutes of intraoperative elevations of 2:20 mmHg over the preoperative MAP in combination with intraoperative hypotension; this was also more common when surgery lasted more than 2 hours. Patients who had intraoperative hypotension tended to have an immediate decrease in MAP at the onset of anesthesia and were often purposefully maintained at MAPs less than their usual level during surgery with fentanyl and neuromuscular blocking agents. Patients who had intraoperative hyper/hypotension tended to have repeated elevations in MAP above their preoperative levels during the course of surgery, and such elevations precipitated interventions with neuromuscular blocking agents and/or fentanyl. Neither pattern was more common among patients who developed net intraoperative negative fluid balances. Both hypotension and hyper/hypotension were associated with increased renal and cardiac complications after operation. Patients with cardiac disease, especially diabetics, and those with negative fluid balances also had increased complications. Preoperative characteristics influence the susceptibility to intraoperative hypotension and hypertension, which are related to postoperative complications.

Laryngeal involvement in systemic lupus erythematosus

Laryngeal involvement in systemic lupus erythematosus (SLE) can range from mild ulcerations, vocal cord paralysis, and edema to necrotizing vasculitis with airway obstruction. In this report, four cases showing the range of severity of this disease manifestation are presented, accompanied by a comprehensive review of the literature. The clinical course of 97 patients with laryngeal involvement with SLE are reviewed, of whom 28% had laryngeal edema and 11% had vocal cord paralysis. In the majority of cases, symptoms such as hoarseness, dyspnea, and vocal cord paralysis resolved with corticosteroid therapy. Other, less common causes of this entity included subglottic stenosis, rheumatoid nodules, inflammatory mass lesions, necrotizing vasculitis, and epiglottitis. The clinical presentation of laryngeal involvement in patients with SLE follows a highly variable course, ranging from an asymptomatic state to severe, life-threatening upper airway compromise. With its unpredictable course and multiple causations, this complication remains a diagnostic and therapeutic challenge to physicians involved in the care of patients with SLE.

A Walking Education Program for Patients with Osteoarthritis of the Knee: Theory and Intervention Strategies

This work was supported by NIH Multipurpose Arthritis Center Program grant no. 1 P60 AR38520-01A1, and in part by a predoctoral research fellowship grant to Dr. Kovar from the Arthritis Foundation. We thank Dr. Kate Long of the Stanford Arthritis Center, for providing numerous helpful suggestions m the early stages of developing this program; our colleagues at the Cornell Arthritis and Musculoskeletal Diseases Center, Dr. Mary Charlson and Dr. Mark Kasper, for reading and commenting on several drafts of the manuscript; and Dr. Lawren Daltroy, of the Multipurpose Arthritis Center at the Bngham and Womens Hospital, and the anonymous reviewers, whose helpful comments and editorial guidance enabled us to improve the manuscript. Portions of this paper were presented at the Northeast Arthritis Health Professions Association, May 19, 1990, New York, NY, and the 41st Annual Meeting of the Society for Public Health Education, October 5, 1990, New York, NY.

Professionalism and Medicine

It is widely acknowledged that potent forces of a political, legal, and market-driven nature are producing great stress on the practice of medicine [2–5]. Recognizing that such influences potentially threaten the underpinnings that unite physicians, patients, and society, there is widespread concern both inside and outside the profession concerning the impact such forces impart on medical practice. As a consequence of these matters, the discourse pertaining to medical professionalism is of considerable interest to the practicing physician and their professional societies, the institutions where they work, and the myriad of bodies that oversee and regulate the practice of medicine. This interest has spawned a substantial literature examining the influences that bear on how medicine is practiced and broadly perceived. This paper is an attempt to distill the prodigious and sometimes contentious literature.

The post-operative electrocardiogram and creatine kinase: Implications for diagnosis of myocardial infarction after non-cardiac surgery

The objective of this study was to evaluate different approaches to the diagnosis of post-operative myocardial infarction. A total of 232 patients, mostly hypertensive and/or diabetic patients, who were undergoing elective non-cardiac surgery were evaluated pre-operatively. They were followed serially from the day of operation to discharge or the sixth post-operative day with daily clinical evaluations, electrocardiograms, creatine kinase and creatine kinase isoenzymes. In total 22% (51/232) of the patients had post-operative ECG changes in two or more leads. Only 1% developed new Q waves; most of the changes involved changes in the T or ST segments. Seventy percent of patients who had changes in their electrocardiogram were completely asymptomatic. The highest risk of ECG changes or symptoms occurred on the day of operation and the first post-operative day; evidence of post-operative infarction was infrequent after the second post-operative day. Creatine kinase levels rose an average of 250-300 IU on the first and second post-operative day (also the peak time for post-operative ECG changes), reducing its utility as an adjunct to the diagnosis of post-operative infarctions. Importantly, 52% (12/23) of the patients who had greater than or equal to 5% MB isoenzyme had neither ECG changes nor symptoms; the diagnosis of a myocardial infarction should not be made in these patients. In summary, most patients who experience ischemia or infarction post-operatively are asymptomatic. Symptoms should not be required for the diagnosis of post-operative infarction. Seemingly minor differences in criteria can produce major discrepancies in post-operative myocardial infarction rates (from 1 to 9%). The development of a final set of criteria will require further study but the diagnosis of post-operative infarction should probably be based on ECG changes, their duration and consistency, and the association of a positive MB fraction.

Complementary and Alternative Medicine in Rheumatoid Arthritis: No Longer the Last Resort!

Complementary and alternative medicine (CAM) has become popular with consumers worldwide and accounts for significant private and public health expenditures. According to earlier reports, the prevalence of CAM use by rheumatoid arthritis (RA) patients in the United States is anywhere between 28% and 90%. Extensive use among RA patients and the limited knowledge among physicians had confirmed the need to evaluate the increasing prevalence of various CAM modalities. The primary aim of this study was to identify the incidence of CAM usage among our RA patients. Additionally, we aimed to correlate patient demographics and disease characteristics with the use of specific CAM modalities. An analysis of data extracted from our institution’s RA longitudinal registry was performed. The patients were asked to select from a list the modalities they were currently using and/or had used in the past. Of patients, 75.9% reported current or past use of CAM with >10% using 12 different modalities. Nutritional supplements and touch therapies were the most widely used overall, with mind–body therapies more prevalent among younger patients. CAM users were found to have more extra-articular manifestations and fewer comorbidities than non-CAM users. The use of CAM among RA patients is widespread with a broad spectrum of CAM modalities being used in early stages of the disease, frequently in conjunction with mainstream conventional treatments. Therefore, CAM may no longer be considered the rheumatoid patients’ last resort.

Nuances of Informed Consent: The Paradigm of Regional Anesthesia

Informed Consent is the primary method employed in clinical practice by which patients and their physicians incorporate a patient’s values, preferences, expectations, and fears in treatment decision-making [1]. Grounded in the philosophical concept of autonomy, it reflects a departure from the paternalistic tradition of western medicine, revealed first in the writings of Hippocrates and remaining dominant until recent times [2]. The practice of Informed Consent in the clinical arena evolved primarily through the medical profession’s responses to various decisions by the courts. In this paper we review the concept of Informed Consent from a historical and ethical perspective and, in so doing, provide a context for a discussion of these considerations to a specific clinical domain, that of regional anesthesia.

Stress Dose Steroids: Myths and Perioperative Medicine.

Perioperative medication management for patients with systemic autoimmune inflammatory diseases has focused on strategies to improve outcomes and mitigate risks. The emphasis has been to minimize the risk of infection associated with most antirheumatic medications, while attempting to avoid flares of disease precipitated by medication withdrawal. Management of glucocorticoids in the perioperative period has been based on an assumption that supraphysiologic increases in dose were always necessary to avoid hypotension and shock in glucocorticoid treated patients, and alternative strategies were rarely considered despite the known infectious, metabolic, and wound healing risks associated with glucocorticoid administration. This paper will review current recommendations for perioperative glucocorticoid administration for glucocorticoid treated patients with systemic inflammatory autoimmune diseases and discuss glucocorticoid physiology to analyze the basis for these recommendations and consider alternative perioperative management strategies.