Effect of maximum exercise on left ventricular deformation and its correlation with cardiopulmonary exercise capacity in competitive athletes

BACKGROUND

Global longitudinal strain (GLS) and global myocardial work index (GWI) allow early detection of subclinical changes in left ventricular (LV) systolic function. The aim of the study was to investigate the immediate effects of maximum physical exercise by different exercise testing methods on early post exercise LV deformation parameters in competitive athletes and to analyze their correlation with cardiopulmonary exercise capacity.

METHODS

To reach maximum physical exercise, cardiopulmonary exercise testing (CPET) was performed by semi-recumbent ergometer in competitive handball players (n = 13) and by treadmill testing in competitive football players (n = 19). Maximum oxygen uptake (VO2max) indexed to body weight (relative VO2max) was measured in all athletes. Transthoracic echocardiography and blood pressure measurements were performed at rest and 5 min after CPET in all athletes. GLS, GWI and their changes before and after CPET (ΔGLS, ΔGWI) were correlated with (relative) VO2max.

RESULTS

In handball and football players, GLS and GWI did not differ significantly before and after CPET. There were no significant correlations between GLS and relative VO2max, but moderate correlations were found between ΔGWI and relative VO2max in handball (r = 0.631; P = 0.021) and football players (r = 0.592; P = 0.008). Furthermore, handball (46.7 ml/min*kg ± 4.7 ml/min*kg vs. 37.4 ml/min*kg ± 4.2; P = 0.004) and football players (58.3 ml/min*kg ± 3.7 ml/min*kg vs. 49.7 ml/min*kg ± 6.8; P = 0.002) with an increased ΔGWI after CPET showed a significant higher relative VO2max.

CONCLUSION

Maximum physical exercise has an immediate effect on LV deformation, irrespective of the used testing method. The correlation of relative VO2max with ΔGWI in the early post exercise period, identifies ΔGWI as an echocardiographic parameter for characterizing the current individual training status of athletes.

The impact of upright posture on left ventricular deformation in athletes

Besides LV ejection fraction (LVEF), global longitudinal strain (GLS) and global myocardial work index (GWI) are increasingly important for the echocardiographic assessment of left ventricular (LV) function in athletes. Since exercise testing is frequently performed on a treadmill, we investigated the impact of upright posture on GLS and GWI. In 50 male athletes (mean age 25.7 ± 7.3 years) transthoracic echocardiography (TTE) and simultaneous blood pressure measurements were performed in upright and left lateral position. LVEF (59.7 ± 5.3% vs. 61.1 ± 5.5%; P = 0.197) was not affected by athletes' position, whereas GLS (- 11.9 ± 2.3% vs. - 18.1 ± 2.1%; P < 0.001) and GWI (1284 ± 283 mmHg% vs. 1882 ± 247 mmHg%; P < 0.001) were lower in upright posture. Longitudinal strain was most frequently reduced in upright posture in the mid-basal inferior, and/or posterolateral segments. Upright posture has a significant impact on LV deformation with lower GLS, GWI and regional LV strain in upright position. These findings need to be considered when performing echocardiography in athletes.

SARS-CoV2 infection: functional and morphological cardiopulmonary changes in elite handball players

Background

There is increasing evidence of cardiac involvement in SARS-COV-2 infections. This may not only apply to symptomatic infections but may also affect asymptomatic athletes. This study aimed to characterize the possible acute cardiac involvement of SARS-COV-2 infection in athletes both morphologically and functionally.

Methods and results

Eight elite handball players (27±3.5 y) with past SARS-COV-2 infection were retrospectively analyzed and compared with four uninfected team-mates (22±2.6 y). Athletes were examined 19±7 d after positive PCR-test. Echocardiographic assessment of the global longitudinal strain under resting conditions was not significantly changed after SARS-CoV2 infection (−17.7% vs. −18.1%) but magnetic resonance imaging showed minor signs of acute inflammation/edema in all patients (T2-mapping: +4.1ms) without reaching the Lake-Louis criteria. Spiroergometric analysis showed a significant reduction in VO2max (−292 ml/min, −7.0%), oxygen-pulse (−2.4 ml/beat, −10.4%), and respiratory minute volume (VE) (−18.9 l/min, −13.8%) in athletes with a history of SARS-CoV2 infection (p<0.05, respectively). The parameters were unchanged in the control group.

Conclusion

SARS-CoV2 infection caused functional impairment of cardiopulmonary performance primarily under stress in elite athletes.

It seems reasonable to screen athletes after SARS-CoV2 infection at least with spiroergometry to mark performance limitations and to ensure an optimal return to competition.

FUNDunding Acknowledgement

Type of funding sources: None.

Intraoperative 3D imaging in intraarticular tibial plateau fractures - Does it help to improve the patients' outcomes?

BACKGROUND

In tibial plateau fractures (TPF) the restoration of an anatomical joint surface as well as an exact subchondral screw position for postoperative stability is crucial for the outcome. The aim of this study was to determine whether the additional use of an intraoperative 3D imaging intensifier (3D) might help to improve the outcome of complex TPF.

METHODS

We performed a retrospective case-control study of a level 1 trauma center. Patients with AO/OTA 41 B3 and C-TPF operated on using a 3D imaging intensifier between November 2015 and December 2018 (3D group) were included. The outcomes of this patients were compared to patients operated without 3D imaging between January 2005 to December 2014 (2D group). The comparison of the groups was performed by matched pair analysis. The functional outcome of both groups was measured by KOOS and Lysholm Score after a follow-up period of at least 12 months. Operation time, infections and postoperative revisions were registered.

RESULTS

In total, 18 patients were included in the 3D group (mean age: 51.0± 16.4 years; 12 females) and an equal number of matching partners from the 2D group (mean age: 50.3± 15.2 years; 11 females) were found (p=0.82; p=0.79). We found 9x B3, 2x C1, 1x C2, 6x C3 fractures according to AO/OTA for each group (p=1.00) with comparable ASA score (p=0.27). The mean operation time was 127.9± 45.9 min and 116.1± 45.7 min for the 3D and 2D group (p=0.28). The mean follow-up time was 20.9± 10.7 months for the 3D and 55.5± 34.7 months for the 2D group (p< 0.001). For the 3D group a mean Lysholm overall score of 67.4± 26.8 and KOOS overall score of 72.6± 23.5 could be assessed. In contrast, a mean Lysholm overall score of 62.0± 21.4 and KOOS overall score of 65.8± 21.6 could be measured in the 2D group (p=0.39; p=0.31). Thereby, functional outcome of the 3D group showed a significant higher KOOS Sport/Rec sub score of 54.7± 35.0 in comparison to the 2D group with 26.7± 31.6 (p= 0.01). Postoperative revisions had to be performed in 27.8% of cases in both groups (p=1.00). Due to the 3D imaging an intraoperative revision was performed in 33.3% (6/18).

CONCLUSION

In our study we could show that re-reduction of the fracture or implant re-positioning were performed in relevant numbers based on the 3D imaging. This was associated with a midterm clinical benefit in regard to better KOOS Sport/Rec scores.

TRIAL REGISTRATION

AZ 488 /20-ek.

Left ventricular longitudinal strain in professional athletes, a useful tool to detect an athletes hearts?

Background

Professional cyclists frequently present with physiological adaptations to endurance exercise with an increase in left ventricular wall thickness and mass. Global longitudinal strain (GLS) is an early and sensitive echocardiographic method to detect left ventricular dysfunction. However, it is unclear whether GLS is able to differentiate between athlete's hearts or different pathological conditions of left ventricular hypertrophy.

Methods

A total of 87 professional athletes (37 professional cyclists, 29 professional soccer players, and 21 professional handball players) were compared to 125 patients with different forms of left ventricular hypertrophy (17 hypertrophic obstructive cardiomyopathy (HOCM), 36 hypertensive heart disease (HHD), 35 severe aortic valve stenosis (AVS); 37 untrained individuals served as controls. Examinations were performed between October 2018 to October 2019. All subjects underwent echocardiographic examination, including GLS.

Results

In all 212 participants/patients included a preserved ejection fraction &gt;50% (mean 61±7%) was detected. Left ventricular mass index (LVMI) in professional cyclists (165.5±37.1 g/m2) was increased when compared to professional soccer players (97.3±12.4 g/m2, p&lt;0.001), professional handball players (92.2±15.8 g/m2, p&lt;0.001) and healthy controls (94.3±20.7 g/m2, p&lt;0.001), as well as to patients with HHD (129.2±30.0 g/m2, p&lt;0.001), or AVS (140.1±35.4 g/m2, p=0.064), but not to patients with HOCM (159.7±39.4 g/m2, p=0.64). Professional cyclists (−21.0±3.5%) achieved higher average GLS values than professional soccer (−18.4 ± %, p=0.004) or handball players (−18.4 ± %, p=0.021), healthy controls (−19.0±3.0%, p=0.008), HOCM (−15.0±6.5%, p&lt;0.001), HHD (−13.8±5.9%, p&lt;0.001), and AVS (−16.0±7.0%, p&lt;0.001) (Figure 1).

Conclusion

In professional cyclists, higher LVMI and average GLS values were detected compared to professional soccer and handball players with lower excessive endurance exercise, as well as untrained healthy controls. Average GLS can help to differentiate between athletes' hearts in professional cyclists compared to pathologic patterns in different diseases characterized by left ventricular hypertrophy with elevated LVMI.

Figure 1

Funding Acknowledgement

Type of funding source: None

Effects of surgical and FFP2/N95 face masks on cardiopulmonary exercise capacity

Background

Due to the SARS-CoV2 pandemic, medical face masks are widely recommended for a large number of individuals and long durations. The effect of wearing a surgical and a FFP2/N95 face mask on cardiopulmonary exercise capacity has not been systematically reported.

Methods

This prospective cross-over study quantitated the effects of wearing no mask (nm), a surgical mask (sm) and a FFP2/N95 mask (ffpm) in 12 healthy males (age 38.1 ± 6.2 years, BMI 24.5 ± 2.0 kg/m²). The 36 tests were performed in randomized order. The cardiopulmonary and metabolic responses were monitored by ergo-spirometry and impedance cardiography. Ten domains of comfort/discomfort of wearing a mask were assessed by questionnaire.

Results

The pulmonary function parameters were significantly lower with mask (forced expiratory volume: 5.6 ± 1.0 vs 5.3 ± 0.8 vs 6.1 ± 1.0 l/s with sm, ffpm and nm, respectively; p = 0.001; peak expiratory flow: 8.7 ± 1.4 vs 7.5 ± 1.1 vs 9.7 ± 1.6 l/s; p < 0.001). The maximum power was 269 ± 45, 263 ± 42 and 277 ± 46 W with sm, ffpm and nm, respectively; p = 0.002; the ventilation was significantly reduced with both face masks (131 ± 28 vs 114 ± 23 vs 99 ± 19 l/m; p < 0.001). Peak blood lactate response was reduced with mask. Cardiac output was similar with and without mask. Participants reported consistent and marked discomfort wearing the masks, especially ffpm.

Conclusion

Ventilation, cardiopulmonary exercise capacity and comfort are reduced by surgical masks and highly impaired by FFP2/N95 face masks in healthy individuals. These data are important for recommendations on wearing face masks at work or during physical exercise.

Perioperative anxiety and length of hospital stay after caesarean section - A cohort study

OBJECTIVE

The caesarean section is one of the most frequently performed surgeries. Due to growing economic challenges, hospitals are encouraged to improve their cost-efficiency. One factor that influences hospital costs of caesarean sections is a prolonged hospital stay.

STUDY DESIGN

The aim of the current prospective study was to investigate psychosocial factors, with an emphasis on anxiety, and sociodemographic factors that are associated with longer hospital stay after caesarean sections with no medical complications. Data of 195 women who gave birth by caesarean section was analyzed. As possible predictors anxiety levels measured pre-, peri- and postoperative as well as age, parity (primiparous/multiparous), repeated caesarean (yes/no), BMI (<30/ ≥30), STAI-Trait scores, duration of surgery, PH arterial and Apgar 5 min. were entered into a backward linear regression with duration of hospital stay as the dependent factor.

RESULTS

The analysis revealed that higher age, primiparity as well as higher anxiety scores during the postoperative phase are significant factors associated with prolonged hospital stay. The significant model explains 22.1 % of the variance.

CONCLUSION

The results should sensitize the medical team to these risk factors in order to improve patients' recovery and shorten hospital stays.

[Perioperative music-induced analgesia : Comparison of the effect of music on pain between preoperative, intraoperative and postoperative application]

BACKGROUND

Despite suitable analgesia procedures and interventions only approximately 24% of inpatients with strong to very strong pain receive adequate treatment. Besides opioids, which are associated with numerous side effects and risks, non-pharmacological approaches are increasingly being used. In this context, one of the oldest known methods are music interventions; however, the state of evidence is heterogeneous and there are no explicit manuals and recommendations for the effective implementation of music interventions.

OBJECTIVE

This review aimed to determine the optimal time point at which perioperative music interventions can most effectively relieve pain.

MATERIAL AND METHODS

A PubMed search was conducted and publications investigating the effect of music during the preoperative, intraoperative and postoperative stages of various interventions were identified.

RESULTS

During the preoperative phase, only positive effects of music on pain relief have been reported but availability of data is sparse. During the intraoperative stage of a medical intervention the effect of music seems to be mediated by the type of anesthesia procedure and sedation depth. Only patients who can consciously perceive the music seem to profit from it. Positive alleviating effects on subjective pain perception and analgesia needs were shown in the postoperative stage.

CONCLUSION

Music is a non-pharmacological method to alleviate pain, which is free of side effects. Important considerations for the use of music interventions for relief of acute pain associated with surgery are discussed taking into account numerous mediating factors, which influence the efficacy of the treatment.

Comparing the course of anxiety in women receiving their first or repeated caesarean section: A prospective cohort study

BACKGROUND

Around 30% of births are through caesarean section and repetition rates for receiving a caesarean section are high.

AIM

The aim of the prospective study was to compare the course of anxiety in women undergoing their first caesarean section and women experiencing a repeated caesarean section.

PARTICIPANTS

304 women with an indication for an elective caesarean section took part. 155 received their first caesarean section and 149 received a repeated caesarean section.

METHODS

In order to measure the course of anxiety on the day of the caesarean section subjective anxiety levels were measured and saliva samples for cortisol determination were taken at admission, during skin closure and two hours after the surgery. Blood pressure and heart rate were documented at skin incision and skin closure.

RESULTS

Women experiencing their first caesarean section displayed significantly higher anxiety levels compared to women with a repeated caesarean section. Scores of the STAI-State and visual analogue scale for anxiety differed significantly at admission (p=.006 and p<.001) and heart rate and alpha amylase levels were significantly higher at skin closure (p=.027 and p=.029).

CONCLUSION

The results show that previous experience with a caesarean section has a soothing effect. The study aims to sensitize surgeons, anesthetists, nurses and midwives when treating women receiving a caesarean section and encourage them to incorporate soothing interventions, especially for women receiving their first caesarean section to reduce anxiety levels and consequently improve postoperative recovery and patients' satisfaction.

Abstract GS5-03: Lifestyle Intervention and Effect on Disease-free Survival in Early Breast Cancer Pts: Interim Analysis from the Randomized SUCCESS C Study

Background:

Recent trials have provided evidence that obesity and a low level of physical activity are not only associated with a higher risk of developing breast cancer, but also with an increased risk for recurrence and reduced survival in breast cancer patients (pts). The SUCCESS C study is the first randomized Phase III trial to evaluate the effect of an intensive lifestyle intervention program, focusing on both physical activity and healthy diet following adjuvant chemotherapy on disease-free survival in women with early breast cancer.

Methods:

SUCCESS C is a German multicenter, 2×2 factorial design, randomized phase III study comparing disease-free survival (DFS) in pts with HER2-negative early breast cancer treated with either 3 cycles of epirubicine, fluorouracil, cyclophosphamide chemotherapy followed by 3 cycles of docetaxel (FEC-D) or 6 cycles of docetaxel-cyclophosphamide (DC). The second randomization compares DFS in pts with a body mass index (BMI) of 24—40 kg/m2 receiving either a telephone-based individualized lifestyle intervention (LI) program aiming at moderate weight loss for 2 years (LI arm) or general recommendations for a healthy lifestyle alone (non-LI arm). DFS according to lifestyle intervention was analyzed using both univariable cox regressions and multivariable cox regressions adjusted for age (years, continuous), BMI (kg/m2, continuous), menopausal status (premenopausal, postmenopausal), tumor size (pT1, pT2, pT3/pT4), nodal stage (pN0, pN1, pN2, pN3), hormone receptor status (positive, negative), grading (G1, G2, G3), histological type (ductal, lobular, other) and chemotherapy randomization (FEC-D, DC). Median follow-up was 64.2 months.

Results:

Overall, 2292 of the 3643 pts recruited for the SUCCESS C study were randomized for the lifestyle intervention program (1146 pts in both the non-LI arm and the LI arm). The Intention-to-treat analysis revealed no difference in DFS between the two treatment arms (LI vs. non-LI) in univariable analysis (hazard ratio [HR] 0.99, 95% confidence interval [CI] 0.76 — 1.28, p = 0.922) and in adjusted multivariable cox regression (HR 0.91, 95% CI 0.70 — 1.18, p = 0.48). At the 2-year follow up, pts in the LI arm lost on average 1.0 kg weight compared to the start of the LI program, while pts in the non-LI arm gained on average 0.95 kg (p &lt; 0.001). Overall, 1477 pts completed the 2-year LI program (non-LI arm: 80.7%, 925 of 1146 pts; LI arm: 48.2%, 552 of 1146 pts; p &lt; 0.001). Pts that completed the 2-year LI program had a significant better DFS than non-completers (HR 0.35, 95% CI 0.27 — 0.45, p &lt; 0.001). Among completers, pts in the LI arm had a significantly better DFS than pts in the non-LI arm both in univariable analysis (HR 0.53, 95% CI 0.35 — 0.82, p = 0.004) and in adjusted multivariable cox regression (HR 0.51, 95% CI 0.33 — 0.78, p = 0.002).

Conclusions:

This explorative and non-planned interim analysis indicates that the completion of a systematic telephone life style intervention program may positively impact patient outcome in early breast cancer.

Citation Format: Janni W, Rack BK, Friedl TW, Müller V, Lorenz R, Rezai M, Tesch H, Heinrich G, Andergassen U, Harbeck N, Schochter F, De Gregorio A, Tzschaschel M, Huober J, Hepp P, Fehm TN, Schneeweiss A, Lichtenegger W, Blohmer J, Hauner D, Beckmann MW, Häberle L, Fasching PA, Hauner H. Lifestyle Intervention and Effect on Disease-free Survival in Early Breast Cancer Pts: Interim Analysis from the Randomized SUCCESS C Study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr GS5-03.

An atypical presentation of necrotising fasciitis

Necrotising fasciitis is a rare infection with a high mortality rate. Clinical manifestation may be influenced by an underlying disease state. We report a case of a 70-year-old man with an anaplastic large-cell lymphoma who presented with inconclusive signs of necrotising fasciitis following a neutropenic phase after chemotherapy. Surgical exploration did not reveal the typical macroscopic features of necrotising fasciitis. Microbiological investigations revealed Escherichia coli. The lack of massive tissue inflammation, probably due to the neutropenia in our patient, has not been described by other authors. Diagnostic uncertainties owing to masked or uncharacteristic signs in immune compromised patients may lead to a delayed surgical debridement, of which clinicians should be aware.

Improved accuracy of K-wire positioning into the glenoid vault by intraoperative 3D image intensifier-based navigation for the glenoid component in shoulder arthroplasty

INTRODUCTION

This article aimed to show that navigation, based on an intraoperative mobile 3D image intensifier, can improve the accuracy of central K-wire placement into the glenoid vault for glenoid component.

HYPOTHESIS

The navigated k-wire placement is more accurate and shows a smaller deviation angle to the standard centerline compared to the classical "free hand technic".

METHODS

In 34 fresh frozen sheep scapulae, 17 K-wire placements using the navigation (group 1) were compared with 17 using standard "face plane technique" (group 2). The relation to glenoid standard and alternative centerlines (CL) and the position within the glenoid vault were analyzed.

RESULTS

In groups 1 and 2 the angle between the K-wire and standard CL was 2.2° and 4.7°, respectively (P=0.01). The angle between the K-wire and alternative CL was 14.4° for group 1 and 17.2° for group 2 (P=0.02). More navigated K-wire positions were identified within a 5mm corridor along the glenoid vault CL (52 vs. 39; P=0.004).

DISCUSSION

Intraoperative 3D image intensifier-based navigation was more accurate and precise than standard K-wire placement.

TYPE OF STUDY AND LEVEL OF PROOF

Basic science study, evidence level III.