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Valle C, von Roth P. [Prehabilitation before total knee arthroplasty]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024:10.1007/s00132-024-04544-0. [PMID: 39190158 DOI: 10.1007/s00132-024-04544-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/12/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND Prehabilitation before knee joint replacement surgery is gaining increasing importance due to the rising prevalence of knee osteoarthritis. The aim is to optimize the preoperative condition to improve postoperative recovery and reduce complications. MATERIALS AND METHODS This review is based on a systematic literature search in the databases Medline, Cochrane Library, and Web of Science on the topic of prehabilitation in knee joint replacement. RESULTS The current evidence shows heterogeneous results regarding the effectiveness of prehabilitation before knee joint replacement; some studies report improved postoperative outcomes such as reduced pain, increased function, and shorter hospital stays through preoperative training measures, while others found no significant differences. Additional preoperatively modifiable risk factors such as reduced physical fitness, substance abuse, nutritional status, comorbidities, and psychological factors should already be addressed during prehabilitation. Digital therapy and education measures offer a promising solution for the implementation of prehabilitation programs and are well received by patients. CONCLUSION Overall, the evidence for preoperative training before knee joint replacement remains heterogeneous. Despite positive indications, evidence on exercise content, duration, frequency, and setting remains incomplete, requiring a critical review of current meta-analyses and systematic reviews. Modern prehabilitation before knee joint replacement should include musculoskeletal training and address preoperative risk factors to improve postoperative outcomes.
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Affiliation(s)
- Christina Valle
- Medical Park Chiemsee, Birkenallee 41, 83233, Bernau am Chiemsee, Deutschland.
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Deutschland.
| | - Philipp von Roth
- Standort Straubing, SPORTHOPAEDICUM, Bahnhofplatz 27, 94315, Straubing, Deutschland
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2
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López-Hernández A, Gimeno-Santos E, Navarro-Ripoll R, Arguis MJ, Romano-Andrioni B, López-Baamonde M, Teres S, Sanz-de la Garza M, Martinez-Palli G. Differential response to preoperative exercise training in patients candidates to cardiac valve replacement. BMC Anesthesiol 2024; 24:280. [PMID: 39123146 PMCID: PMC11311913 DOI: 10.1186/s12871-024-02671-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 08/01/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND There is lack of evidence regarding safety, effectiveness and applicability of prehabilitation on cardiac surgery population, particularly in patients candidates to cardiac valve replacement. The aim of the study is to assess and compare the effect of a multimodal prehabilitation program on functional capacity in patients with severe aortic stenosis (AoS) and severe mitral regurgitation (MR) proposed for valve replacement surgery. METHODS Secondary analysis from a randomised controlled trial whose main objective was to analyze the efficacy of a 4-6 weeks multimodal prehabilitation program in cardiac surgery on reducing postoperative complications. For this secondary analysis, only candidates for valve replacement surgery were selected. The primary outcome was the change in endurance time (ET) from baseline to preoperative assessment measured by a cycling constant work-rate cardiopulmonary exercise test. RESULTS 68 patients were included in this secondary analysis, 34 (20 AoS and 14 MR) were allocated to the prehabilitation group and 34 (20 AoS and 14 MR) to control group. At baseline, patients with AoS had better left systolic ventricular function and lower prevalence of atrial fibrillation compared to MR (p = 0.022 and p = 0.035 respectively). After prehabilitation program, patients with MR showed greater improvement in ET than AoS patients (101% vs. 66% increase from baseline). No adverse events related to the prehabilitation program were observed. CONCLUSIONS A 4-6 week exercise training program is safe and overall improves functional capacity in patients with severe AoS and MR. However, exercise response is different according to the cardiac valve type disfunction, and further studies are needed to know the factors that predispose some patients to have better training response. TRIAL REGISTRATION The study has been registered on the Registry of National Institutes of Health ClinicalTrials.gov (NCT03466606) (05/03/2018).
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Affiliation(s)
- Antonio López-Hernández
- Anesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Elena Gimeno-Santos
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Barcelona of Global Health Institute (ISGlobal) - Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Carlos III Health Institute, Madrid, Spain
| | - Ricard Navarro-Ripoll
- Anesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - María José Arguis
- Anesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Bárbara Romano-Andrioni
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- Nutrition and Clinical Dietetics, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Manuel López-Baamonde
- Anesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Silvia Teres
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - María Sanz-de la Garza
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Cardiovascular Institute, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Graciela Martinez-Palli
- Anesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain.
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain.
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
- CIBER de Enfermedades Respiratorias (CIBERES), Carlos III Health Institute, Madrid, Spain.
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Wang X, Li J, Zhou J, Gao M, Wang B, Tong Y, Cao Y, Chen W. Based on Cardiopulmonary Exercise Testing to Construct and Validate Nomogram of Long-Term Prognosis Within 12 Months for NSCLC. THE CLINICAL RESPIRATORY JOURNAL 2024; 18:e13806. [PMID: 39118279 PMCID: PMC11310092 DOI: 10.1111/crj.13806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/08/2023] [Accepted: 06/28/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVE Construction nomogram was to effectively predict long-term prognosis in patients with non-small cell lung cancer (NSCLC). MATERIALS AND METHODS The nomogram is developed by a retrospective study of 347 patients with NSCLC who underwent cardiopulmonary exercise testing (CPET) before surgery from May 2019 to February 2022. Cross-validation divided the data into a training cohort and validation cohort. The discrimination and accuracy ability of the nomogram were proofed by concordance index (C-index), calibration curve, receiver operating characteristic (ROC) curve, the area under the curve (AUC), and time-dependent ROC in validation cohort. RESULTS Age, intraoperative blood loss, VO2 peak, and VE/VCO2 slope were included in the model of nomogram. The model demonstrated good discrimination and accuracy with C-index of 0.770 (95% CI: 0.712-0.822). AUC of 6 (AUC: 0.789, 95% CI: 0.726-0.851) and 12 months (AUC: 0.787, 95% CI: 0.724-0.850) were shown in ROC. Time-independent ROC maintains a good effect within 12 months. CONCLUSION We developed a nomogram based on CPET. This model has a good ability of discrimination and accuracy. It could help clinicians to make treatment decision in clinical decision.
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Affiliation(s)
- Xinyu Wang
- Department of Rehabilitation MedicineXuzhou Rehabilitation Hospital Affiliated to Xuzhou Medical UniversityXuzhouChina
| | - Jin Li
- Department of Rehabilitation Medicine, Xuzhou Central HospitalThe Xuzhou Clinical College of Xuzhou Medical UniversityXuzhouChina
| | - Jingjie Zhou
- Department of Rehabilitation MedicineXuzhou Rehabilitation Hospital Affiliated to Xuzhou Medical UniversityXuzhouChina
| | - Min Gao
- Department of Rehabilitation Medicine, Xuzhou Central HospitalThe Xuzhou Clinical College of Xuzhou Medical UniversityXuzhouChina
| | - Bin Wang
- Department of Rehabilitation MedicineXuzhou Rehabilitation Hospital Affiliated to Xuzhou Medical UniversityXuzhouChina
| | - Yiman Tong
- Department of Rehabilitation MedicineXuzhou Rehabilitation Hospital Affiliated to Xuzhou Medical UniversityXuzhouChina
| | - Yuhan Cao
- Department of Rehabilitation MedicineXuzhou Rehabilitation Hospital Affiliated to Xuzhou Medical UniversityXuzhouChina
| | - Wei Chen
- Department of Rehabilitation MedicineXuzhou Rehabilitation Hospital Affiliated to Xuzhou Medical UniversityXuzhouChina
- Department of Rehabilitation Medicine, Xuzhou Central HospitalThe Xuzhou Clinical College of Xuzhou Medical UniversityXuzhouChina
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Butson G, Edbrooke L, Ismail H, Denehy L. Exercise capacity prior to major cancer surgery: A cross-sectional observational study of the validity of the 6-minute walk and 30-second sit-to-stand tests. Asia Pac J Clin Oncol 2024; 20:497-506. [PMID: 38685578 DOI: 10.1111/ajco.14069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 02/26/2024] [Accepted: 04/06/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION Cardiopulmonary exercise testing (CPET) is the gold standard for measuring exercise capacity, however, it is resource intensive and has limited availability. This study aimed to determine: 1) the association between the 6-min walk test (6MWT) and the 30-s sit-to-stand test (30STS) with CPET peak oxygen uptake (VO2peak) and anaerobic threshold (AT) and 2) 6MWT and 30STS cut points associated with a higher risk of postoperative complications. METHODS A cross-sectional study, retrospectively analyzing data collected from a tertiary cancer center over a 23-month period. Measures included CPET VO2peak and AT, 6MWT and 30STS test. Correlations were used to characterize relationships between variables. Receiver operating characteristic curve analyses determined 6MWT and 30STS cut points that aligned with CPET variable cut points. RESULTS Note that, 156 participants were included. The 6MWT and 30STS displayed moderate correlations with VO2peak, rho = 0.65, p = 0.01 and rho = 0.52, p < 0.005 respectively. Fair correlations were observed between AT and 6MWT (rho = 0.36, p = 0.01) and 30STS (rho = 0.41, p < 0.005). The optimal cut points to identify VO2peak < 15 mL/kg/min were 493.5 m on the 6MWT and 12.5 stands on the 30STS test and for AT < 11 mL/kg/min were 506.5 m on the 6MWT and 12.5 stands on the 30STS test. CONCLUSION Both the 6MWT and 30STS test could be used as alternative tools for measuring exercise capacity preoperatively in the cancer setting where CPET is not available. A range of 6MWT and 30STS cut points, according to sensitivity and specificity levels, may be used to evaluate risk of postoperative outcomes.
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Affiliation(s)
- Grace Butson
- Department of Physiotherapy, The Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Lara Edbrooke
- Department of Health Services Research, The Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Physiotherapy, The University of Melbourne, Melbourne, Australia
| | - Hilmy Ismail
- Department of Anesthesia, Perioperative and Pain Medicine, The Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Linda Denehy
- Department of Health Services Research, The Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Physiotherapy, The University of Melbourne, Melbourne, Australia
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Vetsch T, Eggmann S, Jardot F, von Gernler M, Engel D, Beilstein CM, Wuethrich PY, Eser P, Wilhelm M. Ventilatory efficiency as a prognostic factor for postoperative complications in patients undergoing elective major surgery: a systematic review. Br J Anaesth 2024; 133:178-189. [PMID: 38644158 DOI: 10.1016/j.bja.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/08/2024] [Accepted: 03/16/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Major surgery is associated with high complication rates. Several risk scores exist to assess individual patient risk before surgery but have limited precision. Novel prognostic factors can be included as additional building blocks in existing prediction models. A candidate prognostic factor, measured by cardiopulmonary exercise testing, is ventilatory efficiency (VE/VCO2). The aim of this systematic review was to summarise evidence regarding VE/VCO2 as a prognostic factor for postoperative complications in patients undergoing major surgery. METHODS A medical library specialist developed the search strategy. No database-provided limits, considering study types, languages, publication years, or any other formal criteria were applied to any of the sources. Two reviewers assessed eligibility of each record and rated risk of bias in included studies. RESULTS From 10,082 screened records, 65 studies were identified as eligible. We extracted adjusted associations from 32 studies and unadjusted from 33 studies. Risk of bias was a concern in the domains 'study confounding' and 'statistical analysis'. VE/VCO2 was reported as a prognostic factor for short-term complications after thoracic and abdominal surgery. VE/VCO2 was also reported as a prognostic factor for mid- to long-term mortality. Data-driven covariable selection was applied in 31 studies. Eighteen studies excluded VE/VCO2 from the final multivariable regression owing to data-driven model-building approaches. CONCLUSIONS This systematic review identifies VE/VCO2 as a predictor for short-term complications after thoracic and abdominal surgery. However, the available data do not allow conclusions about clinical decision-making. Future studies should select covariables for adjustment a priori based on external knowledge. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42022369944).
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Affiliation(s)
- Thomas Vetsch
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Centre for Rehabilitation & Sports Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
| | - Sabrina Eggmann
- Department of Physiotherapy, Inselspital, Bern University Hospital, Bern, Switzerland
| | - François Jardot
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc von Gernler
- Medical Library, University Library of Bern, University of Bern, Bern, Switzerland
| | - Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian M Beilstein
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Prisca Eser
- Centre for Rehabilitation & Sports Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Wilhelm
- Centre for Rehabilitation & Sports Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Fleurent-Grégoire C, Burgess N, Denehy L, Edbrooke L, Engel D, Testa GD, Fiore JF, McIsaac DI, Chevalier S, Moore J, Grocott MP, Copeland R, Levett D, Scheede-Bergdahl C, Gillis C. Outcomes reported in randomised trials of surgical prehabilitation: a scoping review. Br J Anaesth 2024; 133:42-57. [PMID: 38570300 PMCID: PMC11213997 DOI: 10.1016/j.bja.2024.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/09/2024] [Accepted: 01/29/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Heterogeneity of reported outcomes can impact the certainty of evidence for prehabilitation. The objective of this scoping review was to systematically map outcomes and assessment tools used in trials of surgical prehabilitation. METHODS MEDLINE, EMBASE, PsychInfo, Web of Science, CINAHL, and Cochrane were searched in February 2023. Randomised controlled trials of unimodal or multimodal prehabilitation interventions (nutrition, exercise, psychological support) lasting at least 7 days in adults undergoing elective surgery were included. Reported outcomes were classified according to the International Society for Pharmacoeconomics and Outcomes Research framework. RESULTS We included 76 trials, mostly focused on abdominal or orthopaedic surgeries. A total of 50 different outcomes were identified, measured using 184 outcome assessment tools. Observer-reported outcomes were collected in 86% of trials (n=65), with hospital length of stay being most common. Performance outcomes were reported in 80% of trials (n=61), most commonly as exercise capacity assessed by cardiopulmonary exercise testing. Clinician-reported outcomes were included in 78% (n=59) of trials and most frequently included postoperative complications with Clavien-Dindo classification. Patient-reported outcomes were reported in 76% (n=58) of trials, with health-related quality of life using the 36- or 12-Item Short Form Survey being most prevalent. Biomarker outcomes were reported in 16% of trials (n=12) most commonly using inflammatory markers assessed with C-reactive protein. CONCLUSIONS There is substantial heterogeneity in the reporting of outcomes and assessment tools across surgical prehabilitation trials. Identification of meaningful outcomes, and agreement on appropriate assessment tools, could inform the development of a prehabilitation core outcomes set to harmonise outcome reporting and facilitate meta-analyses.
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Affiliation(s)
- Chloé Fleurent-Grégoire
- School of Human Nutrition, McGill University, Montreal, QC, Canada; Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Nicola Burgess
- Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia
| | - Linda Denehy
- Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, Melbourne, VIC, Australia; Department of Health Services Research, The Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Lara Edbrooke
- Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, Melbourne, VIC, Australia; Department of Health Services Research, The Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Giuseppe Dario Testa
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Julio F Fiore
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Stéphanie Chevalier
- School of Human Nutrition, McGill University, Montreal, QC, Canada; Research Institute of the McGill University Health Centre, Montreal, QC, Canada; Department of Medicine, McGill University, Montreal, QC, Canada
| | - John Moore
- Department of Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - Michael P Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton - University of Southampton, Southampton, UK
| | - Robert Copeland
- Advanced Wellbeing Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Denny Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton - University of Southampton, Southampton, UK
| | - Celena Scheede-Bergdahl
- Department of Kinesiology and Physical Education, McGill Research, Centre for Physical Activity & Health, McGill University, Montreal, QC, Canada
| | - Chelsia Gillis
- School of Human Nutrition, McGill University, Montreal, QC, Canada; Department of Surgery, McGill University, Montreal, QC, Canada; Department of Anesthesia, McGill University, Montreal, QC, Canada.
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Staes M, Gyselinck I, Goetschalckx K, Troosters T, Janssens W. Identifying limitations to exercise with incremental cardiopulmonary exercise testing: a scoping review. Eur Respir Rev 2024; 33:240010. [PMID: 39231595 PMCID: PMC11372471 DOI: 10.1183/16000617.0010-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 05/28/2024] [Indexed: 09/06/2024] Open
Abstract
Cardiopulmonary exercise testing (CPET) is a comprehensive and invaluable assessment used to identify the mechanisms that limit exercise capacity. However, its interpretation remains poorly standardised. This scoping review aims to investigate which limitations to exercise are differentiated by the use of incremental CPET in literature and which criteria are used to identify them. We performed a systematic, electronic literature search of PubMed, Embase, Cochrane CENTRAL, Web of Science and Scopus. All types of publications that reported identification criteria for at least one limitation to exercise based on clinical parameters and CPET variables were eligible for inclusion. 86 publications were included, of which 57 were primary literature and 29 were secondary literature. In general, at the level of the cardiovascular system, a distinction was often made between a normal physiological limitation and a pathological one. Within the respiratory system, ventilatory limitation, commonly identified by a low breathing reserve, and gas exchange limitation, mostly identified by a high minute ventilation/carbon dioxide production slope and/or oxygen desaturation, were often described. Multiple terms were used to describe a limitation in the peripheral muscle, but all variables used to identify this limitation lacked specificity. Deconditioning was a frequently mentioned exercise limiting factor, but there was no consensus on how to identify it through CPET. There is large heterogeneity in the terminology, the classification and the identification criteria of limitations to exercise that are distinguished using incremental CPET. Standardising the interpretation of CPET is essential to establish an objective and consistent framework.
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Affiliation(s)
- Michaël Staes
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
- Clinical Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Iwein Gyselinck
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
- Clinical Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Kaatje Goetschalckx
- Research Unit Cardiovascular Imaging and Dynamics, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
- Clinical Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Thierry Troosters
- Clinical Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Wim Janssens
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
- Clinical Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
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Rai J, Pring ET, Knight K, Tilney H, Gudgeon J, Gudgeon M, Taylor F, Gould LE, Wong J, Andreani S, Mai DVC, Drami I, Lung P, Athanasiou T, Roxburgh C, Jenkins JT. Sarcopenia is independently associated with poor preoperative physical fitness in patients undergoing colorectal cancer surgery. J Cachexia Sarcopenia Muscle 2024. [PMID: 38925534 DOI: 10.1002/jcsm.13536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 04/05/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Accurate preoperative risk assessment for major colorectal cancer (CRC) surgery remains challenging. Body composition (BC) and cardiopulmonary exercise testing (CPET) can be used to evaluate risk. The relationship between BC and CPET in patients undergoing curative CRC surgery is unclear. METHODS Consecutive patients undergoing CPET prior to CRC surgery between 2010 and 2020 were identified between two different UK hospitals. Body composition phenotypes such as sarcopenia, myosteatosis, and visceral obesity were defined using widely accepted thresholds using preoperative single axial slice CT image at L3 vertebrae. Relationships between clinicopathological, BC, and CPET variables were investigated using linear regression analysis. RESULTS Two hundred eighteen patients with stage I-III CRC were included. The prevalence of sarcopenia, myosteatosis, and visceral obesity was 62%, 33%, and 64%, respectively. The median oxygen uptake at anaerobic threshold (VO2 at AT) was 12.2 mL/kg/min (IQR 10.6-14.2), and oxygen uptake at peak exercise (VO2 peak) was 18.8 mL/kg/min (IQR 15.4-23). On univariate linear regression analysis, male sex (P < 0.001) was positively associated with VO2 at AT. While ASA grade (P < 0.001) and BMI (P = 0.007) were negatively associated with VO2 at AT, on multivariate linear regression analysis, these variables remained significant (P < 0.05). On univariate linear regression analysis, male sex (P < 0.001) was positively associated with VO2 peak, whereas age (P < 0.001), ASA grade (P < 0.001), BMI (P = 0.003), sarcopenia (P = 0.015), and myosteatosis (P < 0.001) were negatively associated with VO2 peak. On multivariate linear regression analysis age (P < 0.001), ASA grade (P < 0.001), BMI (P < 0.001), and sarcopenia (P = 0.006) were independently and negatively associated with VO2 peak. CONCLUSIONS The novel finding that sarcopenia is independently associated with reduced VO2 peak performance in CPET supports the supposition that reduced muscle mass relates to poor physical function in CRC patients. Further work should be undertaken to assess whether sarcopenia diagnosed on CT can act as suitable surrogate for CPET to further enhance personalized risk stratification.
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Affiliation(s)
- Jason Rai
- BiCyCLE Research Group, St Mark's the National Bowel Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Edward T Pring
- BiCyCLE Research Group, St Mark's the National Bowel Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Katrina Knight
- Department of Surgery, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Henry Tilney
- Department of Surgery and Cancer, Imperial College London, London, UK
- Frimley Park Hospital, Frimley Health NHS Foundation Trust, Frimley, UK
| | - Judy Gudgeon
- Frimley Park Hospital, Frimley Health NHS Foundation Trust, Frimley, UK
| | - Mark Gudgeon
- Frimley Park Hospital, Frimley Health NHS Foundation Trust, Frimley, UK
| | - Fiona Taylor
- Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
| | - Laura E Gould
- BiCyCLE Research Group, St Mark's the National Bowel Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Joel Wong
- Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
| | - Stefano Andreani
- Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
| | - Dinh V C Mai
- BiCyCLE Research Group, St Mark's the National Bowel Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ioanna Drami
- BiCyCLE Research Group, St Mark's the National Bowel Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Phillip Lung
- BiCyCLE Research Group, St Mark's the National Bowel Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Thanos Athanasiou
- BiCyCLE Research Group, St Mark's the National Bowel Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Campbell Roxburgh
- Department of Surgery, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - John T Jenkins
- BiCyCLE Research Group, St Mark's the National Bowel Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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Benmassaoud A, Gillis C, Geraci O, Martel M, Awasthi R, Barkun J, Chen T, Edgar L, Sebastiani G, Carli F, Bessissow A. Prehabilitation in patients with cirrhosis awaiting liver transplantation: protocol of a feasibility study. BMJ Open 2024; 14:e081362. [PMID: 38925705 PMCID: PMC11202729 DOI: 10.1136/bmjopen-2023-081362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 05/30/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION Patients with cirrhosis awaiting liver transplantation (LT) are often frail, and malnourished. The period of time on the waitlist provides an opportunity to improve their physical fitness. Prehabilitation appears to improve the physical fitness of patients before major surgery. Little is known about prehabilitation in patients with cirrhosis. The aim of this feasibility study will be to investigate the feasibility, safety, and effectiveness of a multimodal prehabilitation programme in this patient population. METHODS AND ANALYSIS This is an open-label single-arm feasibility trial recruiting 25 consecutive adult patients with cirrhosis active on the LT waiting list of the McGill University Health Centre (MUHC). Individuals will be excluded based on criteria developed for the safe exercise training in patients with cirrhosis. Enrolled individuals will participate in a multimodal prehabilitation programme conducted at the PeriOperative Programme complex of the MUHC. It includes exercise training with a certified kinesiologist (aerobic and resistance training), nutritional optimisation with a registered dietician and psychological support with a nurse specialist. The exercise training programme is divided into an induction phase with three sessions per week for 4 weeks followed by a maintenance phase with one session every other week for 20 weeks. Aerobic training will be individualised based on result from cardiopulmonary exercise testing (CPET) and will include a high-intensity interval training on a cycle ergometer. Feasibility, adherence and acceptability of the intervention will be assessed. Adverse events will be reviewed before each visit. Changes in exercise capacity (6-minute walk test, CPET, liver frailty index), nutritional status and health-related quality of life will be assessed during the study. Post-transplantation outcomes will be recorded. ETHICS AND DISSEMINATION The research ethics board of the MUHC has approved this study (2021-7646). Our findings will be submitted for presentation at national and international conferences, and for peer-reviewed publication. TRIAL REGISTRATION NUMBER NCT05237583.
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Affiliation(s)
- Amine Benmassaoud
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Chelsia Gillis
- School of Human Nutrition, McGill University, Montreal, Quebec, Canada
| | - Olivia Geraci
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Myriam Martel
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Rashami Awasthi
- PeriOperative Program, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jeffrey Barkun
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tianyan Chen
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Linda Edgar
- PeriOperative Program, McGill University Health Centre, Montreal, Quebec, Canada
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada
| | - Amal Bessissow
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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10
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Dennis AT, Traer E, Ismail H, Riedel B. Hemodynamic, ventilatory and gas exchange responses to exercise using a cycle ergometer and the incremental shuttle walk test in pregnant women. Am Heart J 2024; 272:56-68. [PMID: 38493884 DOI: 10.1016/j.ahj.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 03/04/2024] [Accepted: 03/13/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Cardiovascular disease, including hypertension, in pregnant women is a leading cause of morbidity and mortality globally. The development of reference intervals for cardiovascular responses using exercising testing to measure oxygen utilisation (V̇O2) with cardiopulmonary exercise testing (CPET), and distances walked using the incremental shuttle walk test (ISWT), may be promising methods to assess and stratify pregnant women regarding their risk of adverse pregnancy outcomes, to encourage exercise during pregnancy, and to improve exercise prescriptions during pregnancy. We aimed to determine the reference intervals for V̇O2 at rest, anaerobic threshold (AT), and submaximal exercise using CPET, and the reference interval for the ISWT, to develop a correlation equitation that predicts submaximal V̇O2 from the distance walked in the ISWT, and to explore the relationship between hemoglobin (Hb) and ferritin concentration and V̇O2 at AT in women in second trimester. METHODS After prospective IRB approval (HREC 15/23) and clinical trials registration (ANZCTR ACTRN12615000964516), and informed written consent, we conducted CPET and the ISWT according to international guidelines in a university associated tertiary referral obstetric and adult medicine hospital, in healthy pregnant women in second trimester (14 to 27 gestational weeks). Hemoglobin and ferritin concentrations were recorded from pathology results in the participants' medical records at the time of exercise testing. Adverse events were recorded. RESULTS About 90 participants undertook CPET, 28 of which also completed the ISWT. The mean ± SD age and body mass index (BMI) were 32 ± 3.2 years, and 25 ± 2.7 kg/m2. Median (IQR) gestation was 23 (22-24) weeks. One in 4 women were 24 weeks or greater gestation. The reference intervals for V̇O2 at rest, AT, and submaximal exercise were 2.9 to 5.3, 8.1 to 20.7, and 14.1 to 30.5 mL/kg/min respectively. The reference interval for the ISWT was 218 to 1058 meters. The correlation equation to predict submaximal V̇O2 from the distance walked in the ISWT was submaximal V̇O2 (mL/kg/min) = 0.012*distance walked in ISWT (m) + 14.7 (95%CI slope 0.005-0.070, Pearson r = 0.5426 95%CI 0.2126-0.7615, P = .0029). Hemoglobin concentration was positively correlated with V̇O2 at AT (AT V̇O2 (mL/kg/min) = 0.08*Hb (g/L) + 4.9 (95%CI slope 0.0791-0.143, Pearson r = 0.2538 95%CI 0.049-0.438, P = .016). There was no linear association between ferritin and submaximal V̇O2 (Pearson r = 0.431 P = .697). There were no maternal or fetal complications. CONCLUSIONS CPET and ISWT are safe and feasible in women in second trimester including those at or beyond 24 weeks gestation. We have established the reference interval for V̇O2 at rest, AT, and submaximal exercise by CPET, the reference interval for the distance walked for the ISWT, and a correlation equation to predict submaximal V̇O2 for use in clinical practice and research. Hemoglobin rather than ferritin is likely correlated with exercise capacity in pregnancy suggesting vigilance to correct lower hemoglobin levels may positively impact maternal health. CLINICAL TRIALS REGISTRY The study was prospectively registered with the Australian and New Zealand Clinical Date of registration - 15/9/2015; Date of initial participant enrolment - 4/11/2015; Clinical trial identification number; ACTRN12615000964516; URL of the registration site - https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369216.
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Affiliation(s)
- Alicia Therese Dennis
- Division of Obstetric Anesthesia, Department of Anesthesiology, Perioperative medicine and Pain Medicine, Brigham and Women's Hospital, Boston, MA; Department of Anaesthesia, The Royal Women's Hospital, Parkville, Australia; Department of Anaesthesia and Perioperative Medicine, Western Health, Sunshine, Australia; School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia; Departments of Critical Care, Obstetrics and Gynaecology, and Pharmacology, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia; Honorary researcher, Peter MacCallum Cancer Centre, Victoria, Australia.
| | - Emily Traer
- Division of Obstetric Anesthesia, Department of Anesthesiology, Perioperative medicine and Pain Medicine, Brigham and Women's Hospital, Boston, MA; Department of Anaesthesia Peter MacCallum Cancer Centre, Victoria, Australia
| | - Hilmy Ismail
- Department of Anaesthesia Peter MacCallum Cancer Centre, Victoria, Australia
| | - Bernhard Riedel
- Department of Anaesthesia and Perioperative Medicine, Western Health, Sunshine, Australia; Department of Anaesthesia Peter MacCallum Cancer Centre, Victoria, Australia
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11
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West MA, Rahman S, Jack S, Grocott MP, Levett DZ, Rashid Y, Griffiths J, Ezra M, Ayres L, Neville-Webbe H, Javed MS, Shrotri M, Khan I, Whitmore D, Prabhu P, Timbrell D, Allen S, Packham AO, Sharpe D, Anderson H, Minto G, McAleer S, McPhail S, Alasmar M, Hartley RA, Sultan J, Grace B, Underwood TJ, Byrne J, Noble F, Kelly J, Ansell G, Edwards M. Cardiopulmonary exercise variables and their association with postoperative morbidity and mortality after major oesophagogastric cancer surgery-a multicentre observational study. BJA OPEN 2024; 10:100289. [PMID: 38947220 PMCID: PMC11214286 DOI: 10.1016/j.bjao.2024.100289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 05/01/2024] [Indexed: 07/02/2024]
Abstract
Background Outcomes after oesophagogastric cancer surgery remain poor. Cardiopulmonary exercise testing (CPET) used for risk stratification before oesophagogastric cancer surgery is based on conflicting evidence. This study explores the relationship between CPET and postoperative outcomes, specifically for patients undergoing neoadjuvant treatment. Methods Patients undergoing oesophagogastric cancer resection and CPET (pre- or post-neoadjuvant treatment, or both) were retrospectively enrolled into a multicentre pooled cohort study. Oxygen uptake at peak exercise (VO2 peak) was compared with 1-yr postoperative survival. Secondary analyses explored relationships between patient characteristics, tumour pathology characteristics, CPET variables (absolute, relative to weight, ideal body weight, and body surface area), and postoperative outcomes (morbidity, 1-yr and 3-yr survival) were assessed using logistic regression analyses. Results Seven UK centres recruited 611 patients completing a 3-yr postoperative follow-up period. Oesophagectomy was undertaken in 475 patients (78%). Major complications occurred in 25%, with 18% 1-yr and 43% 3-yr mortality. No association between VO2 peak or other selected CPET variables and 1-yr survival was observed in the overall cohort. In the overall cohort, the anaerobic threshold relative to ideal body weight was associated with 3-yr survival (P=0.013). Tumour characteristics (ypT/ypN/tumour regression/lymphovascular invasion/resection margin; P<0.001) and Clavien-Dindo ≥3a (P<0.001) were associated with 1-yr and 3-yr survival. On subgroup analyses, pre-neoadjuvant treatment CPET; anaerobic threshold (absolute; P=0.024, relative to ideal body weight; P=0.001, body surface area; P=0.009) and VE/VCO2 at anaerobic threshold (P=0.026) were associated with 3-yr survival. No other CPET variables (pre- or post-neoadjuvant treatment) were associated with survival. Conclusions VO2 peak was not associated with 1-yr survival after oesophagogastric cancer resection. Tumour characteristics and major complications were associated with survival; however, only some selected pre-neoadjuvant treatment CPET variables were associated with 3-yr survival. CPET in this cohort of patients demonstrates limited outcome predictive precision. Clinical trial registration NCT03637647.
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Affiliation(s)
- Malcolm A. West
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
| | - Saqib Rahman
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Sandy Jack
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michael P.W. Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Denny Z.H. Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - the Perioperative Exercise Testing and Training Society (POETTS)
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Departments of Anaesthesia and Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Department of General Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
- Department of Anaesthetics, The Royal Surrey Foundation NHS Trust, Guildford, UK
- Anaesthetic Department, Frimley Park Hospital, Frimley Health NHS Foundation Trust, UK
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Minimal Access Therapy Training Unit (MATTU), Guildford, UK
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK
- Department of Gastro-Intestinal Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
- Directorate of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Emergency Medical Retrieval and Transfer Service, Cymru, Joint Hospital Group (Southwest), UK
- Institute of Naval Medicine, Alverstoke, UK
- Salford Royal NHS Foundation Trust, Salford Royal, Salford, UK
- Division of Cancer Sciences, School of Medical Sciences, University of Manchester, UK
- University Hospitals Southampton, Department of Surgery, Southampton, UK
| | - Yasir Rashid
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - John Griffiths
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Martin Ezra
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Lyndsay Ayres
- Departments of Anaesthesia and Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Helen Neville-Webbe
- Departments of Anaesthesia and Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Department of General Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Muhammad Shafiq Javed
- Department of General Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Milind Shrotri
- Department of General Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Iftikhar Khan
- Department of General Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - David Whitmore
- Departments of Anaesthesia and Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Pradeep Prabhu
- Department of Anaesthetics, The Royal Surrey Foundation NHS Trust, Guildford, UK
| | - David Timbrell
- Department of Anaesthetics, The Royal Surrey Foundation NHS Trust, Guildford, UK
- Anaesthetic Department, Frimley Park Hospital, Frimley Health NHS Foundation Trust, UK
| | - Sophie Allen
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - Andrew O. Packham
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - David Sharpe
- Department of Gastro-Intestinal Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Helen Anderson
- Directorate of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Gary Minto
- Directorate of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Samuel McAleer
- Directorate of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Emergency Medical Retrieval and Transfer Service, Cymru, Joint Hospital Group (Southwest), UK
| | - Stuart McPhail
- Directorate of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Institute of Naval Medicine, Alverstoke, UK
| | - Mohamed Alasmar
- Salford Royal NHS Foundation Trust, Salford Royal, Salford, UK
- Division of Cancer Sciences, School of Medical Sciences, University of Manchester, UK
| | - Robert A. Hartley
- Salford Royal NHS Foundation Trust, Salford Royal, Salford, UK
- Division of Cancer Sciences, School of Medical Sciences, University of Manchester, UK
| | - Javed Sultan
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Minimal Access Therapy Training Unit (MATTU), Guildford, UK
- Salford Royal NHS Foundation Trust, Salford Royal, Salford, UK
- Division of Cancer Sciences, School of Medical Sciences, University of Manchester, UK
| | - Ben Grace
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Timothy J. Underwood
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- University Hospitals Southampton, Department of Surgery, Southampton, UK
| | - James Byrne
- University Hospitals Southampton, Department of Surgery, Southampton, UK
| | - Fergus Noble
- University Hospitals Southampton, Department of Surgery, Southampton, UK
| | - Jamie Kelly
- University Hospitals Southampton, Department of Surgery, Southampton, UK
| | - Gillian Ansell
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospitals Southampton, Department of Surgery, Southampton, UK
| | - Mark Edwards
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospitals Southampton, Department of Surgery, Southampton, UK
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12
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Ranasinghe C, Kariyawasam K, Liyanage J, Walpita Y, Rajasinghe U, Abayadeera A, Chandrasinghe P, Gunasekara M, Kumarage S, De Silva M, Ranathunga K, Deen K, Ismail H. Translation, cross-cultural adaptation, and validation of the Duke Activity Status Index (DASI) to Sinhala language. Perioper Med (Lond) 2024; 13:38. [PMID: 38735972 PMCID: PMC11089684 DOI: 10.1186/s13741-024-00386-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 04/10/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Duke Activity Status Index (DASI) is a widely used tool to assess functional capacity among patients, but there is no Sinhala version validated for patients in Sri Lanka. This study aimed to cross-culturally adapt and test the validity and reliability of the Sinhala version of DASI (DASI-S). METHODS The translation and cross-cultural adaptation of the DASI questionnaire were conducted following the standard guidelines. It was pre-tested on ten pre-operative patients and further modified. The construct validity and reliability of DASI-S were evaluated by administering the modified final DASI-S, which comprised 12 items, along with the physical functioning sub-scale of the 36-item short-form health survey (SF-36), consisting of 10 items to eighty-one patients who were awaiting non-cardiac surgeries at university surgical wards, National Hospital of Sri Lanka (NHSL), and Colombo North Teaching Hospital (CNTH), Sri Lanka. Reliability was assessed through Cronbach alpha, while the validity was evaluated using factor analysis and Spearman's correlation. The ethical approval was obtained from the Ethics Review Committee, Faculty of Medicine, University of Colombo, Sri Lanka. RESULTS The mean age of the participants was 46.2 (± 16.6) years and the majority were females (54.3%). The mean height, weight, and body mass index of the sample were 160.5 (± 9.6) cm, 60.3 (± 11.9) kg, and 23.4 (± 4.5) kgm-2 respectively. The Cronbach's alpha coefficient for the internal consistency of DASI-S was 0.861. The concurrent validity of DASI-S was substantiated by positively correlating (p < 0.01, rs = 0.466) with the physical sub-scale of SF-36. There was a significant difference (p < 0.01) in the total score of DASI-S between the two age groups. CONCLUSIONS Sinhala version of the DASI appears to be a valid, reliable and easy-to-administer tool to assess functional capacity among patients who are awaiting non-cardiac surgeries.
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Affiliation(s)
- C Ranasinghe
- Center for Sport and Exercise Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
- Department of Allied Health Sciences, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
| | - K Kariyawasam
- Department of Allied Health Sciences, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - J Liyanage
- Department of Allied Health Sciences, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Y Walpita
- Department of Community Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - U Rajasinghe
- Department of Allied Health Sciences, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - A Abayadeera
- Department of Anaesthesiology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - P Chandrasinghe
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | - M Gunasekara
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | - S Kumarage
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | - M De Silva
- Department of Cardiothoracic Anaesthesiology, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - K Ranathunga
- Department of Cardiothoracic Anaesthesiology, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - K Deen
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | - H Ismail
- Cardio Pulmonary Exercise Testing (CPET) Laboratory, Peter MacCallum Cancer Hospital Melbourne, Melbourne, Australia
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13
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Lanzi S, Pousaz A, Fresa M, Besson C, Desgraz B, Gremeaux-Bader V, Mazzolai L. Short-duration aerobic high-intensity intervals versus moderate exercise training intensity in patients with peripheral artery disease: study protocol for a randomised controlled trial (the Angiof-HIIT Study). BMJ Open 2024; 14:e081883. [PMID: 38631833 PMCID: PMC11029310 DOI: 10.1136/bmjopen-2023-081883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/25/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Supervised exercise training is among the first-line therapies for patients with peripheral artery disease (PAD). Current recommendations for exercise include guidance focusing on claudication pain, programme and session duration, and frequency. However, no guidance is offered regarding exercise training intensity. This study aims to compare the effects of 12-week-long supervised walking exercise training (high-intensity interval training (HIIT) vs moderate-intensity exercise (MOD)) in patients with chronic symptomatic PAD. METHODS AND ANALYSIS This study is a monocentric, interventional, non-blinded randomised controlled trial. 60 patients (30 in each group) will be randomly allocated (by using the random permuted blocks) to 12 weeks (three times a week) of HIIT or MOD. For HIIT, exercise sessions will consist of alternating brief high-intensity (≥85% of the peak heart rate (HRpeak)) periods (≤60 s) of work with periods of passive rest. Patients will be asked to complete 1 and then 2 sets of 5-7 (progressing to 10-15×60 s) walking intervals. For the MOD group, exercise training sessions will consist of an alternation of periods of work performed at moderate intensity (≤76% HRpeak) and periods of passive rest. Interventions will be matched by training load. The primary outcome will be the maximal walking distance. Secondary outcomes will include functional performance, functional capacity, heath-related quality of life, self-perceived walking abilities, physical activity and haemodynamic parameters. ETHICS AND DISSEMINATION The Angiof-HIIT Study was approved by the Human Research Ethics Committee of the Canton de Vaud (study number: 2022-01752). Written consent is mandatory prior to enrolment and randomisation. The results will be disseminated via national and international scientific meetings, scientific peer-reviewed journals and social media. TRIAL REGISTRATION NUMBER NCT05612945.
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Affiliation(s)
- Stefano Lanzi
- Angiology Department, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Switzerland, Lausanne, Switzerland
| | - Anina Pousaz
- Angiology Department, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Switzerland, Lausanne, Switzerland
| | - Marco Fresa
- Angiology Department, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Switzerland, Lausanne, Switzerland
| | - Cyril Besson
- Department of Sports Medicine, Swiss Olympic Medical Center, CHUV, Lausanne, Switzerland
- Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland
| | - Benoit Desgraz
- Department of Sports Medicine, Swiss Olympic Medical Center, CHUV, Lausanne, Switzerland
| | - Vincent Gremeaux-Bader
- Department of Sports Medicine, Swiss Olympic Medical Center, CHUV, Lausanne, Switzerland
- Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland
| | - Lucia Mazzolai
- Angiology Department, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Switzerland, Lausanne, Switzerland
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14
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Kristenson K, Hedman K. Percent predicted peak oxygen uptake is superior to weight-indexed peak oxygen uptake in risk stratification before lung cancer lobectomy. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00187-9. [PMID: 38452887 DOI: 10.1016/j.jtcvs.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/16/2024] [Accepted: 02/22/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To improve preoperative risk stratification in lung cancer lobectomy by identifying and comparing optimal thresholds for peak oxygen uptake (VO2peak) presented as weight-indexed and percent of predicted values, respectively. METHODS This was a longitudinal cohort study including national registry data on patients scheduled for cancer lobectomy that used available data from preoperative cardiopulmonary exercise testing. The measured VO2peak was indexed by body mass (mL/kg/min) and also compared with 2 established reference equations (Wasserman-Hansen and Study of Health in Pomerania, respectively). By receiver operating characteristic analysis, a lower 90% specificity and an upper 90% sensitivity threshold were determined for each measure, in relation to the outcome of any major complication or death. For each measure and based on these thresholds, patients were categorized as low risk, intermediate risk, or high risk. The frequency of complications was compared between groups using χ2. RESULTS The frequency of complications differed significantly between the proposed low-, intermediate-, and high-risk groups when using % predicted Study of Health in Pomerania (5%, 21%, 35%, P = .007) or % predicted Wasserman-Hansen (5%, 25%, 35%, P = .002) but not when using the weight-indexed VO2peak groups (7%, 23%, 15%, P = .08). Nonsignificant differences were found using the threshold <15 mL/kg/min (P = .34). CONCLUSIONS This study showed that weight-indexed VO2peak was of less use as a marker of risk at the lower range of exercise capacity, whereas % predicted VO2peak was associated with a continuously increasing risk of major complications, also at the lower end of exercise capacity. As identifying subjects at high risk of complications is important, % predicted VO2peak is therefore preferable.
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Affiliation(s)
- Karolina Kristenson
- Department of Cardiothoracic and Vascular Surgery, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
| | - Kristofer Hedman
- Department of Clinical Physiology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Kornuijt A, Bongers BC, G J Marcellis R, Lenssen AF. Submaximal cardiopulmonary exercise testing to assess preoperative aerobic capacity in patients with knee osteoarthritis scheduled for total knee arthroplasty: a feasibility study. Physiother Theory Pract 2024; 40:603-616. [PMID: 36205558 DOI: 10.1080/09593985.2022.2126740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 08/22/2022] [Accepted: 09/13/2022] [Indexed: 10/10/2022]
Abstract
OBJECTIVE To investigate the feasibility of submaximal cardiopulmonary exercise testing (CPET) in patients with knee osteoarthritis (OA) scheduled for primary total knee arthroplasty (TKA) surgery. Secondly, to assess their preoperative aerobic capacity. METHODS In this observational, single-center study, participants performed a submaximal CPET 3-6 weeks before surgery. To examine their experiences, participants completed a questionnaire and one week later they were contacted by telephone. CPET was deemed feasible when five feasibility criteria were met. Aerobic capacity was evaluated by determining the oxygen uptake (VO2) at the ventilatory anaerobic threshold (VAT) and oxygen uptake efficiency slope (OUES). OUES values were compared with two sets of normative values. RESULTS All feasibility criteria were met as 14 representative participants were recruited (recruitment rate: 60.9%), and all participants were able to perform the test and reached the VAT. No adverse events occurred, and all participants were positive toward submaximal CPET. The median VO2 at the VAT was 12.8 mL/kg/min (IQR 11.3-13.6). The median OUES/kg was 23.1 (IQR 20.2-28.9), 106.4% and 109.4% of predicted. CONCLUSION Submaximal CPET using cycle ergometry seems feasible in patients with knee OA scheduled for TKA surgery to evaluate preoperative aerobic capacity.
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Affiliation(s)
- Anke Kornuijt
- Sports and Orthopedics Research Center, Anna Hospital, Geldrop, the Netherlands
- Department of Physical Therapy, Anna Hospital, Geldrop, the Netherlands
- Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Rik G J Marcellis
- Department of Physical Therapy, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Antoine F Lenssen
- Department of Physical Therapy, Maastricht University Medical Center+, Maastricht, the Netherlands
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Driessens H, Wijma AG, Buis CI, Nijkamp MW, Nieuwenhuijs-Moeke GJ, Klaase JM. Prehabilitation: tertiary prevention matters. Br J Surg 2024; 111:znae028. [PMID: 38436470 PMCID: PMC10910596 DOI: 10.1093/bjs/znae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/24/2023] [Accepted: 01/30/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Heleen Driessens
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, The Netherlands
| | - Allard G Wijma
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, The Netherlands
| | - Carlijn I Buis
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, The Netherlands
| | - Maarten W Nijkamp
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Joost M Klaase
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, The Netherlands
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Roxburgh BH, Campbell HA, Cotter JD, Reymann U, Williams MJA, Gwynne-Jones D, Thomas KN. Upper-Limb High-Intensity Interval Training or Passive Heat Therapy to Optimize Cardiorespiratory Fitness Prior to Total Hip or Knee Arthroplasty: A Randomized Controlled Trial. Arthritis Care Res (Hoboken) 2024; 76:393-402. [PMID: 37728076 DOI: 10.1002/acr.25238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 08/30/2023] [Accepted: 09/15/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVE Preoperative exercise training, or prehabilitation, aims to optimize cardiorespiratory fitness before surgery to reduce the risk of adverse perioperative events and delayed recovery. However, traditional exercise such as walking and cycling can be difficult for people with degenerative joint diseases of the lower limbs, such as osteoarthritis. The purpose of this study was to compare the effect of three low-impact interventions on cardiorespiratory fitness, physical function, and subjective health before total hip or knee arthroplasty. METHODS This was a randomized controlled trial involving 93 participants with severe knee or hip osteoarthritis awaiting joint replacement surgery. Participants underwent cardiopulmonary exercise testing (to measure peak oxygen consumption [V ̇ $$ \dot{V} $$ O2 ]), then were randomized to heat therapy (Heat; 20-30 min immersed in 40°C water followed by ~15 min light-resistance exercise), high-intensity interval training (HIIT; 6-8 × 60 s intervals on a cross-trainer or arm ergometer at ~90%-100% peakV ̇ $$ \dot{V} $$ O2 ), or home-based exercise (Home; ~15 min light-resistance exercise); for up to 36 sessions (3 sessions per week for 12 weeks). RESULTS PeakV ̇ $$ \dot{V} $$ O2 increased by 16% across HIIT and to a greater extent than Heat (+2.5 mL × min-1 × kg-1 [95% CI: 0.5-4.4], P = 0.009) and Home (+3.2 mL × min-1 × kg-1 [1.2-5.2], P = 0.001). The anaerobic threshold increased across HIIT (+1.5 mL × min-1 × kg-1 [0.7-2.3], P < 0.001) and Heat (+1.2 mL × min-1 × kg-1 [0.4-1.9], P = 0.004), but not Home (-0.5 mL × min-1 × kg-1 [-1.3 to 0.3], P = 0.248). Subjective severity of osteoarthritis was unchanged with any intervention (P ≥ 0.250). CONCLUSION Heat therapy and HIIT improved indices of cardiorespiratory fitness preoperatively in patients who have difficulty performing lower-limb exercise.
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Tetlow N, Dewar A, Arina P, Tan M, Sridhar AN, Kelly JD, Arulkumaran N, Stephens RC, Martin DS, Moonesinghe SR, Whittle J. Preoperative aerobic fitness and perioperative outcomes in patients undergoing cystectomy before and after implementation of a national lockdown. BJA OPEN 2024; 9:100255. [PMID: 38298206 PMCID: PMC10828563 DOI: 10.1016/j.bjao.2023.100255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/16/2023] [Indexed: 02/02/2024]
Abstract
Background Lower fitness is a predictor of adverse outcomes after radical cystectomy. Lockdown measures during the COVID-19 pandemic affected daily physical activity. We hypothesised that lockdown during the pandemic was associated with a reduction in preoperative aerobic fitness and an increase in postoperative complications in patients undergoing radical cystectomy. Methods We reviewed routine preoperative cardiopulmonary exercise testing (CPET) data collected prior to the pandemic (September 2018 to March 2020) and after lockdown (March 2020 to July 2021) in patients undergoing radical cystectomy. Differences in CPET variables, Postoperative Morbidity Survey (POMS) data, and length of hospital stay were compared. Results We identified 267 patients (85 pre-lockdown and 83 during lockdown) who underwent CPET and radical cystectomy. Patients undergoing radical cystectomy throughout lockdown had lower ventilatory anaerobic threshold (9.0 [7.9-10.9] vs 10.3 [9.1-12.3] ml kg-1 min-1; P=0.0002), peak oxygen uptake (15.5 [12.9-19.1] vs 17.5 [14.4-21.0] ml kg-1 min-1; P=0.015), and higher ventilatory equivalents for carbon dioxide (34.7 [31.4-38.5] vs 33.4 [30.5-36.5]; P=0.030) compared with pre-lockdown. Changes were more pronounced in males and those aged >65 yr. Patients undergoing radical cystectomy throughout lockdown had a higher proportion of day 5 POMS-defined morbidity (89% vs 75%, odds ratio [OR] 2.698, 95% confidence interval [CI] 1.143-6.653; P=0.019), specifically related to pulmonary complications (30% vs 13%, OR 2.900, 95% CI 1.368-6.194; P=0.007) and pain (27% vs 9%, OR 3.471, 95% CI 1.427-7.960; P=0.004), compared with pre-lockdown on univariate analysis. Conclusions Lockdown measures in response to the COVID-19 pandemic were associated with a reduction in fitness and an increase in postoperative morbidity among patients undergoing radical cystectomy.
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Affiliation(s)
- Nicholas Tetlow
- Department of Anaesthesia and Peri-operative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
- Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
- Human Physiology and Performance Laboratory (HPPL), Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | - Amy Dewar
- Department of Anaesthesia and Peri-operative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
- Human Physiology and Performance Laboratory (HPPL), Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | - Pietro Arina
- Human Physiology and Performance Laboratory (HPPL), Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
- Bloomsbury Institute for Intensive Care Medicine, University College London, London, UK
| | - Melanie Tan
- Department of Anaesthesia and Peri-operative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ashwin N. Sridhar
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - John D. Kelly
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Nishkantha Arulkumaran
- Human Physiology and Performance Laboratory (HPPL), Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
- Bloomsbury Institute for Intensive Care Medicine, University College London, London, UK
| | - Robert C.M. Stephens
- Department of Anaesthesia and Peri-operative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
- Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | | | - Suneetha R. Moonesinghe
- Department of Anaesthesia and Peri-operative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
- Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | - John Whittle
- Department of Anaesthesia and Peri-operative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
- Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
- Human Physiology and Performance Laboratory (HPPL), Centre for Peri-operative Medicine, Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
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Smart N. Are pulses racing fast enough? Colorectal Dis 2024; 26:225-226. [PMID: 38415916 DOI: 10.1111/codi.16923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
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Bates A, West MA, Jack S, Grocott MPW. Preparing for and Not Waiting for Surgery. Curr Oncol 2024; 31:629-648. [PMID: 38392040 PMCID: PMC10887937 DOI: 10.3390/curroncol31020046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
Cancer surgery is an essential treatment strategy but can disrupt patients' physical and psychological health. With worldwide demand for surgery expected to increase, this review aims to raise awareness of this global public health concern, present a stepwise framework for preoperative risk evaluation, and propose the adoption of personalised prehabilitation to mitigate risk. Perioperative medicine is a growing speciality that aims to improve clinical outcome by preparing patients for the stress associated with surgery. Preparation should begin at contemplation of surgery, with universal screening for established risk factors, physical fitness, nutritional status, psychological health, and, where applicable, frailty and cognitive function. Patients at risk should undergo a formal assessment with a qualified healthcare professional which informs meaningful shared decision-making discussion and personalised prehabilitation prescription incorporating, where indicated, exercise, nutrition, psychological support, 'surgery schools', and referral to existing local services. The foundational principles of prehabilitation can be adapted to local context, culture, and population. Clinical services should be co-designed with all stakeholders, including patient representatives, and require careful mapping of patient pathways and use of multi-disciplinary professional input. Future research should optimise prehabilitation interventions, adopting standardised outcome measures and robust health economic evaluation.
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Affiliation(s)
- Andrew Bates
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Malcolm A. West
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Sandy Jack
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Michael P. W. Grocott
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
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21
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Syversen A, Dosis A, Jayne D, Zhang Z. Wearable Sensors as a Preoperative Assessment Tool: A Review. SENSORS (BASEL, SWITZERLAND) 2024; 24:482. [PMID: 38257579 PMCID: PMC10820534 DOI: 10.3390/s24020482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/06/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024]
Abstract
Surgery is a common first-line treatment for many types of disease, including cancer. Mortality rates after general elective surgery have seen significant decreases whilst postoperative complications remain a frequent occurrence. Preoperative assessment tools are used to support patient risk stratification but do not always provide a precise and accessible assessment. Wearable sensors (WS) provide an accessible alternative that offers continuous monitoring in a non-clinical setting. They have shown consistent uptake across the perioperative period but there has been no review of WS as a preoperative assessment tool. This paper reviews the developments in WS research that have application to the preoperative period. Accelerometers were consistently employed as sensors in research and were frequently combined with photoplethysmography or electrocardiography sensors. Pre-processing methods were discussed and missing data was a common theme; this was dealt with in several ways, commonly by employing an extraction threshold or using imputation techniques. Research rarely processed raw data; commercial devices that employ internal proprietary algorithms with pre-calculated heart rate and step count were most commonly employed limiting further feature extraction. A range of machine learning models were used to predict outcomes including support vector machines, random forests and regression models. No individual model clearly outperformed others. Deep learning proved successful for predicting exercise testing outcomes but only within large sample-size studies. This review outlines the challenges of WS and provides recommendations for future research to develop WS as a viable preoperative assessment tool.
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Affiliation(s)
- Aron Syversen
- School of Computing, University of Leeds, Leeds LS2 9JT, UK
| | - Alexios Dosis
- School of Medicine, University of Leeds, Leeds LS2 9JT, UK; (A.D.); (D.J.)
| | - David Jayne
- School of Medicine, University of Leeds, Leeds LS2 9JT, UK; (A.D.); (D.J.)
| | - Zhiqiang Zhang
- School of Electrical Engineering, University of Leeds, Leeds LS2 9JT, UK;
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22
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Van Hooren B, Souren T, Bongers BC. Accuracy of respiratory gas variables, substrate, and energy use from 15 CPET systems during simulated and human exercise. Scand J Med Sci Sports 2024; 34:e14490. [PMID: 37697640 DOI: 10.1111/sms.14490] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/07/2023] [Accepted: 08/25/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE Various systems are available for cardiopulmonary exercise testing (CPET), but their accuracy remains largely unexplored. We evaluate the accuracy of 15 popular CPET systems to assess respiratory variables, substrate use, and energy expenditure during simulated exercise. Cross-comparisons were also performed during human cycling experiments (i.e., verification of simulation findings), and between-session reliability was assessed for a subset of systems. METHODS A metabolic simulator was used to simulate breath-by-breath gas exchange, and the values measured by each system (minute ventilation [V̇E], breathing frequency [BF], oxygen uptake [V̇O2 ], carbon dioxide production [V̇CO2 ], respiratory exchange ratio [RER], energy from carbs and fats, and total energy expenditure) were compared to the simulated values to assess the accuracy. The following manufacturers (system) were assessed: COSMED (Quark CPET, K5), Cortex (MetaLyzer 3B, MetaMax 3B), Vyaire (Vyntus CPX, Oxycon Pro), Maastricht Instruments (Omnical), MGC Diagnostics (Ergocard Clinical, Ergocard Pro, Ultima), Ganshorn/Schiller (PowerCube Ergo), Geratherm (Ergostik), VO2master (VO2masterPro), PNOĒ (PNOĒ), and Calibre Biometrics (Calibre). RESULTS Absolute percentage errors during the simulations ranged from 1.15%-44.3% for V̇E, 1.05-3.79% for BF, 1.10%-13.3% for V̇O2 , 1.07%-18.3% for V̇CO2 , 0.62%-14.8% for RER, 5.52%-99.0% for Kcal from carbs, 5.13%-133% for Kcal from fats, and 0.59%-12.1% for total energy expenditure. Between-session variation ranged from 0.86%-21.0% for V̇O2 and 1.14%-20.2% for V̇CO2 , respectively. CONCLUSION The error of respiratory gas variables, substrate, and energy use differed substantially between systems, with only a few systems demonstrating a consistent acceptable error. We extensively discuss the implications of our findings for clinicians, researchers and other CPET users.
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Affiliation(s)
- Bas Van Hooren
- Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Tjeu Souren
- Independent Consultant, Utrecht, The Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
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Kristenson K, Gerring E, Björnsson B, Sandström P, Hedman K. Peak oxygen uptake in combination with ventilatory efficiency improve risk stratification in major abdominal surgery. Physiol Rep 2024; 12:e15904. [PMID: 38163673 PMCID: PMC10758333 DOI: 10.14814/phy2.15904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024] Open
Abstract
This pilot study aimed to evaluate if peak VO2 and ventilatory efficiency in combination would improve preoperative risk stratification beyond only relying on peak VO2 . This was a single-center retrospective cohort study including all patients who underwent cardiopulmonary exercise testing (CPET) as part of preoperative risk evaluation before major upper abdominal surgery during years 2008-2021. The primary outcome was any major cardiopulmonary complication during hospitalization. Forty-nine patients had a preoperative CPET before decision to pursue to surgery (cancer in esophagus [n = 18], stomach [6], pancreas [16], or liver [9]). Twenty-five were selected for operation. Patients who suffered any major cardiopulmonary complication had lower ventilatory efficiency (i.e., higher VE/VCO2 slope, 37.3 vs. 29.7, p = 0.031) compared to those without complications. In patients with a low aerobic capacity (i.e., peak VO2 < 20 mL/kg/min) and a VE/VCO2 slope ≥ 39, 80% developed a major cardiopulmonary complication. In this pilot study of patients with preoperative CPET before major upper abdominal surgery, patients who experienced a major cardiopulmonary complication had significantly lower ventilatory efficiency compared to those who did not. A low aerobic capacity in combination with low ventilatory efficiency was associated with a very high risk (80%) of having a major cardiopulmonary complication.
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Affiliation(s)
- Karolina Kristenson
- Department of Thoracic and Vascular Surgery in Östergötland, and Department of Health, Medicine and Caring SciencesLinköping UniversityLinköpingSweden
| | - Edvard Gerring
- Department of Clinical Physiology, and Department of Health, Medicine and Caring SciencesLinköping UniversityLinköpingSweden
| | - Bergthor Björnsson
- Department of Surgery, Department of Biomedicine and Clinical SciencesLinköping UniversityLinköpingSweden
| | - Per Sandström
- Department of Surgery, Department of Biomedicine and Clinical SciencesLinköping UniversityLinköpingSweden
| | - Kristofer Hedman
- Department of Clinical Physiology, and Department of Health, Medicine and Caring SciencesLinköping UniversityLinköpingSweden
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Franssen RFW, Berkel AEM, Ten Cate DWG, van der Palen J, van Meeteren NLU, Vogelaar FJ, Slooter G, Klaase JM, Janssen-Heijnen MLG, Bongers BC. A retrospective analysis of the association of effort-independent cardiopulmonary exercise test variables with postoperative complications in patients who underwent elective colorectal surgery. Langenbecks Arch Surg 2023; 409:7. [PMID: 38093118 DOI: 10.1007/s00423-023-03197-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 12/05/2023] [Indexed: 12/18/2023]
Abstract
PURPOSE This study aimed to investigate the association of effort-independent variables derived from the preoperative cardiopulmonary exercise test (CPET) with 30-day postoperative complications after elective colorectal surgery. METHODS A multicenter (n=4) retrospective explorative study was performed using data of patients who completed a preoperative CPET and underwent elective colorectal surgery. The preoperative slope of the relation between minute ventilation and carbon dioxide production (VE/VCO2-slope) and the oxygen uptake efficiency slope (OUES), as well as 30-day postoperative complications, were assessed. Multivariable logistic regression analyses and receiver operating characteristic (ROC) curves were used to investigate the prognostic value of the relationship between these preoperative CPET-derived effort-independent variables and postoperative complications. RESULTS Data from 102 patients (60.1% males) with a median age of 72.0 (interquartile range 67.8-77.4) years were analyzed. Forty-four patients (43.1%) had one or more postoperative complications (of which 52.3% general and 77.3% surgical complications). Merely 10 (9.8%) patients had a general complication only. In multivariate analysis adjusted for surgical approach (open versus minimally invasive surgery), the VE/VCO2-slope (odds ratio (OR) 1.08, confidence interval (CI) 1.02-1.16) and OUES (OR 0.94, CI 0.89-1.00) were statistically significant associated with the occurrence of 30-day postoperative complications. CONCLUSION The effort-independent VE/VCO2-slope and OUES might be used to assist in future preoperative risk assessment and could especially be of added value in patients who are unable or unwilling to deliver a maximal cardiorespiratory effort. Future research should reveal the predictive value of these variables individually and/or in combination with other prognostic (CPET-derived) variables for postoperative complications. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT05331196.
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Affiliation(s)
- Ruud F W Franssen
- Department of Clinical Physical Therapy, VieCuri Medical Center, Tegelseweg 210, 5912, BL, Venlo, The Netherlands.
- Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Annefleur E M Berkel
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
- General Practice, Rijk-Berkel, Hengelo, The Netherlands
| | - David W G Ten Cate
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Job van der Palen
- Department of Epidemiology, Medisch Spectum Twente, Enschede, The Netherlands
- Section Cognition, Data and Education, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
| | - Nico L U van Meeteren
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Top Sector Life Sciences & Health, The Hague, The Netherlands
| | - F Jeroen Vogelaar
- Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Gerrit Slooter
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Joost M Klaase
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Maryska L G Janssen-Heijnen
- Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Epidemiology, VieCuri Medical Center, Venlo, The Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Arbee-Kalidas N, Moutlana HJ, Moodley Y, Kebalepile MM, Motshabi Chakane P. The association between cardiopulmonary exercise testing and postoperative outcomes in patients with lung cancer undergoing lung resection surgery: A systematic review and meta-analysis. PLoS One 2023; 18:e0295430. [PMID: 38060569 PMCID: PMC10703215 DOI: 10.1371/journal.pone.0295430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Exercise capacity should be determined in all patients undergoing lung resection for lung cancer surgery and cardiopulmonary exercise testing (CPET) remains the gold standard. The purpose of this study was to investigate associations between preoperative CPET and postoperative outcomes in patients undergoing lung resection surgery for lung cancer through a review of the existing literature. METHODS A search was conducted on PubMed, Scopus, Cochrane Library and CINAHL from inception until December 2022. Studies investigating associations between preoperative CPET and postoperative outcomes were included. Risk of bias was assessed using the QUIPS tool. A random effect model meta-analysis was performed. I2 > 40% indicated a high level of heterogeneity. RESULTS Thirty-seven studies were included with 6450 patients. Twenty-eight studies had low risk of bias. [Formula: see text] peak is the oxygen consumption at peak exercise and serves as a marker of cardiopulmonary fitness. Higher estimates of [Formula: see text] peak, measured and as a percentagege of predicted, showed significant associations with a lower risk of mortality [MD: 3.66, 95% CI: 0.88; 6.43 and MD: 16.49, 95% CI: 6.92; 26.07] and fewer complications [MD: 2.06, 95% CI: 1.12; 3.00 and MD: 9.82, 95% CI: 5.88; 13.76]. Using a previously defined cutoff value of > 15mL/kg/min for [Formula: see text] peak, showed evidence of decreased odds of mortality [OR: 0.55, 95% CI: 0.28-0.81] and but not decreased odds of postoperative morbidity [OR: 0.82, 95% CI: 0.64-1.00]. There was no relationship between [Formula: see text] slope, which depicts ventilatory efficiency, with mortality [MD: -9.60, 95% CI: -27.74; 8.54] however, patients without postoperative complications had a lower preoperative [Formula: see text] [MD: -2.36, 95% CI: -3.01; -1.71]. Exercise load and anaerobic threshold did not correlate with morbidity or mortality. There was significant heterogeneity between studies. CONCLUSIONS Estimates of cardiopulmonary fitness as evidenced by higher [Formula: see text] peak, measured and as a percentage of predicted, were associated with decreased morbidity and mortality. A cutoff value of [Formula: see text] peak > 15mL/kg/min was consistent with improved survival but not with fewer complications. Ventilatory efficiency was associated with decreased postoperative morbidity but not with improved survival. The heterogeneity in literature could be remedied with large scale, prospective, blinded, standardised research to improve preoperative risk stratification in patients with lung cancer scheduled for lung resection surgery.
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Affiliation(s)
- Nabeela Arbee-Kalidas
- Department of Anaesthesiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Hlamatsi Jacob Moutlana
- Department of Anaesthesiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yoshan Moodley
- Department of Anaesthesiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Moses Mogakolodi Kebalepile
- Department of Anaesthesiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Palesa Motshabi Chakane
- Department of Anaesthesiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Behnia M, Sietsema KE. Utility of Cardiopulmonary Exercise Testing in Chronic Obstructive Pulmonary Disease: A Review. Int J Chron Obstruct Pulmon Dis 2023; 18:2895-2910. [PMID: 38089541 PMCID: PMC10710955 DOI: 10.2147/copd.s432841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/17/2023] [Indexed: 12/18/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a disease defined by airflow obstruction with a high morbidity and mortality and significant economic burden. Although pulmonary function testing is the cornerstone in diagnosis of COPD, it cannot fully characterize disease severity or cause of dyspnea because of disease heterogeneity and variable related and comorbid conditions affecting cardiac, vascular, and musculoskeletal systems. Cardiopulmonary exercise testing (CPET) is a valuable tool for assessing physical function in a wide range of clinical conditions, including COPD. Familiarity with measurements made during CPET and its potential to aid in clinical decision-making related to COPD can thus be useful to clinicians caring for this population. This review highlights pulmonary and extrapulmonary impairments that can contribute to exercise limitation in COPD. Key elements of CPET are identified with an emphasis on measurements most relevant to COPD. Finally, clinical applications of CPET demonstrated to be of value in the COPD setting are identified. These include quantifying functional capacity, differentiating among potential causes of symptoms and limitation, prognostication and risk assessment for operative procedures, and guiding exercise prescription.
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Affiliation(s)
- Mehrdad Behnia
- Pulmonary and Critical Care, University of Central Florida, Orlando, FL, USA
| | - Kathy E Sietsema
- The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, CA, USA
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Brown LA, Griffiths JA, Santer P, Jakeman PM, Smith TG. Potential for using simulated altitude as a means of prehabilitation: a physiology study. Anaesthesia 2023; 78:1472-1480. [PMID: 37877784 PMCID: PMC10953332 DOI: 10.1111/anae.16158] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 10/26/2023]
Abstract
The current pandemic of surgical complications necessitates urgent and pragmatic innovation to reduce postoperative morbidity and mortality, which are associated with poor pre-operative fitness and anaemia. Exercise prehabilitation is a compelling strategy, but it has proven difficult to establish that it improves outcomes either in isolation or as part of a multimodal approach. Simulated altitude exposure improves performance in athletes and offers a novel potential means of improving cardiorespiratory and metabolic fitness and alleviating anaemia within the prehabilitation window. We aimed to provide an initial physiological foundation for 'altitude prehabilitation' by determining the physiological effects of one week of simulated altitude (FI O2 15%, equivalent to approximately 2438 m (8000 ft)) in older sedentary volunteers. The study used a randomised, double-blind, sham-controlled crossover design. Eight participants spent counterbalanced normoxic and hypoxic weeks in a residential hypoxia facility and underwent repeated cardiopulmonary exercise tests. Mean (SD) age of participants was 64 (7) y and they were unfit, with mean (SD) baseline anaerobic threshold 12 (2) ml.kg-1 .min-1 and mean (SD) peak V̇O2 15 (3) ml.kg-1 .min-1 . Hypoxia was mild (mean (SD) Sp O2 93 (2) %, p < 0.001) and well-tolerated. Despite some indication of greater peak exercise capacity following hypoxia, overall there was no effect of simulated altitude on anaerobic threshold or peak V̇O2 . However, hypoxia induced a substantial increase in mean (SD) haemoglobin of 1.5 (2.7) g.dl-1 (13% increase, p = 0.028). This study has established the concept and feasibility of 'altitude prehabilitation' and demonstrated specific potential for improving haematological fitness. Physiologically, there is value in exploring a possible role for simulated altitude in pre-operative optimisation.
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Affiliation(s)
| | - J. A. Griffiths
- Nuffield Department of AnaesthesiaOxford University Hospitals NHS Foundation TrustOxfordUK
| | - P. Santer
- Department of Anesthesia, Critical Care and Pain MedicineBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMAUSA
| | - P. M. Jakeman
- Health Research Institute and Department of Physical Education and Sport SciencesUniversity of LimerickLimerickIreland
| | - T. G. Smith
- Centre for Human and Applied Physiological SciencesKing's College LondonLondonUK
- Department of AnaesthesiaGuy's and St Thomas' NHS Foundation TrustLondonUK
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Li X, Zhao L, Xu T, Shi G, Li J, Shuai W, Yang Y, Yang Y, Tian W, Zhou Y. Cardiac telerehabilitation under 5G internet of things monitoring: a randomized pilot study. Sci Rep 2023; 13:18886. [PMID: 37919385 PMCID: PMC10622509 DOI: 10.1038/s41598-023-46175-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/28/2023] [Indexed: 11/04/2023] Open
Abstract
Owing to issues such as time and cost, patients often show poor acceptance of and adherence to center-based cardiac rehabilitation (CBCR), which impacts the effectiveness of rehabilitation. Therefore, there is growing interest in home-based cardiac rehabilitation and cardiac telerehabilitation (CTR), which entail less time and cost than CBCR. This study aimed to compare the changes in physiological and psychological indicators, compliance, and satisfaction after CTR and CBCR. In this single-blind, randomized, controlled trial, the intervention group received CTR via the 5G Internet of Things platform, while the control group received CBCR. Data from 50 patients (age 66.28 ± 4.01 years) with acute myocardial infarction who underwent percutaneous coronary intervention were analyzed. After an intervention period of three months, the maximal oxygen uptake and metabolic equivalent of task were 5.53 ± 0.12 and 19.32 ± 0.17, respectively, in the intervention group, and 4.15 ± 0.13 and 16.52 ± 0.18, respectively, in the control group. After three months of intervention, there were significant differences between the two groups in all observed indicators (p < 0.05), except for low-density lipoprotein and the incidence of major adverse cardiovascular events (p > 0.05). The use of a 5G Internet of Things platform cardiac rehabilitation model effectively improved outcomes in patients with acute myocardial infarction who underwent percutaneous coronary intervention. Trials registry: The study protocol was registered at Chinese Clinical Trials Registry (ChiCTR), first trial registration 07/08/2023, identification number ChiCTR2300074435.
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Affiliation(s)
- Xiaojie Li
- Nursing School, Guizhou University of Traditional Chinese Medicine, Guiyang, 550025, Guizhou, China
| | - Lvheng Zhao
- Nursing School, Guizhou University of Traditional Chinese Medicine, Guiyang, 550025, Guizhou, China
| | - Tao Xu
- Department of Cardiovascular Internal Medicine, Second Affiliated Hospital, Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China
| | - Guofeng Shi
- Nursing School, Guizhou University of Traditional Chinese Medicine, Guiyang, 550025, Guizhou, China
| | - Jie Li
- Nursing School, Guizhou University of Traditional Chinese Medicine, Guiyang, 550025, Guizhou, China
| | - Wei Shuai
- Second Affiliated Hospital, Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China
| | - Yanqun Yang
- Department of Cardiovascular Internal Medicine, Second Affiliated Hospital, Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China
| | - Yang Yang
- Department of Cardiovascular Internal Medicine, Second Affiliated Hospital, Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China
| | - Weiyi Tian
- Guizhou University of Traditional Chinese Medicine, Guiyang, 550025, Guizhou, China.
| | - Yixia Zhou
- Nursing School, Guizhou University of Traditional Chinese Medicine, Guiyang, 550025, Guizhou, China.
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Van Hooren B, Mennen B, Gronwald T, Bongers BC, Rogers B. Correlation properties of heart rate variability to assess the first ventilatory threshold and fatigue in runners. J Sports Sci 2023:1-10. [PMID: 37916488 DOI: 10.1080/02640414.2023.2277034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 10/22/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE The short-term scaling exponent alpha1 of detrended fluctuation analysis (DFA-a1) of heart rate variability (HRV) has shown potential to delineate the first ventilatory threshold (VT1). The aims of this study were to investigate the accuracy of this method for VT1 determination in runners using a consumer grade chest belt and to explore the effects of acute fatigue. METHODS We compared oxygen uptake (V̇O2) and heart rate (HR) at gas exchange VT1 to V̇O2 and HR at a DFA-a1 value of 0.75. Gas exchange and HRV data were obtained from 14 individuals during a treadmill run involving two incremental ramps. Agreement was assessed using Bland-Altman analysis and linear regression. RESULTS Bland-Altman analysis between gas exchange and HRV V̇O2 and HR at VT1 during the first ramp showed a mean (95% limits of agreement) bias of -0.5 (-6.8 to 5.8) ml∙kg-1∙min-1, and -0.9 (-12.2 to 10.5) beats∙min-1, with R2 of 0.83 and 0.56, respectively. During the second ramp, the differences were -7.3 (-18.1 to 3.5) ml∙kg-1∙min-1 and -12.3 (-30.4 to 5.9) beats∙min-1, with R2 of 0.62 and 0.43, respectively. CONCLUSION A chest-belt derived DFA-a1 of 0.75 is closely related to gas exchange VT1, with the variability in accuracy at an individual level being similar to gas exchange methods. This suggests this to be a useful method for exercise intensity demarcation. The altered relationship during the second ramp indicates that DFA-a1 is only able to accurately demarcate exercise intensity thresholds in a non-fatigued state, but also opens opportunities for fatigue-based training prescription.
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Affiliation(s)
- Bas Van Hooren
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Bram Mennen
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Thomas Gronwald
- MSH Medical School Hamburg, Institute of Interdisciplinary Exercise Science and Sports Medicine, Hamburg, Germany
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Bruce Rogers
- College of Medicine, University of Central Florida, Orlando, Florida, USA
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Girardi M, Gattoni C, Stringer WW, Rossiter HB, Casaburi R, Ferguson C, Capelli C. Current definitions of the breathing cycle in alveolar breath-by-breath gas exchange analysis. Am J Physiol Regul Integr Comp Physiol 2023; 325:R433-R445. [PMID: 37519253 DOI: 10.1152/ajpregu.00065.2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/14/2023] [Accepted: 07/25/2023] [Indexed: 08/01/2023]
Abstract
Identification of the breathing cycle forms the basis of any breath-by-breath gas exchange analysis. Classically, the breathing cycle is defined as the time interval between the beginning of two consecutive inspiration phases. Based on this definition, several research groups have developed algorithms designed to estimate the volume and rate of gas transferred across the alveolar membrane ("alveolar gas exchange"); however, most algorithms require measurement of lung volume at the beginning of the ith breath (VLi-1; i.e., the end-expiratory lung volume of the preceding ith breath). The main limitation of these algorithms is that direct measurement of VLi-1 is challenging and often unavailable. Two solutions avoid the requirement to measure VLi-1 by redefining the breathing cycle. One method defines the breathing cycle as the time between two equal fractional concentrations of lung expired oxygen (Fo2) (or carbon dioxide; Fco2), typically in the alveolar phase, whereas the other uses the time between equal values of the Fo2/Fn2 (or Fco2/Fn2) ratios [i.e., the ratio of fractional concentrations of lung expired O2 (or CO2) and nitrogen (N2)]. Thus, these methods identify the breathing cycle by analyzing the gas fraction traces rather than the gas flow signal. In this review, we define the traditional approach and two alternative definitions of the human breathing cycle and present the rationale for redefining this term. We also explore the strengths and limitations of the available approaches and provide implications for future studies.
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Affiliation(s)
- Michele Girardi
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, United Kingdom
| | - Chiara Gattoni
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - William W Stringer
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States
| | - Harry B Rossiter
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States
| | - Richard Casaburi
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States
| | - Carrie Ferguson
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States
| | - Carlo Capelli
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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31
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Smits A, Agius CM, Blake D, Ang C, Kucukmetin A, van Ham M, Pijnenborg JMA, Knight J, Rundle S. Is Cardiopulmonary Exercise Testing Predictive of Surgical Complications in Patients Undergoing Surgery for Ovarian Cancer? Cancers (Basel) 2023; 15:5185. [PMID: 37958358 PMCID: PMC10648080 DOI: 10.3390/cancers15215185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/16/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Preoperative cardiopulmonary exercise testing (CPET) provides an objective assessment of functional capability. In other intra-abdominal surgical specialties, CPET outcomes are predictive of operative morbidity. However, in ovarian cancer surgery, its predictive value remains unknown. In this study, we evaluated the association between CPET performance and surgical morbidity in ovarian cancer patients. Secondly, we assessed the association between CPET performance and other surgical outcomes (i.e., hospital stay, readmission and residual disease). This was a retrospective cohort study of patients undergoing primary surgery for ovarian cancer between 2020 and 2023. CPET performance included peak oxygen uptake (VO2 max), ventilatory efficiency (VE/VO2) and anaerobic threshold. Outcomes were operative morbidity and included intra- and postoperative complications (Clavien-Dindo), hospital stay, readmission within 30 days and residual disease. A total of 142 patients were included. A lower VO2 peak and a higher VE/VCO2 were both associated with the occurrence of postoperative complications, and a poorer anaerobic threshold was associated with more transfusions. VE/VCO2 remained significantly associated after multivariate analysis (p = 0.035). None of the CPET outcomes were associated with length of stay, readmission or residual disease. In conclusion, VE/VCO2 was significantly associated with an increased risk of all-cause postoperative complications in ovarian cancer patients undergoing primary surgery.
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Affiliation(s)
- Anke Smits
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK
- Department of Gynaecological Oncology, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | - Claire-Marie Agius
- Department of Anaesthetics, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK
| | - Dominic Blake
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK
| | - Christine Ang
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK
| | - Ali Kucukmetin
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK
| | - Maaike van Ham
- Department of Gynaecological Oncology, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | | | - Joanne Knight
- Department of Anaesthetics, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK
| | - Stuart Rundle
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK
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Sietsema KE, Rossiter HB. Exercise Physiology and Cardiopulmonary Exercise Testing. Semin Respir Crit Care Med 2023; 44:661-680. [PMID: 37429332 DOI: 10.1055/s-0043-1770362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
Aerobic, or endurance, exercise is an energy requiring process supported primarily by energy from oxidative adenosine triphosphate synthesis. The consumption of oxygen and production of carbon dioxide in muscle cells are dynamically linked to oxygen uptake (V̇O2) and carbon dioxide output (V̇CO2) at the lung by integrated functions of cardiovascular, pulmonary, hematologic, and neurohumoral systems. Maximum oxygen uptake (V̇O2max) is the standard expression of aerobic capacity and a predictor of outcomes in diverse populations. While commonly limited in young fit individuals by the capacity to deliver oxygen to exercising muscle, (V̇O2max) may become limited by impairment within any of the multiple systems supporting cellular or atmospheric gas exchange. In the range of available power outputs, endurance exercise can be partitioned into different intensity domains representing distinct metabolic profiles and tolerances for sustained activity. Estimates of both V̇O2max and the lactate threshold, which marks the upper limit of moderate-intensity exercise, can be determined from measures of gas exchange from respired breath during whole-body exercise. Cardiopulmonary exercise testing (CPET) includes measurement of V̇O2 and V̇CO2 along with heart rate and other variables reflecting cardiac and pulmonary responses to exercise. Clinical CPET is conducted for persons with known medical conditions to quantify impairment, contribute to prognostic assessments, and help discriminate among proximal causes of symptoms or limitations for an individual. CPET is also conducted in persons without known disease as part of the diagnostic evaluation of unexplained symptoms. Although CPET quantifies a limited sample of the complex functions and interactions underlying exercise performance, both its specific and global findings are uniquely valuable. Some specific findings can aid in individualized diagnosis and treatment decisions. At the same time, CPET provides a holistic summary of an individual's exercise function, including effects not only of the primary diagnosis, but also of secondary and coexisting conditions.
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Affiliation(s)
- Kathy E Sietsema
- Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, California
| | - Harry B Rossiter
- Division of Respiratory and Critical Care Physiology and Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, California
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Alfitian J, Riedel B, Ismail H, Ho KM, Xie S, Zimmer P, Kammerer T, Wijeysundera DN, Cuthbertson BH, Schier R. Sex-related differences in functional capacity and its implications in risk stratification before major non-cardiac surgery: a post hoc analysis of the international METS study. EClinicalMedicine 2023; 64:102223. [PMID: 37811489 PMCID: PMC10556582 DOI: 10.1016/j.eclinm.2023.102223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 08/24/2023] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Background Poor functional capacity has been identified as an important modifiable risk factor for postoperative complications. Cardiopulmonary exercise testing (CPET) provides objective parameters of functional capacity (e.g., oxygen consumption at peak exercise, peak VO2), with significant prognostication for postoperative complications. However, sex-specific thresholds for functional capacity to predict surgical risk are yet to be established. Therefore, we performed a post hoc analysis of the international, multicentre, prospective observational METS (Measurement of Exercise Tolerance before Surgery) study to evaluate if sex-specific thresholds of peak VO2 improve risk prediction of postoperative complications. Methods We undertook a post hoc analysis (HREC/71824/PMCC) of the METS study, which was performed between March 2013 and March 2016. We investigated whether sex-specific differences exist for CPET-derived parameters and associated thresholds for predicting postoperative complications in this large cohort of patients that had major non-cardiac surgery (n = 1266). Logistic regression models were analyzed for the association of low peak VO2 with moderate-to-severe in-hospital postoperative complications. Optimal sex-specific peak VO2 thresholds were obtained by maximizing the Youden index of receiver operating characteristic (ROC) curves. Finally, multivariable logistic regression models tested the resulting sex-specific thresholds against the established non-sex-specific peak VO2 threshold (14 mL kg-1 min-1) adjusted for clinically relevant features such as comorbidities and surgical complexity. Models were evaluated by bootstrapping optimism-corrected area under the ROC curve and the net reclassification improvement index (NRI). Findings Female patients (n = 480) had a lower mean (SD) peak VO2 than males (16.7 (4.9) mL kg-1 min-1 versus 21.2 (6.5) mL kg-1 min-1, p < 0.001) and a lower postoperative complication rate (10.4% versus 15.3%; p = 0.018) than males (n = 786). The optimal peak VO2 threshold for predicting postoperative complications was 12.4 mL kg-1 min-1 for females and 22.3 mL kg-1 min-1 for males, respectively. In the multivariable regression model, low non-sex-specific peak VO2 did not independently predict postoperative complications. In contrast, low sex-specific peak VO2 was an independent predictor of postoperative complications (OR 2.29; 95% CI: 1.60, 3.30; p < 0.001). The optimism-corrected AUC-ROC of the sex-specific model was higher compared with the non-sex-specific model (0.73 versus 0.7; DeLong's test: p = 0.021). The sex-specific model classified 39% of the patients more correctly than the baseline model (NRI = 0.39; 95% CI: 0.24, 0.55). In contrast, the non-sex-specific model only classified 9% of the patients more correctly when compared against the baseline model (NRI = 0.09; 95% CI: -0.04, 0.22). Interpretation Our data report sex-specific differences in preoperative CPET-derived functional capacity parameters. Sex-specific peak VO2 thresholds identify patients at increased risk for postoperative complications with a higher discriminatory ability than a sex-unspecific threshold. As such, sex-specific threshold values should be considered in preoperative CPET to potentially improve risk stratification and to guide surgical decision-making, including eligibility for surgery, preoperative optimization strategies (prehabilitation) or seeking non-surgical options. Funding There was no funding for the present study. The original METS study was funded by Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.
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Affiliation(s)
- Jonas Alfitian
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Australia
- The Department of Critical Care, University of Melbourne, Melbourne, Australia
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Hilmy Ismail
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Australia
- The Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Kwok M. Ho
- University of Western Australia and Murdoch University, Australia
| | - Sophia Xie
- Peter MacCallum Cancer Centre, Centre for Biostatistics and Clinical Trials, Australia
| | - Philipp Zimmer
- Division of Performance and Health, Institute for Sport and Sport Science, TU Dortmund University, Germany
| | - Tobias Kammerer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
| | - Duminda N. Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael’s Hospital, Toronto, ON, Canada
| | - Brian H. Cuthbertson
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Robert Schier
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Marburg, Campus Fulda, Germany
| | - the METS Study Investigators
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Australia
- The Department of Critical Care, University of Melbourne, Melbourne, Australia
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- University of Western Australia and Murdoch University, Australia
- Peter MacCallum Cancer Centre, Centre for Biostatistics and Clinical Trials, Australia
- Division of Performance and Health, Institute for Sport and Sport Science, TU Dortmund University, Germany
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael’s Hospital, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Marburg, Campus Fulda, Germany
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Bailey DM, Davies RG, Rose GA, Lewis MH, Aldayem AA, Twine CP, Awad W, Jubouri M, Mohammed I, Mestres CA, Chen EP, Coselli JS, Williams IM, Bashir M. Myths and methodologies: Cardiopulmonary exercise testing for surgical risk stratification in patients with an abdominal aortic aneurysm; balancing risk over benefit. Exp Physiol 2023; 108:1118-1131. [PMID: 37232485 PMCID: PMC10988440 DOI: 10.1113/ep090816] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
The extent to which patients with an abdominal aortic aneurysm (AAA) should exercise remains unclear, given theoretical concerns over the perceived risk of blood pressure-induced rupture, which is often catastrophic. This is especially pertinent during cardiopulmonary exercise testing, when patients are required to perform incremental exercise to symptom-limited exhaustion for the determination of cardiorespiratory fitness. This multimodal metric is being used increasingly as a complementary diagnostic tool to inform risk stratification and subsequent management of patients undergoing AAA surgery. In this review, we bring together a multidisciplinary group of physiologists, exercise scientists, anaesthetists, radiologists and surgeons to challenge the enduring 'myth' that AAA patients should be fearful of and avoid rigorous exercise. On the contrary, by appraising fundamental vascular mechanobiological forces associated with exercise, in conjunction with 'methodological' recommendations for risk mitigation specific to this patient population, we highlight that the benefits conferred by cardiopulmonary exercise testing and exercise training across the continuum of intensity far outweigh the short-term risks posed by potential AAA rupture.
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Affiliation(s)
- Damian M. Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and EducationUniversity of South WalesGlamorganUK
| | - Richard G. Davies
- Neurovascular Research Laboratory, Faculty of Life Sciences and EducationUniversity of South WalesGlamorganUK
- Department of AnaestheticsUniversity Hospital of WalesCardiffUK
| | - George A. Rose
- Neurovascular Research Laboratory, Faculty of Life Sciences and EducationUniversity of South WalesGlamorganUK
| | - Michael H. Lewis
- Neurovascular Research Laboratory, Faculty of Life Sciences and EducationUniversity of South WalesGlamorganUK
| | | | | | - Wael Awad
- Neurovascular Research Laboratory, Faculty of Life Sciences and EducationUniversity of South WalesGlamorganUK
- Department of Cardiothoracic SurgeryBart's Heart Centre, St Bartholomew's Hospital, Bart's Health NHS TrustLondonUK
| | | | - Idhrees Mohammed
- Institute of Cardiac and Aortic DisordersSRM Institutes for Medical Science (SIMS Hospital)ChennaiTamil NaduIndia
| | - Carlos A. Mestres
- Department of Cardiac SurgeryUniversity Hospital ZürichZürichSwitzerland
| | - Edward P. Chen
- Division of Cardiovascular and Thoracic SurgeryDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Joseph S. Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of SurgeryBaylor College of MedicineHoustonTexasUSA
- The Texas Heart InstituteHoustonTexasUSA
- St Luke's‐Baylor St. Luke's Medical CenterHoustonTexasUSA
| | - Ian M. Williams
- Neurovascular Research Laboratory, Faculty of Life Sciences and EducationUniversity of South WalesGlamorganUK
- Department of Vascular SurgeryUniversity Hospital of WalesCardiffUK
| | - Mohamad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and EducationUniversity of South WalesGlamorganUK
- Vascular and Endovascular SurgeryHealth & Education Improvement WalesCardiffUK
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Wallis TJM, Minnion M, Freeman A, Bates A, Otto JM, Wootton SA, Fletcher SV, Grocott MPW, Feelisch M, Jones MG, Jack S. Individualised Exercise Training Enhances Antioxidant Buffering Capacity in Idiopathic Pulmonary Fibrosis. Antioxidants (Basel) 2023; 12:1645. [PMID: 37627640 PMCID: PMC10451244 DOI: 10.3390/antiox12081645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/13/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Exercise training is recommended for patients with idiopathic pulmonary fibrosis (IPF); however, the mechanism(s) underlying its physiological benefits remain unclear. We investigated the effects of an individualised aerobic interval training programme on exercise capacity and redox status in IPF patients. IPF patients were recruited prospectively to an 8-week, twice-weekly cardiopulmonary exercise test (CPET)-derived structured responsive exercise training programme (SRETP). Systemic redox status was assessed pre- and post-CPET at baseline and following SRETP completion. An age- and sex-matched non-IPF control cohort was recruited for baseline comparison only. At baseline, IPF patients (n = 15) had evidence of increased oxidative stress compared with the controls as judged by; the plasma reduced/oxidised glutathione ratio (median, control 1856 vs. IPF 736 p = 0.046). Eleven IPF patients completed the SRETP (median adherence 88%). Following SRETP completion, there was a significant improvement in exercise capacity assessed via the constant work-rate endurance time (+82%, p = 0.003). This was accompanied by an improvement in post-exercise redox status (in favour of antioxidants) assessed via serum total free thiols (median increase, +0.26 μmol/g protein p = 0.005) and total glutathione concentration (+0.73 μM p = 0.03), as well as a decrease in post-exercise lipid peroxidation products (-1.20 μM p = 0.02). Following SRETP completion, post-exercise circulating nitrite concentrations were significantly lower compared with baseline (-0.39 μM p = 0.04), suggestive of exercise-induced nitrite utilisation. The SRETP increased both endurance time and systemic antioxidant capacity in IPF patients. The observed reduction in nitrite concentrations provides a mechanistic rationale to investigate nitrite/nitrate supplementation in IPF patients.
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Affiliation(s)
- Tim J. M. Wallis
- NIHR Southampton Biomedical Research Centre, Respiratory and Critical Care, University Hospital Southampton, Southampton SO16 6YD, UK; (M.M.); (A.F.); (A.B.); (J.M.O.); (S.V.F.); (M.P.W.G.); (M.F.); (M.G.J.); (S.J.)
- Academic School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK;
| | - Magdalena Minnion
- NIHR Southampton Biomedical Research Centre, Respiratory and Critical Care, University Hospital Southampton, Southampton SO16 6YD, UK; (M.M.); (A.F.); (A.B.); (J.M.O.); (S.V.F.); (M.P.W.G.); (M.F.); (M.G.J.); (S.J.)
- Academic School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK;
| | - Anna Freeman
- NIHR Southampton Biomedical Research Centre, Respiratory and Critical Care, University Hospital Southampton, Southampton SO16 6YD, UK; (M.M.); (A.F.); (A.B.); (J.M.O.); (S.V.F.); (M.P.W.G.); (M.F.); (M.G.J.); (S.J.)
- Academic School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK;
| | - Andrew Bates
- NIHR Southampton Biomedical Research Centre, Respiratory and Critical Care, University Hospital Southampton, Southampton SO16 6YD, UK; (M.M.); (A.F.); (A.B.); (J.M.O.); (S.V.F.); (M.P.W.G.); (M.F.); (M.G.J.); (S.J.)
- Academic School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK;
- Department of Critical Care and Anaesthesia, University Hospital Southampton, Southampton SO16 6YD, UK
| | - James M. Otto
- NIHR Southampton Biomedical Research Centre, Respiratory and Critical Care, University Hospital Southampton, Southampton SO16 6YD, UK; (M.M.); (A.F.); (A.B.); (J.M.O.); (S.V.F.); (M.P.W.G.); (M.F.); (M.G.J.); (S.J.)
- Academic School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK;
- Department of Critical Care and Anaesthesia, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Stephen A. Wootton
- Academic School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK;
- NIHR Southampton Biomedical Research Centre, Nutrition and Metabolism, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Sophie V. Fletcher
- NIHR Southampton Biomedical Research Centre, Respiratory and Critical Care, University Hospital Southampton, Southampton SO16 6YD, UK; (M.M.); (A.F.); (A.B.); (J.M.O.); (S.V.F.); (M.P.W.G.); (M.F.); (M.G.J.); (S.J.)
- Academic School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK;
| | - Michael P. W. Grocott
- NIHR Southampton Biomedical Research Centre, Respiratory and Critical Care, University Hospital Southampton, Southampton SO16 6YD, UK; (M.M.); (A.F.); (A.B.); (J.M.O.); (S.V.F.); (M.P.W.G.); (M.F.); (M.G.J.); (S.J.)
- Academic School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK;
- Department of Critical Care and Anaesthesia, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Martin Feelisch
- NIHR Southampton Biomedical Research Centre, Respiratory and Critical Care, University Hospital Southampton, Southampton SO16 6YD, UK; (M.M.); (A.F.); (A.B.); (J.M.O.); (S.V.F.); (M.P.W.G.); (M.F.); (M.G.J.); (S.J.)
- Academic School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK;
| | - Mark G. Jones
- NIHR Southampton Biomedical Research Centre, Respiratory and Critical Care, University Hospital Southampton, Southampton SO16 6YD, UK; (M.M.); (A.F.); (A.B.); (J.M.O.); (S.V.F.); (M.P.W.G.); (M.F.); (M.G.J.); (S.J.)
- Academic School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK;
- Institute for Life Sciences, University of Southampton, Southampton SO17 1BJ, UK
| | - Sandy Jack
- NIHR Southampton Biomedical Research Centre, Respiratory and Critical Care, University Hospital Southampton, Southampton SO16 6YD, UK; (M.M.); (A.F.); (A.B.); (J.M.O.); (S.V.F.); (M.P.W.G.); (M.F.); (M.G.J.); (S.J.)
- Academic School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK;
- Department of Critical Care and Anaesthesia, University Hospital Southampton, Southampton SO16 6YD, UK
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Ahmed B, Shaw S, Pratt O, Forde C, Lal S, Carlson Cbe G. Oxygen utilisation in patients on prolonged parenteral nutrition; a case-controlled study. Clin Nutr ESPEN 2023; 56:152-157. [PMID: 37344066 DOI: 10.1016/j.clnesp.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 05/17/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Parenteral nutrition (PN) deficient in mitochondrial substrates and thiamine may lead to acidosis. This, combined with fatigue seen in patients with intestinal failure (IF), may suggest suboptimal oxidative metabolism. We therefore studied oxygen utilisation in otherwise apparently well-nourished individuals with intestinal failure receiving long term PN. METHODS This was a retrospective analysis conducted in a tertiary IF institution, from 2010 to 2019, comparing treadmill/bicycle cardiopulmonary exercise test (CPET) derived variables including peak oxygen consumption (VO2 peak), anaerobic threshold (AT) and ventilatory efficiency (minute ventilation (VE)/CO2 output (VCO2) of patients with IF (cases) to those without (controls), matched in a 1:2 ratio for age ( ± 3 years), gender, use of beta-blockers and physiology parameters of p-POSSUM score ( ± 5). All subjects were free of sepsis and metastatic malignancy. Mann-Whitney or Student's t-test for continuous and Fisher's exact or chi-squared test for categorical variables were used as appropriate. Data shown represent mean or median values. RESULTS Participants (31 cases, 62 controls) were comparable in age (65.4 vs. 65.3, p = 0.98); p-POSSUM parameters (18.0 vs. 17.0, p = 0.45); gender (p = 1.00); smoking status (p = 0.52); use of beta-blockers (p = 1.00) and ≤10 mg/day of oral steroids (p = 0.34). Participants had been on PN for 11.0 (6.0-24.0) months and were adequately nourished (requirements 27.6 kcal/kg/day, replacement 23.5 kcal/kg/day). No differences were found between VO2 peak (15.2 vs. 14.6 ml/kg/min, p = 0.96), AT (10.4 vs. 11.0 ml/kg/min, p = 0.44) and VE/VCO2 (33.0 vs. 33.0, p = 0.96) of the examined groups. CONCLUSION Patients with intestinal failure receiving PN who are apparently well-nourished also appear to have normal oxygen utilisation, suggesting alternative causes for fatigue. More studies will be required to determine whether CPET could reliably be used to assess perioperative risk in this group of patients.
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Affiliation(s)
- Babur Ahmed
- Intestinal Failure Unit, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford. M6 8HD, UK.
| | - Simon Shaw
- Intestinal Failure Unit, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford. M6 8HD, UK.
| | - Oliver Pratt
- Department of Anaesthesia, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford. M6 8HD, UK.
| | - Claire Forde
- Intestinal Failure Unit, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford. M6 8HD, UK.
| | - Simon Lal
- Intestinal Failure Unit, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford. M6 8HD, UK.
| | - Gordon Carlson Cbe
- Intestinal Failure Unit, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford. M6 8HD, UK.
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37
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Plumb JOM, Otto JM, Kumar SB, Bali S, Wakatsuki M, Schmidt WFJ, Montgomery HE, Grocott MPW, Levett DZ. Cardiopulmonary exercise testing before and after intravenous iron in preoperative patients: a prospective clinical study. Perioper Med (Lond) 2023; 12:31. [PMID: 37400931 DOI: 10.1186/s13741-023-00319-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/16/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Anemia is associated with impaired physical performance and adverse perioperative outcomes. Iron-deficiency anemia is increasingly treated with intravenous iron before elective surgery. We explored the relationship between exercise capacity, anemia, and total hemoglobin mass (tHb-mass) and the response to intravenous iron in anemic patients prior to surgery. METHODS A prospective clinical study was undertaken in patients having routine cardiopulmonary exercise testing (CPET) with a hemoglobin concentration ([Hb]) < 130 g.l-1 and iron deficiency/depletion. Patients underwent CPET and tHb-mass measurements before and a minimum of 14 days after receiving intravenous (i.v.) Ferric derisomaltose (Monofer®) at the baseline visit. Comparative analysis of hematological and CPET variables was performed pre and post-iron treatment. RESULTS Twenty-six subjects were recruited, of whom 6 withdrew prior to study completion. The remaining 20 (9 [45%] male; mean ± SD age 68 ± 10 years) were assessed 25 ± 7 days between baseline and the final visit. Following i.v. iron, increases were seen in [Hb] (mean ± SD) from 109 ± 14 to 116 ± 12 g l-1 (mean rise 6.4% or 7.3 g l-1, p = < 0.0001, 95% CI 4.5-10.1); tHb-mass from 497 ± 134 to 546 ± 139 g (mean rise 9.3% or 49 g, p = < 0.0001, 95% CI 29.4-69.2). Oxygen consumption at anerobic threshold ([Formula: see text] O2 AT) did not change (9.1 ± 1.7 to 9.8 ± 2.5 ml kg-1 min-1, p = 0.09, 95% CI - 0.13 - 1.3). Peak oxygen consumption ([Formula: see text] O2 peak) increased from 15.2 ± 4.1 to 16 ± 4.4 ml.kg.-1 min-1, p = 0.02, 95% CI 0.2-1.8) and peak work rate increased from 93 [67-112] watts to 96 [68-122] watts (p = 0.02, 95% CI 1.3-10.8). CONCLUSION Preoperative administration of intravenous iron to iron-deficient/deplete anemic patients is associated with increases in [Hb], tHb-mass, peak oxygen consumption, and peak work rate. Further appropriately powered prospective studies are required to ascertain whether improvements in tHb-mass and performance in turn lead to reductions in perioperative morbidity. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT 033 46213.
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Affiliation(s)
- James O M Plumb
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK.
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK.
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK.
| | - James M Otto
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
| | - Shriya B Kumar
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Sitara Bali
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Mai Wakatsuki
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
| | - Walter F J Schmidt
- Department of, Sports Medicine/Sports Physiology, University of Bayreuth, Bayreuth, Germany
| | - Hugh E Montgomery
- Centre for Human Health and Performance/Institute of Sport, Exercise and Health, University College London, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Denny Z Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
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38
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Sliwinski S, Werneburg E, Faqar-Uz-Zaman SF, Detemble C, Dreilich J, Mohr L, Zmuc D, Beyer K, Bechstein WO, Herrle F, Malkomes P, Reissfelder C, Ritz JP, Vilz T, Fleckenstein J, Schnitzbauer AA. A toolbox for a structured risk-based prehabilitation program in major surgical oncology. Front Surg 2023; 10:1186971. [PMID: 37435472 PMCID: PMC10332323 DOI: 10.3389/fsurg.2023.1186971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/17/2023] [Indexed: 07/13/2023] Open
Abstract
Prehabilitation is a multimodal concept to improve functional capability prior to surgery, so that the patients' resilience is strengthened to withstand any peri- and postoperative comorbidity. It covers physical activities, nutrition, and psychosocial wellbeing. The literature is heterogeneous in outcomes and definitions. In this scoping review, class 1 and 2 evidence was included to identify seven main aspects of prehabilitation for the treatment pathway: (i) risk assessment, (ii) FITT (frequency, interventions, time, type of exercise) principles of prehabilitation exercise, (iii) outcome measures, (iv) nutrition, (v) patient blood management, (vi) mental wellbeing, and (vii) economic potential. Recommendations include the risk of tumor progression due to delay of surgery. Patients undergoing prehabilitation should perceive risk assessment by structured, quantifiable, and validated tools like Risk Analysis Index, Charlson Comorbidity Index (CCI), American Society of Anesthesiology Score, or Eastern Co-operative Oncology Group scoring. Assessments should be repeated to quantify its effects. The most common types of exercise include breathing exercises and moderate- to high-intensity interval protocols. The program should have a duration of 3-6 weeks with 3-4 exercises per week that take 30-60 min. The 6-Minute Walking Testing is a valid and resource-saving tool to assess changes in aerobic capacity. Long-term assessment should include standardized outcome measurements (overall survival, 90-day survival, Dindo-Clavien/CCI®) to monitor the potential of up to 50% less morbidity. Finally, individual cost-revenue assessment can help assess health economics, confirming the hypothetic saving of $8 for treatment for $1 spent for prehabilitation. These recommendations should serve as a toolbox to generate hypotheses, discussion, and systematic approaches to develop clinical prehabilitation standards.
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Affiliation(s)
- Svenja Sliwinski
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Elisabeth Werneburg
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Sara Fatima Faqar-Uz-Zaman
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Charlotte Detemble
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Julia Dreilich
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Lisa Mohr
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Dora Zmuc
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Katharina Beyer
- Department of General, Visceral and Vascular Surgery, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
| | - Wolf O. Bechstein
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Florian Herrle
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Romed Klinik Prien am Chiemsee, Klinik für Allgemein- und Viszeralchirurgie, Prien am Chiemsee, Germany
| | - Patrizia Malkomes
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Christoph Reissfelder
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Joerg P. Ritz
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Helios Clinics Schwerin, Department for General and Visceral Surgery, Schwerin, Germany
| | - Tim Vilz
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Department of General, Visceral, Thoracic, and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Johannes Fleckenstein
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- Department of Pain Medicine, Hospital Landsberg am Lech, Landsberg am Lech, Germany
| | - Andreas A. Schnitzbauer
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
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Mahendran S, Thiagalingam A, Hillis G, Halliwell R, Pleass HC, Chow CK. Cardiovascular risk management in the peri-operative setting. Med J Aust 2023. [PMID: 37302136 DOI: 10.5694/mja2.51988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 03/17/2023] [Accepted: 03/27/2023] [Indexed: 06/13/2023]
Abstract
Peri-operative cardiovascular events occur in up to 3% of patients undergoing non-cardiac surgery. Accurate cardiovascular risk assessment is important in the peri-operative setting, as it allows informed and shared decisions regarding the appropriateness of proceeding with surgery, guides surgical and anaesthetic approaches, and may influence the use of preventive medications and post-operative cardiac monitoring. Quantitative risk assessment may also inform a reconsideration of choosing a more limited lower risk type of surgery, or conservative management. Pre-operative cardiovascular risk assessment starts with clinical assessment and should include an estimate of functional capacity. Specialised cardiac investigations are rarely indicated specifically to assess pre-operative cardiovascular risk. The decision regarding cardiac investigations is influenced by the nature, extent and urgency of surgery. The strategy of performing pre-operative revascularisation to improve post-operative outcomes is not evidence-based and recent international guidelines recommend against this.
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Affiliation(s)
| | | | | | | | - Henry Cc Pleass
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW
| | - Clara K Chow
- Westmead Hospital, Sydney, NSW
- University of Sydney, Sydney, NSW
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40
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Molenaar CJL, Minnella EM, Coca-Martinez M, ten Cate DWG, Regis M, Awasthi R, Martínez-Palli G, López-Baamonde M, Sebio-Garcia R, Feo CV, van Rooijen SJ, Schreinemakers JMJ, Bojesen RD, Gögenur I, van den Heuvel ER, Carli F, Slooter GD. Effect of Multimodal Prehabilitation on Reducing Postoperative Complications and Enhancing Functional Capacity Following Colorectal Cancer Surgery: The PREHAB Randomized Clinical Trial. JAMA Surg 2023; 158:572-581. [PMID: 36988937 PMCID: PMC10061316 DOI: 10.1001/jamasurg.2023.0198] [Citation(s) in RCA: 76] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 11/19/2022] [Indexed: 03/30/2023]
Abstract
Importance Colorectal surgery is associated with substantial morbidity rates and a lowered functional capacity. Optimization of the patient's condition in the weeks prior to surgery may attenuate these unfavorable sequelae. Objective To determine whether multimodal prehabilitation before colorectal cancer surgery can reduce postoperative complications and enhance functional recovery. Design, Setting, and Participants The PREHAB randomized clinical trial was an international, multicenter trial conducted in teaching hospitals with implemented enhanced recovery after surgery programs. Adult patients with nonmetastasized colorectal cancer were assessed for eligibility and randomized to either prehabilitation or standard care. Both arms received standard perioperative care. Patients were enrolled from June 2017 to December 2020, and follow-up was completed in December 2021. However, this trial was prematurely stopped due to the COVID-19 pandemic. Interventions The 4-week in-hospital supervised multimodal prehabilitation program consisted of a high-intensity exercise program 3 times per week, a nutritional intervention, psychological support, and a smoking cessation program when needed. Main Outcomes and Measures Comprehensive Complication Index (CCI) score, number of patients with CCI score more than 20, and improved walking capacity expressed as the 6-minute walking distance 4 weeks postoperatively. Results In the intention-to-treat population of 251 participants (median [IQR] age, 69 [60-76] years; 138 [55%] male), 206 (82%) had tumors located in the colon and 234 (93%) underwent laparoscopic- or robotic-assisted surgery. The number of severe complications (CCI score >20) was significantly lower favoring prehabilitation compared with standard care (21 of 123 [17.1%] vs 38 of 128 [29.7%]; odds ratio, 0.47 [95% CI, 0.26-0.87]; P = .02). Participants in prehabilitation encountered fewer medical complications (eg, respiratory) compared with participants receiving standard care (19 of 123 [15.4%] vs 35 of 128 [27.3%]; odds ratio, 0.48 [95% CI, 0.26-0.89]; P = .02). Four weeks after surgery, 6-minute walking distance did not differ significantly between groups when compared with baseline (mean difference prehabilitation vs standard care 15.6 m [95% CI, -1.4 to 32.6]; P = .07). Secondary parameters of functional capacity in the postoperative period generally favored prehabilitation compared with standard care. Conclusions and Relevance This PREHAB trial demonstrates the benefit of a multimodal prehabilitation program before colorectal cancer surgery as reflected by fewer severe and medical complications postoperatively and an optimized postoperative recovery compared with standard care. Trial Registration trialregister.nl Identifier: NTR5947.
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Affiliation(s)
| | - Enrico Maria Minnella
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Miquel Coca-Martinez
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
- Department of Anesthesia, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Marta Regis
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Rashami Awasthi
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | | | | | - Raquel Sebio-Garcia
- Physical Medicine and Rehabilitation Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Carlo Vittorio Feo
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
- Unit of Provincial General Surgery, Azienda Unità Sanitaria Locale Ferrara, Ferrara, Italy
| | | | | | - Rasmus Dahlin Bojesen
- Center for Surgical Science, Zealand University Hospital, Roskilde, Denmark
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Surgery, Zealand University Hospital, Køge, Denmark
| | - Edwin R. van den Heuvel
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Francesco Carli
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
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Mendelson AA, Erickson D, Villar R. The role of the microcirculation and integrative cardiovascular physiology in the pathogenesis of ICU-acquired weakness. Front Physiol 2023; 14:1170429. [PMID: 37234410 PMCID: PMC10206327 DOI: 10.3389/fphys.2023.1170429] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023] Open
Abstract
Skeletal muscle dysfunction after critical illness, defined as ICU-acquired weakness (ICU-AW), is a complex and multifactorial syndrome that contributes significantly to long-term morbidity and reduced quality of life for ICU survivors and caregivers. Historically, research in this field has focused on pathological changes within the muscle itself, without much consideration for their in vivo physiological environment. Skeletal muscle has the widest range of oxygen metabolism of any organ, and regulation of oxygen supply with tissue demand is a fundamental requirement for locomotion and muscle function. During exercise, this process is exquisitely controlled and coordinated by the cardiovascular, respiratory, and autonomic systems, and also within the skeletal muscle microcirculation and mitochondria as the terminal site of oxygen exchange and utilization. This review highlights the potential contribution of the microcirculation and integrative cardiovascular physiology to the pathogenesis of ICU-AW. An overview of skeletal muscle microvascular structure and function is provided, as well as our understanding of microvascular dysfunction during the acute phase of critical illness; whether microvascular dysfunction persists after ICU discharge is currently not known. Molecular mechanisms that regulate crosstalk between endothelial cells and myocytes are discussed, including the role of the microcirculation in skeletal muscle atrophy, oxidative stress, and satellite cell biology. The concept of integrated control of oxygen delivery and utilization during exercise is introduced, with evidence of physiological dysfunction throughout the oxygen delivery pathway - from mouth to mitochondria - causing reduced exercise capacity in patients with chronic disease (e.g., heart failure, COPD). We suggest that objective and perceived weakness after critical illness represents a physiological failure of oxygen supply-demand matching - both globally throughout the body and locally within skeletal muscle. Lastly, we highlight the value of standardized cardiopulmonary exercise testing protocols for evaluating fitness in ICU survivors, and the application of near-infrared spectroscopy for directly measuring skeletal muscle oxygenation, representing potential advancements in ICU-AW research and rehabilitation.
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Affiliation(s)
- Asher A. Mendelson
- Section of Critical Care Medicine, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Dustin Erickson
- Section of Critical Care Medicine, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Rodrigo Villar
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB, Canada
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Chaumont M, Forton K, Gillet A, Tcheutchoua Nzokou D, Lamotte M. How Does the Method Used to Measure the VE/VCO 2 Slope Affect Its Value? A Cross-Sectional and Retrospective Cohort Study. Healthcare (Basel) 2023; 11:healthcare11091292. [PMID: 37174834 PMCID: PMC10178610 DOI: 10.3390/healthcare11091292] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/25/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
Cardiopulmonary exercise testing (CPET) was limited to peak oxygen consumption analysis (VO2peak), and now the ventilation/carbon dioxide production (VE/VCO2) slope is recognized as having independent prognostic value. Unlike VO2peak, the VE/VCO2 slope does not require maximal effort, making it more feasible. There is no consensus on how to measure the VE/VCO2 slope; therefore, we assessed whether different methods affect its value. This is a retrospective study assessing sociodemographic data, left ventricular ejection fraction, CPET parameters, and indications of patients referred for CPET. The VE/VCO2 slope was measured to the first ventilatory threshold (VT1-slope), secondary threshold (VT2-slope), and included all test data (full-slope). Of the 697 CPETs analyzed, 308 reached VT2. All VE/VCO2 slopes increased with age, regardless of test indications. In patients not reaching VT2, the VT1-slope was 32 vs. 36 (p < 0.001) for the full-slope; in those surpassing VT2, the VT1-slope was 29 vs. 33 (p < 0.001) for the VT2-slope and 37 (all p < 0.001) for the full-slope. The mean difference between the submaximal and full-slopes was ±4 units, sufficient to reclassify patients from low to high risk for heart failure or pulmonary hypertension. We conclude that the method used for determining the VE/VCO2 slope greatly influences the result, the significant variations limiting its prognostic value. The calculation method must be standardized to improve its prognostic value.
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Affiliation(s)
- Martin Chaumont
- Department of Cardiology, Erasme Hospital, 1070 Brussels, Belgium
| | - Kevin Forton
- Department of Cardiology, Erasme Hospital, 1070 Brussels, Belgium
| | - Alexis Gillet
- Department of Cardiology, Erasme Hospital, 1070 Brussels, Belgium
| | | | - Michel Lamotte
- Department of Cardiology, Erasme Hospital, 1070 Brussels, Belgium
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Nordén KR, Semb AG, Dagfinrud H, Hisdal J, Ødegård S, Sexton J, Fongen C, Skandsen J, Blanck T, Metsios GS, Tveter AT. Associations between cardiovascular risk factors, disease activity and cardiorespiratory fitness in patients with inflammatory joint disease: a cross-sectional analysis. BMC Sports Sci Med Rehabil 2023; 15:63. [PMID: 37085935 PMCID: PMC10120183 DOI: 10.1186/s13102-023-00678-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/19/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND Inflammatory joint diseases (IJD) are accompanied by an increased risk of cardiovascular disease (CVD). Cardiorespiratory fitness (CRF) is a modifiable CVD risk factor and low levels of CRF associate with an elevated CVD risk. This study aimed to investigate the associations between CVD risk factors, disease activity and CRF in patients with IJD and to explore differences between patients with normal versus low levels of CRF. METHODS CRF was measured as peak oxygen uptake (VO2peak) with a cardiopulmonary exercise test. Participants were also evaluated for: Body composition, blood pressure, blood lipids, inflammatory markers and disease activity. Patient-reported use of cigarettes/snuff, medication, disease duration, pain, fatigue, CVD history, habitual physical activity and exercise beliefs and self-efficacy were collected by questionnaire. Cross-sectional associations between CVD risk factors, disease-related factors and CRF were analyzed by multiple linear regression. CRF was categorized to normal CRF (VO2peak ≥ 80%) or low CRF (VO2peak < 80%) according to age- and gender-stratified reference data. Differences in demographic, CVD and disease-related factors between patients with normal versus low CRF were explored. RESULTS In 60 Norwegian patients with IJD [34 females, age 59 years (IQR: 52-63)], mean VO2peak was 30.2 (± 6.9) mL/kg/min, corresponding to 83% (± 18) of normative reference values. Age (coefficient: - 0.18 years, p = 0.01) and fat mass (coefficient: - 0.67 %, p < 0.001) were inversely associated with CRF, while physical activity index (coefficient: 0.13 points, p = 0.05) was positively associated with CRF (R2 = 0.66). There were no significant associations between CRF, classical CVD risk factors and disease-related variables. Compared to patients with low CRF (n = 30), patients with normal CRF (n = 30) had higher peak oxygen uptake (+ 9.4 mL/kg/min, p < 0.001), high-density lipoprotein cholesterol (+ 0.5 mmol L-1, p < 0.001), and exercise self-efficacy (+ 6.9, p < 0.01) as well as lower fat mass (- 8.7%, p < 0.001), resting heart rate (- 8.0 beats/min, p < 0.01) and triglycerides (- 0.5 mmol L-1, p < 0.01). CONCLUSIONS In this sample of IJD-patients, age, fatmass and physical activity level were associated with CRF. CRF was lower than reference values and patients with normal CRF presented with a more favorable health profile. There is a continued need for exercise interventions to improve CRF in patients with IJD. TRIAL REGISTRATION NCT04922840.
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Affiliation(s)
- Kristine Røren Nordén
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Postboks 23, 0319, Vinderen, Oslo, Norway.
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.
- Norwegian National Advisory Unit on Rehabilitation in Rheumatology, Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway.
| | - Anne Grete Semb
- The Preventive Cardio-Rheuma Clinic, Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Hanne Dagfinrud
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Postboks 23, 0319, Vinderen, Oslo, Norway
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- Norwegian National Advisory Unit on Rehabilitation in Rheumatology, Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Jonny Hisdal
- Department of Vascular Surgery, Oslo University Hospital-Aker, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Sigrid Ødegård
- Norwegian National Unit for Rehabilitation for Rheumatic Patients with Special Needs, Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Joseph Sexton
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Postboks 23, 0319, Vinderen, Oslo, Norway
| | - Camilla Fongen
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Postboks 23, 0319, Vinderen, Oslo, Norway
- Norwegian National Advisory Unit on Rehabilitation in Rheumatology, Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Jon Skandsen
- Patient Advisory Board, Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Thalita Blanck
- Patient Advisory Board, Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - George S Metsios
- Department of Nutrition and Dietetics, University of Thessaly, Trikala, Thessaly, Greece
| | - Anne Therese Tveter
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Postboks 23, 0319, Vinderen, Oslo, Norway
- Norwegian National Advisory Unit on Rehabilitation in Rheumatology, Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
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Bongers BC. Steep ramp test protocol for preoperative risk assessment and short-term high-intensity interval training to evaluate, improve, and monitor cardiorespiratory fitness in surgical oncology. J Surg Oncol 2023; 127:891-895. [PMID: 36621860 DOI: 10.1002/jso.27201] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/13/2022] [Accepted: 12/30/2022] [Indexed: 01/10/2023]
Affiliation(s)
- Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.,Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
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Feasibility of Seated Stepping and Handshaking as a Cardiopulmonary Exercise Testing: A Pilot Study. J Clin Med 2023; 12:jcm12062140. [PMID: 36983144 PMCID: PMC10057871 DOI: 10.3390/jcm12062140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/06/2023] [Accepted: 03/08/2023] [Indexed: 03/11/2023] Open
Abstract
Cardiopulmonary function is usually assessed by cardiopulmonary exercise testing (CPX) using a cycle ergometer (CE-CPX) or a treadmill, which is difficult in patients with lower extremity motor dysfunction. A stepping and handshaking (SHS) exercise has been developed that can be performed safely and easily while sitting on a chair. This study compared peak oxygen uptake (peak V.O2) between CE-CPX and SHS-CPX in healthy adults and investigated the safety and validity of SHS-CPX. Twenty young adults (mean age 27.8 ± 4.4 years) were randomly assigned to perform CE-CPX or SHS-CPX, with the other test to follow 1–2 weeks later. The peak V.O2, respiratory exchange ratio (RER), peak heart rate, blood pressure, and test completion time were compared between CE-CPX and SHS-CPX. All subjects completed the examination and met the criteria for peak V.O2. SHS-CPX and CE-CPX showed a strong correlation with peak V.O2 (r = 0.85, p < 0.0001). The peak V.O2 (40.4 ± 11.3 mL/min/kg vs. 28.9 ± 8.0 mL/min/kg), peak heart rate (190.6 ± 8.9 bpm vs. 172.1 ± 12.6 bpm), and test completion time (1052.8 ± 143.7 s vs. 609.1 ± 96.2 s) were significantly lower in the SHS-CPX (p < 0.0001). There were no adverse events. The peak V.O2 with SHS-CPX was equivalent to about 70% of that with CE-CPX despite the exercise being performed in a sitting position, suggesting its suitability as a submaximal exercise test.
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McCarthy OM, Kristensen KB, Christensen MB, Schmidt S, Ranjan AG, Nicholas C, Bain SC, Nørgaard K, Bracken R. Metabolic and physiological responses to graded exercise testing in individuals with type 1 diabetes using insulin pump therapy. Diabetes Obes Metab 2023; 25:878-888. [PMID: 36482870 PMCID: PMC10107979 DOI: 10.1111/dom.14938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/20/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022]
Abstract
AIMS To profile acute glycaemic dynamics during graded exercise testing (GXT) and explore the influence of glycaemic indicators on the physiological responses to GXT in adults with type 1 diabetes using insulin pump therapy. METHODS This was a retrospective analysis of pooled data from four clinical trials with identical GXT protocols. Data were obtained from 45 adults with type 1 diabetes using insulin pumps [(30 females); haemoglobin A1c 59.5 ± 0.5 mmol/mol (7.6 ± 1.0%); age 49.7 ± 13.0 years; diabetes duration 31.2 ± 13.5 years; V̇O2peak 29.5 ± 8.0 ml/min/kg]. Integrated cardiopulmonary variables were collected continuously via spiroergometry. Plasma glucose was obtained every 3 min during GXT as well as the point of volitional exhaustion. Data were assessed via general linear modelling techniques with age and gender adjustment. Significance was accepted at p ≤ .05. RESULTS Despite increasing duration and intensity, plasma glucose concentrations remained similar to rest values (8.8 ± 2.3 mmol/L) throughout exercise (p = .419) with an overall change of +0.3 ± 1.1 mmol/L. Starting glycaemia bore no influence on subsequent GXT responses. Per 1% increment in haemoglobin A1c there was an associated decrease in V̇O2peak of 3.8 ml/min/kg (p < .001) and powerpeak of 0.33 W/kg (p < .001) concomitant with attenuations in indices of peripheral oxygen extraction [(O2 pulse) -1.2 ml/beat, p = .023]. CONCLUSION In adults with long-standing type 1 diabetes using insulin pump therapy, circulating glucose remains stable during a graded incremental cycle test to volitional exhaustion. Glycaemic indicators are inversely associated with aerobic rate, oxygen economy and mechanical output across the exercise intensity spectrum. An appreciation of these nexuses may help guide appropriate decision making for optimal exercise management strategies.
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Affiliation(s)
- Olivia M McCarthy
- Applied Sport, Technology, Exercise and Medicine Research Centre, Swansea University, Swansea, UK
- Copenhagen University Hospital-Steno Diabetes Center Copenhagen, Herlev, Denmark
| | | | | | - Signe Schmidt
- Copenhagen University Hospital-Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Ajenthen G Ranjan
- Copenhagen University Hospital-Steno Diabetes Center Copenhagen, Herlev, Denmark
- Danish Diabetes Academy, Odense, Denmark
| | - Chloe Nicholas
- Applied Sport, Technology, Exercise and Medicine Research Centre, Swansea University, Swansea, UK
| | | | - Kirsten Nørgaard
- Copenhagen University Hospital-Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Richard Bracken
- Applied Sport, Technology, Exercise and Medicine Research Centre, Swansea University, Swansea, UK
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Smoking Habit and Respiratory Function Predict Patients' Outcome after Surgery for Lung Cancer, Irrespective of Histotype and Disease Stage. J Clin Med 2023; 12:jcm12041561. [PMID: 36836096 PMCID: PMC9967492 DOI: 10.3390/jcm12041561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/05/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Growing evidence suggests that sublobar resections offer more favorable outcomes than lobectomy in early-stage lung cancer surgery. However, a percentage of cases that cannot be ignored develops disease recurrence irrespective of the surgery performed with curative intent. The goal of this work is thus to compare different surgical approaches, namely, lobectomy and segmentectomy (typical and atypical) to derive prognostic and predictive markers. PATIENTS AND METHODS Here we analyzed a cohort of 153 NSCLC patients in clinical stage TNM I who underwent pulmonary resection surgery with a mediastinal hilar lymphadenectomy from January 2017 to December 2021, with an average follow-up of 25.5 months. Partition analysis was also applied to the dataset to detect outcome predictors. RESULTS The results of this work showed similar OS between lobectomy and typical and atypical segmentectomy for patients with stage I NSCLC. In contrast, lobectomy was associated with a significant improvement in DFS compared with typical segmentectomy in stage IA, while in stage IB and overall, the two treatments were similar. Atypical segmentectomy showed the worst performance, especially in 3-year DFS. Quite unexpectedly, outcome predictor ranking analysis suggests a prominent role of smoking habits and respiratory function, irrespective of the tumor histotype and the patient's gender. CONCLUSIONS Although the limited follow-up interval cannot allow conclusive remarks about prognosis, the results of this study suggest that both lung volumes and the degree of emphysema-related parenchymal damage are the strongest predictors of poor survival in lung cancer patients. Overall, these data point out that greater attention should be addressed to the therapeutic intervention for co-existing respiratory diseases to obtain optimal control of early lung cancer.
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Frisch C, Fantin R, Raab H. [The Status of Spiroergometry in Preoperative Risk Assessment]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:112-118. [PMID: 36791775 DOI: 10.1055/a-1786-7877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Physical performance is considered as a prognostic factor for perioperative mortality and morbidity. Thus, in recent years, spiroergometry has gained increasing significance in preoperative assessment. Beside the measurement of functional capacity, spiroergometric results may yield indications for cardiocirculatory or pulmonary disorders. A significant increased risk profile is reflected in the values VO2max < 15 ml/kg/min, VO2 at the first ventilatory threshold (VT1) < 11 ml/kg/min, and VE/VCO2 at VT1 > 34. Prior to the examination, contraindications should be taken into account and standardized conduction must be adhered to. Many studies substantiate the positive effect of prehabilitation on morbidity, quality of life, and length of hospitalization, in particular in abdominal, thoracic and hepatobiliary surgery. Using the data acquired in the performance diagnostic, an optimized individual training plan can be drawn up. Besides, the risk evaluation contributes to planning surgical and anaesthetic procedures. Regular training and interdisciplinary teamwork are of utmost importance for the correct interpretation and application of the partly rather complex results.
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Pella E, Alexandrou ME, Boutou A, Theodorakopoulou M, Dipla K, Zafeiridis A, Sarafidis P. Effect of kidney transplantation on indices of cardiorespiratory fitness assessed with cardiopulmonary exercise testing: a systematic review and meta-analysis. Expert Rev Respir Med 2023; 17:171-179. [PMID: 36803358 DOI: 10.1080/17476348.2023.2182772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Patients with kidney failure often present with reduced cardiovascular reserve. Kidney transplantation (KT) is the optimal treatment for patients with end-stage kidney disease as it is associated with longer survival and improved quality of life compared to dialysis. METHODS This is a systematic review and meta-analysis of studies using cardiopulmonary-exercise-testing to examine the cardiorespiratory fitness of patients with kidney failure before and after KT. The primary outcome was difference in pre- and post-transplantation values of peak oxygen uptake (VO2peak). Literature search involved three databases (PubMed-Web of Science-Scopus), manual search, and grey literature. RESULTS From 379 records initially retrieved, six studies were included in final meta-analysis. A marginal, but not significant, improvement was observed in VO2peak after KT compared to pre-transplantation values (SMD: 0.32, 95%CI -0.02; 0.67). Oxygen consumption at anaerobic threshold was significantly improved after KT (WMD: 2.30 ml/kg/min, 95%CI 0.50; 4.09). Consistent results were shown between preemptive and after-dialysis-initiation transplantation and a trend for improvement in VO2peak was observed at least 3 months post-transplantation, but not earlier. CONCLUSION Several major indices of cardiorespiratory fitness tend to improve after KT. This finding may represent another modifiable factor contributing to better survival rates of kidney transplant recipients compared to patients undergoing dialysis.
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Affiliation(s)
- Eva Pella
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria-Eleni Alexandrou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Afroditi Boutou
- Department of Respiratory Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Marieta Theodorakopoulou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantina Dipla
- Department of Sports Science At Serres, Exercise Physiology and Biochemistry Laboratory, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Andreas Zafeiridis
- Department of Sports Science At Serres, Exercise Physiology and Biochemistry Laboratory, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Roxburgh BH, Cotter JD, Campbell HA, Reymann U, Wilson LC, Gwynne-Jones D, van Rij AM, Thomas KN. Physiological relationship between cardiorespiratory fitness and fitness for surgery: a narrative review. Br J Anaesth 2023; 130:122-132. [PMID: 36529576 DOI: 10.1016/j.bja.2022.10.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 10/11/2022] [Accepted: 10/24/2022] [Indexed: 12/23/2022] Open
Abstract
Epidemiological evidence has highlighted a strong relationship between cardiorespiratory fitness and surgical outcomes; specifically, fitter patients possess heightened resilience to withstand the surgical stress response. This narrative review draws on exercise and surgical physiology research to discuss and hypothesise the potential mechanisms by which higher fitness affords perioperative benefit. A higher fitness, as indicated by higher peak rate of oxygen consumption and ability to sustain metabolic homeostasis (i.e. higher anaerobic threshold) is beneficial postoperatively when metabolic demands are increased. However, the associated adaptations with higher fitness, and the related participation in regular exercise or physical activity, might also underpin the observed perioperative benefit through a process of hormesis, a protective adaptive response to the moderate and intermittent stress of exercise. Potential mediators discussed include greater antioxidant capacity, metabolic flexibility, glycaemic control, lean body mass, and improved mood.
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Affiliation(s)
- Brendon H Roxburgh
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; School of Physical Education, Sport and Exercise Sciences, Dunedin, University of Otago, New Zealand.
| | - James D Cotter
- School of Physical Education, Sport and Exercise Sciences, Dunedin, University of Otago, New Zealand
| | - Holly A Campbell
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Ulla Reymann
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Luke C Wilson
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - David Gwynne-Jones
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; Department of Orthopaedic Surgery, Southern District Health Board, Dunedin, New Zealand
| | - Andre M van Rij
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Kate N Thomas
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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