Pezzuto B; Centro Cardiologico Monzino, IRCCS, Milan, Italy.
Contini M; Berna G; Galotta A; Cattaneo G; Maragna R; Gugliandolo P; Agostoni P;

International journal of cardiology [Int J Cardiol] 2024 Apr 19, pp. 132041.
Date of Electronic Publication: 2024 Apr 19.

Background: In chronic heart failure (HF), exercise-induced increase in pulmonary capillary pressure may cause an increase of pulmonary congestion, or the development of pulmonary edema. We sought to assess in HF patients the exercise-induced intra-thoracic fluid movements, by measuring plasma brain natriuretic peptide (BNP), lung comets and lung diffusion for carbon monoxide (DLCO) and nitric oxide (DLNO), as markers of hemodynamic load changes, interstitial space and alveolar-capillary membrane fluids, respectively.
Methods and Results: Twenty-four reduced ejection fraction HF patients underwent BNP, lung comets and DLCO/DLNO measurements before, at peak and 1 h after the end of a maximal cardiopulmonary exercise test. BNP significantly increased at peak from 549 (328-841) to 691 (382-1207, p < 0.0001) pg/mL and almost completely returned to baseline value 1 h after exercise. Comets number increased at peak from 9.4 ± 8.2 to 24.3 ± 16.7, returning to baseline (9.7 ± 7.4) after 1 h (p < 0.0001). DLCO did not change significantly at peak (from 18.01 ± 4.72 to 18.22 ± 4.73 mL/min/mmHg), but was significantly reduced at 1 h (16.97 ± 4.26 mL/min/mmHg) compared to both baseline (p = 0.0211) and peak (p = 0.0174). DLNO showed a not significant trend toward lower values 1 h post-exercise.
Conclusions: Moderate/severe HF patients have a 2-step intra-thoracic fluid movement with exercise: the first during active exercise, from the vascular space toward the interstitial space, as confirmed by comets increase, without any effect on diffusion, and the second, during recovery, toward the alveolar-capillary membrane, clearing the interstitial space but worsening gas diffusion.

Vetsch T; Department of Anaesthesiology and Pain Medicine,  Bern University Hospital, University of Bern, Bern, Switzerland;
Jardot F; von Gernler M; Engel D; Beilstein CM; Wuethrich PY; Eser P; Wilhelm M;

British journal of anaesthesia [Br J Anaesth] 2024 Apr 20.
Date of Electronic Publication: 2024 Apr 20.

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/VCO ₂ ). The aim of this systematic review was to summarise evidence regarding VE/VCO ₂ 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/VCO ₂ was reported as a prognostic factor for short-term complications after thoracic and abdominal surgery. VE/VCO ₂ 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/VCO ₂ from the final multivariable regression owing to data-driven model-building approaches.
Conclusions: This systematic review identifies VE/VCO ₂ 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.

Hajibandeh S; Several departments, University Hospital of Wales, Cardiff, UK.
Gilham I; Tam W; Kirby E; Babs-Osibodu AO; Jones W; Rose GA; Bailey DM; .Morris C; Hargest R; Clayton A; Davies RG;

The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland [Surgeon] 2024 Apr 22.
Date of Electronic Publication: 2024 Apr 22.

Objectives: To evaluate whether computed tomography (CT)-derived psoas major muscle measurements could predict preoperative cardiopulmonary exercise testing (CPET) performance and long-term mortality in patients undergoing major colorectal surgery and to compare predictive performance of psoas muscle measurements using 2D approach and 3D approach.
Methods: A retrospective cohort study compliant with STROCSS standards was conducted. Consecutive patients undergoing major colorectal surgery between January 2011 and January 2017 following CPET as part of their preoperative assessment were included. Regression analyses were modelled to investigate association between the CT-derived psoas major muscle mass variables [total psoas muscle area (TPMA), total psoas muscle volume (TPMV) and psoas muscle index (PMI)] and CPET performance and mortality (1-year and 5-year). Discriminative performances of the variables were evaluated using Receiver Operating Characteristic (ROC) curve analysis.
Results: A total of 457 eligible patients were included. The median TPMA and TPMV were 21 ​cm ² (IQR: 15-27) and 274 ​cm ³ (IQR: 201-362), respectively. The median PMI measured via 2D and 3D approaches were 7 ​cm ² /m ² (IQR: 6-9) and 99 ​cm ³ /m ² (IQR: 76-120), respectively. The risks of 1-year and 5-year mortality were 7.4% and 27.1%, respectively. Regression analyses showed TPMA, TPMV, and PMI can predict preoperative CPET performance and long-term mortality. However, ROC curve analyses showed no significant difference in predictive performance amongst TPMA, TPMV, and PMI.
Conclusion: Radiologically-measured psoas muscle mass variables may predict preoperative CPET performance and may be helpful with informing more objective selection of patients for preoperative CPET and prehabilitation.
Competing Interests: Declaration of competing interest Damian M. Bailey is Editor-in-Chief of Experimental Physiology, Chair of the Life Sciences Working Group, a member of the Human Spaceflight and Exploration Science Advisory Committee to the European Space Agency, a member of the Space Exploration Advisory Committee to the UK Space Agency, and a member of the National Cardiovascular Network for Wales and South East Wales Vascular Network. Damian M. Bailey is also affiliated to the companies FloTBI Inc. and Bexorg Inc., focused on the technological development of novel biomarkers of brain injury in humans. All other authors declare no conflict of interest.

Martis WR; Department of Anaesthetics,  Peter MacCallum Cancer Centre, Melbourne, VIC, Australia;
Oughton C; Traer E; Ismail H; Riedel B;

British journal of anaesthesia [Br J Anaesth] 2024 Apr 25.
Date of Electronic Publication: 2024 Apr 25.

No abstract available

Leonardi B; Department of Pediatric Cardiology, Cardiac Surgery and Heart Lung Transplantation, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy.
Sollazzo F; Gentili F; Bianco M; Pomiato E; Kikina SS; Wald RM;Palmieri V; Secinaro A; Calcagni G; Butera G; Giordano U; Cafiero G; Drago F;

Journal of clinical medicine [J Clin Med] 2024 Feb 20; Vol. 13 (5). Date of Electronic Publication: 2024 Feb 20.

Background: Despite a successful repair of tetralogy of Fallot (rToF) in childhood, residual lesions are common and can contribute to impaired exercise capacity. Although both cycle ergometer and treadmill protocols are often used interchangeably these approaches have not been directly compared. In this study we examined cardiopulmonary exercise test (CPET) measurements in rToF.
Methods: Inclusion criteria were clinically stable rToF patients able to perform a cardiac magnetic resonance imaging (CMR) and two CPET studies, one on the treadmill (incremental Bruce protocol) and one on the cycle ergometer (ramped protocol), within 12 months. Demographic, surgical and clinical data; functional class; QRS duration; CMR measures; CPET data and international physical activity questionnaire (IPAQ) scores of patients were collected.
Results: Fifty-seven patients were enrolled (53% male, 20.5 ± 7.8 years at CPET). CMR measurements included a right ventricle (RV) end-diastolic volume index of 119 ± 22 mL/m ² , a RV ejection fraction (EF) of 55 ± 6% and a left ventricular (LV) EF of 56 ± 5%. Peak oxygen consumption (VO₂ )/Kg (25.5 ± 5.5 vs. 31.7 ± 6.9; p < 0.0001), VO ₂ at anaerobic threshold (AT) (15.3 ± 3.9 vs. 22.0 ± 4.5; p < 0.0001), peak O₂ pulse (10.6 ± 3.0 vs. 12.1± 3.4; p = 0.0061) and oxygen uptake efficiency slope (OUES) (1932.2 ± 623.6 vs. 2292.0 ± 639.4; p < 0.001) were significantly lower on the cycle ergometer compared with the treadmill, differently from ventilatory efficiency (VE/VCO₂ ) max which was significantly higher on the cycle ergometer (32.2 ± 4.5 vs. 30.4 ± 5.4; p < 0.001). Only the VE/VCO₂ slope at the respiratory compensation point (RCP) was similar between the two methodologies ( p = 0.150).
Conclusions: The majority of CPET measurements differed according to the modality of testing, with the exception being the VE/VCO₂ slope at RCP. Our data suggest that CPET parameters should be interpreted according to test type; however, these findings should be validated in larger populations and in a variety of institutions.

Hijleh AA;  Department of Medicine, Queen’s University, Kingston, Ontario, Canada.
Wang S; Berton DC; Neder-Serafini I;Vincent S; James M; Domnik N; Phillips D; Nery LE; O’Donnell DE; Neder JA

Scandinavian journal of medicine & science in sports [Scand J Med Sci Sports] 2024 Apr; Vol. 34 (4), pp. e14625.

Heightened sensation of leg effort contributes importantly to poor exercise tolerance in patient populations. We aim to provide a sex- and age-adjusted frame of reference to judge symptom’s normalcy across progressively higher exercise intensities during incremental exercise. Two-hundred and seventy-five non-trained subjects (130 men) aged 19-85 prospectively underwent incremental cycle ergometry. After establishing centiles-based norms for Borg leg effort scores (0-10 category-ratio scale) versus work rate, exponential loss function identified the centile that best quantified the symptom’s severity individually. Peak O ₂ uptake and work rate (% predicted) were used to threshold gradually higher symptom intensity categories. Leg effort-work rate increased as a function of age; women typically reported higher scores at a given age, particularly in the younger groups (p < 0.05). For instance, “heavy” (5) scores at the 95th centile were reported at ~200 W (<40 years) and ~90 W (≥70 years) in men versus ~130 W and ~70 W in women, respectively. The following categories of leg effort severity were associated with progressively lower exercise capacity: ≤50th (“mild”), >50th to <75th (“moderate”), ≥75th to <95th (“severe”), and ≥ 95th (“very severe”) (p < 0.05). Although most subjects reporting peak scores <5 were in “mild” range, higher scores were not predictive of the other categories (p > 0.05). This novel frame of reference for 0-10 Borg leg effort, which considers its cumulative burden across increasingly higher exercise intensities, might prove valuable to judging symptom’s normalcy, quantifying its severity, and assessing the effects of interventions in clinical populations.

Hamilton B; School of Sport and Health Sciences, University of Brighton, Brighton, UK.;
Brown A; Montagner-Moraes S; Comeras-Chueca C; Bush PG; Guppy FM; Pitsiladis YP;

British journal of sports medicine [Br J Sports Med] 2024 Apr 10.
Date of Electronic Publication: 2024 Apr 10.

Objective: The primary objective of this cross-sectional study was to compare standard laboratory performance metrics of transgender athletes to cisgender athletes.
Methods: 19 cisgender men (CM) (mean±SD, age: 37±9 years), 12 transgender men (TM) (age: 34±7 years), 23 transgender women (TW) (age: 34±10 years) and 21 cisgender women (CW) (age: 30±9 years) underwent a series of standard laboratory performance tests, including body composition, lung function, cardiopulmonary exercise testing, strength and lower body power. Haemoglobin concentration in capillary blood and testosterone and oestradiol in serum were also measured.
Results: In this cohort of athletes, TW had similar testosterone concentration (TW 0.7±0.5 nmol/L, CW 0.9±0.4 nmol/), higher oestrogen (TW 742.4±801.9 pmol/L, CW 336.0±266.3 pmol/L, p=0.045), higher absolute handgrip strength (TW 40.7±6.8 kg, CW 34.2±3.7 kg, p=0.01), lower forced expiratory volume in 1 s:forced vital capacity ratio (TW 0.83±0.07, CW 0.88±0.04, p=0.04), lower relative jump height (TW 0.7±0.2 cm/kg; CW 1.0±0.2 cm/kg, p<0.001) and lower relative V̇O ₂ max (TW 45.1±13.3 mL/kg/min/, CW 54.1±6.0 mL/kg/min, p<0.001) compared with CW athletes. TM had similar testosterone concentration (TM 20.5±5.8 nmol/L, CM 24.8±12.3 nmol/L), lower absolute hand grip strength (TM 38.8±7.5 kg, CM 45.7±6.9 kg, p = 0.03) and lower absolute V̇O ₂ max (TM 3635±644 mL/min, CM 4467±641 mL/min p = 0.002) than CM.
Conclusion: While longitudinal transitioning studies of transgender athletes are urgently needed, these results should caution against precautionary bans and sport eligibility exclusions that are not based on sport-specific (or sport-relevant) research.
Competing Interests: Competing interests: YPP is a member of the IOC Medical and Scientific Commission, which recently published articles and framework documents on the topic. BH and FMG have recently published articles on the topic on behalf of the International Federation of Sports Medicine (FIMS). All authors declare no further conflict of interest or competing interests.
(© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Wolf C;  University of Pittsburgh & other American Universities
Blackwell TL; Johnson E;Glynn NW; Nicklas B; Kritchevsky SB; Carnero EA; Cummings SR;Toledo FGS; Newman AB; Forman DE; Goodpaster BH;

Medicine and science in sports and exercise [Med Sci Sports Exerc] 2024 Apr 11.
Date of Electronic Publication: 2024 Apr 11.

Purpose: Cardiorespiratory fitness (CRF) measured by peak oxygen consumption (VO 2 peak) declines with aging and correlates with mortality and morbidity. Cardiopulmonary Exercise Testing (CPET) is the criterion method to assess CRF, but its feasibility, validity and reliability in older adults is unclear. Our objective was to design and implement a dependable, safe and reliable CPET protocol in older adults.
Methods: VO 2 peak was measured by CPET, performed using treadmill exercise in 875 adults ≥70 years in the Study of Muscle, Mobility and Aging (SOMMA). The protocol included a symptom-limited peak (maximal) exercise and two submaximal walking speeds. An adjudication process was in place to review tests for validity if they met any prespecified criteria [VO 2 peak < 12.0 ml/kg/min; maximum heart rate (HR) <100 bpm; respiratory exchange ratio (RER) <1.05 and a rating of perceived exertion <15]. A subset (N = 30) performed a repeat test to assess reproducibility.
Results: CPET was safe and well tolerated, with 95.8% of participants able to complete the VO 2 peak phase of the protocol. Only 56 (6.4%) participants had a risk alert and only two adverse events occurred: a fall and atrial fibrillation. Mean ± SD VO 2 peak was 20.2 ± 4.8 mL/kg/min, peak HR 142 ± 18 bpm, and peak RER 1.14 ± 0.09. Adjudication was indicated in 47 tests; 20 were evaluated as valid, 27 as invalid (18 data collection errors, 9 did not reach VO 2 peak). Reproducibility of VO 2 peak was high (intraclass correlation coefficient = 0.97).
Conclusions: CPET was feasible, effective and safe for older adults, including many with multimorbidity or frailty. These data support a broader implementation of CPET to provide insight into the role of CRF and its underlying determinants of aging and age-related conditions.
Competing Interests: Conflict of Interest and Funding Source: None of the authors have conflicts of interest to report. The Study of Muscle, Mobility and Aging is supported by funding from the National Institute on Aging, grant number AG059416. Study infrastructure support was funded in part by NIA Claude D. Pepper Older American Independence Centers at University of Pittsburgh (P30AG024827) and Wake Forest University (P30AG021332) and the Clinical and Translational Science Institutes, funded by the National Center for Advancing Translational Science, at Wake Forest University (UL1 0TR001420).

Carrick L; Centre of Metabolism, Ageing & Physiology (COMAP),  Department of Surgery and Anaesthetics Royal Derby Hospital UK.
Doleman B; Wall J; Gates A; Lund JN; Williams JP; Phillips BE;

Aging medicine (Milton (N.S.W)) [Aging Med (Milton)] 2023 Dec 26; Vol. 7 (1), pp. 60-66.
Date of Electronic Publication: 2023 Dec 26 (Print Publication: 2024).

Objectives: Cardiorespiratory fitness (CRF) declines with advancing and has also, independent of age, been shown to be predictive of all-cause mortality, morbidity, and poor clinical outcomes. In relation to the older patient, there is a particular wealth of evidence highlighting the relationship between low CRF and poor surgical outcomes. Cardiopulmonary exercise testing (CPET) is accepted as the gold-standard measure of CRF. However, this form of assessment has significant personnel and equipment demands and is not feasible for those with certain age-associated physical limitations, including joint and cardiovascular comorbidities. As such, alternative ways to assess the CRF of older patients are very much needed.
Methods: Sixty-four participants (45% female) with a median age of 74 (65-90) years were recruited to this study via community-based advertisements. All participants completed three tests of physical function: (1) a step-box test; (2) handgrip strength dynamometry; and (3) a CPET on a cycle ergometer; and also had their muscle architecture (vastus lateralis) assessed by B-mode ultrasonography to provide measures of muscle thickness, pennation angle, and fascicle length. Multivariate linear regression was then used to ascertain bedside predictors of CPET parameters from the alternative measures of physical function and demographic (age, gender, body mass index (BMI)) data.
Results: There was no significant association between ultrasound-assessed parameters of muscle architecture and measures of CRF. VO _2peak was predicted to some extent from fast step time during the step-box test, gender, and BMI, leading to a model that achieved an R ² of 0.40 ( p  < 0.001). Further, in aiming to develop a model with minimal assessment demands (i.e., using handgrip dynamometry rather than the step-box test), replacing fast step time with non-dominant HGS led to a model which achieved an R ² of 0.36 ( p  < 0.001). Non-dominant handgrip strength combined with the step-box test parameter of fast step time and BMI delivered the most predictive model for VO _2peak with an R ² of 0.45 ( p  < 0.001).
Conclusions: Our findings show that simple-to-ascertain patient characteristics and bedside assessments of physical function are able to predict CPET-derived CRF. Combined with gender and BMI, both handgrip strength and fast step time during a step-box test were predictive for VO _2peak . Future work should apply this model to a clinical population to determine its utility in this setting and to explore if simple bedside tests are predictive of important clinical outcomes in older adults (i.e., post-surgical complications).

Fleurent-Grégoire C;  Montreal, Canada & Melbourne, Australia & Manchester and Southampton UK
Burgess N; Denehy L; Edbrooke L; Engel D; Dario Testa G; Fiore JF Jr;McIsaac DI;Chevalier S; Moore J; Grocott MP;Copeland R;
Levett D; Scheede-Bergdahl C; Gillis C;

British journal of anaesthesia [Br J Anaesth] 2024 Apr 02.
Date of Electronic Publication: 2024 Apr 02.

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.