Francesco Carli, Guillaume Bousquet-Dion, Rashami Awasthi, Noha Elsherbini, Sender Liberman , Marylise Boutros, Barry Stein , Patrick Charlebois, Gabriela Ghitulescu, Nancy Morin, Thomas Jagoe , Celena Scheede-Bergdahl, Enrico Maria Minnella , Julio F Fiore Jr

JAMA Surg 2020 Jan 22  [On line ahead of print]

Importance: Research supports use of prehabilitation to optimize physical status before and after colorectal cancer resection, but its effect on postoperative complications remains unclear. Frail patients are a target for prehabilitation interventions owing to increased risk for poor postoperative outcomes.
Objective: To assess the extent to which a prehabilitation program affects 30-day postoperative complications in frail patients undergoing colorectal cancer resection compared with postoperative rehabilitation.
Design, setting, and participants: This single-blind, parallel-arm, superiority randomized clinical trial recruited patients undergoing colorectal cancer resection from September 7, 2015, through June 19, 2019. Patients were followed up for 4 weeks before surgery and 4 weeks after surgery at 2 university-affiliated tertiary hospitals. A total of 418 patients 65 years or older were assessed for eligibility. Of these, 298 patients were excluded (not frail [n = 290], unable to exercise [n = 3], and planned neoadjuvant treatment [n = 5]), and 120 frail patients (Fried Frailty Index,≥2) were randomized. Ten patients were excluded after randomization because they refused surgery (n = 3), died before surgery (n = 3), had no cancer (n = 1), had surgery without bowel resection (n = 1), or were switched to palliative care (n = 2). Hence, 110 patients were included in the intention-to-treat analysis (55 in the prehabilitation [Prehab] and 55 in the rehabilitation [Rehab] groups). Data were analyzed from July 25 through August 21, 2019.
Interventions: Multimodal program involving exercise, nutritional, and psychological interventions initiated before (Prehab group) or after (Rehab group) surgery. All patients were treated within a standardized enhanced recovery pathway.
Main outcomes and measures: The primary outcome included the Comprehensive Complications Index measured at 30 days after surgery. Secondary outcomes were 30-day overall and severe complications, primary and total length of hospital stay, 30-day emergency department visits and hospital readmissions, recovery of walking capacity, and patient-reported outcome measures.
Results: Of 110 patients randomized, mean (SD) age was 78 (7) years; 52 (47.3%) were men and 58 (52.7%) were women; 31 (28.2%) had rectal cancer; and 87 (79.1%) underwent minimally invasive surgery. There was no between-group difference in the primary outcome measure, 30-day Comprehensive Complications Index (adjusted mean difference, -3.2; 95% CI, -11.8 to 5.3; P = .45). Secondary outcome measures were also not different between groups.
Conclusions and relevance: In frail patients undergoing colorectal cancer resection (predominantly minimally invasive) within an enhanced recovery pathway, a multimodal prehabilitation program did not affect postoperative outcomes. Alternative strategies should be considered to optimize treatment of frail patients preoperatively.

Balmain BN; Weinstein K; Bernhardt V; Marines-Price R; Tomlinson AR; Babb TG;

Respiratory Physiology & Neurobiology [Respir Physiol Neurobiol] 2019 Dec 30; Vol. 274, pp. 103365. Date of Electronic Publication: 2019 Dec 30.

We investigated the contributions of obesity on multidimensional aspects of dyspnea on exertion (DOE) in patients referred for clinical cardiopulmonary exercise testing (CPET). Ratings of perceived breathlessness (RPB, Borg scale 0-10) were collected in obese (BMI ≥ 30; n = 47) and nonobese (BMI ≤ 25; n = 27) patients during two (one lower: ∼30 W; and one higher: ∼50 W) 4-6 min constant load cycling bouts. Multidimensional dyspnea profiles (MDP) were collected in the final 26 obese and 14 nonobese patients of the sample. RPB was greater (p = 0.05) in obese (3.3 ± 2.2 vs 2.4 ± 1.4) at lower work rates, but similar at higher work rates (4.9 ± 2.2 vs 4.4 ± 1.8). MDP sensory score including unpleasantness was 4.3 ± 2.2 in obese vs 2.5 ± 1.9 in nonobese (p < 0.001). The affective score was 1.9 ± 2.2 vs 0.7 ± 0.7, respectively (p < 0.01). Breathing sensations including ‘air hunger’, ‘effort’, and ‘breathing at lot’ were greater (p < 0.05) in obese, making these patients more frustrated/angry (p < 0.05). Obesity should be considered as a potential independent influencing factor that provokes DOE and unpleasantness when assessing breathlessness during CPET.

Ozemek C; Arena R; Fernhall B

Exercise And Sport Sciences Reviews [Exerc Sport Sci Rev] 2020 Jan; Vol. 48 (1), pp. 2-3.

NO abstract available

Sabbahi A; Severin R; Ozemek C; Phillips SA; Arena R;

Expert Review Of Respiratory Medicine [Expert Rev Respir Med] 2020 Jan 03, pp. 1-11. Date of Electronic Publication: 2020 Jan 03.

Introduction: Pulmonary hypertension (PH) is a broad pathophysiological disorder primarily characterized by increased pulmonary vascular resistance due to multiple possible etiologies. Patients typically present with multiple complaints that worsen as disease severity increases. Although initially discouraged due to safety concerns, exercise interventions for patients with PH have gained wide interest and multiple investigations have established the effective role of exercise training in improving the clinical profile, exercise tolerance, and overall quality of life.Areas covered: In this review, we discuss the pathophysiology of PH during rest and exercise, the role of cardiopulmonary exercise testing (CPX) in the diagnosis and prognosis of PAH, the role of exercise interventions in this patient population, and the expected physiological adaptations to exercise training.Expert opinion: Exercise testing, in particular CPX, provides a wealth of clinically valuable information in the PH population. Moreover, the available evidence strongly supports the safety and efficacy of exercise training as a clinical tool in improving exercise tolerance and quality of life. Although clinical trials investigating the role of exercise in this PH population are relatively few compared to other chronic conditions, current available evidence supports the clinical implementation of exercise training as a safe and effective treatment modality.

Hebestreit H; Hulzebos EHJ; Schneiderman JE; Karila C; Boas SR; Kriemler
S; Dwyer T; Sahlberg M; Urquhart DS; Lands LC; Ratjen F; Takken T;Varanistkaya L; Rucker V; Hebestreit A;
Usemann J; Radtke T; PrognosticValue of CPET in CF Study Group.

American Journal of Respiratory & Critical Care Medicine. 199(8):987-995,
2019 04 15.

RATIONALE: The prognostic value of cardiopulmonary exercise testing (CPET)
for survival in cystic fibrosis (CF) in the context of current clinical
management, when controlling for other known prognostic factors, is
unclear.

OBJECTIVES: To determine the prognostic value of CPET-derived measures
beyond peak oxygen uptake ( V. o2peak) following rigorous adjustment for
other predictors.

METHODS: Data from 10 CF centers in Australia, Europe, and North America
were collected retrospectively. A total of 510 patients completed a cycle
CPET between January 2000 and December 2007, of which 433 fulfilled the
criteria for a maximal effort. Time to death/lung transplantation was
analyzed using Cox proportional hazards regression. In addition,
phenotyping using hierarchical Ward clustering was performed to
characterize high-risk subgroups.

MEASUREMENTS AND MAIN RESULTS: Cox regression showed, even after
adjustment for sex, FEV1% predicted, body mass index (z-score), age at
CPET, Pseudomonas aeruginosa status, and CF-related diabetes as covariates
in the model, that V. o2peak in % predicted (hazard ratio [HR], 0.964; 95%
confidence interval [CI], 0.944-0.986), peak work rate (% predicted; HR,
0.969; 95% CI, 0.951-0.988), ventilatory equivalent for oxygen (HR, 1.085;
95% CI, 1.041-1.132), and carbon dioxide (HR, 1.060; 95% CI, 1.007-1.115)
(all P < 0.05) were significant predictors of death or lung
transplantation at 10-year follow-up. Phenotyping revealed that
CPET-derived measures were important for clustering. We identified a
high-risk cluster characterized by poor lung function, nutritional status,
and exercise capacity.

CONCLUSIONS: CPET provides additional prognostic information to
established predictors of death/lung transplantation in CF. High-risk
patients may especially benefit from regular monitoring of exercise
capacity and exercise counseling.

Trachsel LD; Nigam A; Fortier A; Lalongé J; Juneau M; Gayda M;

Revista Espanola De Cardiologia (English Ed.) [Rev Esp Cardiol (Engl Ed)] 2019 Dec 11. Date of Electronic Publication: 2019 Dec 11.

Introduction and Objectives: We compared the effects of 12 weeks of low-volume high-intensity interval training (LV-HIIT) vs moderate-intensity continuous exercise training (MICET) on cardiopulmonary exercise test parameters and the proportion of non/low responders (NLR) to exercise training in post-acute coronary syndrome (ACS) patients.
Methods: Patients with a recent ACS were randomized to LV-HIIT, MICET, or a usual care group. LV-HIIT consisted of 2 to 3 sets of 6 to 10minutes with repeated bouts of 15 to 30seconds at 100% of peak workload alternating with 15 to 30seconds of passive recovery. Cardiopulmonary exercise test parameters were assessed, and key exercise variables were calculated. Training response was assessed according to the median VO2peak change post vs pretraining in the whole cohort (stratification NLR vs high response).
Results: Fifty patients were included in the analysis (LV-HIIT, n=23; MICET, n=18; usual care, n=9) and 74% were male. The proportion of NLR was higher in the LV-HIIT group than in the MICET group (LV-HIIT 61%, MICET 21%, and usual care 80%; P=.0040). VO2peak-dependent variables (VO2peak, percent-predicted VO2peak) improved in both training groups (P=.002 and P <.0001 for time with LV-HIIT and MICET, respectively), but the improvement was more pronounced with MICET (P=.004 and P=.001 for interaction, respectively). The ΔVO2/Δworkload slope improved only with MICET (P=.021).
Conclusions: In patients with a recent ACS, several prognostic VO2peak-dependent variables were improved after LV-HIIT, but the improvement was more pronounced or only found after MICET. Low-volume HIIT resulted in a higher proportion of NLR than isocaloric MICET. Clinical trialsregistered at ClinicalTrials.gov (Identifiers: NCT03414996 and NCT02048696).

Redón P; Grassi G; Redon J; Álvarez-Pitti J; Lurbe E;

Blood Pressure [Blood Press] 2019 Dec 12, pp. 1-8. Date of Electronic Publication: 2019 Dec 12.

Background: Childhood obesity, including overweight, continues increasing worldwide affecting health expectancy, quality of life and healthcare expenditure. These subjects have higher probability of suffering or developing cardio metabolic risk factors. Recent studies have revealed cardiorespiratory fitness (CRF) as a valuable clinical parameter to identify these subjects and have even suggested cut-off values. However, evaluating CRF in overweight and obese youth can be difficult to implement, unfriendly and expensive.
Objective: Develop a screening tool to identify high-risk subjects in a representative population of those attending overweight/obesity assessment programmes without prior intervention. It will be based on heart rate variability parameters, which has strong association with CRF and cardio metabolic risk factors.
Methods: Sixty-three subjects, overweight and obese, between 9 and 17 years of age, and of both sexes were enrolled. None of them had secondary obesity syndromes and/or suffered from acute or chronic disease. Anthropometric parameters, electrocardiogram signal recording under resting conditions and cardiorespiratory fitness – evaluated by oxygen consumption and time elapsed of cardiopulmonary exercise test – were measured.
Results: Significant differences in the sympathetic nervous system activity – assessed by heart rate variability analysis – are observed when grouping by overweight and obesity degree as well as by CRF (poor/normal). Body mass index, puberty and sympathetic nervous system activity are the significant variables of a logistic regression model develop to identify poor CRF individuals. Its accuracy reaches 92%.
Conclusions: A screening tool based on heart rate variability and anthropometric parameters was developed to identify subjects with higher probability of suffering or developing cardio metabolic risk factors.

DeCato TW; Haverkamp H; Hegewald MJ

American Journal Of Respiratory And Critical Care Medicine [Am J Respir Crit Care Med] 2020 Jan 01; Vol. 201 (1), pp. P1-P2.

No abstract available

Sabbahi A; Severin R; Ozemek C; Phillips SA; Arena R;

Expert Review Of Respiratory Medicine [Expert Rev Respir Med] 2020 Jan 03, pp. 1-11. Date of Electronic Publication: 2020 Jan 03.

Introduction: Pulmonary hypertension (PH) is a broad pathophysiological disorder primarily characterized by increased pulmonary vascular resistance due to multiple possible etiologies. Patients typically present with multiple complaints that worsen as disease severity increases. Although initially discouraged due to safety concerns, exercise interventions for patients with PH have gained wide interest and multiple investigations have established the effective role of exercise training in improving the clinical profile, exercise tolerance, and overall quality of life.Areas covered: In this review, we discuss the pathophysiology of PH during rest and exercise, the role of cardiopulmonary exercise testing (CPX) in the diagnosis and prognosis of PAH, the role of exercise interventions in this patient population, and the expected physiological adaptations to exercise training.Expert opinion: Exercise testing, in particular CPX, provides a wealth of clinically valuable information in the PH population. Moreover, the available evidence strongly supports the safety and efficacy of exercise training as a clinical tool in improving exercise tolerance and quality of life. Although clinical trials investigating the role of exercise in this PH population are relatively few compared to other chronic conditions, current available evidence supports the clinical implementation of exercise training as a safe and effective treatment modality.

Wouters EF; Posthuma R; Koopman M; Liu WY; Sillen MJ; Hajian B; Sastry M; Spruit M;Franssen FM;

Expert Review Of Respiratory Medicine [Expert Rev Respir Med] 2020 Jan 14, pp. 1-13. Date of Electronic Publication: 2020 Jan 14.

Introduction: Pulmonary rehabilitation (PR) is one of the core components in the management of patients with chronic obstructive pulmonary disease (COPD). In order to achieve the maximal level of independence, autonomy, and functioning of the patient, targeted therapies and interventions based on the identification of physical, emotional and social traits need to be provided by a dedicated, interdisciplinary PR team.Areas covered: The review discusses cardiopulmonary exercise testing in the selection of different modes of training modalities. Neuromuscular electrical stimulation as well as gait assessment and training are discussed as well as add-on therapies as oxygen, noninvasive ventilator support or endoscopic lung volume reduction in selected patients. The potentials of pulsed inhaled nitric oxide in patients with underlying pulmonary hypertension is explored as well as nutritional support. The impact of sleep quality on outcomes of PR is reviewed.Expert opinion: Individualized, comprehensive intervention based on thorough assessment of physical, emotional, and social traits in COPD patients forms a continuous challenge for health-care professionals and PR organizations in order to dynamically implement and adapt these strategies based on dynamic, more optimal understanding of underlying pathophysiological mechanisms.