Assessment of functional capacity in clinical and research applications: An advisory from the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association

Medium-Term Disability and Long-Term Functional Impairment Persistence in Survivors of Severe COVID-19 ARDS: Clinical and Physiological Insights

BACKGROUND

Although the medium- and long-term sequelae of survivor of acute respiratory distress syndrome (ARDS) of any cause have been documented, little is known about the way in which COVID-19-induced ARDS affects functional disability and exercise components. Our aims were to examine the medium-term disability in severe COVID-19-associated ARDS survivors, delineate pathophysiological changes contributing to their exercise intolerance, and explore its utility in predicting long-term functional impairment persistence.

METHODS

We studied 108 consecutive subjects with severe COVID-19 ARDS who remained alive 6 months after intensive care unit (ICU) discharge. Lung morphology was assessed with chest non-contrast CT scans and CT angiography. Functional evaluation included spirometry, plethysmography, muscle strength, and diffusion capacity, with assessment of gas exchange components through diffusing capacity of nitric oxide. Disability was assessed through an incremental exercise test, and measurements were repeated 12 and 24 months later in patients with functional impairments.

RESULTS

At 6 months after ICU discharge, a notable dissociation between morphological and clinical-functional sequelae was identified. Moderate-severe disability was present in 47% of patients and these subjects had greater limitation of ventilatory mechanics and gas exchange, as well as greater symptomatic perception during exercise and a probable associated cardiac limitation. Female sex, hypothyroidism, reduced membrane diffusion component, lower functional residual capacity, and high-attenuation lung volume were independently associated with the presence of moderate-severe functional disability, which in turn was related to higher frequency and greater intensity of dyspnea and worse quality of life. Out of the 71 patients with reduced lung volumes or diffusion capacity at 6 months post-ICU discharge, only 19 maintained a restrictive disorder associated with gas exchange impairment at 24 months post-discharge. In these patients, 6-month values for diffusion membrane component, maximal oxygen uptake, ventilatory equivalent for CO2, and dead space to tidal volume ratio were identified as independent risk factors for persistence of long-term functional sequelae.

CONCLUSIONS

Less than half of survivors of COVID-19 ARDS have moderate-severe disability in the medium term, identifying several risk factors. In turn, diffusion membrane component and exercise tolerance at 6-month ICU discharge are independently associated with the persistence of long-term functional sequelae.

Validation of the Duke Activity Status Index questionnaire by telephone In individuals after stroke

Background

Due to social restrictions caused by the pandemic, there was a need to validate outcome measures that could be administered by telephone call. Administration by telephone allows to remotely follow up stroke survivors since most of them have mobility restrictions. This study aims to investigate the validity of the Duke Activity Status Index (DASI) questionnaire administration to chronic stroke survivors through telephone call.

Methods

This is a cross-sectional study, developed according to COSMIN and GRRAS recommendations. It was recruited chronic stroke survivors, who answered the DASI questionnaire in two different time-points, in person and after a period of 5-7 days through a telephone call.

Results

Out of 260 subjects, 50 individuals (52% women) with a mean age of 56 ± 17 years were included. No statistically significant differences were observed (MD = -0.88; SD:4.14; 95% CI, -2.06 to 0.28; p = 0.13) on the total score of DASI administered in person and by telephone call. There was a very high agreement between the administration modes (ICC - 0.99; 95% CI, 0.94-0.98; p < 0.05). The Kappa coefficient ranged from 0.390 to 1.000, with the first item showing the best agreement (k = 1.000) and the fourth showing the worst agreement (k = 0.390).

Conclusions

The DASI questionnaire is valid to assess functional capacity and can be administered through telephone in chronic stroke survivors. Thus, clinicians and researchers may decide to avoid patient transportations administering DASI through telephone call, as a reliable measure for stroke survivors.

Translation, cross-cultural adaptation, reliability, and validity of the Turkish version of the Duke Activity Status Index in patients with pulmonary hypertension

BACKGROUND AND OBJECTIVES

In patients with pulmonary hypertension (PH), shortness of breath, fatigue, chest pain, and syncope limit exercise capacity. Exercise tests are often time-consuming, expensive, and some patients may not be able to perform such procedures and they are also difficult to apply in the studies including large samples. The aim of this study was to translate and culturally adapt the DASI into Turkish and to investigate its reliability and validity in patients with PH.

METHODS

The final Turkish version of the DASI questionnaire was applied to 109 clinically stable patients with a diagnosis of PH. Exercise capacity of the patients was determined by maximal VO 2 achieved in the 6-minute walk test (6MWT) and quality of life by the EmPHasis-10 questionnaire. Cronbach alpha (internal consistency) was used to assess the questionnaire's reliability. The validity assessment was performed by using Spearman correlation.

RESULTS

Internal consistency of the DASI was high (Cronbach's alpha = 0.99) and the test-retest reliability was excellent (ICC = 0.98). Validity was supported by significant correlations of DASI-VO 2 scores with estimated VO 2 (6MWT) scores (r = 0.58, p < 0.0001) and EmPHasis-10 (= -0.62, p < 0.0001). No floor or ceiling effect was present for the questionnaire.

CONCLUSIONS

The Turkish version of the culturally adapted DASI questionnaire was found to be a valid and reliable assessment tool. It is a rapidly administered, simple-toscore questionnaire for assessing the functional ability of individuals with PH. The use of the DASI to assess exercise capacity in patients with PH may assist researchers and clinicians detecting functional impairment in these patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical Indicators of Effects of Yoga Breathing Exercises on Patients With Lung Cancer After Surgical Resection: A Randomized Controlled Trial

BACKGROUND

Cancer itself and surgery pose a heavy burden on adults with lung cancer. Yoga breathing exercises have been proposed as a form of pulmonary rehabilitation exercises to improve these patients' perioperative outcomes.

OBJECTIVE

To investigate the impact of yoga breathing exercises based on a problem-solving model on dyspnea, exercise capacity, anxiety, depression, and postoperative indwelling time of thoracic drainage tube and compliance in adults with lung cancer undergoing surgery.

METHODS

One hundred eight lung cancer patients were randomly assigned to receive problem-solving model-based yoga breathing exercises, yoga breathing exercises, or usual care. Outcomes were collected at admission, the day before surgery, and at discharge.

RESULTS

Patients in the combined intervention group showed a significantly greater improvement in dyspnea, exercise capacity, and anxiety compared with the control group. Yoga breathing training can significantly improve patients' dyspnea and anxiety. Significant difference favoring the combined group was observed in exercise capability and compliance between the 2 intervention groups. However, there was no significant difference in depression or indwelling time of thoracic drainage tube among the 3 groups at any time point.

CONCLUSION

Findings indicate that yoga breathing exercises are effective in alleviating perioperative symptoms of lung resection patients. Compared with yoga breathing exercises, applying additional problem-solving model may achieve a better effect.

IMPLICATIONS FOR PRACTICE

Yoga breathing exercises can be considered as a promising pulmonary rehabilitation strategy for lung cancer patients with surgery. The problem-solving model could be integrated into yoga breathing exercises in clinical practice to enhance the rehabilitation effect.

Effects of Concurrent, Within-Session, Aerobic and Resistance Exercise Training on Functional Capacity and Muscle Performance in Elderly Male Patients with Chronic Heart Failure

BACKGROUND

The best format of exercise training (ET) in the setting of cardiac rehabilitation in patients with chronic heart failure (CHF) is still to be defined. Current guidelines recommend aerobic exercises, such as running and cycling, including some sessions per week of resistance exercise.

AIM

The aim of this study was to address the effectiveness of a concurrent exercise training program utilizing a circuit of sequential endurance and resistance exercises on functional capacity and muscular strength in patients with CHF.

METHODS

Ninety-five consecutive male patients (age 63.1 ± 6 years) with CHF (EF < 40%) in NYHA functional class II/III, were randomly assigned on 1:1 basis to a 12-week aerobic continuous training (AT) or concurrent CT), aerobic + resistance, training (CT), three times a week, with each session lasting 80 min. We used high quality, specifically designed ergometers, connected with each other and governed by a central console, and managed by a single physiotherapist. Before and after training all patients performed a symptoms-limited exercise test on a treadmill and a 6-min walking test (6MWT). Patients in the CT group also performed resistance exercises of upper and lower body.

RESULTS

The 6MWT and exercise duration at ergometric test increased significantly in both AT and CT groups, with the increase being greater in CT group (p < 0.001; ES = 0.13; p < 0.01; ES = 0.07). Muscular strength increased significantly in the CT group, particularly in the lower body muscular districts (p < 0.001). Quality of life improved in both groups, with a significantly greater improvement in the CT group (p < 0.05). No side effects leading to discontinuation of training were observed.

CONCLUSIONS

These findings indicate that concurrent, within-session training results in larger improvements in functional capacity, in addition to muscle performance, in patients with CHF, in comparison to single-mode aerobic training.

Delphi Consensus on American Society of Anesthesiologists' Physical Status Classification in an Asian Tertiary Women's Hospital

Background

The American Society of Anesthesiologists (ASA) score is generated based on patients’ clinical status. Accurate ASA classification is essential for the communication of perioperative risks and resource planning. Literature suggests that ASA classification can be automated for consistency and time-efficiency. To develop a rule-based algorithm for automated ASA classification, this study seeks to establish consensus in ASA classification for clinical conditions encountered at a tertiary women’s hospital.

Methods

Thirty-seven anesthesia providers rated their agreement on a 4-point Likert scale to ASA scores assigned to items via the Delphi technique. After Round 1, the group’s collective responses and individual item scores were shared with participants to improve their responses for Round 2. For each item, the percentage agreement (‘agree’ and ‘strongly agree’ responses combined), median (interquartile range/IQR), and SD were calculated. Consensus for each item was defined as a percentage agreement ≥ 70%, IQR ≤ 1.0, and SD < 1.0.

Results

All participants completed the study and none had missing data. The number of items that reached consensus increased from 25 (51.0%) to 37 (75.5%) in the second Delphi round, particularly for items assigned ASA scores of III and IV. Nine items, which pertained to alcohol intake, asthma, thyroid disease, limited exercise tolerance, and stable angina, did not reach consensus even after two Delphi rounds.

Conclusions

Delphi consensus was attained for 37 of the 49 study items (75.5%), facilitating their incorporation into a rule-based clinical support system designed to automate the prediction of ASA classification.

Influence of Intrinsic Aerobic Exercise Capacity and Sex on Cardiac Injury Following Acute Myocardial Ischemia and Reperfusion

Purpose: Previous reports have suggested that active exercise aside, intrinsic aerobic running capacity (Low = LCR, high = HCR) in otherwise sedentary animals may influence several cardiovascular health-related indicators. Relative to the HCR phenotype, the LCR phenotype is characterized by decreased endothelial reactivity, increased susceptibility to reperfusion-induced arrhythmias following short, non-infarction ischemia, and increased diet-induced insulin resistance. More broadly, the LCR phenotype has come to be characterized as a "disease prone" model, with the HCRs as "disease resistant." Whether these effects extend to injury outcomes in an overt infarction or whether the effects are gender specific is not known. This study was designed to determine whether HCR/LCR phenotypic differences would be evident in injury responses to acute myocardial ischemia-reperfusion injury (AIR), measured as infarct size and to determine whether sex differences in infarction size were preserved with phenotypic selection. Methods: Regional myocardial AIR was induced in vivo by either 15 or 30 min ligation of the left anterior descending coronary artery, followed by 2 h of reperfusion. Global ischemia was induced in isolated hearts ex vivo using a Langendorff perfusion system and cessation of perfusion for either 15 or 30 min followed by 2 h of reperfusion. Infarct size was determined using 2, 3, 5-triphenyltetrazolium chloride (TTC) staining, and normalized to area at risk in the regional model, or whole heart in the global model. Portions of the tissue were paraffin embedded for H&E staining and histology analysis. Results: Phenotype dependent differences in infarct size were seen with 15 min occlusion/2 h reperfusion (LCR > HCR, p < 0.05) in both regional and global models. In both models, longer occlusion times (30 min/2 h) produced significantly larger infarctions in both phenotypes, but phenotypic differences were no longer present (LCR vs. HCR, p = n.s.). Sex differences in infarct size were present in each phenotype (LCR male > LCR female, p < 0.05; HCR male > HCR female, p < 0.05 regardless of length of occlusion, or ischemia model. Conclusions: There is cardioprotection afforded by high intrinsic aerobic capacity, but it is not infinite/continuous, and may be overcome with sufficient injury burden. Phenotypic selection based on endurance running capacity preserved sex differences in response to both short and longer term coronary occlusive challenges. Outcomes could not be associated with differences in system characteristics such as circulating inflammatory mediators or autonomic nervous system influences, as similar phenotypic injury patterns were seen in vivo, and in isolated crystalloid perfused heart ex vivo.

Congenital heart disease: Saving lives and securing liveliness with early primary care and expert family care

Pertinent perspectives for practical applications is advantageous professionalism. Congenital heart diseases (CHDs) are of varied types, severity, and complexity. Simple scientific approach along with sophistication is required for successful management at all levels. We gleaned important information from published evidence and authoritative resources and have put things in practical perspective. These include current prevention, care, correction, cure, and rehabilitation strategies for robust practices. Prospective prevention is with preconception counseling and addressing environmental factors. Fetal echocardiography and nondirective genetic counseling are important. Early detection and expert diligence is desirable. The suspicion is clinical. A number of clinical and investigative diagnostic modalities are available and should be utilized as guided by the clinical cues. Medical management includes general health maintenance, immunizations, monitoring, and complications treatment. Pediatric interventional cardiology is making rapid strides and treating many types of lesions. Understanding of procedure done is a prerequisite of follow-up care. Surgery is of curative, reparative, or palliative types. After surgical correction in early childhood long-term sequelae are rare. After reparative surgery some have life-long sequelae and some have significant late impairment. The number of postintervention/surgery survivors into adulthood is increasing. Microsurgical techniques are leading the way for precision and fewer complications. Follow-up care with "Ten Points Information and Action Plan (TP-IAP)" is suggested. The Armed Forces scenario involves frequent movements to difficult and harsh conditions. Special precautions for affected children needed. Cardiovascular health is enhanced by avoiding a sedentary lifestyle and obesity. Various intrinsic and extrinsic factors limiting functioning need to be suitably addressed.

Protocol for the WARM Hearts study: examining cardiovascular disease risk in middle-aged and older women - a prospective, observational cohort study

INTRODUCTION

Cardiovascular disease (CVD) is a leading cause of death in women. Novel approaches to detect early signs of elevated CVD risk in women are needed. Enhancement of traditional CVD risk assessment approaches through the addition of procedures to assess physical function or frailty as well as novel biomarkers of cardiovascular, gut and muscle health could improve early identification. The Women's Advanced Risk-assessment in Manitoba (WARM) Hearts study will examine the use of novel non-invasive assessments and biomarkers to identify women who are at elevated risk for adverse cardiovascular events.

METHODS AND ANALYSIS

One thousand women 55 years of age or older will be recruited and screened by the WARM Hearts observational, cohort study. The two screening appointments will include assessments of medical history, gender variables, body composition, cognition, frailty status, functional fitness, physical activity levels, nutritional status, quality of life questionnaires, sleep behaviour, resting blood pressure (BP), BP response to moderate-intensity exercise, a non-invasive measure of arterial stiffness and heart rate variability. Blood sample analysis will be used to assess lipid and novel biomarker profiles and stool samples will support the characterisation of gut microbiota. The incidence of the adverse cardiovascular outcomes will be assessed 5 years after screening to compare WARM Hearts approaches to the Framingham Risk Score, the current clinical standard of assessing CVD risk in Canada.

ETHICS AND DISSEMINATION

The University of Manitoba Health Research Ethics Board (7 October 2019) and the St Boniface Hospital Research Review Committee (7 October 2019) approved the trial (Ethics Number HS22576 (H2019:063)). Recruitment started 10 October 2020. Data gathered from the WARM Hearts study will be published in peer-reviewed journals and presented at national and international conferences. Knowledge translation strategies will be created to share our findings with stakeholders who are positioned to implement evidence-informed CVD risk assessment programming.

TRIAL REGISTRATION NUMBER

NCT03938155.

Health State Utilities of Patients with Heart Failure: A Systematic Literature Review

BACKGROUND AND OBJECTIVES

New treatments and interventions are in development to address clinical needs in heart failure. To support decision making on reimbursement, cost-effectiveness analyses are frequently required. A systematic literature review was conducted to identify and summarize heart failure utility values for use in economic evaluations.

METHODS

Databases were searched for articles published until June 2019 that reported health utility values for patients with heart failure. Publications were reviewed with specific attention to study design; reported values were categorized according to the health states, 'chronic heart failure', 'hospitalized', and 'other acute heart failure'. Interquartile limits (25th percentile 'Q1', 75th percentile 'Q3') were calculated for health states and heart failure subgroups where there were sufficient data.

RESULTS

The systematic literature review identified 161 publications based on data from 142 studies. Utility values for chronic heart failure were reported by 128 publications; 39 publications published values for hospitalized and three for other acute heart failure. There was substantial heterogeneity in the specifics of the study populations, methods of elicitation, and summary statistics, which is reflected in the wide range of utility values reported. EQ-5D was the most used instrument; the interquartile limit for mean EQ-5D values for chronic heart failure was 0.64-0.72.

CONCLUSIONS

There is a wealth of published utility values for heart failure to support economic evaluations. Data are heterogenous owing to specificities of the study population and methodology of utility value elicitation and analysis. Choice of value(s) to support economic models must be carefully justified to ensure a robust economic analysis.

Prognostic value of 6-minute walk test and cardiopulmonary exercise test in acute heart failure (from the ESCAPE trial)

Introduction

We aim to study the utility of 6-minute walk distance (6MWD) and cardiopulmonary exercise testing (CPET) in patients with acute systolic heart failure (HF) in predicting post-discharge outcomes.

Methods

The ESCAPE trial data was utilized to examine the prognostic role of 6MWD and CPET in predicting 6-month all-cause mortality and rehospitalization in acute HF.

Results

The average 6MWD recorded in 271 and 292 patients on admission and discharge was 597 and 765 ft., respectively. Compared with non-survivors, survivors had significantly higher 6MWD on admission (624 vs. 463 ft., P = 0.006) and discharge (789 vs. 636 ft., P = 0.006). Admission and discharge 6MWD had an AUC of 0.629 (P = 0.0047) and 0.628 (P = 0.0093) in predicting mortality. The combination of optimal 6MWD cutoff values of >288 ft. on admission and > 320 ft. on discharge was associated with significantly lower mortality (11.1% vs. 28.3%, OR 0.316, P = 0.002). When dividing the sample into quartiles of increasing walking distance, patients in the 1st quartile had significantly higher mortality on admission (OR 3.59, 95% CI 1.396-9.282, P = 0.008) and discharge (OR 3.66, 95% CI 1.357-9.839, P = 0.01) compared with 4th quartile. P-value for the trend in mortality across quartiles of 6MWD on admission and discharge was 0.016 and 0.047, respectively. Cox proportional hazard analysis revealed that admission (HR 0.632, 95% CI 0.449-0.890, P = 0.009) and discharge 6MWD (HR 0.657, 95% CI 0.467-0.926, P = 0.016) were independent mortality determinants after adjustment for age, creatinine, sodium, systolic blood pressure and NYHA class, all on admission. CPET-derived variables did not predict either outcomes.

Conclusion

6MWD is an independent mortality determinant in advanced systolic HF.

Quality of patient-reported outcomes used for quality of life, physical function, and functional capacity in trials of childhood fractures

AIMS

This study evaluates the quality of patient-reported outcome measures (PROMs) reported in childhood fracture trials and recommends outcome measures to assess and report physical function, functional capacity, and quality of life using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) standards.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic review of OVID Medline, Embase, and Cochrane CENTRAL was performed to identify all PROMs reported in trials. A search of OVID Medline, Embase, and PsycINFO was performed to identify all PROMs with validation studies in childhood fractures. Development studies were identified through hand-searching. Data extraction was undertaken by two reviewers. Study quality and risk of bias was evaluated by COSMIN guidelines and recorded on standardized checklists.

RESULTS

Searches yielded 13,672 studies, which were screened to identify 124 trials and two validation studies. Review of the 124 trials identified 16 reported PROMs, of which two had validation studies. The development papers were retrieved for all PROMs. The quality of the original development studies was adequate for Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility and Upper Extremity and doubtful for the EuroQol Five Dimension Youth questionnaire (EQ-5D-Y). All other PROMs were found to have inadequate development studies. No content validity studies were identified. Reviewer-rated content validity was acceptable for six PROMs: Activity Scale for Kids (ASK), Childhood Health Assessment Questionnaire, PROMIS Upper Extremity, PROMIS Mobility, EQ-5D-Y, and Pediatric Quality of Life Inventory (PedsQL4.0). The Modified Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was shown to have indeterminate reliability and convergence validity in one study and PROMIS Upper Extremity had insufficient convergence validity in one study.

CONCLUSION

There is insufficient evidence to recommend strongly the use of any single PROM to assess and report physical function or quality of life following childhood fractures. There is a need to conduct validation studies for PROMs. In the absence of these studies, we cautiously recommend the use of the PROMIS or ASK-P for physical function and the PedsQL4.0 or EQ-5D-Y for quality of life. Cite this article: Bone Joint J 2020;102-B(12):1599-1607.

Hemodynamic Adaptations Induced by Short-Term Run Interval Training in College Students

Perceived lack of time is one of the most often cited barriers to exercise participation. High intensity interval training has become a popular training modality that incorporates intervals of maximal and low-intensity exercise with a time commitment usually shorter than 30 min. The purpose of this study was to examine the effects of short-term run interval training (RIT) on body composition (BC) and cardiorespiratory responses in undergraduate college students. Nineteen males (21.5 ± 1.6 years) were randomly assigned to a non-exercise control (CON, n = 10) or RIT (n = 9). Baseline measurements of systolic and diastolic blood pressure, resting heart rate (HRrest), double product (DP) and BC were obtained from both groups. VO_2max and running speed associated with VO_2peak (sVO_2peak) were then measured. RIT consisted of three running treadmill sessions per week over 4 weeks (intervals at 100% sVO_2peak, recovery periods at 40% sVO_2peak). There were no differences in post-training BC or VO₂max between groups (p > 0.05). HRrest (p = 0.006) and DP (p ≤ 0.001) were lower in the RIT group compared to CON at completion of the study. RIT lowered HRrest and DP in the absence of appreciable BC and VO_2max changes. Thereby, RIT could be an alternative model of training to diminish health-related risk factors in undergraduate college students.

Proposed method for evaluation and categorization of functional capacity of children, adolescents, and adults with cardiac diseases to bring them in existing social justice system by creating the cardiac disability criteria

INTRODUCTION

Emerging epidemiological trends in India indicate the rising burden of cardiovascular diseases (CVDs) demanding a need of a social support system. Yet, the list of 21 benchmark disabilities notified by the Department of Empowerment of Persons with Disabilities, Ministry of Social Justice and Empowerment, Government of India, does not include CVDs under the newly enacted Rights of Persons with Disabilities (RPWD) Act, 2016. While the RPWD Act 2016 has acknowledged the dynamic nature of disabilities associated with congenital diseases like thalassemia, it has also provided an opportunity to bring in "cardiac disability" under its tenets. This would allow India to adopt strategies for the benefit of cardiac patients in accordance with policies adopted by developed countries such as the United States of America (USA), the United Kingdom of Great Britain (UK), and Canada. This document is to initiate a thought process of recruitment of cardiac patients in the social justice system.

AIMS AND OBJECTIVES

(1) To define cardiac disability, (2) to categorize cardiac diseases/defects (groups A-C) according to severity and need for interventions, (3) to identify operated and unoperated patients with normal functional capacity and their eligibility to avail normal opportunities similar to their peer groups, (4) to create a comprehensive cardiac disability scoring (CCDS) system for disability certification based on subjective and objective evaluation of functional capacity and the corresponding heart disease category group, and (5) to create a reference literature for the issues of education, employability, insurability, and vocational counseling based on this document.

METHODOLOGY

The evolution of this manuscript has been discussed in view of relevant observations made by a team of cardiologists, cardiac surgeons, intensivists, pediatricians, social workers, etc.

CONCLUSION

This manuscript suggests a CCDS system to lay down criteria for disability status for eligible patients suffering from cardiovascular diseases. It intends to offer a unique scientific tool to address the psychosocial and socio-economic bias against patients with heart diseases of heterogeneous nature.

Maximal Heart Rate for Swimmers

The main purpose of this study was to identify whether a different protocol to achieve maximal heart rate should be used in sprinters when compared to middle-distance swimmers. As incorporating running training into swim training is gaining increased popularity, a secondary aim was to determine the difference in maximal heart rate between front crawl swimming and running among elite swimmers. Twelve elite swimmers (4 female and 8 male, 7 sprinters and 5 middle-distance, age 18.8 years and body mass index 22.9 kg/m²) swam three different maximal heart rate protocols using a 50 m, 100 m and 200 m step-test protocol followed by a maximal heart rate test in running. There were no differences in maximal heart rate between sprinters and middle-distance swimmers in each of the swimming protocols or between land and water (all p ≥ 0.05). There were no significant differences in maximal heart rate beats-per-minute (bpm) between the 200 m (mean ± SD; 192.0 ± 6.9 bpm), 100 m (190.8 ± 8.3 bpm) or 50 m protocol (191.9 ± 8.4 bpm). Maximal heart rate was 6.7 ± 5.3 bpm lower for swimming compared to running (199.9 ± 8.9 bpm for running; p = 0.015). We conclude that all reported step-test protocols were suitable for achieving maximal heart rate during front crawl swimming and suggest that no separate protocol is needed for swimmers specialized on sprint or middle-distance. Further, we suggest conducting sport-specific maximal heart rate tests for different sports that are targeted to improve the aerobic capacity among the elite swimmers of today.

Social Support Moderates the Relationship Between Perceived Stress and Quality of Life in Patients With a Left Ventricular Assist Device

BACKGROUND

Living with a left ventricular assist device has significant psychosocial sequelae that affect health-related quality of life (HRQOL).

OBJECTIVE

The purpose of this study was to (1) describe psychosocial indicators of stress including perceived stress, depression, fatigue, and coping; (2) examine relationships among stress indicators by level of perceived stress; (3) examine relationships among indicators of stress and clinical outcomes; and (4) test the moderation of social support on the relationship between stress and clinical outcomes.

METHODS

Participants were recruited from 2 outpatient clinics in a cross-sectional study design. Standardized measures were self-administered via survey. Descriptive statistics, correlation, and multiple linear regression analysis were conducted.

RESULTS

The sample (N = 62) was mostly male (78%), black (47%), and married (66%), with a mean age of 56.5 ± 13 years. The overall sample had a moderate stress profile: moderate perceived stress (mean, 11.7 ± 7), few depressive symptoms (mean, 3.2 ± 3.9), and moderate fatigue (mean, 14.3 ± 9.1). Increased perceived stress was associated with fatigue, depressive symptoms, and maladaptive coping (P < .001). Regression analysis demonstrated that perceived stress and fatigue were significant correlates of overall HRQOL (adj. R = 0.41, P < .0001). Social support moderated the relationship between perceived stress and HRQOL, controlling for fatigue (R = 0.49, P < .001).

CONCLUSIONS

Individuals living with left ventricular assist device with high perceived stress have worse depressive symptoms, fatigue, and coping. The influence of high social support to improve the relationship between stress and HRQOL underscores the importance of a comprehensive plan to address psychosocial factors.

Physiological and Psychological Stress in Patients Living With a Left Ventricular Assist Device

Patients with a left ventricular assist device (LVAD) commonly experience psychological distress post-implantation, but physiological stress and differences by implant strategy remain unstudied. This study describes indicators of physiological (salivary cortisol, C-reactive protein, sleep quality) and psychological (perceived stress, depression, and fatigue) stress by implant strategy and examines relationships between stress and outcomes (quality of life [QOL] and functional status). Prospective, cross-sectional data were collected from patients ≥3 months post-LVAD implantation (n = 44), and descriptive statistics and logistic regression were used. The study sample was average age 57.7 ± 13 years, mostly male (73%), married (70.5%), and racially diverse. Median LVAD support was 18.2 months. Most had normal cortisol awakening response and fair sleep quality, with moderate psychological stress. There were no differences in stress by implant strategy. Normal cortisol awakening response was correlated with low depressive symptoms. Sleep quality and psychological stress were associated with QOL, whereas cortisol and C-reactive protein levels were associated with functional status. This is the first report of salivary biomarkers and stress in LVAD outpatients. Future research should examine physiological and psychological stress and consider potential clinical implications for stress measurement for tailored approaches to stress management in this population.

Assessment of functional performance in Chagas heart disease by Human Activity Profile questionnaire

PURPOSE

To verify the association between Human Activity Profile and functional capacity, functional class and systolic function of the patients with Chagas heart disease (CHD).

METHODS

Sixty-two patients with CHD were evaluated by echocardiography, maximal exercise testing and Human Activity Profile questionnaire. The sample was stratified, according to the values of peak oxygen uptake (low or normal), functional class (symptomatic or asymptomatic), and left ventricular ejection fraction (preserved or systolic dysfunction). Linear regression and two-group comparisons analyses were used. Receiver-operating characteristic analysis was used to determine different cutoff values of the Human Activity Profile for low peak oxygen uptake prediction.

RESULTS

Peak oxygen uptake was an independent predictor of Human Activity Profile (R²-adjusted = 0.27). Patients with low peak oxygen uptake had lower scores in Human Activity Profile [difference of 6.9 (95%CI 2.5-11.4)] than those with normal peak oxygen uptake. Symptomatic patients also showed lower scores when compared to the asymptomatic [difference of 6.2 (95%CI 1.7-10.8)]. There was no difference between left ventricular ejection fraction classes. The Human Activity Profile score of 76.5 was the optimal cut point value in predicting low peak oxygen uptake (sensitivity = 66.0% and specificity = 71.8%).

CONCLUSION

The Human Activity Profile questionnaire is associated with functional capacity of patients with CHD and is able to identify individuals with low peak oxygen uptake.Implications for rehabilitationFunctional impairment is one of the most common clinical findings in all stages and is an important predictor of poor prognosis of the Chagas heart disease;A patient-derived measure of functional capacity is potentially useful in the setting of the Chagas heart disease;The Human Activity Profile questionnaire is effective in the identification of patients with Chagas heart disease with functional impairment and may be a valid method for functional evaluation.

Peak oxygen uptake, six-minute walk distance, six-meter walk speed, and pulse pressure as predictors of seven year all-cause and cardiovascular mortality in community-living older adults

Cardiorespiratory fitness and physical performance measures predict mortality. It is uncertain whether pulse pressure (PP), a measure that is routinely available in healthcare settings, may also predict mortality with a comparable degree of accuracy. In a study consisting of older adults (709 men and 467 women) living in the community, we examined the relationship between PP, peak oxygen uptake (VO2 peak), 6-minute walk distance (6MWD) and 6-meter walking speed (6MWS) and seven year all-cause and cardiovascular mortality. Receiver operator characteristic (ROC) curve was used to compare predictive performance. In the prediction of all-cause mortality, in men, 6MWD, 6MWS and PP all have comparable area under curve (AUC) values compared with VO2 peak: 0.736, 0.723, 0.736 and 0.734 respectively. Similar results were observed for women, although all the AUC values were slightly lower (corresponding values were 0.723, 0.713, 0.702 and 0.747 respectively). For cardiovascular mortality, the findings are similar although in men all AUC values were higher. We conclude that PP predicts 7 year all-cause and cardiovascular mortality in older adults with an accuracy similar to VO2 peak, 6MWD and 6MWS, although the association is less strong in women.

Exercise training for advanced lung cancer

BACKGROUND

Patients with advanced lung cancer have a high symptom burden, which is often complicated by coexisting conditions. These issues, combined with the indirect effects of cancer treatment, can cumulatively lead patients to continued deconditioning and low exercise capacity. This is a concern as exercise capacity is considered a measure of whole body health, and is critical in a patient's ability to participate in life activities and tolerate difficult treatments. There is evidence that exercise training improves exercise capacity and other outcomes, such as muscle force and health-related quality of life (HRQoL), in cancer survivors. However, the effectiveness of exercise training on these outcomes in people with advanced lung cancer is currently unclear.

OBJECTIVES

The primary aim of this review was to investigate the effects of exercise training on exercise capacity in adults with advanced lung cancer. Exercise capacity was defined as the six-minute walk distance (6MWD; in meters) measured during a six-minute walk test (6MWT; i.e. how far an individual can walk in six minutes on a flat course), or the peak oxygen uptake (i.e. VO₂peak) measured during a maximal incremental cardiopulmonary exercise test (CPET).The secondary aims were to determine the effects of exercise training on the force-generating capacity of peripheral muscles, disease-specific global HRQoL, physical functioning component of HRQoL, dyspnoea, fatigue, feelings of anxiety and depression, lung function, level of physical activity, adverse events, performance status, body weight and overall survival in adults with advanced lung cancer.

SEARCH METHODS

We searched CENTRAL, MEDLINE (via PubMed), Embase (via Ovid), CINAHL, SPORTDiscus, PEDro, and SciELO on 7 July 2018.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) which compared exercise training versus no exercise training in adults with advanced lung cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the studies and selected those for inclusion. We performed meta-analyses for the following outcomes: exercise capacity, disease-specific global HRQoL, physical functioning HRQoL, dyspnoea, fatigue, feelings of anxiety and depression, and lung function (forced expiratory volume in one second (FEV1)). Two studies reported force-generating capacity of peripheral muscles, and we presented the results narratively. Limited data were available for level of physical activity, adverse events, performance status, body weight and overall survival.

MAIN RESULTS

We identified six RCTs, involving 221 participants. The mean age of participants ranged from 59 to 70 years; the sample size ranged from 20 to 111 participants. Overall, we found that the risk of bias in the included studies was high, and the quality of evidence for all outcomes was low.Pooled data from four studies demonstrated that, on completion of the intervention period, exercise capacity (6MWD) was significantly higher in the intervention group than the control group (mean difference (MD) 63.33 m; 95% confidence interval (CI) 3.70 to 122.96). On completion of the intervention period, disease-specific global HRQoL was significantly better in the intervention group compared to the control group (standardised mean difference (SMD) 0.51; 95% CI 0.08 to 0.93). There was no significant difference between the intervention and control groups in physical functioning HRQoL (SMD 0.11; 95% CI -0.36 to 0.58), dyspnoea (SMD -0.27; 95% CI -0.64 to 0.10), fatigue (SMD 0.03; 95% CI -0.51 to 0.58), feelings of anxiety (MD -1.21 units on Hospital Anxiety and Depression Scale; 95% CI -5.88 to 3.45) and depression (SMD -1.26; 95% CI -4.68 to 2.17), and FEV1 (SMD 0.43; 95% CI -0.11 to 0.97).

AUTHORS' CONCLUSIONS

Exercise training may improve or avoid the decline in exercise capacity and disease-specific global HRQoL for adults with advanced lung cancer. We found no significant effects of exercise training on dyspnoea, fatigue, feelings of anxiety and depression, or lung function. The findings of this review should be viewed with caution because of the heterogeneity between studies, the small sample sizes, and the high risk of bias of included studies. Larger, high-quality RCTs are needed to confirm and expand knowledge on the effects of exercise training in this population.

Impact of Body Mass Index on Activities of Daily Living in Inpatients with Acute Heart Failure

OBJECTIVES

To investigate the impact of body mass index on activities of daily living in inpatients with acute heart failure.

DESIGN

A retrospective cohort study.

SETTING

A hospital-based database contains Diagnosis Procedure Combination survey data from 100 participating acute-care hospitals.

PARTICIPANTS

11,301 inpatients aged 20 year or older who were admitted to the participating hospitals with a diagnosis of acute heart failure.

MEASUREMENTS

The Barthel Index score at discharge and hospital death.

RESULTS

The number of patients with a body mass index of <18.5 kg/m2 (underweight), 18.5-22.9 kg/m2 (low-normal weight), 23.0-24.9 kg/m2 (high-normal weight), 25.0-29.9 kg/m2 (overweight), and ≥30.0 kg/m2 (obesity) were 1689 (15%), 4715 (42%), 1809 (16%), 2306 (20%), and 782 (7%), respectively. Median Barthel Index scores at admission and discharge were 65 and 100, respectively. Hospital death occurred in 101 (0.9%) patients. Lower body mass index was associated with lower Barthel Index score at discharge and higher mortality. Multivariable analysis adjusted for body mass index, age, sex, New York Heart Association classification, Barthel Index score at admission, the updated Charlson Comorbidity Index, length of hospital stay, number of drugs administered, and rehabilitation during hospitalization revealed that body mass index was independently associated with Barthel Index score at discharge (beta: 0.354; 95% confidence interval: 0.248-0.461) and hospital death (odds ratio: 0.926, 95% confidence interval: 0.877-0.978).

CONCLUSION

Overweight and obese inpatients showed greater independence in activities of daily living at discharge and lower rates of mortality, indicating the obesity paradox. A combination of rehabilitation and improved nutrition seems to be important in underweight patients with acute heart failure.

Phase Angle Is Moderately Associated With Muscle Quality and Functional Capacity, Independent of Age and Body Composition in Older Women

BACKGROUND AND PURPOSE

There is a growing body of evidence indicating that phase angle (PhA) can be used as an indicator of nutritional status, disease prognosis, and mortality risk; however, it is still unknown whether PhA can be used as an explanator of functional capacity and muscle quality in older women. The main purpose of this cross-sectional study was to explore whether PhA is associated with muscle quality and functional capacity in older women, regardless of total and regional body composition.

METHODS

A total of 125 older women-66.7 (4.7) years; 65.6 (10.9) kg body mass; 156.1 (5.2) cm height; 26.9 (4.0) kg/m body mass index-participated in this study. Anthropometric, PhA, body composition (whole-body dual-energy x-ray absorptiometry) and muscle quality (defined as total muscular strength per kilogram of appendicular lean soft tissue) were measured. The functional capacity was assessed by 4 tests: 10-m walk test, rising from sitting position, rising from ventral decubitus position, and rising from a chair and walking around the house. The summing z-scores for the 4 tests was used as a continuous functional capacity score. Linear regression analysis was conducted to test whether PhA is related to the dependent variables (muscle quality and functional capacity), after adjusting for potential covariates.

RESULTS

The PhA presented a small-to-moderate relationship with muscle quality (r = 0.27; P < .01) and functional capacity (r = 0.31; P < .01), respectively. These relationships remained significant after adjustment for age, lower limb lean soft tissue, and total fat mass for muscle quality (β= 0.55; P < .01) and functional capacity (β= 1.38; P < .01).

CONCLUSION

Our findings suggest that healthy elderly women with higher values of PhA have a better muscle quality and functionality, regardless of age and body composition.

The Amount of Weight Loss Six Months after Bariatric Surgery: It Makes a Difference

BACKGROUND

Bariatric surgery, especially Roux-en-Y gastric bypass (RYGB), has become the most frequently used therapy for morbid obesity.

OBJECTIVES

The aim of this study was to examine the effects of surgically induced weight loss on cardiopulmonary function 6 months after the procedure, as well as the effect of such an intervention on well-known risk factors for cardiovascular diseases.

METHODS

This is a cross-sectional study on 66 morbidly obese patients (BMI ≥40 or ≥35 kg/m2 with present comorbidities), comparing their cardiopulmonary function prior to and 6 months after RYGB surgery.

RESULTS

The substantial amount of weight loss (29.80 ± 13.27 kg) after RYGB surgery was associated with significant reduction of comorbidities, especially diabetes and sedentary lifestyle (p = 0.005 and p = 0.002, respectively). Regarding functional capacity, there was significant increase in peak oxygen uptake (VO2 peak, p = 0.003), duration of exercise testing, metabolic equivalents (exercise time and METs, p < 0.001), and in peak O2 pulse. These findings were particularly pronounced in a group of patients who had lost more than 18% of initial weight.

CONCLUSIONS

Reduction of body weight after RYGB surgery is associated with significantly improved cardiorespiratory function 6 months after surgery, especially in patients who lost more than 18% of their initial body weight. In addition, substantial decreases in body weight were also associated with a reduction of cardiovascular risk factors such as diabetes, smoking, hypertriglyceridemia, and sedentary lifestyle.

The Possible Use of Preoperative Natriuretic Peptides for Discriminating Low Versus Moderate-High Surgical Risk Patient

Perioperative risk scores for patients undergoing noncardiac surgery are generally considered inaccurate, poor, or, at best, modest. We propose estimating a patient’s pretest and posttest probability of cardiac morbidity and death using the preoperative scoring system plus the negative likelihood ratio from brain natriuretic peptide (BNP) or N-terminal proB-type natriuretic peptide (NT-proBNP) plasma levels. Our clinical challenge scenario showed a pretest probability of postoperative major cardiac complications with the patient risk factor as 6.6% for the Revised Cardiac Risk Index and between 1% and 5% (intermediate risk) per the recent European Society of Cardiology and the European Society of Anesthesiologist guidelines for surgical risk estimation. In fact, the American College of Cardiology and the American Heart Association guidelines consider the same surgical procedure for elevated risk. The posttest probability takes advantage of a negative likelihood ratio from BNP plasma levels, with patient risk factor reduced to 0.8% and surgical risk to 1.1%. In the same way, the pretest American College of Surgeons National Surgical Quality Improvement Program score decreased from 18.8% to 3.5% for severe complications and from 0.9% to 0.1% for death at ≤90 days. Following noncardiac surgery, postoperative complications and mortality are often cardiac in nature. The negative likelihood ratio of BNP and NT-proBNP plasma levels provides a quick, low-cost tool for recognizing and reclassifying the cardiovascular risk of those undergoing noncardiac surgery, thereby singling out low- versus moderate-high-risk surgical patients.

The relationship of sit-to-stand tests with 6-minute walk test in healthy young adults

The aim of this study was to evaluate the timed sit-to-stand (STS) test performances of healthy young adults and to investigate the relationship of timed STS tests with 6-minute walk test (6MWT). A cross-sectional study was performed. A total of 40 healthy volunteers (mean age: 21.7 ± 1.2 years) were evaluated with 10, 30, and 60 seconds STS tests and 6MWT. Fatigue and shortness of breath were rated using Borg category-ratio scale (CR10) before and after each test. Weekly energy expenditures of volunteers were calculated using International Physical Activity Questionnaire. 30 and 60 seconds STS tests were moderately (r = 0.611 and r = 0.647, respectively) (P < .001) and 10 seconds STS test was weakly (r = 0.344) (P = .028) correlated with 6MWT. Among correlations of each STS test with 6MWT, none of them was statistically stronger to one another (P > .05). Borg fatigue scores after 10, 30, and 60 seconds STS tests were weakly correlated with fatigue score after 6MWT (r = 0.321, r = 0.378, and r = 0.405, respectively) (P < .05). Weekly energy expenditure (MET-min/week) was moderately correlated with 10, 30, and 60 seconds STS tests and 6MWT (r = 0.533, r = 0.598, r = 0.598, and r = 0.547, respectively) (P < .001). Considering the statistically significant relationship between timed STS tests and 6MWT, any of the timed STS tests may be used for a quick and alternative measurement of physical performance and functional capacity in healthy young adults.

Physical fitness improvement in overweight postmenopausal women who do not lose fat mass in response to exercise training

OBJECTIVE

The aim of this study was to examine if overweight postmenopausal women who do not experience fat mass loss after a 1-year aerobic exercise (AE) and resistance training (RT) program can still improve physical fitness.

METHODS

Thirty-one overweight women (body mass index 28-40 kg/m or waist circumference ≥88 cm) participated in three weekly supervised AE and RT sessions for 1 year. All women were categorized according to their fat mass changes after the intervention: 14 women were considered as responders (fat mass loss ≥5% of initial fat mass) and 17 as nonresponders (fat mass loss <5% of initial fat mass). The main outcome measures were absolute and relative body strength, peak aerobic capacity, lower limbs power, flexibility, and body composition (DXA). Total energy intake (3-day dietary record) and physical activity level (physical activity scale for the elderly questionnaire) were also measured before, halfway through and after the intervention.

RESULTS

At baseline, nonresponders participants had higher body mass index (P = 0.04). After the intervention, relative and absolute upper and lower body strength, peak aerobic capacity (all P < 0.005), and flexibility increased similarly in the nonresponders and responders groups (P = 0.01).

CONCLUSIONS

Although some participants did not respond to exercise by decreasing fat mass, they still experienced important physical fitness benefits from AE and RT. These results suggest that body composition changes should not be the sole indicator of the benefits of exercise in overweight postmenopausal women.

Anesthetic management of the patient undergoing heart transplantation

Cardiac transplantation is the treatment of choice for patients with end-stage heart failure. Over the years, significant advances in patient selection, donor optimization and selection, and optimization of immunosuppression strategies have markedly improved outcomes. In this review, we highlight patient selection, donor management and procurement, heart transplantation procedure, and intraoperative and postoperative management of heart transplants.

Estimated Glomerular Filtration Rate and 6-Minute Walk Distance in African Americans with Mild to Moderate Heart Failure

BACKGROUND/AIMS

The 6-minute walk test is a measure of functional capacity in patients with heart failure (HF) or chronic kidney disease (CKD). The association between estimated glomerular filtration rate (eGFR) and 6-minute walk distance (6MWD) has not been investigated in African-Americans (AA), despite them having a higher incidence of CKD and chronic HF. Thus, our aim was to determine if eGFR was an independent predictor of 6MWD in AA >50 years of age with HF.

METHODS

In this cross-sectional study, we examined the relationship between eGFR and 6MWD in 45 AA patients with HF from an urban outpatient HF clinic, using logistic regression with bootstrapping.

RESULTS

The sample consisted of 53% females; mean age = 64.8 ± 9 years, mean eGFR = 61.6 ± 20 mL/min/1.73 m², and mean 6MWD = 222 ± 78 m. A decrease in eGFR by 10 mL/min/1.73 m² was associated with 46% higher odds (p = 0.02) of a 6MWD ≤200 m in an unadjusted model and 39-41% higher odds (p = 0.03) of a 6MWD ≤200 m in adjusted models.

CONCLUSION

A decrease in eGFR significantly predicted a shorter 6MWD in AA patients with HF. Therefore, a reduction in eGFR may be used as an early marker to identify and manage declining functional capacity in these patients.

Evaluation of the Glittre-ADL test as an instrument for classifying functional capacity of individuals with cardiovascular diseases

•

Conventional cardiovascular tests exclusively evaluate lower limb function.

•

The functional evaluation should include upper limb activities.

•

The Glittre-ADL test has the potential to be used in cardiovascular evaluation.

•

Glittre-ADL test can discriminate functional classes of individuals with CVD.

Background

The assessment of functional capacity in individuals with cardiovascular disease is closely related to lower limb function. The Glittre-ADL test is a global test to evaluate this patients.

Objective

We aimed to verify whether the Glittre-ADL test discriminates functional status while evaluating individuals with cardiovascular disease.

Methods

A total of 42 participants were evaluated using the Glittre-ADL test Incremental Shuttle Walking Test (shuttle test), Human Activity Profile, and Duke Activity Status Index. Data from the shuttle test, Human Activity Profile, and DASI were divided into tertiles for statistical analysis. The time required to complete the Glittre-ADL test was compared among tertiles of the shuttle test, Duke Activity Status Index and Human Activity Profile using analysis of variance.

Results

There were significant differences between the tertiles of the shuttle test. Tertile 1 was different from tertiles 2 (mean difference, 47.63; 95% CI, 19.86–75.39) and 3 (mean difference, 67.15; 95% CI, 41.25–93.05). For the Duke Activity Status Index there were significant between-group differences. Tertile 1 was different from tertiles 2 (mean difference, 42.45; 95% CI, 8.82–76.09) and 3 (mean difference, 43.56; 95% CI, 13.68–73.44). For the Human Activity Profile there were significant between-group differences. Tertile 3 was different from tertiles 1 (mean difference, 51.46; 95% CI, 21.27–81.64) and 2 (mean difference, 33.01; 95% CI, 3.52–62.51).

Conclusion

The Glittre-ADL test is able to discriminate the functional status in individuals with cardiovascular disease, most of whom have hypertension. The Glittre-ADL test was sensitive to discriminate more functionally affected individuals.

Exercise training for advanced lung cancer

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

The primary aim of this study is to investigate the effects of exercise training on exercise capacity in adults with advanced lung cancer. Exercise capacity is defined as the Six‐Minute Walk Distance (6MWD; in meters) measured during a 6MWT (i.e. how far an individual can walk in 6 minutes on a flat course) or the peak oxygen uptake (i.e. VO₂peak) measured during a maximal incremental CPET.

The secondary aims are to determine the effects of exercise training on the force‐generating capacity of peripheral muscles, HRQoL, dyspnea, fatigue, feelings of anxiety and depression, lung function, and physical activity levels in adults with advanced lung cancer.

Resveratrol and exercise to treat functional limitations in late life: design of a randomized controlled trial

Skeletal muscle mitochondrial function declines with age and is a key factor in the maintenance of physical function among older adults. Research studies from animals and humans have consistently demonstrated that exercise improves skeletal muscle mitochondrial function in early and middle adulthood. However, mitochondrial adaptations to both acute and chronic exercise are attenuated in late life. Thus, there is an important need to identify adjuvant therapies capable of augmenting mitochondrial adaptations to exercise (e.g. improved mitochondrial respiration, muscle mitochondria biogenesis) among older adults. This study is investigating the potential of resveratrol supplementation for this purpose. The objective of this randomized, double-masked pilot trial is to evaluate the efficacy of resveratrol supplementation combined with a comprehensive supervised exercise program exercise for improving physical function among older adults. Moderately functioning, sedentary participants aged ≥60 years will perform 24 sessions (2 day/wk for 12 weeks) of center-based walking and resistance training and are randomly assigned to receive either (1) 500 mg/day resveratrol (2) 1000 mg/day resveratrol or (3) placebo. Study dependent outcomes include changes in 1) knee extensor strength, 2) objective measures of physical function (e.g. 4m walk test, Short Physical Performance Battery), 3) subjective measures of physical function assessed by Late Life Function and Disability Instrument, and 4) skeletal muscle mitochondrial function. This study will provide novel information regarding the therapeutic potential of resveratrol supplementation combined with exercise while also informing about the long-term clinical viability of the intervention by evaluating participant safety and willingness to engage in the intervention.

Exercise And Heart Failure: Advancing Knowledge And Improving Care

Exercise limitation is the hallmark of heart failure, and an increasing degree of intolerance is associated with poor prognosis. Objective evaluation of functional class (e.g., cardiopulmonary exercise testing) is essential for adequate prognostication in patients with advanced heart failure and for implementing an appropriate exercise training program. A graded exercise program has been shown to be beneficial in patients with heart failure and has become an essential component of comprehensive cardiac rehabilitation in these patients. An exercise program tailored to the patient's preferences, possibilities, and physiologic reserve has the greatest chance of being successful. Despite being safe, effective, and a guideline-recommended treatment to improve quality of life, exercise training remains grossly underutilized. Patient, physician, insurance and practice barriers need to be addressed to improve this quality gap.

Measurement properties of the Human Activity Profile questionnaire in hospitalized patients

OBJECTIVE

To test the measurement properties (reproducibility, internal consistency, ceiling and floor effects, and construct validity) of the Human Activity Profile (HAP) questionnaire in hospitalized patients.

METHODS

This measurement properties study recruited one-hundred patients hospitalized for less than 48h for clinical or surgical reasons. The HAP was administered at baseline and after 48h in a test-retest design). The International Physical Activity Questionnaire (IPAQ-6) was also administered at baseline, aiming to assess the construct validity. We tested the following measurement properties: reproducibility (reliability assessed by type 2,1 intraclass correlation coefficient (ICC2,1)); agreement by the standard error of measurement (SEM) and by the minimum detectable change with 90% confidence (MDC90), internal consistency by Cronbach's alpha, construct validity using a chi-square test, and ceiling and floor effects by calculating the proportion of patients who achieved the minimum or maximum scores.

RESULTS

Reliability was excellent with an ICC of 0.99 (95% CI=0.98-0.99). SEM was 1.44 points (1.5% of the total score), the MDD90 was 3.34 points (3.5% of the total score) and the Cronbach's alpha was 0.93 (alpha if item deleted ranging from 0.94 to 0.94). An association was observed between patients classified by HAP and by IPAQ-6 (χ2=3.38; p=0.18). Ceiling or floor effects were not observed.

CONCLUSION

The HAP shows adequate measurement properties for the assessment of the physical activity/inactivity level in hospitalized patients.

Brief communication (Original). The effect of physical activity on 6-minute walked distance among niqab wearing healthy Saudi women

Background: Wearing a face veil (niqab) was found to have a negative effect on the ventilatory function of Saudi adult women, which may challenge their functional exercise capacity.

Objectives: To investigate the effect of physical activity on a 6-minute walked distance (6-MWD) among young adult niqab-wearing healthy Saudi women.

Materials and Methods: Forty healthy young Saudi women were recruited for this study. The study participants (aged 22.8 ± 2.5 years) were selected from students and administrative staff at King Saud University. They were normotensive, nonsmokers, and of normal or mildly overweight. They were divided into 2 groups on basis of niqab wearing. A 6- minute walk test was implemented as measure of the participant’s functional exercise capacity. Their physical activity level was expressed as low, moderate, or high levels using the International Physical Activity Questionnaire-Short Form. Comparisons between the basal physiological characters of the 2 groups, 6-MWD, and physical activity level were conducted. A two-way independent ANOVA was used to study the interaction of niqab wearing and the physical activity level on the 6-MWD for niqab wearing women.

Results: Women in the niqab wearing group had a significantly higher physical activity level and longer 6-MWD than those in the niqab nonwearing group (370.7 ± 62.95 and 510.0 ± 81.75 m (mean ± SD) respectively).

Conclusion: A physically active lifestyle improves and preserves the functional exercise capacity reflected by longer 6-MWD among the physically active niqab-wearing Saudi adult healthy women compared with less active women who did not wear the niqab.

Exercise Testing: Who, When, and Why?

There are different modalities of exercise testing that can provide valuable information to physicians about patient and athlete fitness and cardiopulmonary status. Cardiopulmonary exercise testing (CPX) is a form of exercise testing that measures ventilatory and gas exchange, heart rate, electrocardiogram, and blood pressures to provide detailed information on the cardiovascular, pulmonary, and muscular systems. This testing allows an accurate quantification of functional capacity/measure of exercise tolerance, diagnosis of cardiopulmonary disease, disease-progression monitoring or response to intervention, and the prescription of exercise and training. CPX directly measures inhaled and exhaled ventilator gases to determine the maximal oxygen uptake, which reflects the body's maximal use of oxygen and defines the limits of the cardiopulmonary system. CPX is the ideal modality to evaluate causes of exertional fatigue and dyspnea, especially in complex cases in which the etiology could be cardiac, pulmonary, or deconditioning. Exercise tolerance has become an important outcome measure in patients with chronic obstructive pulmonary disease and congestive heart failure, as well as other chronic diseases, and is a well-recognized predictor of mortality. Older athletes or those with underlying medical conditions could benefit from exercise testing for risk stratification and clearance to participate, as well as to help set their training zones and determine their functional limitations.

Assessment of functional capacity and sleep quality of patients with chronic heart failure

Background:

Adequate sleep improves physical and mental alertness. However, there is a dearth of empirical data on functional capacity (FC) and sleep quality (SpQ) in patients with chronic heart failure (CHF).

Objective:

This study investigated the relationship between FC and SpQ of patients with CHF and apparently healthy controls (HCs).

Methods:

This case-control study recruited 50 patients with CHF whose left ventricular ejection fraction (LVEF) was <40%, attending cardiac clinics of selected government hospitals in Osun State. Furthermore, 50 age- and sex-matched healthy individuals were recruited as controls. Socio-demographic characteristics and cardiovascular parameters were assessed. The FC (VO₂ max) and SpQ were assessed using the 6-minute walk test (6-MWT) and Pittsburgh Sleep Quality Index (PSQI), respectively. Data were analysed using descriptive and inferential statistics. Alpha level was set at p < 0.05.

Results:

Patients had a significantly lower FC and poorer SpQ than HCs, 4.6 ± 0.5 versus 11.3 ± 1.6 mL/kg/min (t = −3.452; p = 0.001) and 8.74 ± 1.6 versus 3.8 ± 1.3 (t = −5.371; p = 0.001), respectively. HCs were about five times more likely to walk longer distance [odds ratio (OR), 4.8; confidence interval (CI), 2.0–11.1] and had a better heart rate (OR, 2.8; CI, 1.4–5.3) than patients. SpQ had a significant negative correlation with FC of patients (r = −0.362; p = 0.001) but a significant positive correlation with HCs (r = 0.481; p = 0.041). Furthermore, there were significant correlations between FC and body mass index in both groups (CHF: r = 0.247, p = 0.022; HCs: r = 0.321, p = 0.040).

Conclusion:

Patients with heart failure demonstrated lower functional capacity and poorer sleep quality.

Heart Failure: Diagnosis, Severity Estimation and Prediction of Adverse Events Through Machine Learning Techniques

Heart failure is a serious condition with high prevalence (about 2% in the adult population in developed countries, and more than 8% in patients older than 75 years). About 3-5% of hospital admissions are linked with heart failure incidents. Heart failure is the first cause of admission by healthcare professionals in their clinical practice. The costs are very high, reaching up to 2% of the total health costs in the developed countries. Building an effective disease management strategy requires analysis of large amount of data, early detection of the disease, assessment of the severity and early prediction of adverse events. This will inhibit the progression of the disease, will improve the quality of life of the patients and will reduce the associated medical costs. Toward this direction machine learning techniques have been employed. The aim of this paper is to present the state-of-the-art of the machine learning methodologies applied for the assessment of heart failure. More specifically, models predicting the presence, estimating the subtype, assessing the severity of heart failure and predicting the presence of adverse events, such as destabilizations, re-hospitalizations, and mortality are presented. According to the authors' knowledge, it is the first time that such a comprehensive review, focusing on all aspects of the management of heart failure, is presented.

A Novel and Effective Method for Congestive Heart Failure Detection and Quantification Using Dynamic Heart Rate Variability Measurement

Risk assessment of congestive heart failure (CHF) is essential for detection, especially helping patients make informed decisions about medications, devices, transplantation, and end-of-life care. The majority of studies have focused on disease detection between CHF patients and normal subjects using short-/long-term heart rate variability (HRV) measures but not much on quantification. We downloaded 116 nominal 24-hour RR interval records from the MIT/BIH database, including 72 normal people and 44 CHF patients. These records were analyzed under a 4-level risk assessment model: no risk (normal people, N), mild risk (patients with New York Heart Association (NYHA) class I-II, P1), moderate risk (patients with NYHA III, P2), and severe risk (patients with NYHA III-IV, P3). A novel multistage classification approach is proposed for risk assessment and rating CHF using the non-equilibrium decision-tree-based support vector machine classifier. We propose dynamic indices of HRV to capture the dynamics of 5-minute short term HRV measurements for quantifying autonomic activity changes of CHF. We extracted 54 classical measures and 126 dynamic indices and selected from these using backward elimination to detect and quantify CHF patients. Experimental results show that the multistage risk assessment model can realize CHF detection and quantification analysis with total accuracy of 96.61%. The multistage model provides a powerful predictor between predicted and actual ratings, and it could serve as a clinically meaningful outcome providing an early assessment and a prognostic marker for CHF patients.

Relationship Between Exercise Workload During Cardiac Rehabilitation and Outcomes in Patients With Coronary Heart Disease

The purpose of this retrospective, observational study was to describe the relation between exercise workload during cardiac rehabilitation (CR), expressed as metabolic equivalents of task (METs), and prognosis among patients with coronary heart disease. We included patients with coronary heart disease who participated in CR between January 1998 and June 2007. METs were calculated from treadmill workload. Cox regression analysis was used to describe the relationship between METs and time to a composite outcome of all-cause mortality, nonfatal myocardial infarction, or heart failure hospitalization. Among 1,726 patients (36% women; median age 59 years [interquartile range, 52 to 66]), there were 467 events (27%) during a median follow-up of 5.8 years (interquartile range, 2.6 to 8.7). In analyses adjusted for age, sex, Charlson co-morbidity index, hypertension, diabetes, and CR referral diagnosis, METs were independently related to the composite outcome at CR start (Wald chi-square 43, hazard ratio 0.59 [95% confidence interval 0.51 to 0.70]) and CR end (Wald chi-square 47, hazard ratio 0.68 [95% confidence interval 0.61 to 0.76]). Patients exercising below 3.5 METs on exit from CR represent a high-risk group with 1- and 3-year event rates ≥7% and ≥18%, respectively. In conclusion, METs during CR is available at no additional cost and can be used to identify patients at increased risk for an event who may benefit from closer follow-up, extended length of stay in CR, and/or participation in other strategies aimed at maximizing adherence to secondary preventive behaviors and improving exercise capacity.

Influence of Adjuvant Therapy in Cancer Survivors on Endothelial Function and Skeletal Muscle Deoxygenation

The cardiotoxic effects of adjuvant cancer treatments (i.e., chemotherapy and radiation treatment) have been well documented, but the effects on peripheral cardiovascular function are still unclear. We hypothesized that cancer survivors i) would have decreased resting endothelial function; and ii) altered muscle deoxygenation response during moderate intensity cycling exercise compared to cancer-free controls. A total of 8 cancer survivors (~70 months post-treatment) and 9 healthy controls completed a brachial artery FMD test, an index of endothelial-dependent dilation, followed by an incremental exercise test up to the ventilatory threshold (VT) on a cycle ergometer during which pulmonary V˙O2 and changes in near-infrared spectroscopy (NIRS)-derived microvascular tissue oxygenation (TOI), total hemoglobin concentration ([Hb]_total), and muscle deoxygenation ([HHb] ≈ fractional O₂ extraction) were measured. There were no significant differences in age, height, weight, and resting blood pressure between cancer survivors and control participants. Brachial artery FMD was similar between groups (P = 0.98). During exercise at the VT, TOI was similar between groups, but [Hb]_total and [HHb] were significantly decreased in cancer survivors compared to controls (P < 0.01) The rate of change for TOI (ΔTOIΔ/V˙O2) and [HHb] (Δ[HHb]/ΔV˙O2) relative to ΔV˙O2 were decreased in cancer survivors compared to controls (P = 0.02 and P = 0.03 respectively). In cancer survivors, a decreased skeletal muscle microvascular function was observed during moderate intensity cycling exercise. These data suggest that adjuvant cancer therapies have an effect on the integrated relationship between O₂ extraction, V˙O2 and O₂ delivery during exercise.