Dynamic Ventilatory Reserve During Incremental Exercise: Reference Values and Clinical Validation in Chronic Obstructive Pulmonary Disease.

Ventilatory demand-capacity imbalance, as inferred based on a low ventilatory reserve, is currently assessed only at peak cardiopulmonary exercise testing (CPET). Peak ventilatory reserve, however, is poorly sensitive to the submaximal, dynamic mechanical ventilatory abnormalities that are key to dyspnea genesis and exercise intolerance. After establishing sex- and age-corrected norms for dynamic ventilatory reserve at progressively higher work rates, we compared peak and dynamic ventilatory reserve for their ability to expose increased exertional dyspnea and poor exercise tolerance in mild to very severe chronic obstructive pulmonary disease (COPD).

The relationship between perceived and performance fatigability in severe fibrotic interstitial lung disease: a prospective, cross-sectional study.

https://bit.ly/3lpIUPs.

Beyond the Lungs: O 2 Supplementation Improves Cerebral Oxygenation and Fatigue during Exercise in Interstitial Lung Disease.

Purpose: Cerebral hypoxia may exacerbate the perception of fatigue. We previously demonstrated that exercise-related hypoxemia, a hallmark of fibrotic interstitial lung disease ( f -ILD), dose dependently impairs cerebral oxygenation in these patients. It is unknown whether normalizing cerebral oxygenation with O 2 supplementation would be associated with positive changes in a relevant patient-centered outcome during exercise in f -ILD, such as improved perceived fatigue.

Exertional oscillatory ventilation in subjects without heart failure reporting chronic dyspnoea.

https://bit.ly/3Tyl7bE.

Quantifying leg muscle deoxygenation during incremental cycling in hypoxemic patients with fibrotic interstitial lung disease.

Background: Hypoxaemia and cardiocirculatory abnormalities may impair muscle oxygen (O ) delivery relative to O requirements thereby increasing the rate of O extraction during incremental exercise in fibrotic interstitial lung disease (f-ILD). Using changes in deoxyhaemoglobin concentration ([HHb]) by near-infrared spectroscopy (NIRS) as a proxy of O extraction, we investigated whether a simplified (double-linear) approach, previously tested in heart failure, would provide useful estimates of muscle deoxygenation in f-ILD.

Methods: A total of 25 patients (23 men, 72 ± 8 years; 20 with idiopathic pulmonary fibrosis, lung diffusing capacity for carbon monoxide = 44 ± 11% predicted) and 12 age- and sex-matched healthy controls performed incremental cycling to symptom limitation.

The Exercising Brain: An Overlooked Factor Limiting the Tolerance to Physical Exertion in Major Cardiorespiratory Diseases?

"Exercise starts and ends in the brain": this was the title of a review article authored by Dr. Bengt Kayser back in 2003. In this piece of work, the author highlights that pioneer studies have primarily focused on the cardiorespiratory-muscle axis to set the human limits to whole-body exercise tolerance.

Exertional ventilation/carbon dioxide output relationship in COPD: from physiological mechanisms to clinical applications.

There is well established evidence that the minute ventilation (')/carbon dioxide output (' ) relationship is relevant to a number of patient-related outcomes in COPD. In most circumstances, an increased '/' reflects an enlarged physiological dead space ("wasted" ventilation), although alveolar hyperventilation (largely due to increased chemosensitivity) may play an adjunct role, particularly in patients with coexistent cardiovascular disease. The '/' nadir, in particular, has been found to be an important predictor of dyspnoea and poor exercise tolerance, even in patients with largely preserved forced expiratory volume in 1 s.

Use of Sodium-Glucose Cotransporter-2 Inhibitors in Renal Transplant Patients With Diabetes: A Brief Review of the Current Literature.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a novel class of oral hypoglycemic agents commonly prescribed in type 2 diabetes (T2D). They have been shown to slow the progression of diabetic nephropathy and improve cardiovascular outcomes in high-risk individuals, although major cardiovascular and renal outcome clinical trials have excluded renal transplant patients. The aim of this review was to determine the outcomes and safety with use of SGLT2 inhibitors in renal transplant patients with diabetes.

Clinical Interpretation of Cardiopulmonary Exercise Testing: Current Pitfalls and Limitations.

Several shortcomings on cardiopulmonary exercise testing (CPET) interpretation have shed a negative light on the test as a clinically useful tool. For instance, the reader should recognize patterns of dysfunction based on clusters of variables rather than relying on rigid interpretative algorithms. Correct display of key graphical data is of foremost relevance: prolixity and redundancy should be avoided.

The role of peripheral muscle fatigability on exercise intolerance in COPD.

Introduction: Exercise limitation in chronic obstructive pulmonary disease (COPD) is multi-factorial; however, growing evidence indicates that muscle dysfunction may contribute in some patients.

Areas Covered: This work outlines current evidence for and against increased peripheral muscle fatigability in COPD through a comprehensive review of relevant literature available on PubMed/MEDLINE until May 2020. The authors first discuss key methodological issues relative to muscle fatigue assessment by non-volitional techniques, particularly magnetic stimulation.

Are the "critical" inspiratory constraints actually decisive to limit exercise tolerance in COPD?

https://bit.ly/2A6bCxD.

Current Evidence for Minimally Invasive Surgery During the COVID-19 Pandemic and Risk Mitigation Strategies: A Narrative Review.

Objective: Our objective was to review the literature surrounding the risks of viral transmission during laparoscopic surgery and propose mitigation measures to address these risks.

Summary Background Data: The SARS-CoV-2 pandemic has caused surgeons the world over to re-evaluate their approach to surgical procedures given concerns over the risk of aerosolization of viral particles and exposure of operating room staff to infection. International society guidelines advise against the use of laparoscopy; however, the evidence on this topic is scant and recommendations are based on the perceived most cautious course of action.

Introduction of new techniques and technologies in surgery: Where is transanal total mesorectal excision today?

The introduction of new surgical techniques and technologies has traditionally been unregulated. In many settings surgeons frequently adopt novel procedures without following a structured program of implementation or supervision. The appearance of innovative technology played a pivotal role in the advancement of new surgical techniques during the industrial revolution.

A frame of reference for assessing the intensity of exertional dyspnoea during incremental cycle ergometry.

Assessment of dyspnoea severity during incremental cardiopulmonary exercise testing (CPET) has long been hampered by the lack of reference ranges as a function of work rate (WR) and ventilation ( ). This is particularly relevant to cycling, a testing modality which overtaxes the leg muscles leading to a heightened sensation of leg discomfort.Reference ranges based on dyspnoea percentiles (0-10 Borg scale) at standardised work rates and were established in 275 apparently healthy subjects aged 20-85 years (131 men).

Complex surgery and perioperative systemic therapy for genitourinary cancer of the retroperitoneum.

Objective: The purpose of the present guideline is to recommend surgical or systemic treatment for metastatic testicular cancer; T3b or T4, or node-positive, and metastatic renal cell cancer (rcc); and T3, T4, or node-positive upper tract urothelial (utuc) cancer.

Methods: Draft recommendations were formulated based on evidence obtained through a systematic review of randomized controlled trials, comparative retrospective studies, and guideline endorsement. The draft recommendations underwent an internal review by clinical and methodology experts, and an external review by clinical practitioners.

Moving Towards Common Data Elements and Core Outcome Measures in Frailty Research.

With aging populations around the world, frailty is becoming more prevalent increasing the need for health systems and social systems to deliver optimal evidence based care. However, in spite of the growing number of frailty publications, high-quality evidence for decision making is often lacking. Inadequate descriptions of the populations enrolled including frailty severity and frailty conceptualization, lack of use of validated frailty assessment tools, utilization of different frailty instruments between studies, and variation in reported outcomes impairs the ability to interpret, generalize and implement the research findings.

Uncovering the mechanisms of exertional dyspnoea in combined pulmonary fibrosis and emphysema.

The prevailing view is that exertional dyspnoea in patients with combined idiopathic pulmonary fibrosis (IPF) and emphysema (CPFE) can be largely explained by severe hypoxaemia. However, there is little evidence to support these assumptions.We prospectively contrasted the sensory and physiological responses to exercise in 42 CPFE and 16 IPF patients matched by the severity of exertional hypoxaemia.

Reduced exercise ventilatory efficiency in adults with cystic fibrosis and normal to moderately impaired lung function.

Despite being a hallmark and an independent prognostic factor in several cardiopulmonary diseases, ventilatory efficiency-i.e., minute ventilation/carbon dioxide output relationship (V̇e/V̇co)-has never been systematically explored in cystic fibrosis (CF).

Concomitant anti-platelet therapy in warfarin-treated patients undergoing cardiac rhythm device implantation: A secondary analysis of the BRUISE CONTROL trial.

Background: Anti-platelet therapy is commonly used in patients receiving oral anticoagulation and may increase bleeding risk among patients undergoing cardiac implantable electronic device (CIED) surgery. We sought to determine the proportion of anticoagulated patients who are concomitantly receiving anti-platelet therapy, the associated risk of clinically significant hematoma (CSH), and the proportion of patients in whom anti-platelet usage is guideline-indicated.

Methods: A secondary analysis of the Bridge or Continue Coumadin for Device Surgery Randomized Controlled Trial (BRUISE CONTROL).

ERS statement on respiratory muscle testing at rest and during exercise.

Assessing respiratory mechanics and muscle function is critical for both clinical practice and research purposes. Several methodological developments over the past two decades have enhanced our understanding of respiratory muscle function and responses to interventions across the spectrum of health and disease. They are especially useful in diagnosing, phenotyping and assessing treatment efficacy in patients with respiratory symptoms and neuromuscular diseases.

Use of a maternal newborn audit and feedback system in Ontario: a collective case study.

Background: As part of a larger study examining the effectiveness of the Maternal Newborn Dashboard, an electronic audit and feedback system to improve maternal-newborn care practices and outcomes, the purpose of this study was to increase our understanding of factors explaining variability in performance after implementation of the Dashboard in Ontario, Canada.

Methods: A collective case study. A maximum variation sampling approach was used to invite hospitals reflecting different criteria to participate in a 1-day to 2-day site visit by the research team.