Sizing and mending of appendicular muscle mass for hydration during the 12-lead electrocardiogram: True incidence of sarcopenia in heart failure.

BACKGROUND: Our aim was to develop and evaluate a method for the measurement of muscle mass during the 12-channel electrocardiogram (ECG), to determine the incidence of sarcopenia in patients with overhydration and to correct it for congestion. METHODS: A 12-channel ECG that simultaneously provided multifrequency segmental impedance data was used to measure total body water (TBW), extracellular water (ECW), ECW/TBW ratio and appendicular muscle mass (AppMM), validated by whole-body dual-energy X-ray absorptiometry. The mean ECW/TBW ratio was 0.24 ± 0.018 (SD) and 0.25 ± 0.016 for young (age range 20-25 years) healthy males (n = 77) and females (n = 88), respectively. The deviation of the ECW/TBW ratio from this mean was used to correct AppMM for excess ECW ('dry AppMM') in 869 healthy controls and in 765 patients with chronic heart failure (CHF) New York Heart Association classes II-IV. The association of AppMM and dry AppMM with grip strength was also examined in 443 controls and patients. RESULTS: With increasing N-terminal pro-brain natriuretic peptide (NT-proBNP), a continuous decline of AppMM indices is observed, which is more pronounced for dry AppMM indices (for males with NT-proBNP < 125 pg/mL: AppMM index mean = 8.4 ± 1.05, AppMM index dry mean = 8.0 ± 1.46 [n = 201, P < 0.001]; for females with NT-proBNP < 150 pg/mL: AppMM index mean = 6.4 ± 1.0, AppMM index dry mean = 5.8 ± 1.18 [n = 198, P < 0.001]; for males with NT-proBNP > 1000 pg/mL: AppMM index mean = 7.6 ± 0.98, AppMM index dry mean = 6.2 ± 1.11 [n = 137, P < 0.001]; and for females with NT-proBNP > 1000 pg/mL: AppMM index mean = 5.9 ± 0.96, AppMM index dry mean = 4.8 ± 0.94 [n = 109, P < 0.001]). The correlation between AppMM and upper-body AppMM and grip strength (r-value) increased from 0.79 to 0.83 (P < 0.001) and from 0.80 to 0.84 (P < 0.001), respectively, after correction (n = 443). The decline of AppMM with age after correction for ECW is much steeper than appreciated, especially in males: In patients with CHF and sarcopenia, the incidence of sarcopenia may be up to 30% higher after correction for ECW excess according to the European (62% vs. 57%, for males, and 43% vs. 31%, for females) and Foundation for the National Institutes of Health (FNIH) (56% vs. 46%, for males, and 54% vs. 38%, for females) consensus guidelines. CONCLUSIONS: The incidence of sarcopenia in CHF as defined by the European Working Group on Sarcopenia and FNIH consensus may be up to 30% higher after correction for ECW excess. This correction improves the correlation between muscle mass and strength. The presented technology will facilitate, on a large scale, screening for sarcopenia, help identify mechanisms and improve understanding of clinical outcomes.

Long-term motor activity, cardiopulmonary performance and quality of life in abdominal wall defect patients.

AIM: To assess whether patients born with an abdominal wall defect (AWD) have impaired cardiorespiratory performance capacity, motor skills, core stability or quality of life in a long-term follow up. METHODS: Patients diagnosed with AWD between 2002 and 2013 were invited to participate in the study, which included clinical examination, spirometry, cardiopulmonary exercise performance testing, assessment of motor activity, ultrasound, electromyography of the abdominal wall and assessment of the Gastrointestinal Quality of Life Index (GIQLI). The results were compared to a healthy control group matched for age, sex, BMI, and physical activity levels. RESULTS: In total, 18 AWD patients (mean age 12.6 ± 3.5 years) were included and there were no significant differences in anthopometric data compared to the control group (n = 18). AWD patients had a significantly lower GIQLI score (AWD mean 137.2 ± 6.8 vs. control mean 141.4 ± 4.9; p = 0.038) and were affected by decreased motor abilities with significantly higher Dordel-Koch-Test values (AWD median 3.54/IQR 1 vs. control median 2.8/IQR 1; p = 0.005). CONCLUSION: Follow-up examinations of AWD patients revealed decreased motor abilities and GIQLI scores while cardiopulmonary function was not different compared to healthy controls. The clinical impact of these findings remains to be elucidated. IMPACT: Clinical examination, assessment of the gastrointestinal quality of life, sport medical testing, electromyography and abdominal wall ultrasound were performed in patients with congenital abdominal wall defect and compared to an age and sex matched healthy control group. Results of spirometry and spiroergometry, ultrasound or electromyography did not significantly differ between the groups. Significantly decreased locomotor function and gastrointestinal quality of life were found in patients with abdominal wall defect. However, the clinical impact of these findings remains to be elucidated.

Performance of Different Accelerometry-Based Metrics to Estimate Oxygen Consumption during Track and Treadmill Locomotion over a Wide Intensity Range.

Accelerometer data can be used to estimate incident oxygen consumption (VO2) during physical activity. Relationships between the accelerometer metrics and VO2 are typically determined using specific walking or running protocols on a track or treadmill. In this study, we compared the predictive performance of three different metrics based on the mean amplitude deviation (MAD) of the raw three-dimensional acceleration signal during maximal tests performed on a track or treadmill. A total of 53 healthy adult volunteers participated in the study, 29 performed the track test and 24 the treadmill test. During the tests, the data were collected using hip-worn triaxial accelerometers and metabolic gas analyzers. Data from both tests were pooled for primary statistical analysis. For typical walking speeds at VO2 less than 25 mL/kg/min, accelerometer metrics accounted for 71-86% of the variation in VO2. For typical running speeds starting from VO2 of 25 mL/kg/min up to over 60 mL/kg/min, 32-69% of the variation in VO2 could be explained, while the test type had an independent effect on the results, except for the conventional MAD metrics. The MAD metric is the best predictor of VO2 during walking, but the poorest during running. Depending on the intensity of locomotion, the choice of proper accelerometer metrics and test type may affect the validity of the prediction of incident VO2.

Tryptophan recovery index as a new biomarker for fitness.

The maximal oxygen uptake (VO2max) and maximal power output (Pmax) are commonly used parameters to evaluate the endurance fitness status. A connection between exercise and the kynurenine pathway (KP), which describes the metabolism of unused tryptophan, has already been reported. However, a potential association of the KP with endurance fitness levels remains unknown. In this study, adolescent competitive athletes performed an exhaustive incremental exercise test. Blood samples were taken before, directly after, and 30 minutes after the end of exercise. Tryptophan (Trp), kynurenine (Kyn) and kynurenic acid (KA) serum levels were determined by high-performance liquid chromatography (HPLC). Forty-four male and 27 female athletes (median age: 16 years) were recruited. During exhaustive exercise tests, Trp initially declined and then increased 30 minutes after discontinuing exercise. Similar findings were observed for Kyn, whereas KA levels behaved inversely. After incremental exhaustive exercise the relative increase of Trp concentrations, termed the tryptophan-recovery-index (TRI), showed a highly significant positive correlation with VO2max and Pmax (r=0.468 and 0.491, p-values <0.001). There was a significant gender-difference with higher levels of all metabolites at all measured time points in male participants. In the present study, a highly significant correlation was found between the TRI and the maximal oxygen uptake in well-trained athletes. The implementation of TRI can therefore be suggested as a biomarker for physical fitness.

Cardiorespiratory performance and locomotor function of patients with anorectal malformations.

The aim of this study was to assess whether adolescents following anorectal malformation repair have a decreased cardiorespiratory performance capacity and impaired motor skills. All eligible children treated for ARMs between 2000 and 2014 were invited to participate in a prospective study consisting of a clinical examination, evaluation of Bowel function and Quality of Life, spirometry, spiroergometry and assessment of the motor activity. The results were compared to a healthy age- and sex-matched control group. There was no statistically significant difference in height, weight, BMI, muscle mass or body fat percentage between the study and the control group. Nine out of 18 patients (50%) had an excellent functional outcome with a normal Bowel Function Score. Spirometry revealed no significant differences between ARM patients and controls, four patients showed a ventilation disorder. Spiroergometry revealed a significantly lower relative performance capacity and the overall rating of the motor activity test showed significantly decreased grades in ARM patients. ARM patients were affected by an impaired cardiopulmonary function and decreased motor abilities. Long-term examinations consisting of routine locomotor function evaluation and spiroergometry are advisable to detect impaired cardiopulmonary function and to prevent a progression of associated complications and related impaired quality of life.

Bicycle spiroergometry: comparison of standardized examination protocols for adolescents: is it necessary to define own standard values for each protocol?

PURPOSE: To compare performance data of adolescents collected with five different bicycle spiroergometry protocols and to assess the necessity for establishing standard values for each protocol. METHODS: One-hundred-twenty adolescents completed two bicycle spiroergometries within 14 days. One of the two tests was performed based on our institutional weight-adapted protocol (P0). The other test was performed based on one out of four exercise protocols widely used for children and adolescents (P1, 2, 3 or 4) with 30 persons each. The two tests were performed in a random order. Routine parameters of cardiopulmonary exercise tests (CPET) such as VO2peak, maximum power, O2 pulse, OUES, VE/VCO2 slope as well as ventilatory and lactate thresholds were investigated. Agreement between protocols was evaluated by Bland-Altman analysis, coefficients of variation (CV) and intra-class correlation coefficients (ICC). RESULTS: None of the CPET parameters were significantly different between P0 and P1, 2, 3 or 4. For most of the parameters, low biases between P0 and P1-P4 were found and 95% confidence intervalls were narrow. CV and ICC values largely corresponded to well-defined analytical goals (CV < 10% and ICC > 0.9). Only maximal power (Pmax) showed differences in size and drift of the bias depending on the length of the step duration of the protocols. CONCLUSION: Comparability between examination protocols has been shown for CPET parameters independent on step duration. Protocol-dependent standard values do not appear to be necessary. Only Pmax is dependent on the step duration, but in most cases, this has no significant influence on the fitness assessment.

Volatile Organic Compounds, Bacterial Airway Microbiome, Spirometry and Exercise Performance of Patients after Surgical Repair of Congenital Diaphragmatic Hernia.

The aim of this study was to analyze the exhaled volatile organic compounds (VOCs) profile, airway microbiome, lung function and exercise performance in congenital diaphragmatic hernia (CDH) patients compared to healthy age and sex-matched controls. A total of nine patients (median age 9 years, range 6-13 years) treated for CDH were included. Exhaled VOCs were measured by GC-MS. Airway microbiome was determined from deep induced sputum by 16S rRNA gene sequencing. Patients underwent conventional spirometry and exhausting bicycle spiroergometry. The exhaled VOC profile showed significantly higher levels of cyclohexane and significantly lower levels of acetone and 2-methylbutane in CDH patients. Microbiome analysis revealed no significant differences for alpha-diversity, beta-diversity and LefSe analysis. CDH patients had significantly lower relative abundances of Pasteurellales and Pasteurellaceae. CDH patients exhibited a significantly reduced Tiffeneau Index. Spiroergometry showed no significant differences. This is the first study to report the VOCs profile and airway microbiome in patients with CDH. Elevations of cyclohexane observed in the CDH group have also been reported in cases of lung cancer and pneumonia. CDH patients had no signs of impaired physical performance capacity, fueling controversial reports in the literature.

Cardiorespiratory performance capacity and airway microbiome in patients following primary repair of esophageal atresia.

BACKGROUND: Patients following repair of an esophageal atresia (EA) or tracheoesophageal fistula (TEF) carry an increased risk of long-term cardiopulmonary malaise. The role of the airway microbiome in EA/TEF patients remains unclear. METHODS: All EA/TEF patients treated between 1980 and 2010 were invited to a prospective clinical examination, spirometry, and spiroergometry. The airway microbiome was determined from deep induced sputum by 16 S rRNA gene sequencing. The results were compared to a healthy age- and sex-matched control group. RESULTS: Nineteen EA/TEF patients with a mean age of 24.7 ± 7 years and 19 age- and sex-matched controls were included. EA/TEF patients showed a significantly lower muscle mass, lower maximum vital capacity (VCmax), and higher rates of restrictive ventilation disorders. Spiroergometry revealed a significantly lower relative performance capacity and lower peak VO2 in EA/TEF patients. Alpha- and beta-diversity of the airway microbiome did not differ significantly between the two groups. Linear discriminant effect size analysis revealed significantly enriched species of Prevotella_uncultured, Streptococcus_anginosus, Prevotella_7_Prevotella_enoeca, and Mogibacterium_timidum. CONCLUSION: EA/TEF patients frequently suffer from restrictive ventilation disorders and impaired cardiopulmonary function associated with minor alterations of the airway microbiome. Long-term examinations of EA/TEF patients seem to be necessary in order to detect impaired cardiopulmonary function. IMPACT: The key messages of the present study are a significantly decreased VCmax and exercise performance, as well as airway microbiome differences in EA/TEF patients. This study is the first to present parameters of lung function and exercise performance in combination with airway microbiome analysis with a mean follow-up of 24 years in EA/TEF patients. Prospective, long-term studies are needed to unravel possible interactions between alterations of the airway microbiome and impaired pulmonary function in EA/TEF patients.

Measurement of aortofemoral volume wave velocity during the routine 12-channel ECG: relation to age, physiological hemoglobin A 1C, triglycerides and SBP in healthy individuals.

OBJECTIVE: Measurements of pulse wave velocity are generally thought to be too impractical for clinical routine. This study aimed to develop a method that can be performed during routine 12-channel ECG. METHODS: A 12-channel ECG simultaneously supplies arterial impedance plethysmographic signals from the extremities beside segmental multifrequency impedance measurements for obtaining body composition. The origin of the plethysmographic signal (volume wave) at the arms and legs was determined at the level of the elbows and the knees. The volume wave velocity (VWV) at the aorta and femoral arteries was calculated from the time difference of the plethysmographic signals between arms and legs. RESULTS: Automated measurement of VWV was highly reproducible (r = 0.96). In 107 participants in perfect health, VWV in different models was positively related to age, physiological hemoglobin A 1C, triglycerides, normal standardized unattended blood pressure, but not to physiological low-density lipoprotein-cholesterol and high-density lipoprotein-cholesterol. Aortofemoral VWV was significantly higher in patients with established coronary artery disease than in healthy controls of the same age group (18.1 ±â€Š5.8 vs. 11.9 ±â€Š1.7 m/s, P < 0.001). VWV in study participants was higher than tonometrically determined pulse wave velocity as muscular arteries are included (13.2 ±â€Š5.81 vs. 8.8 ±â€Š2.98 m/s, n = 115, P < 0.001). CONCLUSION: These background arterial impedance plethysmographic measurements for the measurement of VWV made simultaneously during 12-channel ECG show promise for large-scale, routine clinical assessment of large artery function.

Do Anthropometric and Aerobic Parameters Predict a Professional Career for Adolescent Skiers?

The aim of this study was to evaluate whether spiroergometry performance in adolescent alpine ski racers can predict later advancement to a professional career. Over 10 consecutive years, adolescent skiers of the regional Austrian Youth Skier Squad (local level) underwent annual medical examinations, including exhaustive bicycle spiroergometry. The performance was determined at fixed (2 and 4 mmol/l serum lactate) and individual (individual anaerobic threshold (IAT) and lactate equivalent (LAE)) thresholds. Data from the last available test were compared between skiers who later advanced to the professional level (Austrian national ski team) and those who did not. Ninety-seven alpine skiers (n=51 male; n=46 female); mean age 16.6 years (range 15-18) were included. Of these, 18 adolescents (n=10 male; n=8 female) entered a professional career. No significant differences were found for maximum oxygen uptake (VO2max). Athletes advancing to the professional level had significantly higher performance and VO2 at LAE. Additionally, male professionals had significantly higher performances at fixed thresholds and the IAT. The performance and VO2 at the LAE, and thus the ability to produce power at a particular metabolic threshold, was the most relevant spiroergometric parameter to predict a later professional career.

The influence of acute physical effort on liver stiffness estimation using Virtual Touch Quantification (VTQ). Preliminary results.

AIM: Food intake and acutely decompensated cardiac failure may impair liver stiffness estimations, mainly because these methods are influenced by liver blood flow variation encountered in these conditions. It is well known that also during physical effort liver blood flow changes, due to the redistribution of blood flow mainly to the skeletal muscles. The aim of this study is to assess the change of liver shear- wave velocities immediately after cessation of an acute physical effort. A secondary aim was to find the proper timing for accurate liver stiffness estimation after physical exhaustion. MATERIAL AND METHODS: Liver shear-wave velocities were measured using virtual touch quantification (VTQ) in seven apparently healthy volunteers, in fasting conditions. All subjects underwent a complete abdominal ultrasound study, including the liver VTQ. Then, all subjects performed a spiroergometry and thereafter, another series of three liver shear-wave velocity measurements were performed: immediately after spiroergometry, five min, and ten min after spiroergometry, respectively. RESULTS: Before spiroergoemetry, the mean liver shear-wave velocity was 1.05+/-0.12 m/sec. Immediately after spiroergometry, mean liver shear-wave velocities increased significantly, measuring 1.34+/-0.16 m/sec (p <0.01). The mean liver shear-wave velocities at five and ten minutes after exhausting were 1.23+/-0.14 m/sec and 1.05+/-0.11 m/sec respectively. CONCLUSIONS: Liver stiffness estimation using VTQ was influenced by acute physical exercise in our study group. Despite the small number of subjects, the preliminary results show that if patients had done physical effort before VTQ elastography, they should rest at least ten minutes before reliable liver stiffness estimations can be performed.

Minimally invasive correction of pectus excavatum in adult patients.

OBJECTIVE: The repair of pectus excavatum by minimally invasive surgery (Nuss procedure) is well established among pediatric surgeons. Studies on adult patients are rare. We analyzed the efficacy of minimally invasive pectus repair in a series of adult patients. METHODS: We prospectively included all adult patients with minimally invasive repair of funnel chest treated from 2000 to 2005. The pectus bar was inserted under thoracoscopic control. On the right side a stabilizer was used to prevent bar displacement. Postoperative pain control was provided by epidural catheters. Clinical checks were performed 2 weeks, 3 months, and then annually after discharge. RESULTS: Forty-three adult patients (39 men, 4 women) with a mean age of 22 years (range 18-39 years) were included. Mean duration of the operative procedures was 70 minutes (range 29-125 minutes); mean length of hospital stay was 9.3 days. Bars were removed from 15 patients 3 years after implantation. Minor complications occurred in 8 patients (19%), with intrapleural effusions being most frequent (n = 5). Three patients (7%) had major complications: drainage of a pneumothorax (n = 2) and bar displacement (n = 1). The cosmetic results were excellent and patient satisfaction was high. CONCLUSIONS: We conclude that the Nuss procedure was beneficial in adult patients. Dislocation of the pectus bar can be prevented by submuscular placement. The use of corticosteroids may be helpful in case of repeated, uncontaminated pleural effusions. Patient satisfaction and the acceptable number and kind of complications are encouraging.