The incidence of cardiac arrhythmias during exercise stress testing: a focus on patients with severe obesity undergoing sleeve gastrectomy.

INTRODUCTION: Obesity is associated with a higher risk of cardiac arrhythmias. Sleeve gastrectomy (SG) is a common bariatric surgery with beneficial effects on weight loss and comorbidities. The study aimed to investigate the prevalence of arrhythmias during maximal exercise testing in patients with moderate-severe obesity and to evaluate the impact of SG on these arrhythmic events. METHODS: All patients with moderate or severe obesity who were considered suitable candidates for SG between June 2015 and September 2020 were recruited. Each patient underwent three incremental, maximal, ECG-monitored cardiopulmonary exercise test 1 month before and 6 and 12 months after SG; the frequency and complexity of ventricular premature beats (VPBs) and atrial premature beats (APBs) have been evaluated during rest, exercise and recovery phases. RESULTS: Fifty patients with severe obesity (BMI 46.39 ± 7.89 kg/m2) were included in the study. After SG, patients presented a decreased BMI (34.15 ± 6.25 kg/m2 at 6 months post-SG and 31.87 ± 5.99 kg/m2 at 12 months post-SG). At 6 months post-SG, an increase in VPBs, mainly during the recovery phase, was observed. At 12 months post-SG, a reduction in VPBs compared with the 6 months evaluation was showed. CONCLUSION: Although in the early post-surgical phase the risk of exercise-induced arrhythmias may be higher, SG does not seem to increase the occurrence of arrhythmias in the long-term. No life-threating arrhythmias were found during post-SG evaluations.

Can exercise test intensity and modality affect the prevalence of arrhythmic events in young athletes?

Pre-participation screening is performed to identify underlying cardiac conditions that may also lead to sudden cardiac death. Our aim is to compare submaximal Harvard Step Test (HST) with incremental Maximal Exercise Test (MET) on treadmill to induce and detect arrhythmias in younger athletes. A total of 1000 athletes (mean age 14.6 ± 4.7 years) were evaluated, 500 with MET and 500 with HST, all with continuous ECG monitoring until three minutes of recovery. Pre-test evaluation includes medical history, clinical evaluation and resting electrocardiogram. Ventricular and/or supraventricular arrhythmias were observed in 2.6% of athletes performing HST and in 8.4% during MET (p < 0.001). Incidence of arrhythmias remained higher for MET also considering separately exercise phase (0.8% vs. 5.2%; p < 0.001) and recovery phase (2.0% vs. 6.0%; p < 0.01). No gender differences were observed. Results suggest that MET induces more arrhythmias than submaximal HST, regardless of test phase. Higher test intensity and longer exercise duration might influence test outcomes, making MET more arrhythmogenic.

Physical Fitness as a Prognostic Marker for Infectious Events in Kidney Transplant Recipients.

INTRODUCTION: Infectious events are one of the leading causes of death in kidney transplant recipients (KTRs). KTRs have reduced cardiorespiratory fitness (CRF), a predictor for infections in other populations. The aim of this study was to investigate whether CRF and muscle strength are prognostic markers for infectious events in KTRs. METHODS: In this retrospective cohort study, 155 KTRs underwent an incremental, maximal cardiopulmonary exercise test (CPET) 3 months after transplantation. CRF was analyzed with peak oxygen consumption (VO2 peak) while muscle strength with isometric handgrip (HG) test. Laboratory blood samples and drug therapy were collected. The median follow-up period was 54 (interquartile range 38-62) months. Cox regression analyses were performed to evaluate predictors of infectious events adjusting for potential confounders. RESULTS: During this study, severe infectious events occurred in 41 subjects (26.5%). 15.5% (n = 24) of patients had a severely reduced CRF, defined as a VO2 peak below the 5th percentile of the reference values reported for a matched healthy population. The hazard ratio for infectious events in this subgroup was 2.389 (95% CI = 1.188-4.801, p = 0.014), independently of gender, age, BMI, time on dialysis, hemoglobin concentration, eGFR, diabetes, and immunosuppressive regimen. On the contrary, no significant association of HG strength and infections was found. CONCLUSION: Therefore, low CRF may be considered as a modifiable predictor of severe infectious events in KTRs. A CPET should thus be recommended for cardiovascular screening, evaluation of CRF, and tailored exercise prescription to reduce the risk of infections and potentially improve long-term outcomes of transplantation.

Early repolarization in adolescent athletes: A gender comparison of ECG and echocardiographic characteristics.

BACKGROUND: The early repolarization pattern (ERp) is an electrocardiographic finding previously associated with arrhythmic risk in adults. The purpose of this study is to evaluate the prevalence and characteristics of ERp in a group of adolescent athletes according to gender. Furthermore, potential associations with clinical, electrocardiographic, and echocardiographic parameters are explored. METHODS: In this cross-sectional study young athletes (age < 18 years) were consecutively enrolled during the annual pre-participation evaluation, undergoing also transthoracic echocardiography assessment from January 2015 to March 2020. RESULTS: The prevalence of ERp was 27% in the whole population. Athletes with ERp were more frequently men practicing endurance sports. Women with ERp showed lower heart rate at rest, greater posterior, and relative ventricular wall thickness than those without ERp. Men with ERp presented higher systolic blood pressure at peak exercise, greater septal wall thickness, and indexed left ventricular mass than those without ERp. Both genders with ERp showed increased QRS voltage and narrower QRS duration. The ERp phenotype in men was more frequently notched with higher amplitude and ascending ST segment. Women's ERp presented more frequently a slurred morphology, especially in the inferior leads, and horizontal ST slope. No differences emerged in the occurrence of arrhythmias at rest and during maximal exercise test between groups, even considering higher risk phenotypes. CONCLUSIONS: ERp is an ECG finding compatible with normal cardiac adaptations to training in young athletes. ERp demonstrated gender differences regarding phenotypes previously associated with increased cardiovascular risk, not showing any differences in arrhythmias during maximal exercise test.

Cardiopulmonary exercise testing in patients with moderate-severe obesity: a clinical evaluation tool for OSA?

PURPOSE: Obstructive sleep apnea (OSA) is a widespread comorbidity of obesity. Nasal continuous positive airway pressure (CPAP) has been demonstrated very effective in treating patients with OSA. The aims of this study were to investigate whether or not cardiopulmonary exercise testing (CPET) can characterize patients with OSA and to evaluate the effect of nasal CPAP therapy. METHODS: An observational study was conducted on patients with moderate to severe obesity and suspected OSA. All patients underwent cardiorespiratory sleep study, spirometry, and functional evaluation with ECG-monitored, incremental, maximal CPET. RESULTS: Of the 147 patients, 94 presented with an apnea-hypopnea index (AHI) ≥ 15 events/h and were thus considered to have OSA (52 receiving nasal CPAP treatment; 42 untreated) while 53 formed a control group (AHI < 15 events/h). Patients with untreated OSA showed significantly lower oxygen uptake (VO2), heart rate, minute ventilation (VE), and end tidal carbon dioxide (PETCO2) at peak exercise compared to controls. Patients receiving nasal CPAP showed higher VE and VO2 at peak exercise compared to untreated patients. A difference in PETCO2 between the maximum value reached during test and peak exercise (ΔPETCO2 max-peak) of 1.71 mmHg was identified as a predictor of OSA. CONCLUSION: Patients with moderate to severe obesity and untreated OSA presented a distinctive CPET-pattern characterized by lower aerobic and exercise capacity, higher PETCO2 at peak exercise associated with a lower ventilatory response. Nasal CPAP treatment was shown to positively affect these cardiorespiratory adaptations during exercise. ΔPETCO2 max-peak may be used to suggest OSA in patients with obesity.

Edmonton Obesity Staging System: an improvement by cardiopulmonary exercise testing.

BACKGROUND/OBJECTIVES: Different approaches are used to classify obesity severity. Beyond classical anthropometric measurements, the Edmonton Obesity Staging System (EOSS) considers medical, physical and psychological parameters. However, this method has some limitations, principally due to the absence of an objective measure for physical impairment. The aim of our study is thus to overcome this limitation suggesting a new functional parameter obtained by cardiopulmonary exercise testing (CPET), i.e., cardiorespiratory fitness (CRF), expressed as weight-adjusted peak oxygen consumption (VO2peak/kg). SUBJECTS/METHODS: This observational cross-sectional study conducted on a population of 843 patients affected by obesity finally enrolled 500 subjects. Every patient underwent clinical, anthropometric, biochemical assessment and CPET. First, participants have been classified according to standard EOSS in five stages. Second, patients were reclassified according to the new modified EOSS (EOSS-CRF) based on their age- and gender-appropriate VO2peak/kg percentiles as reported in the healthy normal-weight population of the FRIEND registry. RESULTS: VO2peak/kg was significantly different between standard EOSS classes 1 and 2 and classes 1 and 3 (ANCOVA p model = 0.004), whereas patients in classes 2 and 3 showed similar CRF. The EOSS-CRF classification varied in number of patients in each class compared to EOSS, particularly with a shift from class 2 to class 3. Moreover, CRF showed that physical impairment is less addressed by EOSS when compared to EOSS-CRF. CONCLUSIONS: The integration of EOSS with CRF allowed us to assign to each patient a severity index that considers not only clinical parameters, but also their functional impairment through a quantitative and prognostically important parameter (VO2peak/kg). This improvement of the staging system may also provide a better approach to identify individuals at increased risk of mortality leading to targeted therapeutic management and prognostic risk stratification for patients with obesity.

A clinical evaluation of VO2 kinetics in kidney transplant recipients.

PURPOSE: Aerobic exercise capacity is reduced in patients with chronic kidney disease, partly due to alterations at the muscular and microvascular level. This study evaluated oxygen uptake (VO2) kinetics as indicator of muscular oxidative metabolism in a population of Kidney Transplant Recipients (KTRs). METHODS: Two groups of KTRs enrolled 3 (n = 21) and 12 months (n = 14) after transplantation and a control group of healthy young adults (n = 16) underwent cardiopulmonary exercise testing on cycle-ergometer. The protocol consisted in two subsequent constant, moderate-load exercise phases with a final incremental test until exhaustion. RESULTS: The time constant of VO2 kinetics was slower in KTRs at 3 and 12 months after transplantation compared to controls (50.4 ± 13.1 s and 43.8 ± 11.6 s vs 28.9 ± 8.4 s, respectively; P < 0.01). Peak VO2 was lower in KTRs evaluated 3 months after transplantation compared to patients evaluated after 1 year (21.3 ± 4.3 and 26.4 ± 8.0 mL/kg/min; P = 0.04). Blood haemoglobin (Hb) concentration was higher in KTRs evaluated at 12 months (12.8 ± 1.7 vs 14.6 ± 1.7 g/dL; P < 0.01). Among KTRs, τ showed a moderate negative correlation with Peak VO2 (ρ = - 0.52) and Oxygen uptake efficiency slope (OUES) (r = - 0.57) while no significant correlation with Hb and peak heart rate. CONCLUSIONS: KTRs show slower VO2 kinetics compared to healthy controls. Hb and peak VO2 seem to improve during the first year after transplantation. VO2 kinetics were significantly associated with indices of cardiorespiratory fitness, but less with central determinants of aerobic capacity, thus suggesting a potential usefulness of adding this index of muscular oxidative metabolism to functional evaluation in KTRs.

Exercise prescription and tailored physical activity intervention in onco-hematology inpatients, a personalized bedside approach to improve clinical best practice.

Therapy of hematological malignancies lasts for long periods implicating various complications. The chemotherapy induces fatigue and forces bed rest. These features strongly contribute to a general impairment of the physical efficiency. Oppositely, an increase of physical exercise can prevent or reduce this weakening. Few trials examined the efficacy of an exercise in onco-hematological inpatients, during their hospitalization. Therefore, this study aimed to determine the feasibility of an inter-hospital intervention and the beneficial role of a tailored exercise program in the maintenance of the physical function in onco-hematological inpatients. The study included 42 patients, which were allocated in two groups. In the intervention group (IG) a tailored exercise protocol during patient's hospitalization was administered. Exercise protocol was focused on development of strength, balance control, and flexibility; sessions were directly performed in the patient's hospital room everyday for 15 to 30 minutes. Exercise was supervised by an exercise specialist and driven by a multimedia support. Control group (CG) remained physically inactive for all period of hospitalization. To examine the interaction between the two situations (T0 and T1 ) and the two groups (IG and CG) for all dependent variables, a 2 × 2 within-subjects contrasts model analysis of variance was applied. Within groups analysis displayed significant differences in grip and leg strength and in static balance control (P < 0.05) with medium to very large effect size. Results from this investigation showed that a tailored exercise protocol administered to hospitalized onco-hematological patients was feasible and efficient to promote the maintenance of their physical function, improving clinical best practice including exercise to the traditional treatment. Moreover, the magnitude of the difference between the IG and the CG underlined the importance to invite and stimulate patients to workout to preserve the physical function, counteracting side effects of chemotherapy treatments with a concurrent reduction in bed rest syndrome.

Comparison of cardiovascular screening guidelines for middle-aged/older adults.

PURPOSE: Although both European (EACPR) and American (ACSM) Scientific Societies have devised cardiovascular protocols for the assessment of "middle-aged/older" individuals who are about to participate in sports or physical exercise, there are no data regarding the guidelines' sensitivity of these measures. The aim of this study was to compare the outcomes of different international screening protocols. METHODS: This observational cross-sectional study evaluated 525 subjects (80% males; median age 50 [35-85] years) seeking medical certification before participating in sports or regular exercise. The screening protocol consisted in completing a personal history profile, a physical examination, a resting ECG, a maximal exercise test, and, when required, additional instrumental evaluations. The effectiveness of the current EACPR as well as the former and new ACSM guidelines was thereby analyzed. RESULTS: The full screening protocol uncovered 100 previously undetected cardiovascular conditions (main pathologies detected: 21 coronary artery disease (CAD), 14 arterial hypertension, 38 complex arrhythmias). When the European guideline was used, 49% of these conditions went undetected, including 10 CAD. When the former American guideline was used, 29% (6 CAD) went undetected; when the recently updated edition was used, 50% including 11 CAD went undetected. CONCLUSION: The former ACSM guideline demonstrated a higher diagnostic sensitivity than the newer version and the EACPR guideline. Current screening protocols might be adapted for subjects performing high-intensity exercise due to their higher risk for cardiovascular and exercise-associated adverse events. The use of an incremental ECG-monitored maximal exercise test seems to improve these screening outcomes.

The Fragmented QRS Complex in Lead V1: Time for an Update of the Athlete's ECG?

Differentiating between ECG patterns related to athletes' heart remodeling and pathological findings is a challenge in sports cardiology. As the significance of fragmented complex in athletes remains uncertain, this study aimed to assess the presence of fragmented QRS in lead V1 (fQRSV1) among young athletes and its association with heart adaptations and arrhythmias. Young athletes referred for annual pre-participation screening receiving a maximal exercise testing and transthoracic echocardiography from January 2015 to March 2021 were included. The study included 684 young athletes. The prevalence of fQRSV1 was 33%. Subjects with fQRSV1 had higher exercise capacity and indexes of right ventricular function and remodeling. Among highly trained athletes, the fQRSV1 group demonstrated also increased left ventricular wall thickness. No significant association existed between fQRSV1 and exercise-induced arrhythmias, even in highly trained athletes. The high prevalence of fQRSV1 in young athletes is associated with training-induced heart adaptations but not exercise-induced ventricular arrhythmias.

Respiratory exchange ratio overshoot during exercise recovery: a promising prognostic marker in HFrEF.

BACKGROUND AND AIMS: Transient increases (overshoot) in respiratory gas analyses have been observed during exercise recovery, but their clinical significance is not clearly understood. An overshoot phenomenon of the respiratory exchange ratio (RER) is commonly observed during recovery from maximal cardiopulmonary exercise testing (CPET), but it has been found reduced in patients with heart failure with reduced ejection fraction (HFrEF). The aim of the study was to analyze the clinical significance of these RER recovery parameters and to understand if these may improve the risk stratification of patients with HFrEF. METHODS: This cross-sectional study includes HFrEF patients who underwent functional evaluation with maximal CPET for the heart transplant checklist at our Sports and Exercise Medicine Division. RER recovery parameters, including RER overshoot as the percentual increase of RER during recovery (RER mag), have been evaluated after CPET with assessment of hard clinical long-term endpoints (MACEs/deaths and transplant/LVAD-free survival). RESULTS: A total of 190 patients with HFrEF and 103 controls were included (54.6 ± 11.9 years; 73% male). RER recovery parameters were significantly lower in patients with HFrEF compared to healthy subjects (RER mag 24.8 ± 14.5% vs 31.4 ± 13.0%), and they showed significant correlations with prognostically relevant CPET parameters. Thirty-three patients with HFrEF did not present a RER overshoot, showing worse cardiorespiratory fitness and efficiency when compared with those patients who showed a detectable overshoot (VO2 peak: 11.0 ± 3.1 vs 15.9 ± 5.1 ml/kg/min; VE/VCO2 slope: 41.5 ± 8.7 vs 32.9 ± 7.9; ΔPETCO2: 2.75 ± 1.83 vs 4.45 ± 2.69 mmHg, respectively). The presence of RER overshoot was associated with a lower risk of cardiovascular events and longer transplant-free survival. CONCLUSION: RER overshoot represents a meaningful cardiorespiratory index to monitor during exercise gas exchange evaluation; it is an easily detectable parameter that could support clinicians to comprehensively interpreting patients' functional impairment and prognosis. CPET recovery analyses should be implemented in the clinical decision-making of advanced HF.

Comparison of Cardiorespiratory Fitness Prediction Equations and Generation of New Predictive Model for Patients with Obesity.

PURPOSE: Cardiorespiratory fitness (CRF) is a critical marker of overall health and a key predictor of morbidity and mortality, but the existing prediction equations for CRF are primarily derived from general populations and may not be suitable for patients with obesity. METHODS: Predicted CRF from different non-exercise prediction equations was compared with measured CRF of patients with obesity who underwent maximal cardiopulmonary exercise testing (CPET). Multiple linear regression was used to develop a population-specific non-exercise CRF prediction model for treadmill exercise including age, sex, weight, height and physical activity level as determinants. RESULTS: 660 patients underwent CPET during the study period. Within the entire cohort, R2 values had a range of 0.24-0.46. Predicted CRF was statistically different from measured CRF for 19 included equations. Only 50% of patients were correctly classified into the measured CRF categories according to predicted CRF. A multiple model for CRF prediction (ml/min) was generated (R2 = 0.78) and validated using two cross-validation methods. CONCLUSIONS: Most used equations provide inaccurate estimates of CRF in patients with obesity, particularly in cases of severe obesity and low CRF. Therefore, a new prediction equation was developed and validated specifically for patients with obesity, offering a more precise tool for clinical CPET interpretation and risk stratification in this population.

Serial cardiopulmonary exercise testing in young patients after one-and-half ventricle repair and Fontan procedure: a comparative study.

BACKGROUND: The Fontan procedure is the palliative surgical treatment for different congenital heart diseases (CHD) with a univentricular heart, but it has been associated with decreased exercise capacity, cardiovascular morbidity, and premature mortality. The one-and-half ventricle repair (1.5VR) was introduced as an alternative to the Fontan procedure, specifically for selected patients with borderline hypoplastic right ventricle (HRV), aiming for a more physiological circulation. Despite these efforts, the benefit of 1.5VR over Fontan circulation comparison on clinical and functional outcomes remains unclear. The aim of this study was to investigate and compare young patients with HRV after 1.5VR with those with functional single right or left ventricles (FSRV or FSLV) after Fontan palliation over a 10-year follow-up period. METHODS: In this retrospective observational study, serial cardiopulmonary exercise tests (CPETs) performed in patients with 1.5VR and Fontan circulation between September 2002 and March 2024 have been analyzed. Only patients with at least 10 years of follow-up were considered. RESULTS: A total of 41 patients were included (age at baseline 8.6 ± 2.6 years): 21 with FSLV, 12 with FSRV, and 10 with 1.5VR. No differences in cardiorespiratory fitness and efficiency were shown at the first CPET assessment among the three groups. At 10-year follow-up, 1.5VR had higher cardiorespiratory fitness and efficiency compared to FSLV and FSRV patients. CONCLUSIONS: These findings suggest that the 1.5VR may provide superior long-term functional outcomes than the Fontan procedure in patients with borderline HRV. Further studies are needed to evaluate the impact on hard clinical endpoints.

Analysis of Walking Economy after Sleeve Gastrectomy in Patients with Severe Obesity.

BACKGROUND: Obesity is associated with a higher energy cost of walking which affects activities of daily living. Bariatric surgery with sleeve gastrectomy (SG) has beneficial effects on weight loss and comorbidities. PURPOSE: The aim of this study was to analyze the impact of SG on walking economy in subjects with severe obesity. METHODS: This observational cohort study included all patients with morbid obesity who were considered suitable candidates for SG between June 2017 and June 2019. Each patient underwent an incremental cardiopulmonary exercise test on a treadmill (modified Bruce protocol) one month before and six months after SG. Data on the energy cost of walking were recorded during three protocol stages (stage 0-slow flat walking: speed 2.7 km/h, slope 0%; stage ½-slow uphill walking: speed 2.7 km/h, slope 5%; stage 1-fast uphill walking: speed 4.0 km/h, slope 8%). RESULTS: 139 patients with morbid obesity (78% women; age 44.1 ± 10.7 years; BMI 42.5 ± 4.7 kg/m2) were included in the study. At six months post-SG, patients presented with a significantly decreased body weight (-30.5 ± 17.2 kg; p < 0.05), leading to an average BMI of 31.6 ± 4.2 kg/m2. The net energy cost of walking (measured in J/m and J/kg/m) of the subjects was lower compared to pre-SG at all three protocol stages. This improvement was also confirmed when the subjects were grouped by gender and obesity classes. CONCLUSION: After a significant weight loss induced by SG, regardless of the severity of obesity and gender, patients exhibited a lower energy expenditure and an improved walking economy. These changes make it easier to perform daily routines and may facilitate an increase in physical activity.

The impact of the COVID-19 pandemic on functional capacity in a population of young athletes: should we expect long-time consequences?

BACKGROUND: From 2020, most countries all over the world have implemented strategies aimed at limiting contagion of COVID-19. The pandemic caused a reduction in physical activity (PA) and sports at all levels. The aim of the present study was to analyze and quantify the related impact of imposed PA restrictions on functional capacity in young athletes. METHODS: This observational cohort study evaluated annually the exercise capacity of a sample of young athletes (N.=344) referred for the pre-participation screening at our Sports and Exercise Medicine Division (2017-2021). Standardized maximal exercise testing was performed on treadmill and linear mixed models analyzed metabolic equivalent of tasks (METs) and exercise time as dependent variables. RESULTS: METs and exercise time showed a reduction in the year 2020 and a subsequent increase in 2021, with males revealing a faster recovery in exercise capacity. Athletes who maintained >250 annual training hours were less affected by the pandemic. CONCLUSIONS: These data suggest a significant impact of forced physical inactivity on a cohort of apparently healthy young athletes. The COVID-19-related experience should lead to strategies to avoid negative effects and long-term consequences of containment measures.

Selective Functional Movement Assessment (SFMA) Reliability and Proposal of Its Use in Sports.

INTRODUCTION: The Selective Functional Movement Assessment (SFMA) is a functional movement assessment method to observe movement restrictions in individuals with known musculoskeletal disorders, although it has also been used to evaluate healthy athletes of different sports. AIM: The present paper aimed to evaluate the applicability of SFMA in a clinical setting and to verify whether a student can correctly perform it. METHODS: An introductory and explanatory email was sent to the subjects, containing the instructions needed to produce a video with SFMA evaluation movements. SFMA methodology was then used to analyze the received videos. The results between interobserver and intraobserver agreement were compared to the literature, considered the gold standard methods. RESULTS: Twenty-eight subjects (17.71 ± 1.96 years aged) were rated. The functional non-painful scenario (FN) has been assigned more frequently by all raters. The student's intra-rater reliability proved to be moderate (Kappa coefficient 0.49). Results for inter-rater reliability showed that the reliability degree between the senior physiotherapist and student before and after their educational path is good (Kappa coefficient 0.60 and 0.62, respectively). CONCLUSIONS: The results of this study showed SFMA intra-rater reliability to be moderate, while inter-rater reliability can be considered good. These characteristics make it a valuable tool for sport's needs, even when used by students.

Down-staging of obesity one year after bariatric surgery: a new proposal of Edmonton obesity staging system.

Background: Different approaches are used to classify obesity severity. The Edmonton Obesity Staging System (EOSS) considers medical, physical and psychological parameters. A new modified EOSS with a different functional evaluation method, measuring Cardiorespiratory Fitness (CRF), has been recently proposed, EOSS-CRF. Bariatric surgery (BS) is one of the most efficient treatments of obesity and all aspect of related disorders. No studies have yet applied EOSS-CRF after BS. Therefore, the aim of this study was to evaluate modifications in EOSS and EOSS-CRF before and after BS. Methods: This observational study finally enrolled 72 patients affected by obesity. A multi-disciplinary assessment in order to evaluate eligibility to surgical treatment has been performed, including anamnesis, physical evaluation, anthropometric data measurement, biochemical blood exams and cardiopulmonary exercise testing. One year after BS the same protocol was applied. Patients have been classified according to EOSS and EOSS-CRF before and one year after BS. Results: After BS, patients categorized in classes associated to severe obesity (EOSS ≥ 2 or EOSS-CRF ≥ 2) reduced significantly. Using EOSS, patients without functional impairment were 61% before surgery and 69% after BS (p=0.383). Using EOSS-CRF, patients considered without functional impairment were only 9.7% before BS; this percentage significantly raised to 50% after BS (p<0.001). The impact of functional domains before and after BS is different in grading patients in EOSS and EOSS-CRF, respectively. Conclusions: Improvements obtained after BS are adequately summarized by EOSS and EOSS-CRF. The EOSS-CRF grading method for functional impairment seems to better reflect the known amelioration obtained after BS. Objective measurements of CRF may provide additional value to classify severity of obesity, also in the follow-up after BS.

Sport activities for children and adolescents: the Position of the European Academy of Paediatrics and the European Confederation of Primary Care Paediatricians 2023-Part 1. Pre-participation physical evaluation in young athletes.

The European Academy of Paediatrics (EAP) and the European Confederation of Primary Care Paediatricians (ECPCP) emphasize the importance of promoting healthy lifestyles within the pediatric population. Many health professionals have questions concerning adequate levels of physical activity for both the healthy pediatric population and for those who may have specific complications. Unfortunately, the academic literature that provides recommendations for participation in sport activities within the pediatric population that have been published during the last decade in Europe is limited and is mainly dedicated to specific illnesses or advanced athletes and not toward the general population. The aim of part 1 of the EAP and ECPCP position statement is to assist healthcare professionals in implementing the best management strategies for a pre-participation evaluation (PPE) for participation in sports for individual children and adolescents. In the absence of a uniform protocol, it is necessary to respect physician autonomy for choosing and implementing the most appropriate and familiar PPE screening strategy and to discuss the decisions made with young athletes and their families. This first part of the Position Statement concerning Sport Activities for Children and Adolescents is dedicated to healthy young athletes.

Overshoot of the Respiratory Exchange Ratio during Recovery from Maximal Exercise Testing in Young Patients with Congenital Heart Disease.

INTRODUCTION: The overshoot of the respiratory exchange ratio (RER) after exercise is reduced in patients with heart failure. AIM: The present study aimed to investigate the presence of this phenomenon in young patients with congenital heart disease (CHD), who generally present reduced cardiorespiratory fitness. METHODS: In this retrospective study, patients with CHD underwent a maximal cardiopulmonary exercise testing (CPET) assessing the RER recovery parameters: the RER at peak exercise, the maximum RER value reached during recovery, the magnitude of the RER overshoot and the linear slope of the RER increase after the end of the exercise. RESULTS: In total, 117 patients were included in this study. Of these, there were 24 healthy age-matched control subjects and 93 young patients with CHD (transposition of great arteries, Fontan procedure, aortic coarctation and tetralogy of Fallot). All patients presented a RER overshoot during recovery. Patients with CHD showed reduced aerobic capacity and cardiorespiratory efficiency during exercise, as well as a lower RER overshoot when compared to controls. RER magnitude was higher in the controls and patients with aortic coarctation when compared to those with transposition of great arteries, previous Fontan procedure, and tetralogy of Fallot. The RER magnitude was found to be correlated with the most relevant cardiorespiratory fitness and efficiency indices. CONCLUSIONS: The present study proposes new recovery indices for functional evaluation in patients with CHD. Thus, the RER recovery overshoots analysis should be part of routine CPET evaluation to further improve prognostic risk stratifications in patients with CHD.