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Article ; Online: Occam's razor at the sharp end: simplified preoperative risk assessment.

Davies, Simon J / Minto, Gary

2020 Volume 126, Issue 1, Page(s) 27–30

MeSH term(s)	Exercise Tolerance ; Humans ; Risk Assessment
Language	English
Publishing date	2020-10-21
Publishing country	England
Document type	Editorial ; Comment
ZDB-ID	80074-0
ISSN	1471-6771 ; 0007-0912
ISSN (online)	1471-6771
ISSN	0007-0912
DOI	10.1016/j.bja.2020.09.015
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Article: The impact of universal cardiopulmonary exercise testing on perioperative pathways and short-term patient outcomes following elective pancreatic surgery: A retrospective cohort study.

Mathoulin, Sophie / Minto, Gary / Taylor, Gordon / Erasmus, Paul

Journal of the Intensive Care Society

2021 Volume 23, Issue 4, Page(s) 407–413

Abstract: Background: The utility of Cardiopulmonary Exercise Testing (CPET) to identify higher risk surgical patients remains controversial. There is limited research investigating the value of preoperative CPET to plan perioperative pathways for patients ... ...

Abstract	Background: The utility of Cardiopulmonary Exercise Testing (CPET) to identify higher risk surgical patients remains controversial. There is limited research investigating the value of preoperative CPET to plan perioperative pathways for patients undergoing major pancreatic surgery. Methods: Retrospective cohort study, comprising two groups before and after a change in referral policy for High Risk preoperative anaesthetic clinic with CPET. Period 1 discretionary referral and Period 2: universal referral. The primary aim was to investigate the impact of this policy change on critical care use (planned vs unplanned) on the day of surgery and on delayed critical care admission. Secondary end points included a comparison of the total number of critical care bed days, days in hospital, complication rates and mortality data between the two cohorts. Results: 177 patients were included; 114 in Period 1 and 63 in Period 2. There was a reduction in unplanned day of surgery postoperative admissions to critical care (28.1% vs. 11.1%, p = 0.008). Seven (6.1%) of patients in Period 1 and 1 (1.6%) patient in Period 2 had delayed admission, though no p value was calculated due to the small numbers involved. Complication rates were similar in each group. The median critical care bed days was 1 (range 0-21) days in Period 1 and 1 (0-13) days in Period 2. Conclusions: A universal referral policy for preoperative CPET demonstrated a decrease in unplanned day of surgery critical care admissions and a trend towards reducing delayed (>24 h postop) critical care admission which could be investigated in a larger study. No measurable impact was seen on clinical outcomes.
Language	English
Publishing date	2021-06-16
Publishing country	England
Document type	Journal Article
ZDB-ID	2701626-2
ISSN	1751-1437 ; 1751-1437
ISSN (online)	1751-1437
ISSN	1751-1437
DOI	10.1177/17511437211022128
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Article: Monitoring needs and goal-directed fluid therapy within an enhanced recovery program.

Minto, Gary / Scott, Michael J / Miller, Timothy E

Anesthesiology clinics

2015 Volume 33, Issue 1, Page(s) 35–49

Abstract: Patients having major abdominal surgery need perioperative fluid supplementation; however, enhanced recovery principles mitigate against many of the factors that traditionally led to relative hypovolemia in the perioperative period. An estimate of fluid ... ...

Abstract	Patients having major abdominal surgery need perioperative fluid supplementation; however, enhanced recovery principles mitigate against many of the factors that traditionally led to relative hypovolemia in the perioperative period. An estimate of fluid requirements for abdominal surgery can be made but individualization of fluid prescription requires consideration of clinical signs and hemodynamic variables. The literature supports goal-directed fluid therapy. Application of this evidence to justify stroke volume optimization in the setting of major surgery within an enhanced recovery program is controversial. This article places the evidence in context, reviews controversies, and suggests implications for current practice and future research.
MeSH term(s)	Abdomen/surgery ; Cardiac Output ; Fluid Therapy/methods ; Goals ; Humans ; Hypovolemia/prevention & control ; Monitoring, Intraoperative ; Needs Assessment ; Perioperative Care/methods ; Postoperative Complications/prevention & control
Language	English
Publishing date	2015-03
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	2228899-5
ISSN	2210-3538 ; 1932-2275 ; 0889-8537
ISSN (online)	2210-3538
ISSN	1932-2275 ; 0889-8537
DOI	10.1016/j.anclin.2014.11.003
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Article ; Online: Heart rate recovery after orthostatic challenge and cardiopulmonary exercise testing in older individuals: prospective multicentre observational cohort study.

James, Aaron / Bruce, David / Tetlow, Nicholas / Patel, Amour B U / Black, Ethel / Whitehead, Nicole / Ratcliff, Anna / Jamie Humphreys, Alice / MacDonald, Neil / McDonnell, Gayle / Raobaikady, Ravishankar / Thirugnanasambanthar, Jeeveththaa / Ravindran, Jeuela I / Minto, Gary / Abbott, Tom E F / Jhanji, Shaman / Milliken, Don / Ackland, Gareth L

BJA open

2023 Volume 8, Page(s) 100238

Abstract: Background: Impaired vagal function in older individuals, quantified by the 'gold standard' delayed heart rate recovery after maximal exercise (HRR: Methods: Prospective multicentre cohort study of subjects scheduled for cardiopulmonary exercise ... ...

Abstract	Background: Impaired vagal function in older individuals, quantified by the 'gold standard' delayed heart rate recovery after maximal exercise (HRR Methods: Prospective multicentre cohort study of subjects scheduled for cardiopulmonary exercise testing (CPET) as part of routine care. Before undergoing CPET, heart rate was measured with participants seated for 3 min, before standing for 3 min (HRR Results: A total of 87 participants (mean age: 64 yr [95%CI: 61-66]; 48 (55%) females) completed both tests. Mean heart rate change every 10 s for 1 min after peak heart rate after standing and exercise was significantly correlated ( Conclusion: Prognostically significant heart rate recovery after exhaustive exercise is characterised by quantitative differences in heart rate recovery after orthostatic challenge. These data suggest that orthostatic challenge is a valid, simple test indicating vagal impairment. Clinical trial registration: researchregistry6550.
Language	English
Publishing date	2023-11-03
Publishing country	England
Document type	Journal Article
ISSN	2772-6096
ISSN (online)	2772-6096
DOI	10.1016/j.bjao.2023.100238
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Article ; Online: Autonomic regulation of systemic inflammation in humans: A multi-center, blinded observational cohort study.

Ackland, Gareth L / Minto, Gary / Clark, Martin / Whittle, John / Stephens, Robert C M / Owen, Thomas / Prabhu, Pradeep / Del Arroyo, Ana Gutierrez

Brain, behavior, and immunity

2017 Volume 67, Page(s) 47–53

Abstract: Objective: Experimental animal models demonstrate that autonomic activity regulates systemic inflammation. By contrast, human studies are limited in number and exclusively use heart rate variability (HRV) as an index of cardiac autonomic regulation. HRV ...

Abstract	Objective: Experimental animal models demonstrate that autonomic activity regulates systemic inflammation. By contrast, human studies are limited in number and exclusively use heart rate variability (HRV) as an index of cardiac autonomic regulation. HRV measures are primarily dependent on, and need to be corrected for, heart rate. Thus, independent autonomic measures are required to confirm HRV-based findings. Here, the authors sought to replicate the findings of preceding HRV-based studies by using HRV-independent, exercise-evoked sympathetic and parasympathetic measures of cardiac autonomic regulation to examine the relationship between autonomic function and systemic inflammation. Methods: Sympathetic function was assessed by measuring heart rate changes during unloaded pedaling prior to onset of exercise, divided into quartiles; an anticipatory heart rate (AHRR) rise during this period is evoked by mental stress in many individuals. Parasympathetic function was assessed by heart rate recovery (HRR) 60s after finishing cardiopulmonary exercise testing, divided into quartiles. Parasympathetic dysfunction was defined by delayed heart rate recovery (HRR) ≤12.beats.min Results: In 1624 subjects (65±14y; 67.9% male), lower HRR (impaired vagal activity) was associated with progressively higher NLR (p=0.004 for trend across quartiles). Delayed HRR, recorded in 646/1624 (39.6%) subjects, was associated with neutrophil-lymphocyte ratio >4 (relative risk: 1.43 (95%CI: 1.18-1.74); P=0.0003). Similar results were found for hsCRP (p=0.045). By contrast, AHRR was not associated with NLR (relative risk: 1.24 (95%CI: 0.94-1.65); P=0.14). Conclusions: Delayed HRR, a robust measure of parasympathetic dysfunction, is independently associated with leukocyte ratios indicative of systemic inflammation. These results further support a role for parasympathetic modulation of systemic inflammation in humans.
MeSH term(s)	Aged ; Cohort Studies ; Exercise Test ; Female ; Heart Rate ; Humans ; Inflammation/metabolism ; Inflammation/physiopathology ; Male ; Middle Aged ; Parasympathetic Nervous System/physiopathology ; Prospective Studies ; Sympathetic Nervous System/physiopathology
Language	English
Publishing date	2017-08-12
Publishing country	Netherlands
Document type	Journal Article ; Multicenter Study ; Observational Study
ZDB-ID	639219-2
ISSN	1090-2139 ; 0889-1591
ISSN (online)	1090-2139
ISSN	0889-1591
DOI	10.1016/j.bbi.2017.08.010
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Article ; Online: A multidisciplinary consensus on dehydration: definitions, diagnostic methods and clinical implications.

Lacey, Jonathan / Corbett, Jo / Forni, Lui / Hooper, Lee / Hughes, Fintan / Minto, Gary / Moss, Charlotte / Price, Susanna / Whyte, Greg / Woodcock, Tom / Mythen, Michael / Montgomery, Hugh

Annals of medicine

2019 Volume 51, Issue 3-4, Page(s) 232–251

Abstract: Background: ...

Abstract	Background:
MeSH term(s)	Acute Kidney Injury/epidemiology ; Acute Kidney Injury/etiology ; Acute Kidney Injury/mortality ; Adult ; Aged ; Aged, 80 and over ; Biomarkers ; Body Fluid Compartments/physiology ; Body Water/physiology ; Consensus ; Critical Illness/epidemiology ; Critical Illness/mortality ; Dehydration/diagnosis ; Dehydration/epidemiology ; Dehydration/mortality ; Dehydration/physiopathology ; Delirium/epidemiology ; Delirium/etiology ; Heart Failure/epidemiology ; Heart Failure/etiology ; Heart Failure/mortality ; Humans ; Inpatients/statistics & numerical data ; Middle Aged ; Nursing Homes/statistics & numerical data ; Organism Hydration Status/physiology ; Osmolar Concentration ; Osmotic Pressure/physiology ; Prevalence ; Prognosis ; Risk Assessment ; Thromboembolism/epidemiology ; Thromboembolism/etiology ; Thromboembolism/mortality ; Water-Electrolyte Balance/physiology
Chemical Substances	Biomarkers
Language	English
Publishing date	2019-06-17
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	1004226-x
ISSN	1365-2060 ; 1651-2219 ; 0785-3890 ; 1743-1387
ISSN (online)	1365-2060 ; 1651-2219
ISSN	0785-3890 ; 1743-1387
DOI	10.1080/07853890.2019.1628352
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Article ; Online: Heart rate recovery and morbidity after noncardiac surgery: Planned secondary analysis of two prospective, multi-centre, blinded observational studies.

Ackland, Gareth L / Abbott, Tom E F / Minto, Gary / Clark, Martin / Owen, Thomas / Prabhu, Pradeep / May, Shaun M / Reynolds, Joseph A / Cuthbertson, Brian H / Wijeysundera, Duminda / Pearse, Rupert M

PloS one

2019 Volume 14, Issue 8, Page(s) e0221277

Abstract: Background: Impaired cardiac vagal function, quantified preoperatively as slower heart rate recovery (HRR) after exercise, is independently associated with perioperative myocardial injury. Parasympathetic (vagal) dysfunction may also promote (extra- ... ...

Abstract	Background: Impaired cardiac vagal function, quantified preoperatively as slower heart rate recovery (HRR) after exercise, is independently associated with perioperative myocardial injury. Parasympathetic (vagal) dysfunction may also promote (extra-cardiac) multi-organ dysfunction, although perioperative data are lacking. Assuming that cardiac vagal activity, and therefore heart rate recovery response, is a marker of brainstem parasympathetic dysfunction, we hypothesized that impaired HRR would be associated with a higher incidence of morbidity after noncardiac surgery. Methods: In two prospective, blinded, observational cohort studies, we established the definition of impaired vagal function in terms of the HRR threshold that is associated with perioperative myocardial injury (HRR ≤ 12 beats min-1 (bpm), 60 seconds after cessation of cardiopulmonary exercise testing. The primary outcome of this secondary analysis was all-cause morbidity three and five days after surgery, defined using the Post-Operative Morbidity Survey. Secondary outcomes of this analysis were type of morbidity and time to become morbidity-free. Logistic regression and Cox regression tested for the association between HRR and morbidity. Results are presented as odds/hazard ratios [OR or HR; (95% confidence intervals). Results: 882/1941 (45.4%) patients had HRR≤12bpm. All-cause morbidity within 5 days of surgery was more common in 585/822 (71.2%) patients with HRR≤12bpm, compared to 718/1119 (64.2%) patients with HRR>12bpm (OR:1.38 (1.14-1.67); p = 0.001). HRR≤12bpm was associated with more frequent episodes of pulmonary (OR:1.31 (1.05-1.62);p = 0.02)), infective (OR:1.38 (1.10-1.72); p = 0.006), renal (OR:1.91 (1.30-2.79); p = 0.02)), cardiovascular (OR:1.39 (1.15-1.69); p<0.001)), neurological (OR:1.73 (1.11-2.70); p = 0.02)) and pain morbidity (OR:1.38 (1.14-1.68); p = 0.001) within 5 days of surgery. Conclusions: Multi-organ dysfunction is more common in surgical patients with cardiac vagal dysfunction, defined as HRR ≤ 12 bpm after preoperative cardiopulmonary exercise testing. Clinical trial registry: ISRCTN88456378.
MeSH term(s)	Aged ; Exercise Test ; Female ; Heart Injuries/physiopathology ; Heart Rate ; Humans ; Male ; Middle Aged ; Postoperative Complications/physiopathology ; Prospective Studies ; Vagus Nerve/physiopathology
Language	English
Publishing date	2019-08-21
Publishing country	United States
Document type	Clinical Trial ; Journal Article ; Multicenter Study ; Observational Study ; Research Support, Non-U.S. Gov't
ISSN	1932-6203
ISSN (online)	1932-6203
DOI	10.1371/journal.pone.0221277
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Article ; Online: Correction: Heart rate recovery and morbidity after noncardiac surgery: Planned secondary analysis of two prospective, multi-centre, blinded observational studies.

PloS one

2019 Volume 14, Issue 12, Page(s) e0226379

Abstract: This corrects the article DOI: 10.1371/journal.pone.0221277.]. ...

Abstract	[This corrects the article DOI: 10.1371/journal.pone.0221277.].
Language	English
Publishing date	2019-12-05
Publishing country	United States
Document type	Published Erratum
ISSN	1932-6203
ISSN (online)	1932-6203
DOI	10.1371/journal.pone.0226379
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Article ; Online: Clinical assessment before hepatectomy identifies high-risk patients.

Ulyett, Simon / Wiggans, Matthew G / Bowles, Matthew J / Aroori, Somaiah / Briggs, Christopher D / Erasmus, Paul / Minto, Gary / Stell, David A

The Journal of surgical research

2015 Volume 198, Issue 1, Page(s) 87–92

Abstract: Background: Liver resection is associated with significant morbidity, and assessment of risk is an important part of preoperative consultations. Objective methods exist to assess operative risk, including cardiopulmonary exercise testing (CPX). ... ...

Abstract	Background: Liver resection is associated with significant morbidity, and assessment of risk is an important part of preoperative consultations. Objective methods exist to assess operative risk, including cardiopulmonary exercise testing (CPX). Subjective assessment is also made in clinic, and patients perceived to be high-risk are referred for CPX at our institution. This article addresses clinicians' ability to identify patients with a higher risk of surgical complications after hepatectomy, using selection for CPX as a surrogate marker for increased operative risk. Materials and methods: Prospectively collected data on patients undergoing hepatectomy between February 2008 and November 2013 were retrieved and the cohort divided according to CPX referral. Complications were classified using the Clavien-Dindo system. Results: CPX testing was carried out before 101 of 405 liver resections during the study period. The median age was 72 and 64 in CPX and non-CPX groups, respectively (P < 0.001). The resection size was similar between the groups. No difference was noted for grade III complications between CPX and non-CPX tested-groups; however, 19 (18.8%) and 28 (9.2%) patients suffered grade IV-V complications, respectively (P = 0.009). There was no difference in long-term survival between groups (P = 0.63). Conclusions: This study attempts to assess clinicians' ability to identify patients at greater risk of complications after hepatectomy. The confirmation that patients identified in this way are at greater risk of grade IV-V complications demonstrates the value of preoperative counseling. High-risk patients do not have worse long-term outcomes suggesting survival is determined by other factors, particularly disease recurrence.
MeSH term(s)	Aged ; Exercise Test ; Female ; Hepatectomy/adverse effects ; Humans ; Male ; Middle Aged ; Preoperative Care ; Prospective Studies ; Risk Assessment
Language	English
Publishing date	2015-09
Publishing country	United States
Document type	Journal Article
ZDB-ID	80170-7
ISSN	1095-8673 ; 0022-4804
ISSN (online)	1095-8673
ISSN	0022-4804
DOI	10.1016/j.jss.2015.05.044
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Article ; Online: Cardiopulmonary exercise capacity and preoperative markers of inflammation.

Sultan, Pervez / Edwards, Mark R / Gutierrez del Arroyo, Ana / Cain, David / Sneyd, J Robert / Struthers, Richard / Minto, Gary / Ackland, Gareth L

Mediators of inflammation

2014 Volume 2014, Page(s) 727451

Abstract: Explanatory mechanisms for the association between poor exercise capacity and infections following surgery are underexplored. We hypothesized that aerobic fitness-assessed by cardiopulmonary exercise testing (CPET)-would be associated with circulating ... ...

Abstract	Explanatory mechanisms for the association between poor exercise capacity and infections following surgery are underexplored. We hypothesized that aerobic fitness-assessed by cardiopulmonary exercise testing (CPET)-would be associated with circulating inflammatory markers, as quantified by the neutrophil-lymphocyte ratio (NLR) and monocyte subsets. The association between cardiopulmonary reserve and inflammation was tested by multivariable regression analysis with covariates including anaerobic threshold (AT) and malignancy. In a first cohort of 240 colorectal patients, AT was identified as the sole factor associated with higher NLR (P = 0.03) and absolute and relative lymphopenia (P = 0.01). Preoperative leukocyte subsets and monocyte CD14(+) expression (downregulated by endotoxin and indicative of chronic inflammation) were also assessed in two further cohorts of age-matched elective gastrointestinal and orthopaedic surgical patients. Monocyte CD14(+) expression was lower in gastrointestinal patients (n = 43) compared to age-matched orthopaedic patients (n = 31). The circulating CD14(+)CD16(-) monocyte subset was reduced in patients with low cardiopulmonary reserve. Poor exercise capacity in patients without a diagnosis of heart failure is independently associated with markers of inflammation. These observations suggest that preoperative inflammation associated with impaired cardiorespiratory performance may contribute to the pathophysiology of postoperative outcome.
MeSH term(s)	Aged ; Biomarkers/blood ; Exercise Test ; Exercise Tolerance/physiology ; Female ; Humans ; Inflammation/blood ; Inflammation/physiopathology ; Lipopolysaccharide Receptors/metabolism ; Male ; Middle Aged ; Monocytes/metabolism ; Neutrophils/metabolism ; Receptors, IgG/metabolism
Chemical Substances	Biomarkers ; Lipopolysaccharide Receptors ; Receptors, IgG
Language	English
Publishing date	2014-06-26
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	1137605-3
ISSN	1466-1861 ; 0962-9351
ISSN (online)	1466-1861
ISSN	0962-9351
DOI	10.1155/2014/727451
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