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hi and welcome. I want to. What is the first episode off the Royal Comal Hospitals? Correct Apartments Journal Cup. Very excited to welcome many of you here today. Um, it's great toe. Also welcome many external to the trust here as well. I know we've got quite a few signed up through the external, so I wanted to begin today by briefly and adjusting myself. Give you an overview in terms of how you can enjoy this life event on Also, too. Give you an overview in terms of what I want to achieve with this journal club and what I'll look like moving for it. So in terms off there we go orients. Saw him a little bit. Haven't used live events before living up gripped. So, you know, my my name is Dr Gavin McLean. My PhD is in pediatric sports cardiology. I also do you have research expertise of experience, and I don't Athletes as well for those of you have no joined Microsoft Life event before. Um, you previously probably join the teams event in terms of how you can best enjoy there's some controls at the bottom of the screen and not allow you to pause the action. I just avoid him on. I'll also allow you to Sorry watch. You can also read Watch their clip picking him Frida's vaccine link that we send in terms of participation hawking your best enjoyed of it. Well, there is a cute and a section which you should see on the right of your screen of belief. And then there you can take any questions that you might have, and I'll get fruit of some of those at the end. You can even do so anonymously as well on diffuse that. So that should be on the right hand side of the screen. In terms of what I want to achieve with this general club, it's really to me, a really quite exciting opportunity to share expert knowledge across then a chest, and that's from internal people speaking. And that's also from external people speaking. So that means, if you are interested in, do you want of these emphasis for a general club on an article or a topic that is off interest? You just tell me any meal that govern dog cleaning at any chest up. The second game is really tell lies. The all work up that closer with the m e l been proven that healthcare service that we delivered to your passion by sharing an expert knowledge across one another on finally free is the really drive and appreciation on a really interest in science on dust. Future research collaborations between trust cause that's ultimate height. We're gonna help improve our passion and improve the delivery of the healthcare service. I'm know. Yep. So the topic off today? No. Sorry. Before I begin, it's really important. I am still get that I've in terms of the view points out of expressing today are really reflective of mine and milk, perhaps to trust in the department. They're very much mine fuse and copy of that initially, So I thought I would begin to talk with a little exercise night. These are two lines and the question is, which of these two lines or short? I probably give that way a little bit, but it's really know until I I removed the lines. Even with this red line, I still can't see him still a little bit unsure. I remove those lines. I know they're in the vaccine. Live exercise, too, is what is too cluster. I think we could all know what to tell that. That's for So let's see things up. Let's get a little bit more progressive. Let's get him up. But we're difficult. So 17 times 24 you can pop any of your question, your answers in the little Q and a section there. So what, 17 times? 24. Like you. Some ideas. Is it 12 5 and 609 123 and Attackers, or is it 568? So the answer is 400. For those of you can't wait any longer on don't go on with the rest of this talk with, you know, in their sensor on the point of this, really, is that this Is this really an ulcer? It's a nice example by Daniel Daniel here in this book, or I'm thinking fast and thinking slow, and he describes two ways to thinking he describes Two. Plus two is that you're in. If it's reactionary, we immediately know dance, or at least we think we do. The second is is little bit more difficult. It is slow where we have to concentrate and figure out the insert. The problem is, here is that we are often substitute one for bladder on. Today, I want you to think about this article, this topic in this context. So you might be aware that this is the systematic review with metal in Alice is that we're going to review today. But you might not be aware that it's actually a Cochran review, so it means it was restroom prior to it. Search strategy and it's hard to go free. A very robust on. A very robust protocol in terms of High has been conducted now before, I would in a just a topic been just level into the Eric. Know Erica has a congenital heart disease. She has because of the day or it felt sorry just a little blurry. She, um But this is the question is really Is that something relatively rare? Or is this something just limited to pediatrics? Well, we know. According to this, research 0.1 of 101st wild Worldwide story congenital heart disease is problem. Indeed, we know the number of young adults affected by congenital heart disease is expect to increase by 5% every year on to improve surgical techniques, we noticed individuals able to live longer. We might not know, actually, is that there's no I'm or adults. That and Children with congenital heart disease and indeed the highest instance of where dashes know occurring is in individuals a 65 years or above. So I think we can all agree that congenital heart disease is not something that's any more limited to the pediatric pediatric care. It's also related to the adult parent of Texas. All effect is all in a multi disciplinary approach in that regard. So some things we typically associate it with somebody who's got congenital heart disease would be carted respiratory register, car carda, respiratory fitness, a register health related call his life and reduce physical activity levels. Know if I was to ask you about in terms of a pale props that you might you might prescribe today over passions on, if we could, it would probably be exercise because of the results of all of these number of different issues, and we would think that question is high. How would we do that? Onda, of course, that we know that how you define a good research. Now you find this system review of my analysis. And for those of you are familiar with that pyramid of evidence. You've got that since my little view of men and answers, right, the top level one evidence. And this is really important because if you put it in to public it exercise inventions and congenital heart disease, you can over to Faisal results. So if you're juggling the demands of a busy clinic on, you've got a passion in front of you in your insurance that high the best recommend a profit carrot. You're gonna be not flared drones. A level one evidence like this unfortunate for you. We do you have one on this topic noise. But what I do want to draw your attention to is that all the letters is not gold. I'm not saying about it, they said, by this route, Systematic review. Indeed. I'll show you it's actually really robust. That's got a really good methodology. I just want to draw your attention to the fact that just because it's a system high review does not mean it's gold. There's any systematic reviews out there that are torsion hive, um, can missed misguide. You're on clinical practice in terms of what recommendations you might prior provide your passions. So part of my am today is to equip you with the skills, so therefore you can actually quickly probably use such research on you will be misled by something that isn't so good, so high that they unprotected study. How did they handle the deer? And when I say the handle day, I do appreciate. I've probably got lots of faces like this and the other side of the screen. But bear with me. So how did they hunt blood it? I would consider it. I would encourage you to consider it's a little bit like a little checklist that you would go free when you're a pre is in the system I review. And that would be, for instance, they use the random effects and answer. Is that something that's typically used it in a matter analysis? Because the day it typically is heterogeneous is that means it's basically just variable on. It's more conservative approach. They use Cohen effect sizes to really determine the significance off the fact If you sensitivity analysis night, this is where you might, they offered my identify. A biosimilar to do is remove that study and rerun the stats again. And if there's results from insignificant, I mean is that can include it on. It's Ah, it's okay. And that's something that you you typically want to observe and see in a systematic review with metal else is. But someone they've also done here is that you use great. And this is really useful because in part, is the researcher somewhat and imparts them to greeted the quality of evidence on adjusted recommendations and according to sit up. So here is some degree of certainty findings on to give you some context of example. Let's say it offers find a really significant effect here from physical interventions to improve congenital heart disease. But the evidence equality this stays wasn't so great. They could die in greed. It on their four provide more appropriate recommendations. So it's a really good told that they used. But what's also important to know here and what's really cool is they're actually the first started systematic review to use the new risk of biased assessment for cockroach reviews, which is cool. So next height is 100 then if either articles and this is actually really important, quite often overlooked because in fastest man, it revealed, doesn't get syrup strategy. The offer's community cherry pick What Let's you share supports their argument. But you can see here they've identified over free fights and 100 articles. I think we can all agree that's probably quite sensitive. Search strategy. I'm not going to go into the details of that today, but it's just getting a bit well. And, of course, the morning clinic. Our CT psorinum eyes controls trials that compared the type of physical activity, a type of physical activity. Intervention. Sorry against know physical activity, which is our usual care of my building. So what types? All physical invention activity inventions were included. Well, we have a physical activity promotions, so that's gold setting of actual interviews. They have that exercise training that aerobic correct or resistance trip training programs. And they also have something called I Am Tea and I empty. And that's something that's relatively new. And that's where it's green. A little bit traction recently, that's all by improving ventilation Vental or a part and efficiency. Sorry. So the next question is, why did they measure if this was successful? Any of these exercise recommendations Well, the primary outcomes were kind of respiratory fitness was measured, and 14 of the 15 studies directly and 12 14, they looked a healthy diet, quality of life. So that was measured. And it I've 15/15 size. They reported using this 36 item. Sure, uh, short form survey on, then, while so some of the studies, including a combination of different ones or perhaps use difference and exclusively this was the one of us to use predominantly what was really good here. And he also looked at visiting measures from device war measures, which is important in these applicable to really world. We all wear stuff like garments to read that a lot is the truck that physical activity levels are supposed to relying on something like a questionnaire where we knew it. Outpatient rip recall coming quite perfect. So we know how to conduct. It's that this item. So the next question is really is it new is what they find new and interesting and new to your practice. Well, what really surprised me by the study was that they actually find the peak kind of respiratory fitness. They find a physical activity may only increase. Peacocks should consumption slightly, and I would have paid my bet on it before looking at this is Monica Review of Met Analysis. That would be much more than slightly to improve that peak v 02 and, well, perhaps get into and we will get into sorry why that might be the kiss. What if I help with the quality of life will regard it the evidence to be very uncertain about the effect. Physical activity hard on health related quality of life, not starting to probably the certain data regarding they've done great it because they regard to be very low. And that's probably attributed to the fact that it was from those health questioners on highlight evidence can be quite variable. Next was physical activity levels, and what these revealed was an increase of 10 minutes of moderate to visit group vigorous physical to be predicted. Yeah, the upper week. That's 60 minutes per week. Times 22 weeks, that 120 minutes. So that cumulative the fact is quite powerful, I would say quite good time. Is it true? Because, like I said, I was quite surprised. I would have thought that pick for your tube it of increase a little more. So let's look at things a little deeper and awesome questions. So what happens when we look at kind of respiratory fitness? Spy train invasion. So But, I mean, let's look at it exclusively by exercise, exercise activity, exercise trainings, our our physical activity promotion and I anti defense change. Does that affect it stronger? Doesn't get weaker. Well, here is a forest floor. Okay, I'm gonna breakfast. Four split time first, because if you see one of these before, this looks horribly busy and a little bit confusing. So here in that red box, you have the articles that included not so old articles. Put it within the this analysis. Okay, Here you have your mean You're resting on. You have, uh, you mean your entity for a picture Military for physical activity or no activity here. How about mean difference between the three groups and here, which is quite unique with that new risk of bias Assessment? Is your seat up on the side of this part of this forest block? That's quite useful because I could use some contexts. Is that what you're looking at? Pair study in terms of the risk of bite. So that's that. So it's really quite knows. Well, they ought to be fine. Once they filled all this together, was that that peak flow to increase by 2.74 million per kilogram per minute? But what does that mean? Well, what we know is, of course, that's more than when we grouped everything together with my grip, exercise training. I am ta and fiscal to be promotion. But we also know in the context self 3.5 mL per kilogram per minute, which we know that reduces and a healthy population the chance of cardiovascular diagnosis are then by approximately 15% not a passionate with cardiovascular disease that has associates of 3.5 would be it to 45% reduced risk in mortality. So there is really important findings. But we of course, don't know what the significance right now is off 2.74. When it comes to congenital heart. Is these passions So what can we see them when we look at just got to promotion? Well, you can see the two studies pills, same force block from what really surprised? I was shocked. Here is that you can see a negative effect. I was really surprised to see that on If I don't to be quite bizarre minutely and, um, it really we've only got two studies included here, but I think what we comtech from this is that I think were kidding ourselves when we think that's a simple little small conversation promoting the benefits of exercise at the end of a passion Stagno sick tests a reverent might be is going to be adequate to have a real good cause of change here. The next words I'm teaching in and again that's limited once that. Eight. I think we really have to check things. Pinch your salt on it. It's a really small effect, so I think we really need to see more studies conducted before were to really understand what that what effect, if any of this is gonna have on peak for you, too, who's us with the background in sports science? Or maybe those with an interest in sports outside, for we all know to well, that there's more to kind of respiratory fitness than just peak flow, too. Salam's have to consider something else. While I'm still consider something called gas exchange threshold that's widely regarded to be on aerobic threshold. It's a little example from athlete I've collected before you see the thing to do interviews, these v o c o c 02 days story, not their gas exchange threshold is believes that her around one, that respiratory exchange rate your right one on why that's really important is that if we can increase that, that's going to increase our patient's capacity to do day to day activities with getting really breathless. So that could be simply. Just do some of the grocery shopping or just going for a walk that some of the stuff that we detect for granted it's. And if you think about the cortex off to your wife passion, some of them will actually hit a pick the or two you when they're shoveling snow. So this really is quite important in our passions. Want this thing here when we look at all the does include exercise trainings know I am tea or not Physical activity promotion. They're able to increase up by 2.5, so let's take a step further. Well, that's been a little bit deeper. A game sufficiently impassioned with congenital heart disease prescriptions really been governed by pathology. But is there any difference in the physical activity? Invention Positive impact if we look at pathology for type of protective pathology store, so what we find here was really interested in finding the roles. No significant effect. Not indeed, effect was similar. When you look at patients with a single ventricle, well, you look a passions with T o. F. When you look at patients of other congenital heart disease are indeed and 89 studies where they had a mixed bag of congenital heart disease. So that's really interesting, cause that tells me that it appears that the positive effect, all physical it to the intervention or pierce or me in the seam across puff up there across different pathology types. So the question to me, really I think, is from this one's a draw from this is product. Should it be best not pathology type, not lesion specific room, perhaps more function. So I get into that. So does it. The question, therefore it is doesn't change what we do in practice well for purpose of context. A survey was given on two pediatric specialists in terms off exercise prescription. They've given ticket patients with congenital heart disease. What define they find it. One of the free clinic shins have actually never provided pediatric congenital heart disease patients with written of ice. If I exercise, who really looked at what because of this might be, they find it one and two. Conditions were uncertain, like the appropriate recommendations. So why might not be a kiss? Well, this is a recommendation Paper in 2015 appreciates. It's athletes here, but it's very much like a ball to the normal passion is what patient congenital heart disease on these are quite useful on. Don't criticize them too much, but they do. You have some problems when they're applied in the real world, and I'll walk you through it up. So what this thing is, if you have that passion that's got, revive significant ventricle dysfunctions on the F about 50% no arrhythmias. The what? Flow tract obstruction. They may be considered for not Prince special moderate to high intensity sports. Conversely, on the polar opposite of the the patient with severe dispensable, the function's only have below 40% severe out flow, truck destruction or re occurring are uncontrolled, atrial or eventual arrhythmias. They're restricted for most sports competitive sport with that possible explosion of low intensity sports. But I think the problem here is most of our passions that we see don't fit in this green or red there, and watching between or in the arm bar our as another way picture. It's not. Medicine is not very much black of like there's very much gray in between. But then, what can we do to improve car, respiratory fitness, health related quality of life on physical activity, levels in passions with congenital heart disease? Looking at it from a multi disciplinary approach? Because we know what effects all we know effects both for pediatrics and rattles. We know of more adults and congenital heart disease. That means more passions and heart failure services. Arrhythmia services, primary care, correct rehab, surgical. We know that's going to increase the burden on the different services so high, and then can we improve this? But these factors so that burden is reduced so they can have the Barrett's quality of life will look after our patients that get better. Well, there's a really nice recommendations that I'd like to point you to. It's but it's a bus for recommendations was published in 257 13. This gives us a really individualized approach. Gonna walk you free. So that's that one is the classic history and physical examination we all know that's important. Gives us some clues in terms of passion. Step to this assessment. Five partners or Surratt's on echocardiographic perspective. So looking at the ventricles physical function look at pulmonary artery pressure. Looking at our aorta, we know that's going to be really important. And a lot of congenital heart disease is a order pathology. Sometimes president arrhythmias arrest or during exercise. We know a congenital heart disease. Some correct death journey exercise arrhythmia occurs Is the cause of 10% of that someone a 10 such rational levels, of course, gonna be real important. And if it below 90 95 90% is gonna be of concern, I can take it in consideration of all these five prior, um, ears, we can guide choice off sport for these passions, which is really useful on helpful for, uh, passion both them on their parents or out of the nodules son. So I could stick so step free is fundamental and really crucial to me. You know, it's assessment urine exercise. In my opinion, I think it's really inappropriate to provide patient congenital heart disease with exercise prescription. If we haven't assess them on exercise, we don't know what they're capable off. We don't haven't done so well. Let's see if it controlled environment the internationally. When we think about assessment urine exercise, we we typically think of. I see Pat, however, CPAP hasam limitations and that is that it doesn't provide us with that direct directly attack on cardiac function or my car or can't reserve during exercise where, as you get that signal tedious, see pair with exercise. I think our ago echocardiography specifically with a stream you get good is that you're gonna get an assessment off the mechanics and you're gonna get assessment of that cardiac reserve. And that's going to be much more useful from when you can look at things like that. Force frequency, relationships of heart rate and street and see if a good pulses and pulsetv train this occurring. You can look at it again from a metabolic performance plans curric performance in terms of a pulse of treatment with via to you as well to rely pathology. What's really important to note here is that exercise stress echocardiography has been shown to actually on mask correct dysfunction that it's not detectable breasts in the pediatric congenital heart disease population as well. So that is just a little picture from some research I've undertaken previously. Eso in terms of that Ford a recommendation of exercise With all these diagnostic tests, we can baron form this so much fatter. I'm not really is a shared decision making process. I appreciate. So it's athletes wishes, because that's where his paper was taken from that dear 2021. But it's very much the same in terms of passion wishes, because that choice of sports could vary on oppression. Because we all different interests likes that even. And it depends on what's available today. And it's gonna take in consideration of all those five steps a swell baseline problems that we test. And, of course, it's going to require a periodic valley ashton. So at least until that long that follow up, because this is something that's like it's not fixed. So what we'll need for because that patient's interest might change that pathology might change. It might require on early surgical intervention where it might be that things need to adjust. So bear all this in mind. My tech a message is really from this article. Is that diagnosis based on functional compassion over. We should be in my pee. We should have diagnosis based on functional capacity of relations specific diagnosis with exercise assessment key on just because to patients of the scene, pathology doesn't mean it or seen on that. We know that medicine's very great on this will really, truly help you assess the risk and function and a passion. A shared decision making process is gonna be really key if we're gonna have a good positive impact here because then we need to check ins consideration of patients needs of once. What sports do you like? What bio suppressing? What about what sport do they need on what did a sport to? They have a home Long know assessment is necessary to me on because things change. It's not fixed on. Then we can then act upon and perhaps having early surgical take intervention if necessary, inappropriate for a passion. So thank you very much. for joining today, Um, noise the time. If you do have any questions to pop them in, like you know, section I would like to take the opportunity again. Just invite those internal and external to the trust to present on the topic or or article, story or the interest. And just drop me an email that I've got the size. That's Gavin, Don't McLean and a test on that. I hope you find a nice session to be all value on. I do invite you to 10 future episodes and all that new. I am very, very delighted to nights that are next presentation will be by Dr Debrox for, and I'll be on assessment off diastolic function in light of new basic guidelines on the horizon. So the only 1st 15 June the House five. This will be open in restoration of eventbrite for all those external to trust. So I recommended for me on there, and then you'll get immediate email notification. That's a nice or in terms of follow me into it, and I'll know it's it's really there. So if we do have any questions I can take those night, uh, that then missing Pinker they're send live. Look, that's today cool. Or thank you very much for joining. I'm very delighted that we had some external people join in today on Did very much look forward to seeing you again in the future. But if you do have any questions that you think about that you didn't think about today, just don't hesitate to ask me on government, Doctor clean and a chest that net on if you would like to present and the future upset, um, hesitant. Take it in. Contact me with me if the grit Thank you very much for joining today.