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A 20-year-old male underwent diagnostic testing due to unexplained shortness of breath and chest discomfort. He had no previous medical problems and was not taking any medications. Initial evaluations included cardiopulmonary exercise testing (CPET), which yielded results that were reported as normal. However, over the following 2 months, his symptoms worsened considerably, including dyspnea with climbing stairs and then hemoptysis. Seeking urgent medical care, he presented to the emergency department, where he underwent further testing and was admitted to the hospital. Computed tomography angiogram reported bilateral pulmonary emboli. His parents requested a second opinion regarding the analysis of the CPET data, which revealed previously overlooked abnormalities. This overlooked data delayed pulmonary embolism diagnosis, and the patient ultimately required bilateral pulmonary thromboendarterectomy. In this case, we describe the hallmark signs of pulmonary vascular disease seen during CPET and offer clinical pearls to aid in timely detection., Competing Interests: The authors have no conflicts of interest to disclose., (© 2024 The Authors.)

Background: Exercise pulmonary hypertension (ePH), defined as a mean pulmonary artery pressure (mPAP)/cardiac output (Qc) slope >3 WU during exercise, is common in patients with heart failure with preserved ejection fraction (HFpEF). However, the pulmonary gas exchange-related effects of an exaggerated ePH (EePH) response are not well-defined, especially in relation to dyspnea on exertion (DOE) and exercise intolerance., Methods: 48 HFpEF patients underwent invasive (pulmonary and radial artery catheters) constant-load (20W) and maximal incremental cycle testing. Hemodynamic measurements (mPAP and Qc), arterial blood and expired gases, and ratings of breathlessness (RPB, Borg 0-10) were obtained. The mPAP/Qc slope was calculated from rest-to-20W. Those with a mPAP/Qc slope >4.2 (median) were classified as HFpEF+EePH (n=24) and those with a mPAP/Qc slope <4.2 were classified as HFpEF (without EePH) (n=24). The A-aDO 2 , V D /V T (Bohr equation), and the V E /VCO 2 slope (from rest-to-20W) were calculated., Results: PaO 2 was lower (p=0.03), and V D /V T was higher (p=0.03) at peak exercise in HFpEF+EePH compared with HFpEF. A-aDO 2 was similar at peak exercise between groups (p=0.14); however, HFpEF+EePH achieved the peak A-aDO 2 at a lower peak work rate (p<0.01). The V E /VCO 2 slope was higher in HFpEF+EePH compared with HFpEF (p=0.01). RPB was ≥1-unit higher at 20W and VO 2peak was lower (p<0.01) in HFpEF+EePH compared with HFpEF., Conclusions: These data suggest that EePH contributes to pulmonary gas exchange impairments during exercise by causing a V/Q mismatch that provokes both ventilatory inefficiency and hypoxemia, both of which seem to contribute to DOE and exercise intolerance in patients with HFpEF., (Copyright ©The authors 2024. For reproduction rights and permissions contact permissions@ersnet.org.)

We investigated whether central or peripheral limitations to oxygen uptake elicit different respiratory sensations and whether dyspnea on exertion (DOE) provokes unpleasantness and negative emotions in patients with heart failure with preserved ejection fraction (HFpEF). 48 patients were categorized based on their cardiac output (Q̇c)/oxygen uptake (V̇O 2 ) slope and stroke volume (SV) reserve during an incremental cycling test. 15 were classified as centrally limited and 33 were classified as peripherally limited. Ratings of perceived breathlessness (RPB) and unpleasantness (RPU) were assessed (Borg 0-10 scale) during a 20 W cycling test. 15 respiratory sensations statements (1-10 scale) and 5 negative emotions statements (1-10) were subsequently rated. RPB (Central: 3.5±2.0 vs. Peripheral: 3.4±2.0, p=0.86), respiratory sensations, or negative emotions were not different between groups (p>0.05). RPB correlated (p<0.05) with RPU (r=0.925), "anxious" (r=0.610), and "afraid" (r=0.383). While DOE provokes elevated levels of negative emotions, DOE and respiratory sensations seem more related to a common mechanism rather than central and/or peripheral limitations in HFpEF., Competing Interests: Declaration of Competing Interest No conflicts of interest, financial or otherwise, are declared by the authors., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Heart failure with preserved ejection fraction (HFpEF) patients have an increased ventilatory demand. Whether their ventilatory capacity can meet this increased demand is unknown, especially in those with obesity. Body composition (DXA) and pulmonary function were measured in 20 patients with HFpEF (69 ± 6 yr;9 M/11 W). Cardiorespiratory responses, breathing mechanics, and ratings of perceived breathlessness (RPB, 0-10) were measured at rest, 20 W, and peak exercise. FVC correlated with %body fat (R 2 =0.51,P = 0.0006), V̇O 2peak (%predicted,R 2 =0.32,P = 0.001), and RPB (R 2 =0.58,P = 0.0004). %Body fat correlated with end-expiratory lung volume at rest (R 2 =0.76,P < 0.001), 20 W (R 2 =0.72,P < 0.001), and peak exercise (R 2 =0.74,P < 0.001). Patients were then divided into two groups: those with lower ventilatory reserve (FVC<3 L,2 M/10 W) and those with higher ventilatory reserve (FVC>3.8 L,7 M/1 W). V̇O 2peak was ∼22% less (p < 0.05) and RPB was twice as high at 20 W (p < 0.01) in patients with lower ventilatory reserve. Ventilatory reserves are limited in patients with HFpEF and obesity; indeed, the margin between ventilatory demand and capacity is so narrow that exercise capacity could be ventilatory limited in many patients., Competing Interests: Declaration of Competing Interest No conflicts of interest, financial or otherwise, are declared by the authors., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: The primary cause of dyspnea on exertion in heart failure with preserved ejection fraction (HFpEF) is presumed to be the marked rise in pulmonary capillary wedge pressure during exercise; however, this hypothesis has never been tested directly. Therefore, we evaluated invasive exercise hemodynamics and dyspnea on exertion in patients with HFpEF before and after acute nitroglycerin (NTG) treatment to lower pulmonary capillary wedge pressure., Research Question: Does reducing pulmonary capillary wedge pressure during exercise with NTG improve dyspnea on exertion in HFpEF?, Study Design and Methods: Thirty patients with HFpEF performed two invasive 6-min constant-load cycling tests (20 W): one with placebo (PLC) and one with NTG. Ratings of perceived breathlessness (0-10 scale), pulmonary capillary wedge pressure (right side of heart catheter), and arterial blood gases (radial artery catheter) were measured. Measurements of V˙/Q˙ matching, including alveolar dead space (Vd alv ; Enghoff modification of the Bohr equation) and the alveolar-arterial Po 2 difference (A-aDO 2 ; alveolar gas equation), were also derived. The ventilation (V˙e)/CO 2 elimination (V˙co 2 ) slope was also calculated as the slope of the V˙e and V˙co 2 relationship, which reflects ventilatory efficiency., Results: Ratings of perceived breathlessness increased (PLC: 3.43 ± 1.94 vs NTG: 4.03 ± 2.18; P = .009) despite a clear decrease in pulmonary capillary wedge pressure at 20 W (PLC: 19.7 ± 8.2 vs NTG: 15.9 ± 7.4 mm Hg; P < .001). Moreover, Vd alv (PLC: 0.28 ± 0.07 vs NTG: 0.31 ± 0.08 L/breath; P = .01), A-aDO 2 (PLC: 19.6 ± 6.7 vs NTG: 21.1 ± 6.7; P = .04), and V˙e/V˙co 2 slope (PLC: 37.6 ± 5.7 vs NTG: 40.2 ± 6.5; P < .001) all increased at 20 W after a decrease in pulmonary capillary wedge pressure., Interpretation: These findings have important clinical implications and indicate that lowering pulmonary capillary wedge pressure does not decrease dyspnea on exertion in patients with HFpEF; rather, lowering pulmonary capillary wedge pressure exacerbates dyspnea on exertion, increases V˙/Q˙ mismatch, and worsens ventilatory efficiency during exercise in these patients. This study provides compelling evidence that high pulmonary capillary wedge pressure is likely a secondary phenomenon rather than a primary cause of dyspnea on exertion in patients with HFpEF, and a new therapeutic paradigm is needed to improve symptoms of dyspnea on exertion in these patients., (Copyright © 2023 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

The incidence of syncope during orthostasis increases in early human pregnancy, which may be associated with cerebral blood flow (CBF) dysregulation in the upright posture. In addition, obesity and/or sleep apnea per se may influence CBF regulation due to their detrimental impacts on cerebrovascular function. However, it is unknown whether early pregnant women with obesity and/or sleep apnea could have impaired CBF regulation in the supine position and whether this impairment would be further exacerbated in the upright posture. Dynamic cerebral autoregulation (CA) was evaluated using transfer function analysis in 33 women during early pregnancy (13 with obesity, 8 with sleep apnea, 12 with normal weight) and 15 age-matched nonpregnant women during supine rest. Pregnant women also underwent a graded head-up tilt (30° and 60° for 6 min each). We found that pregnant women with obesity or sleep apnea had a higher transfer function low-frequency gain compared with nonpregnant women in the supine position (P = 0.026 and 0.009, respectively) but not normal-weight pregnant women (P = 0.945). Conversely, the transfer function low-frequency phase in all pregnancy groups decreased during head-up tilt (P = 0.001), but the phase was not different among pregnant groups (P = 0.180). These results suggest that both obesity and sleep apnea may have a detrimental effect on dynamic CA in the supine position during early pregnancy. CBF may be more vulnerable to spontaneous blood pressure fluctuations in early pregnant women during orthostatic stress compared with supine rest due to less efficient dynamic CA, regardless of obesity and/or sleep apnea., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Exercise intolerance is a defining characteristic of heart failure with preserved ejection fraction (HFpEF). A marked rise in pulmonary capillary wedge pressure (PCWP) during exertion is pathognomonic for HFpEF and is thought to be a key cause of exercise intolerance. If true, acutely lowering PCWP should improve exercise capacity. To test this hypothesis, we evaluated peak exercise capacity with and without nitroglycerin to acutely lower PCWP during exercise in patients with HFpEF., Methods: Thirty patients with HFpEF (70±6 years of age; 63% female) underwent 2 bouts of upright, seated cycle exercise dosed with sublingual nitroglycerin or placebo control every 15 minutes in a single-blind, randomized, crossover design. PCWP (right heart catheterization), oxygen uptake (breath × breath gas exchange), and cardiac output (direct Fick) were assessed at rest, 20 Watts (W), and peak exercise during both placebo and nitroglycerin conditions., Results: PCWP increased from 8±4 to 35±9 mm Hg from rest to peak exercise with placebo. With nitroglycerin, there was a graded decrease in PCWP compared with placebo at rest (-1±2 mm Hg), 20W (-5±5 mm Hg), and peak exercise (-7±6 mm Hg; drug × exercise stage P =0.004). Nitroglycerin did not affect oxygen uptake at rest, 20W, or peak (placebo, 1.34±0.48 versus nitroglycerin, 1.32±0.46 L/min; drug × exercise P =0.984). Compared with placebo, nitroglycerin lowered stroke volume at rest (-8±13 mL) and 20W (-7±11 mL), but not peak exercise (0±10 mL)., Conclusions: Sublingual nitroglycerin lowered PCWP during submaximal and maximal exercise. Despite reduction in PCWP, peak oxygen uptake was not changed. These results suggest that acute reductions in PCWP are insufficient to improve exercise capacity, and further argue that high PCWP during exercise is not by itself a limiting factor for exercise performance in patients with HFpEF., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT04068844.

Background: Patients with heart failure with preserved ejection fraction (HFpEF) exhibit many cardiopulmonary abnormalities that could result in V˙/Q˙ mismatch, manifesting as an increase in alveolar dead space (VD alveolar ) during exercise. Therefore, we tested the hypothesis that VD alveolar would increase during exercise to a greater extent in patients with HFpEF compared with control participants., Research Question: Do patients with HFpEF develop VD alveolar during exercise?, Study Design and Methods: Twenty-three patients with HFpEF and 12 control participants were studied. Gas exchange (ventilation [V˙ E ], oxygen uptake [V˙o 2 ], and CO 2 elimination [V˙co 2 ]) and arterial blood gases were analyzed at rest, twenty watts (20W), and peak exercise. Ventilatory efficiency (evaluated as the V˙ E /V˙co 2 slope) also was measured from rest to 20W in patients with HFpEF. The physiologic dead space (VD physiologic ) to tidal volume (VT) ratio (VD/VT) was calculated using the Enghoff modification of the Bohr equation. VD alveolar was calculated as: (VD / VT × VT) - anatomic dead space. Data were analyzed between groups (patients with HFpEF vs control participants) across conditions (rest, 20W, and peak exercise) using a two-way repeated measures analysis of variance and relationships were analyzed using Pearson correlation coefficient., Results: VD alveolar increased from rest (0.12 ± 0.07 L/breath) to 20W (0.22 ± 0.08 L/breath) in patients with HFpEF (P < .01), whereas VD alveolar did not change from rest (0.01 ± 0.06 L/breath) to 20W (0.06 ± 0.13 L/breath) in control participants (P = .19). Thereafter, VD alveolar increased from 20W to peak exercise in patients with HFpEF (0.37 ± 0.16 L/breath; P < .01 vs 20W) and control participants (0.19 ± 0.17 L/breath; P = .03 vs 20W). VD alveolar was greater in patients with HFpEF compared with control participants at rest, 20W, and peak exercise (main effect for group, P < .01). Moreover, the increase in VD alveolar correlated with the V˙ E /V˙co 2 slope (r = 0.69; P < .01), which was correlated with peak V˙o 2peak (r = 0.46; P < .01) in patients with HFpEF., Interpretation: These data suggest that the increase in V˙/Q˙ mismatch may be explained by increases in VD alveolar and that increases in VD alveolar worsens ventilatory efficiency, which seems to be a key contributor to exercise intolerance in patients with HFpEF., (Copyright © 2022 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Heart failure with preserved ejection fraction (HFpEF) is associated with cardiopulmonary abnormalities that may increase physiological dead space to tidal volume (VD/VT) during exercise. However, studies have not corrected VD/VT for apparatus mechanical dead space (VDM), which may confound the accurate calculation of VD/VT. We evaluated whether calculating physiological dead space with (VD/VT VDM ) and without (VD/VT) correcting for VDM impacts the interpretation of gas exchange efficiency during exercise in HFpEF. Fifteen HFpEF (age: 69 ± 6 yr; V̇o 2peak : 1.34 ± 0.45 L/min) and 12 controls (70 ± 3 yr; V̇o 2peak : 1.70 ± 0.51 L/min) were studied. Pulmonary gas exchange and arterial blood gases were analyzed at rest, submaximal (20 W for HFpEF and 40 W for controls), and peak exercise. VD/VT was calculated as [Formula: see text] - [Formula: see text]/[Formula: see text]. VD/VT VDM was calculated as [Formula: see text] - [Formula: see text]/[Formula: see text] - VDM/VT. VD/VT decreased from rest (HFpEF: 0.54 ± 0.07; controls: 0.32 ± 0.07) to submaximal exercise (HFpEF: 0.46 ± 0.07; controls: 0.25 ± 0.06) in both groups ( P < 0.05), but remained stable ( P > 0.05) thereafter to peak exercise (HFpEF: 0.46 ± 0.09; controls: 0.22 ± 0.05). In HFpEF, VD/VT VDM did not change ( P = 0.58) from rest (0.29 ± 0.07) to submaximal exercise (0.29 ± 0.06), but increased ( P = 0.02) thereafter to peak exercise (0.33 ± 0.06). In controls, VD/VT VDM remained stable such that no change was observed ( P > 0.05) from rest (0.17 ± 0.06) to submaximal exercise (0.14 ± 0.06), or thereafter to peak exercise (0.14 ± 0.05). Calculating physiological dead space with and without a VDM correction yields quantitively and qualitatively different results, which could have impact on the interpretation of gas exchange efficiency in HFpEF. Further investigation is required to uncover the clinical consequences and the mechanism(s) explaining the increase in VD/VT VDM during exercise in HFpEF. NEW & NOTEWORTHY Calculating VD/VT with and without correcting for VDM yields quantitively and qualitatively different results, which could have an important impact on the interpretation of V/Q mismatch in HFpEF. The finding that V/Q mismatch and gas exchange efficiency worsened, as reflected by an increase in VD/VT VDM during exercise, has not been previously demonstrated in HFpEF. Thus, further studies are needed to investigate the mechanisms explaining the increase in VD/VT VDM during exercise in patients with HFpEF.

Patients with heart failure with preserved ejection fraction (HFpEF) exhibit cardiopulmonary abnormalities that could affect the predictability of exercise [Formula: see text] from the Jones corrected partial pressure of end-tidal CO 2 (PJ CO 2 ) equation (PJ CO 2  = 5.5 + 0.9 × [Formula: see text] - 2.1 × V T ). Since the dead space to tidal volume (V D /V T ) calculation also includes [Formula: see text] measurements, estimates of V D /V T from PJ CO 2 may also be affected. Because using noninvasive estimates of [Formula: see text] and V D /V T could save patient discomfort, time, and cost, we examined whether partial pressure of end-tidal CO 2 ([Formula: see text]) and PJ CO 2 can be used to estimate [Formula: see text] and V D /V T in 13 patients with HFpEF. [Formula: see text] was measured from expired gases measured simultaneously with radial arterial blood gases at rest, constant-load (20 W), and peak exercise. V D /V T[art] was calculated using the Enghoff modification of the Bohr equation, and estimates of V D /V T were calculated using [Formula: see text] (V D /V T[ET] ) and PJ CO 2 (V D /V T[J] ) in place of [Formula: see text]. [Formula: see text] was similar to [Formula: see text] at rest (-1.46 ± 2.63, P = 0.112) and peak exercise (0.66 ± 2.56, P = 0.392), but overestimated [Formula: see text] at 20 W (-2.09 ± 2.55, P = 0.020). PJ CO 2 was similar to [Formula: see text] at rest (-1.29 ± 2.57, P = 0.119) and 20 W (-1.06 ± 2.29, P = 0.154), but underestimated [Formula: see text] at peak exercise (1.90 ± 2.13, P = 0.009). V D /V T[ET] was similar to V D /V T[art] at rest (-0.01 ± 0.03, P = 0.127) and peak exercise (0.01 ± 0.04, P = 0.210), but overestimated V D /V T[art] at 20 W (-0.02 ± 0.03, P = 0.025). Although V D /V T[J] was similar to V D /V T[art] at rest (-0.01 ± 0.03, P = 0.156) and 20 W (-0.01 ± 0.03, P = 0.133), V D /V T[J] underestimated V D /V T[art] at peak exercise (0.03 ± 0.04, P = 0.013). Exercise [Formula: see text] and V D /V T[ET] provides better estimates of [Formula: see text] and V D /V T[art] than PJ CO 2 and V D /V T[J] does at peak exercise. Thus, estimates of [Formula: see text] and V D /V T should only be used if sampling arterial blood during CPET is not feasible. NEW & NOTEWORTHY  [Formula: see text] provides a better estimate of [Formula: see text] than PJ CO 2 at peak exercise, and V D /V T[ET] provides a better estimate of V D /V T[art] than V D /V T[J] at peak exercise. Although we reported significant correlations, we did not find an identity between [Formula: see text] and estimates of [Formula: see text], nor did we find an identity between V D /V T[art] and estimates of V D /V T[art] . Thus, caution should be taken and estimates of [Formula: see text] and V D /V T should only be used if sampling arterial blood during CPET is not feasible.

Rationale: Obesity presents a mechanical load to the thorax, which could perturb the generation of minute ventilation (V̇e) during exercise. Because the respiratory effects of obesity are not homogenous among all individuals with obesity and obesity-related effects could vary depending on the magnitude of obesity, we hypothesized that the exercise ventilatory response (slope of the V̇e and carbon dioxide elimination [V̇co 2 ] relationship) would manifest itself differently as the magnitude of obesity increases. Objectives: To investigate the V̇e/V̇co 2 slope in an obese population that spanned across a wide body mass index (BMI) range. Methods: A total of 533 patients who presented to a surgical weight loss center for pre-bariatric surgery testing performed an incremental maximal cycling test and were studied retrospectively. The V̇e/V̇co 2 slope was calculated up to the ventilatory threshold. Patients were examined in groups based on BMI (category 1: 30-39.9 kg/m 2 , category 2: 40-49.9 kg/m 2 , and category 3: ≥50 kg/m 2 ). Because the respiratory effects of obesity could be sex and/or age specific, we further examined patients in groups by sex and age (younger: <50 yr and older: ≥50 yr). Differences in the V̇e/V̇co 2 slope were then compared between BMI category, age, and sex using a three-way ANOVA. Results: No significant BMI category by sex by age interactions was detected ( P  = 0.75). The V̇e/V̇co 2 slope decreased with increases in BMI (category 1, 29.1 ± 4.0; category 2, 28.4 ± 4.1; and category 3, 27.1 ± 3.3) and was elevated in women (28.9 ± 4.1) compared with men (26.7 ± 3.2) (BMI category by sex interaction, P  < 0.05). No age-related differences were observed (BMI category by age interaction, P  = 0.55). The partial pressure for end-tidal CO 2 was elevated at the ventilatory threshold in BMI category 3 compared with BMI categories 1 and 2 (both P  < 0.01). Conclusions: These findings suggest that obesity presents a unique challenge to augmenting ventilatory output relative to CO 2 elimination, such that the increase in the exercise ventilatory response becomes blunted as the magnitude of obesity increases. Further studies are required to investigate the clinical consequences and the mechanisms that may explain the attenuation of exercise ventilatory response with increasing BMI in men and women with obesity.

Purpose: The purpose of this study was to assess long-term psychosocial outcomes of anti-N-methyl-d-aspartate (NMDA) receptor encephalitis (anti-NMDARE)., Methods: Adolescents and adults with self-reported anti-NMDARE were invited to complete an online survey distributed by relevant patient organizations. Demographic and clinical information was collected, including the diagnoses initially given for anti-NMDARE symptoms and posthospital care received. Patient-Reported Outcomes Measurement Information System (PROMIS) Psychosocial Impact Illness - Negative short form (Negative PSII) was administered to assess psychosocial outcome of anti-NMDARE. Associations between clinical factors and psychosocial outcomes were evaluated., Results: Sixty-one individuals with anti-NMDARE age 15 years and above participated. Mean age was 33.7 years (standard deviation [SD]: 12.8), and participants were predominantly female (90.2%, n = 55). Mean T-score on PROMIS Negative PSII was 60.7, >1 SD higher (worse psychosocial function) than that of the provided normalized sample enriched for chronic illness (50, SD: 10). Initial misdiagnosis of anti-NMDARE symptoms was associated with decreased odds (odds ratio [OR]: 0.11, p < 0.05), and follow-up with a psychiatrist after hospitalization with increased odds (OR: 8.46, p < 0.05), of return to work/school after illness. Younger age of symptom onset and presence of ongoing neuropsychiatric issues were predictive of worse Negative PSII scores (p < 0.05)., Conclusion: Individuals with anti-NMDARE demonstrate poor psychosocial outcomes, yet there are no current standards for long-term assessment or management of such symptoms in this population. These findings highlight the need for use of more comprehensive outcome measures that include assessment of psychosocial function and the importance of developing interventions that address this domain for individuals with anti-NMDARE., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: The purpose of the study was to assess care transitions and caregiver burden among caregivers of individuals with anti-N-methyl-d-aspartate (NMDA) receptor encephalitis (anti-NMDARE)., Methods: Caregivers of individuals with anti-NMDARE were recruited via patient organization websites. Demographic and clinical information as well as responses to the Care Transition Measure 15 (CTM-15) and Zarit Burden Interview (ZBI) were collected. Exploratory factor analysis (EFA) was conducted on the ZBI, and underlying constructs were analyzed for associations with the CTM-15 and clinical characteristics., Results: Seventy-six caregivers participated. On the CTM-15, the top items where caregivers disagreed or strongly disagreed were the following: "when the patient left the hospital, I had a readable and easily understood written plan that described how all of their healthcare needs were going to be met" (73%), "when the patient left the hospital, I was confident that I know how to manage their health" (62%), and "when the patient left the hospital, I had all the information I needed to be able to take care of them" (58%). Worse care transitions significantly predicted higher caregiver burden scores. Mean ZBI score was 44, falling in the moderate to severe burden range. Exploratory factor analysis was conducted and found four common underlying factors associated with total score. Factor 1, the impact of caring on caregivers' personal lives (accounting for 51% of total score variance), was selected for further analysis because of its modifiable nature. Higher ZBI scores were associated with lower CTM-15 scores (p < 0.003) and the individual with anti-NMDARE not returning to driving (p < 0.002)., Conclusion: This study identified specific elements of care transitions and caregiver burden that are not currently being addressed for individuals with anti-NMDARE. Attention to these aspects of care in the development of targeted interventions may improve outcomes in individuals with anti-NMDARE and their caregivers., (Copyright © 2020 Elsevier Inc. All rights reserved.)

We investigated the contributions of obesity on multidimensional aspects of dyspnea on exertion (DOE) in patients referred for clinical cardiopulmonary exercise testing (CPET). Ratings of perceived breathlessness (RPB, Borg scale 0-10) were collected in obese (BMI ≥ 30; n = 47) and nonobese (BMI ≤ 25; n = 27) patients during two (one lower: ∼30 W; and one higher: ∼50 W) 4-6 min constant load cycling bouts. Multidimensional dyspnea profiles (MDP) were collected in the final 26 obese and 14 nonobese patients of the sample. RPB was greater (p = 0.05) in obese (3.3 ± 2.2 vs 2.4 ± 1.4) at lower work rates, but similar at higher work rates (4.9 ± 2.2 vs 4.4 ± 1.8). MDP sensory score including unpleasantness was 4.3 ± 2.2 in obese vs 2.5 ± 1.9 in nonobese (p < 0.001). The affective score was 1.9 ± 2.2 vs 0.7 ± 0.7, respectively (p < 0.01). Breathing sensations including 'air hunger', 'effort', and 'breathing at lot' were greater (p < 0.05) in obese, making these patients more frustrated/angry (p < 0.05). Obesity should be considered as a potential independent influencing factor that provokes DOE and unpleasantness when assessing breathlessness during CPET., Competing Interests: Declaration of Competing Interest Dr. Balmain has no conflicts of interest to disclose. Mr. Weinstein has no conflicts of interest to disclose. Dr. Bernhardt has no conflicts of interest to disclose. Dr. Marines-Prince has no conflicts of interest to disclose. Dr. Tomlinson has no conflicts of interest to disclose. Dr. Babb has no conflicts of interest to disclose., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To compare temporal bone thickness along a three-dimensional arc of potential osseointegrated implant sites for bone-anchored hearing aids in children with and without aural atresia using computed tomographic imaging (CT)., Study Design: Retrospective case review., Setting: Tertiary children's hospital., Patients: Children with or without aural atresia aged less than 11 years who had a temporal bone CT., Intervention (s): Calvarial bone volume on CT was rendered in three-dimensional and thickness was reconstructed and measured at up to 12 defined sites along an arc of recommended implant sites., Main Outcome Measure (s): Determining whether a majority of observed potential implant sites have 2, 3, or 4 mm of bone thickness while controlling for age differences and atresia status., Results: A total of 40 atretic (from 34 patients) and 34 control (from 34 patients) temporal bones were compared using CT. Likelihood ratio tests indicated that diagnosis did not have a statistically significant effect on whether patients reached thresholds of 2, 3, or 4 mm at most observed sites (p = 0.781, 0.773, and 0.529, respectively) when adjusting for age. For all children measured, 93% had >50% of measured points greater than or equal to 2 mm thick., Conclusion: Most children had greater than 2 mm of temporal bone thickness at >50% of the sites measured regardless of age or atresia diagnosis. The likelihood of reaching 4 mm of thickness at most sites improves with age. In unilateral patients, there was not a significant difference in thickness between affected and unaffected sides. There was also no significant difference in thickness when comparing patients with atresia to those without.

Importance: We present what we believe to be the first case series in which the teres major muscle is used as a free flap in head and neck reconstruction., Objectives: To describe our experience with the teres major muscle in free flap reconstruction of head and neck defects and to identify advantages of this approach., Design, Setting, and Participants: A retrospective review was performed at 2 tertiary care centers between February 1, 2007, and June 30, 2012. Data analysis was conducted from July 31, 2014, through December 1, 2014., Intervention: Teres major muscle free flap for use in head and neck reconstruction., Main Outcomes and Measures: Indications for use, complications, and outcomes including donor site morbidity., Results: The teres major free flap was used in 11 patients as a component of chimeric subscapular system free flaps for a variety of complex head and neck defects. The teres major muscle was used to fill soft-tissue defects of the neck, face, and nasal cavity; it provided substantial soft-tissue volume but was less bulky than the latissimus dorsi muscle. The teres major muscle was also used to provide protection for vascular anastomoses and/or great vessels and to enhance soft-tissue coverage of the mandibular reconstruction plate. In addition, the muscle was selected as a substrate for skin grafting where inadequate neck skin remained. Flap survival occurred in 10 of 11 flaps (91%). Two flaps (18%) demonstrated venous congestion that was managed successfully. Two patients (18%) developed minor recipient-site complications (submental fistula and infection with recurrent wound dehiscence and plate exposure). All donor sites healed well, with chronic, mild shoulder pain noted in 2 patients (18%) and no postoperative seromas observed in any patient., Conclusions and Relevance: Addition of the teres major muscle to a subscapular system free flap is an option for reconstruction of a variety of complex head and neck defects, particularly when a moderate amount of soft tissue is required. In select cases, the teres major muscle may have advantages over the latissimus dorsi muscle.