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Supplementary Data: This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content. Data supplement 1 available at: https://bmjopenrespres.bmj.com/highwire/filestream/140550/field_highwire_adjunct_files/0/bmjresp-2022-001414supp001_data_supplement.pdf Copyright © 2022 Author(s) (or their employer(s)). Introduction: Breathing pattern disorder (BPD) is an abnormal breathing pattern associated with biochemical, biomechanical and psychophysiological changes. While physiotherapy is often offered, limited evidence-based therapies for BPD are available. Music therapy-based singing exercises have been shown to improve quality of life for individuals with respiratory conditions and may also be beneficial for individuals living with BPD. No study has previously compared these participatory interventions in the treatment of people living with BPD. Methods and analysis: This is a study protocol for an assessor blinded 1:1 randomised controlled trial and qualitative interview study. Forty participants aged 18–40 years who score at least 19 on the Nijmegen Questionnaire (NQ) and do not have any underlying respiratory conditions will be recruited. Participants will be randomised to receive either physiotherapy-led or music therapy-led breathing exercises for 6 weeks. The primary outcome will be between-group difference in NQ post-intervention. Semistructured interviews with a purposive sample of participants will be performed. Qualitative data will be analysed using thematic analysis to better understand participants’ intervention and trial experiences. Ethics and dissemination: This study has received ethical approval by Brunel University London College of Health, Medicine and Life Science’s Research Ethics Committee (32483-MHR-Mar/2022-38624-3). The anonymised completed dataset will be made available as an open-access file via Brunel University London Figshare and the manuscript containing anonymised patient data will be published in an open-access journal. Trial registration number This trial is registered on the Open Science Framework Registry (https://osf.io/u3ncw). Brunel University London Internal grant scheme called BRIEF (award number: 12207107).

Dysfunctional breathing (DB) is common among people with and without primary respiratory pathology. While anxiety contributes to DB, the underpinning mechanism is unclear. One explanation is that anxiety induces excessive conscious monitoring of breathing, disrupting ‘automatic’ breathing mechanics. We validated a new tool that quantifies such breathing-related ‘hypervigilance’: the Breathing Vigilance Questionnaire (Breathe-VQ).Three-hundred-and-forty healthy adults (Mage=27.3 years, range: 18-71; 161 men) were recruited online. We developed an initial Breathe-VQ (11 items, 1-5 Likert scale) based on the Pain Vigilance and Awareness Scale, using feedback from the target population and clinicians. At baseline, participants completed the Breathe-VQ, Nijmegen Questionnaire (NQ), State-Trait Anxiety Inventory (form 2), and Movement-Specific Reinvestment Scale (assessing general conscious processing). Eighty-three people repeated the Breathe-VQ two weeks later.We removed five items based on item-level analysis. The resulting six-item Breathe-VQ questionnaire (score range: 6-30) has excellent internal (alpha=.892) and test-retest reliability (ICC=.810), a minimal detectable change of 6.5, and no floor/ceiling effects. Concurrent validity was evidenced by significant positive correlations with trait anxiety and conscious processing scores (r’s=.35-.46). Participants at high-risk of having DB (NQ>23; N=76) had significantly higher Breathe-VQ score (M=19.1±5.0) than low-risk peers (N=225; M=13.8±5.4;pp=.005), even when controlling for risk factors (e.g., trait anxiety).The Breathe-VQ is a valid and reliable tool to measure breathing vigilance. Breathing vigilance may contribute to DB, and could represent a therapeutic target. Further research is warranted to further test the Breathe-VQ’s prognostic value, and assess intervention effects.Key Findings– Dysfunctional breathing (DB) is highly prevalent in the general population as well as in people with respiratory conditions.– Anxiety is identified as a key factor contributing to DB, potentially because it induces conscious, anxious monitoring of breathing.– We developed a short self-reported outcome measure of such breathing-specific vigilance, the Breathe-VQ.– The Breathe-VQ was found to be a valid and reliable tool for use in the general population.– Breathe-VQ scores were positively associated with self-reported breathing problems, after correcting for known risk factors such as trait-anxiety.

Uropathogen resistance, fluoroquinolone-resistance (FQR), and extended spectrum beta-lactamase (ESBL), has been observed to be emerging worldwide with prevalences above recommended thresholds for routine empirical treatment. The primary aim of our study was to determine the prevalence of FQR from a geographically diverse sample of United States emergency departments (EDs).We conducted a multi-center, observational cohort study using a network of 15 geographically diverse US EDs. All patients ≥18 years of age with the primary or secondary diagnosis of urinary tract infection (UTI) in the ED identified using International Classification of Diseases (ICD-10) diagnosis code of cystitis, pyelonephritis, or UTI from 2018 to 2020 were included. We calculated descriptive statistics for uropathogens and susceptibilities. Logistic regression analysis was used to identify antimicrobial resistance risk factors associated with FQR Escherichia coli.Among 3779 patients who met inclusion criteria, median age was 62.9 years (interquartile range [IQR]: 41-77.6) and 76.3% were female. The most common diagnoses were complicated (41.2%) and uncomplicated cystitis (40.3%). E. coli was the most common pathogen (63.2%), followed by Klebsiella pneumoniae (13.2%) and Enterococcus species (5.8%). Across all sites, overall E. coli FQ-resistance prevalence was 22.1%, ranging from 10.5 to 29.7% by site. The prevalence of ESBL-producing uropathogen was 7.4%, ranging from 3.6% to 11.6% by site. Previous IV or oral antimicrobial use in the past 90-days and history of a multi-drug resistant pathogen were associated with FQ-resistant E. coli (odds ratio [OR] 2.68, 95% confidence interval [CI]: 2.04-3.51, and OR 6.93, 95% CI: 4.95-9.70, respectively). Of the patients who had FQ-resistant E. coli or an ESBL-producing uropathogen isolated, 116 (37.1%) and 61 (36.7%) did not have any documented risk factors for resistance.FQ-resistant E. coli is widely prevalent across US sites highlighting the need for ongoing monitoring of antimicrobial resistance and, at some locations, modification of empirical treatments.