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RationaleChronic cough is a common symptom in patients with interstitial lung disease (ILD), negatively contributing to health-related quality of life. Despite this, there is limited information and understanding on the experience of this group of patients with chronic cough. This study aimed to explore the symptom experiences for chronic cough in patients with ILD to identify its characteristics and impacts.MethodsA qualitative study using semi-structured telephone interviews was undertaken in 16 adults with a diagnosis of ILD of any type and severity. Patients were recruited from a quaternary referral centre in Melbourne, Australia. Interviews were transcribed verbatim and coded by two researchers using thematic analysis.ResultsPatients (age range: 39–87 years, forced vital capacity: 53–107% predicted and diffusing capacity of the lung for carbon monoxide: 28–89% predicted) experienced a spectrum of cough severity and characteristics, including both dry and productive coughs. The impact of chronic cough included physical symptoms, social and emotional difficulties, and interference with work and vocational participation. Management strategies used to relieve cough included mucolytics, opiates, throat lozenges, warm drinks, pacing, breath control, relaxation exercises, movement, continuous positive airways pressure and supplemental oxygen. Patients expressed a need for further information and education regarding chronic cough, including its triggers and management.ConclusionsThis study highlights the experience and significance of chronic cough in patients with ILD. The nature and severity of chronic cough in patients with ILD appears to be more heterogeneous than previously described, with physical, social and emotional impacts contributing to symptom burden.

Asthma is a respiratory disease characterised by variable airflow limitation and the presence of respiratory symptoms including wheeze, chest tightness, cough and/or dyspnoea. Exercise training is beneficial for people with asthma; however, the response to conventional models of pulmonary rehabilitation is less clear.To evaluate, in adults with asthma, the effectiveness of pulmonary rehabilitation compared to usual care on exercise performance, asthma control, and quality of life (co-primary outcomes), incidence of severe asthma exacerbations/hospitalisations, mental health, muscle strength, physical activity levels, inflammatory biomarkers, and adverse events.We identified studies from the Cochrane Airways Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform, from their inception to May 2021, as well as the reference lists of all primary studies and review articles.We included randomised controlled trials in which pulmonary rehabilitation was compared to usual care in adults with asthma. Pulmonary rehabilitation must have included a minimum of four weeks (or eight sessions) aerobic training and education or self-management. Co-interventions were permitted; however, exercise training alone was not. DATA COLLECTION AND ANALYSIS: Following the use of Cochrane's Screen4Me workflow, two review authors independently screened and selected trials for inclusion, extracted study characteristics and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. We contacted study authors to retrieve missing data. We calculated between-group effects via mean differences (MD) or standardised mean differences (SMD) using a random-effects model. We evaluated the certainty of evidence using GRADE methodology.We included 10 studies involving 894 participants (range 24 to 412 participants (n = 2 studies involving n100, one contributing to meta-analysis), mean age range 27 to 54 years). We identified one ongoing study and three studies awaiting classification. One study was synthesised narratively, and another involved participants specifically with asthma-COPD overlap. Most programmes were outpatient-based, lasting from three to four weeks (inpatient) or eight to 12 weeks (outpatient). Education or self-management components included breathing retraining and relaxation, nutritional advice and psychological counselling. One programme was specifically tailored for people with severe asthma. Pulmonary rehabilitation compared to usual care may increase maximal oxygen uptake (VO

Cervical spinal cord injury (cSCI) impairs neural drive to the respiratory muscles, causing life- threatening complications such as respiratory insufficiency and diminished airway protection. Repetitive "low dose" acute intermittent hypoxia (AIH) is a promising strategy to restore motor function in people with chronic SCI. Conversely, "high dose" chronic intermittent hypoxia (CIH; ∼8 h/night), such as experienced during sleep apnea, causes pathology. Sleep apnea, spinal ischemia, hypoxia and neuroinflammation associated with cSCI increase extracellular adenosine concentrations and activate spinal adenosine receptors which in turn constrains the functional benefits of therapeutic AIH. Adenosine 1 and 2A receptors (A

RationaleSelf-management is considered as an important part of disease management for people with pulmonary fibrosis (PF), but there is a lack of consensus regarding what components should be included. This study aimed to attain consensus from experts in PF and people living with the disease on the essential components and format of a PF self-management package.MethodsA two-round Delphi process was conducted. In each round, a panel of experts completed an online survey to rate a range of components, formats and delivery methods, followed by an online patient focus group to integrate patient perspectives. Consensus was defineda priori.Results45 experts participated in Round 1 and 51 in Round 2. Both focus groups included six people with PF. 12 components were considered essential for self-management in PF: 1) understanding treatment options; 2) understanding and accessing clinical trials; 3) managing medications; 4) role of oxygen therapy; 5) role and importance of pulmonary rehabilitation and regular physical activity; 6) managing shortness of breath; 7) managing fatigue; 8) managing mood; 9) managing comorbidities; 10) smoking cessation advice and support; 11) accessing community support; and 12) how to communicate with others when living with PF. Both groups agreed that self-management in PF required individualisation, goal setting and feedback.ConclusionThis study identified 12 essential components and highlighted individualisation, goal setting and feedback in self-management of PF. The findings provide a basis for the development of PF self-management interventions.

This study aimed to assess the feasibility of delivering a brief physical activity (PA) intervention to community rehabilitation clients. Participants were randomized to receive one session of stage-of-change-based PA education and counseling in addition to written educational material, or education material alone. Outcomes were measured at baseline and 3 months; the primary outcome was feasibility, measured by the percentage of those who were eligible, consented, randomized, and followed-up. A total of 123 individuals were both eligible and interested in participating, 32% of those screened on admission to the program. Forty participants consented, and 35 were randomized, with mean age 72 years (SD = 12.2). At baseline, 66% had recently commenced or intended to begin regular PA in the next 6 months. A total of 30 participants were followed-up. It is feasible to deliver education and counseling designed to support the long-term adoption of regular PA to community rehabilitation clients. Further refinement of the protocol is warranted (ACTRN12617000519358).

Roost locations can be an important contributor to vulture conflicts with humans, but factors influencing roost-site selection at a landscape level remain largely unexplored. Further, there has been little research comparing how these factors vary between nocturnal and diurnal roosting sites. We used remote cameras to document daily variation in vulture use of 21 roosts (20 communication/water towers and 1 natural roost) near Beaufort, South Carolina, USA from October 2019–August 2020. Numbers of vultures on roosts increased with decreasing urban cover and with greater distance to water, but were not influenced by habitat fragmentation or elevation. Roosts surrounded by greater proportions of urban cover were used more often during the day, whereas roosts adjacent to less urban cover were more commonly used at night. We suggest that this relationship results from a greater daytime association with human development, areas that likely provide food and favorable soaring conditions for vultures. Vultures tended to depart nocturnal roosts before sunrise and return within two hours of sunset, indicating that aircraft collision risk resulting from movement around nocturnal roosts would be elevated during these times. Several communication towers routinely had > 100 vultures roosting on them at once, likely contributing to conflict with humans. Our findings reiterate the generalism of these species and their capacity to exploit novel structures for roosting, which has likely contributed to range expansions and resultant increases in human-vulture conflicts over the past several decades.

ImportanceTumor necrosis factor α (TNF) inhibitor–induced psoriasiform eruption is well recognized in adults, but few reports document this paradoxical effect in children.ObjectiveTo characterize the clinical features and the clinical time course of TNF inhibitor–induced psoriasiform eruptions in children.Design, Setting, and ParticipantsA multicenter retrospective case series of children younger than 18 years seen between January 1, 2000, and December 31, 2016, who developed a new-onset psoriasiform eruption while taking a TNF inhibitor for a nondermatologic disorder. Participating sites were members of the Pediatric Dermatology Research Alliance. Data were entered into a Research Electronic Data Capture database at the Mayo Clinic (ie, the coordinating center).ResultsPsoriasiform eruptions were identified in 103 TNF inhibitor–treated patients (median age, 13.8 years [IQR, 11.7-16.4 years]; 52 female patients [50%]; 57 White patients [55%]), with 67 patients (65%) treated with infliximab, 35 (34%) with adalimumab, and 1 (1%) with certolizumab pegol. Most patients had no personal history (101 [98%]) or family history of psoriasis (60 patients [58%]). Inflammatory bowel disease was the most common indication for treatment with TNF inhibitor (94 patients [91%]). The primary extracutaneous disease was under control in 95 patients (92%) who developed the eruption. Most patients (n = 85 [83%]) developed psoriasiform eruptions at multiple anatomic sites, with scalp involvement being most common (65 patients [63%]). Skin disease developed at a median of 14.5 months (IQR, 9-24 months) after TNF inhibitor initiation. To treat the psoriasiform eruption, topical steroidal and nonsteroidal medication was prescribed for all patients. Systemic therapy was added for 30 patients (29%): methotrexate for 24 patients (23%), oral corticosteroids for 8 patients (8%), and azathioprine for 1 patient (1%). For 26 patients (25%), suboptimal effectiveness with topical medications alone prompted discontinuation of the initial TNF inhibitor and a change to a second-line TNF inhibitor with cutaneous improvement in 23 patients (88%) by a median of 3 months (IQR, 2-4 months). Eight patients (31%) who started a second-line TNF inhibitor developed a subsequent TNF inhibitor–induced psoriasiform eruption at a median of 6 months (IQR, 4-8 months). Persistent skin disease in 18 patients (17%) prompted discontinuation of all TNF inhibitors; 11 patients changed to a non-TNF inhibitor systemic therapy, and 7 discontinued all systemic therapy.Conclusions and RelevanceIn this case series, paradoxical TNF inhibitor–induced psoriasiform eruptions were seen in children treated with TNF inhibitors for any indication, and there appears to be a class effect among the varying TNF inhibitors. The majority of these children were able to continue TNF inhibitor therapy with adequate skin-directed and other adjuvant therapies.

Introduction The COVID-19 pandemic resulted in a rapid transformation of health services. This study aimed to understand the experiences of healthcare by people with interstitial lung disease (ILD), to inform future service delivery. Methods Four specialist clinics in tertiary centres in Australia (Victoria:2 sites; New South Wales: 1 site; Western Australia: 1 site) recruited patients with ILD during an 8-week period from March 2021. Participants completed a COVID-specific questionnaire focused on health-related experiences during 2020. Results Ninety nine (65% of 153) participants completed the questionnaire. 47% had idiopathic pulmonary fibrosis or connective tissue disease-associated ILD, 62% were female and the average age was 66 years. Whilst 56% rated their overall health in 2020 as the same as months prior, 38% indicated a worsening in health attributed to reduced physical activity and fear of contracting the virus. Access to healthcare professionals was ‘good’ in 61%, and ‘fair-to-poor’ for 37% due to missed respiratory assessments, with telehealth (mainly telephone) being perceived as less effective. 89% had contact with respiratory physicians, 68% with general practitioners, predominantly via telephone, with few video consultations. High satisfaction with care was reported by 78%, with lower satisfaction attributed to delays in assessments, disruption to usual services such as pulmonary rehabilitation, and dissatisfaction with telehealth. Conclusion People with ILD were generally satisfied with their care during 2020, however reduced access to healthcare professionals was challenging for those experiencing a deterioration in health. Telehealth was largely well received but did not always meet the needs of people with ILD particularly when unwell.

Quantifying the amount of gas hydrate in a reservoir provides valuable insight on gas hydrates’ potential as a resource and their contribution to the global carbon cycle. We develop a new method to estimate hydrate saturation from density-sensitive X-ray computed tomography (XCT) scans of pressure cores from northern Gulf of Mexico (Green Canyon Block 955). While several studies have used XCT to quantify gas hydrate in the fractures of fine-grained sediments, our study is the one of the few to use XCT for coarse-grained (sand and silt) reservoirs. We calibrate our new method with grain density and quantitative degassing measurements from the same intervals. This paper uses the density difference between gas hydrate (0.924 g/cm3) and porewater brine (1.035 g/cm3) and assume these changes linearly affect the XCT measurements allowing for estimates of hydrate saturation. Overall, the XCT calculations agree with the hydrate saturation from quantitative degassing. For example, in core H005-3FB-3, quantitative degassing indicated a hydrate saturation of 88 ±33.5%, while the XCT calculations yielded a 90 ±4 4.8% saturation. These results are encouraging as they suggest that XCT analysis has the potential to nondestructively estimate hydrate saturation.

Background Pulmonary rehabilitation (PR) is a core component of management people with chronic obstructive pulmonary disease (COPD); yet, people with COPD face significant barriers to attending centre-based PR programs. The emergence of new models of PR, remotely delivered directly into people’s homes, has the potential to improve rehabilitation access and completion by providing patients with a choice of rehabilitation location (centre or home). However, offering patients a choice of rehabilitation model is not usual practice. We are undertaking a 14-site cluster randomised controlled trial to determine whether offering choice of PR location improves rehabilitation completion rates resulting in reduced all-cause unplanned hospitalisation over 12 months. The aim of this paper is to describe the protocol for the process evaluation of the HomeBase2 trial. Methods A mixed methods process evaluation, to be undertaken in real time, has been developed in accordance with UK Medical Research Council (MRC) recommendations on process evaluation of complex interventions. This protocol describes the intended use of two theoretical frameworks (RE-AIM framework (Reach; Effectiveness; Adoption; Implementation; Maintenance) and Theoretical Domains Framework (TDF)) to synthesise findings and interpret data from a combination of qualitative (semi-structured interviews) and quantitative (questionnaires, clinical outcome data, intervention fidelity) methodologies. Data will be collected at an intervention, patient and clinician level. Qualitative and quantitative data will be used to derive context-specific potential and actual barriers and facilitators to offering patients choice of rehabilitation location. Acceptability and sustainability of the intervention will be evaluated for future scale-up. Discussion The process evaluation described here will appraise the clinical implementation of offering a choice of rehabilitation program location for people with COPD. It will identify and evaluate key factors for future scale-up and sustainability and scale-up of offering choice of pulmonary rehabilitation program model for people. Trial registration ClinicalTrials.gov NCT04217330 Registration date: January 3 2020.

Questions: What airway clearance techniques and exercise regimens are used by adults with cystic fibrosis (CF) in Australia when well or unwell? What proportion of these adults believe that exercise can be used as a substitute for traditional airway clearance techniques, and how have they come to this belief? What type of exercise is used as a substitute for traditional airway clearance techniques? Design: Cross-sectional survey at 13 CF centres in Australia, using a purpose-designed questionnaire. Participants: Six hundred and ninety-two adults with CF completed the questionnaire. Outcome measures: The questionnaire included questions about: the participants' current use of traditional airway clearance techniques and exercise, when well and unwell; and beliefs regarding the use of exercise as a substitute for traditional airway clearance techniques. Results: Coughing, huffing and positive expiratory pressure were the most commonly used airway clearance techniques. Walking, jogging and lifting weights were the most commonly used forms of exercise. Overall, 43% of participants believed that exercise could be used as a substitute for traditional airway clearance techniques, with 44% having substituted exercise for traditional airway clearance techniques in the previous 3 months. Personal experience was the most commonly reported factor influencing participants' beliefs about the use of exercise as a substitute for traditional airway clearance techniques. Conclusion: Exercise is commonly used as a substitute for traditional airway clearance techniques. Physiotherapists should advise patients that whilst there is some research suggesting a possible mechanism for exercise as a form of airway clearance, there are currently no medium-term to long-term data supporting exercise as a stand-alone form of airway clearance. These results suggest that future research to investigate the clinical effectiveness of exercise as a substitute for traditional airway clearance techniques should be a priority. Registration: ACTRN12616000994482. Key words: Cystic fibrosis, Exercise, Physical therapy modalities, Respiratory therapy

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease that constitutes a major global health burden. A significant proportion of patients experience skeletal muscle wasting and loss of strength as a comorbidity of their COPD, a condition that severely impacts on their quality of life and survival. At present, the lung pathology is considered to be largely irreversible; however, the inherent adaptability of muscle tissue offers therapeutic opportunities to tackle muscle wasting and potentially reverse or delay the progression of this aspect of the disease, to improve patients' quality of life. Muscle wasting in COPD is complex, with contributions from a number of factors including inflammatory cytokines, oxidative stress, growth and anabolic hormones, nutritional status, and physical activity. In this review, we discuss current and emerging therapeutic approaches to treat muscle wasting in COPD, including a number of pharmacological therapies that are in development for muscle atrophy in other pathological states that could be of relevance for treating muscle wasting in COPD patients.

Debido a que el parasol es un objeto de origen asiático, erróneamente considerado como nativo peruano, uno debe preguntarse cómo llegaron al Perú las imágenes de este objeto utilitario. Los dibujos de enanos y corcovados sosteniendo parasoles en la Nueva corónica son importantes porque demuestran que los recursos visuales utilizados en la crónica son abundantes, variados y van más allá de Europa. Imágenes de este tipo, oriundos del manuscrito Galvin mayormente ilustrado por Guarnan Poma, también aparecen en la Historia general del Perú (hacia 1611-1613), de Martín de Murúa, crónica estrechamente ligada con la Nueva corónica. Más aun, las imágenes de enanos y corcovados con parasoles en estas dos crónicas son las representaciones más tempranas de esta naturaleza que aparecen en el arte del virreinato del Perú. Durante la segunda parte del siglo XVII, retratos de la realeza inca y sus descendientes fueron rutinariamente pintados protegidos bajo parasoles sostenidos por sirvientes enanos corcovados. El propósito de este ensayo es, por consiguiente, trazar la posible trayectoria de estas imágenes de Asia al Nuevo Mundo. Basaré mi trabajo en dos eventos históricos importantes que ocurrieron durante la vida de Guarnan Poma. Uno es la apertura por los españoles de la ruta transpacífica, la cual les permitió conectar todas las regiones de su imperio con Asia y el segundo son las actividades misionales de los jesuitas en Japón antes de 1600, es decir, dieciséis años antes de que Guarnan Poma de Ayala terminara y enmendara su Nueva corónica.

Countries in the Global South are particularly vulnerable to social and political violence. This paper suggests that such violence makes certain recalcitrant economic interests more open to taxes and spending on social welfare. Using results from a survey experiment of business owners and operators in Mexico, we show that relative to more innocuous institutional weaknesses, concerns over violence generally increase support for anti-poverty spending and decrease support for tax cuts. To build a theory, we explore heterogeneous effects and textual data. The findings suggest that business interests see anti-poverty spending as a tool for shoring up costs of violence in consumer markets, with some leaders even extending support to welfare-enhancing taxes. However, violence can create challenges in labor markets that increase operational costs, leading some business interests to resist tax policies that ask them to help fund social programs.

Objective: To determine if the intention to perform an exercise at speed leads to beneficial alterations in kinematic and kinetic components of the movement in people with post-stroke hemiplegia. Design: Comparative study. Setting: Subacute metropolitan rehabilitation hospital. Participants: Convenience sample of patients admitted as an inpatient or outpatient with a diagnosis of stroke with lower limb weakness, functional ambulation category score ≥3, and ability to walk ≥14metres. Methods: Participants performed a single leg squat exercise on their paretic and nonparetic legs on a leg sled under three conditions: 1) self-selected speed (SS), 2) fast speed (FS), 3) jump squat (JS). Measures of displacement, flight time, peak concentric velocity, and muscle excitation (via electromyography) were compared between legs and conditions. Results: Eleven participants (age: 56 ± 17 years; median time since stroke onset: 3.3 [IQR 3,41] months) were tested. All participants achieved a jump during the JS, as measured by displacement and flight time respectively, on both their paretic (0.25 ± 0.16 m and 0.42 ± 0.18 s) and nonparetic (0.49 ± 0.36 m and 0.73 ± 0.28 s) legs; however it was significantly lower on the non-paretic leg (p < 0.05). Peak concentric velocity increased concordantly with intended movement speed (JS-FS paretic: 0.96 m/s, non-paretic: 0.54 m/s; FS-SS paretic 0.69 m/s, nonparetic 0.38 m/s; JS-SS paretic 1.66 m/s, non-paretic 0.92 m/s). Similarly, muscle excitation increased significantly (p < 0.05) with faster speed for the paretic and nonparetic vastus lateralis. For gastrocnemius, the only significant difference was an increase during nonparetic JS vs. SS and FS. Conclusions: Speed affects the kinematic and kinetic components of the movement. Performing exercises ballistically may improve training outcomes for people post-stroke.

Endurance training during PR requires exercise prescription at sufficient intensity to achieve physiological benefits. This analysis sought to investigate whether walking training prescribed from 6-minute walk test (6MWT) average speed provides an appropriate training intensity for people with ILD during PR.Individuals with ILD completed cardiopulmonary exercise test (CPET) and 6MWT in random order. A 10-minute constant speed treadmill walk test (10MTW) was undertaken at 80% of the average 6MWT speed. Oxygen uptake (VOEleven people with ILD (age 71 (8) years; forced vital capacity 73 (18) %predicted, 6-minute walk distance 481 (99) meters, and VOFor people with ILD, walking training prescribed at 80% of 6MWT average speed can provide adequate exercise training intensity for PR.

Supported by the National Health and Medical Research Council Centre of Research Excellence in Pulmonary Fibrosis (GNT1116371), and by foundation partner, Boehringer Ingelheim, and program partners, Roche and Galapagos. Rationale : The interstitial lung disease (ILD) multidisciplinary meetings (MDM), composed of pulmonologists, radiologists, and pathologists, is integral to the rendering of an accurate ILD diagnosis. However, there is significant heterogeneity in the conduct of ILD MDMs, and questions regarding their best practices remain unanswered. Objectives : To achieve consensus among ILD experts on essential components of an ILD MDM. Methods : Using a Delphi methodology, semi-structured interviews with ILD experts were used to identify key themes and features of ILD MDMs. These items informed two subsequent rounds of online questionnaires that were used to achieve consensus among a broader, international panel of ILD experts. Experts were asked to rate their level of agreement on a five-point Likert scale. An a priori threshold for consensus was set at a median score 4 or 5 with an interquartile range of 0. Results : We interviewed 15 ILD experts, and 102 ILD experts participated in the online questionnaires. Five items and two exploratory statements achieved consensus on being essential for an ILD MDM following two questionnaire rounds. There was consensus that the presence of at least one radiologist, a quiet setting with a visual projection system, a high-quality chest high-resolution computed tomography, and a standardized template summarizing collated patient data are essential components of an ILD MDM. Experts also agreed that it would be useful for ILD MDMs to undergo an annual benchmarking process and a validation process by fulfilling a minimum number of cases annually. Twenty-seven additional features were considered to be either highly desirable or desirable features based on the degree of consensus. Although our findings on desirable features are similar to the current literature, several of these remain controversial and warrant further research. The study also showed an agreement among participants on several future concepts to improve the ILD MDM, such as performing regular self-assessments and conducting research into shared practices to develop an international expert guideline statement on ILD MDMs. Conclusions : This Delphi study showed consensus among international ILD experts on essential and desirable features of an ILD MDM. Our data represent an important step toward potential collaborative research into future standardization of ILD MDMs. Postprint