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The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has brought renewed attention to respiratory aerosol and droplet generation. While many studies have robustly quantified aerosol (20 µm diameter) generated by a cohort of 76 adults and children using a water-sensitive paper droplet deposition approach. Unvoiced and voiced activities spanning different levels of loudness, different lengths of sustained phonation, and a specific manner of articulation in isolation were investigated. We find that oral articulation drives >20 µm droplet generation, with breathing generating virtually no droplets and speaking and singing generating on the order of 250 droplets min−1. Lip trilling, which requires extensive oral articulation, generated the most droplets, whereas shouting “Hey,” which requires minimal oral articulation, generated relatively few droplets. Droplet size distributions were all broadly consistent, and no significant differences between the children and adult cohorts were identified. By comparing the aerosol and droplet emissions for the same participants, the full size distribution of respiratory aerosol (0.5–1000 µm) is reported. Although 20 µm droplets dominate the mass concentration. Accurate quantification of aerosol concentrations in the 10–70 μm size range remains very challenging; more robust aerosol analysis approaches are needed to characterize this size range.

Objectives: To assess the frequency of reporting of ethnicity (or ‘race’) and socioeconomic status (SES) indicators in high-impact journals. Design: Targeted literature review Data sources: The 10 highest ranked general medical journals using Google scholar h5 index. Eligibility criteria: Inclusion criteria were, human research, reporting participant level data. Exclusion criteria were non-research article, animal/other non-human participant/subject; or no participant characteristics reported. Data extraction and synthesis: Working backwards from 19/04/2021 in each journal, two independent reviewers selected the 10 most recent articles meeting inclusion/exclusion criteria, to create a sample of 100 articles. Data on the frequency of reporting of ethnicity (or ‘race’) and SES indicators were extracted and presented using descriptive statistics. Results: Of one hundred research articles included, 35 reported ethnicity and 13 SES. By contrast, 99 reported age, and 97 reported sex or gender. Among the articles not reporting ethnicity only 3 (5%) highlighted this as a limitation, and only 6 (7%) where SES data were missing. Median number of articles reporting ethnicity per journal was 2.5/10 (range 0 to 9). Only 2 journals explicitly requested reporting of ethnicity (or race), and 1 requested SES. Conclusions: The majority of research published in high-impact medical journals does not include data on the ethnicity and socioeconomic status of participants, and this omission is rarely acknowledged as a limitation. This situation persists despite the well-established importance of this issue and ICMJE recommendations to include relevant demographic variables to ensure representative samples. Standardized explicit minimum standards are required. Strengths and Limitations of this study - This study included recent studies from a range of the highest impact general medical journals. - Different inclusion/exclusion criteria for articles could be justifiably used which may have produced different results. - We identified high-impact journals using the google scholar h5 index, however various other equally valid impact metrics exist, which could change the journals considered. - Our analysis focused on if ethnicity and/or race was reported, but not how they are reported which is an important and related area for discussion and research to that covered in this study.

Data sharing: Fully anonymised data will be provided upon reasonable request to the corresponding author. Copyright © 2022 The Author(s). Background: There are few evidence-based interventions for long COVID; however, holistic approaches supporting recovery are advocated. We assessed whether an online breathing and wellbeing programme improves health related quality-of-life (HRQoL) in people with persisting breathlessness following COVID-19. Methods: We conducted a parallel-group, single-blind, randomised controlled trial in patients who had been referred from one of 51 UK-based collaborating long COVID clinics. Eligible participants were aged 18 years or older; were recovering from COVID-19 with ongoing breathlessness, with or without anxiety, at least 4 weeks after symptom onset; had internet access with an appropriate device; and were deemed clinically suitable for participation by one of the collaborating COVID-19 clinics. Following clinical assessment, potential participants were given a unique online portal code. Participants were randomly assigned (1:1) to either immediate participation in the English National Opera (ENO) Breathe programme or to usual care. Randomisation was done by the research team using computer-generated block randomisation lists, with block size 10. The researcher responsible for randomisation was masked to responses. Participants in the ENO Breathe group participated in a 6-week online breathing and wellbeing programme, developed for people with long COVID experiencing breathlessness, focusing on breathing retraining using singing techniques. Those in the deferred group received usual care until they exited the trial. The primary outcome, assessed in the intention-to-treat population, was change in HRQoL, assessed using the RAND 36-item short form survey instrument mental health composite (MHC) and physical health composite (PHC) scores. Secondary outcome measures were the chronic obstructive pulmonary disease assessment test score, visual analogue scales (VAS) for breathlessness, and scores on the dyspnoea-12, the generalised anxiety disorder 7-item scale, and the short form-6D. A thematic analysis exploring participant experience was also conducted using qualitative data from focus groups, survey responses, and email correspondence. This trial is registered with ClinicalTrials.gov, NCT04830033. Findings: Between April 22 and May 25, 2021, 158 participants were recruited and randomly assigned. Of these, eight (5%) individuals were excluded and 150 participants were allocated to a treatment group (74 in the ENO Breathe group and 76 in the usual care group). Compared with usual care, ENO Breathe was associated with an improvement in MHC score (regression coefficient 2·42 [95% CI 0·03 to 4·80]; p=0·047), but not PHC score (0·60 [–1·33 to 2·52]; p=0·54). VAS for breathlessness (running) favoured ENO Breathe participation (−10·48 [–17·23 to –3·73]; p=0·0026). No other statistically significant between-group differences in secondary outcomes were observed. One minor self-limiting adverse event was reported by a participant in the ENO Breathe group who felt dizzy using a computer for extended periods. Thematic analysis of ENO Breathe participant experience identified three key themes: (1) improvements in symptoms; (2) feeling that the programme was complementary to standard care; and (3) the particular suitability of singing and music to address their needs. Interpretation: Our findings suggest that an online breathing and wellbeing programme can improve the mental component of HRQoL and elements of breathlessness in people with persisting symptoms after COVID-19. Mind–body and music-based approaches, including practical, enjoyable, symptom-management techniques might have a role supporting recovery. Imperial College London

Lung cancer screening programs provide an opportunity to support people who smoke to quit, but the most appropriate model for delivery remains to be determined. Immediate face-to-face smoking cessation support for people undergoing screening can increase quit rates, but it is not known whether remote delivery of immediate smoking cessation counselling and pharmacotherapy in this context also is effective.Does an immediate telephone smoking cessation intervention increase quit rates compared with usual care among a population enrolled in a targeted lung health check (TLHC)?In a single-masked randomized controlled trial, people 55 to 75 years of age who smoke and attended a TLHC were allocated by day of attendance to receive either immediate telephone smoking cessation intervention (TSI) support (starting immediately and lasting for 6 weeks) with appropriate pharmacotherapy or usual care (UC; very brief advice to quit and signposting to smoking cessation services). The primary outcome was self-reported 7-day point prevalence smoking abstinence at 3 months. Differences between groups were assessed using logistic regression.Three hundred fifteen people taking part in the screening program who reported current smoking with a mean ± SD age of 63 ± 5.4 years, 48% of whom were women, were randomized to TSI (n = 152) or UC (n = 163). The two groups were well matched at baseline. Self-reported quit rates were higher in the intervention arm, 21.1% vs 8.9% (OR, 2.83; 95% CI, 1.44-5.61; P = .002). Controlling for participant demographics, neither baseline smoking characteristics nor the discovery of abnormalities on low-dose CT imaging modified the effect of the intervention.Immediate provision of an intensive telephone-based smoking cessation intervention, delivered within a targeted lung screening context, is associated with increased smoking abstinence at 3 months.IRSCTN registry; No.: ISRCTN12455871; URL: www.IRSCN.com.

Background The coronavirus disease-19 (COVID-19) pandemic led to the prohibition of group-based exercise and the cancellation of sporting events. Evaluation of respiratory aerosol emissions is necessary to quantify exercise-related transmission risk and inform mitigation strategies. Methods Aerosol mass emission rates are calculated from concurrent aerosol and ventilation data, enabling absolute comparison. An aerodynamic particle sizer (0.54–20 μm diameter) samples exhalate from within a cardiopulmonary exercise testing mask, at rest, while speaking and during cycle ergometer-based exercise. Exercise challenge testing is performed to replicate typical gym-based exercise and very vigorous exercise, as determined by a preceding maximally exhaustive exercise test. Results We present data from 25 healthy participants (13 males, 12 females; 36.4 years). The size of aerosol particles generated at rest and during exercise is similar (unimodal ~0.57–0.71 µm), whereas vocalization also generated aerosol particles of larger size (i.e. was bimodal ~0.69 and ~1.74 µm). The aerosol mass emission rate during speaking (0.092 ng s−1; minute ventilation (VE) 15.1 L min−1) and vigorous exercise (0.207 ng s−1, p = 0.726; VE 62.6 L min−1) is similar, but lower than during very vigorous exercise (0.682 ng s−1, p −1). Conclusions Vocalisation drives greater aerosol mass emission rates, compared to breathing at rest. Aerosol mass emission rates in exercise rise with intensity. Aerosol mass emission rates during vigorous exercise are no different from speaking at a conversational level. Mitigation strategies for airborne pathogens for non-exercise-based social interactions incorporating vocalisation, may be suitable for the majority of exercise settings. However, the use of facemasks when exercising may be less effective, given the smaller size of particles produced.

BackgroundOscillatory positive expiratory pressure (OPEP) devices are intended to facilitate sputum clearance and reduce cough, but there is limited evidence for their effectiveness in COPD, or to guide patient selection. We aimed to assess the impact of OPEP therapy on quality of life and objective measures of cough and sleep disturbance in patients with COPD with regular sputum production.MethodsWe enrolled stable patients with COPD, who reported sputum production every day or most days, into an assessor-blind, parallel-group, randomised controlled trial comparing 3 months of using an Acapella device against usual care (including use of the active cycle of breathing technique). The primary outcome was cough-related quality of life measured using the Leicester Cough Questionnaire (LCQ). Secondary outcomes included fatigue (Functional Assessment of Chronic Illness Therapy, FACIT score) and generic quality of life (EuroQol-5 Dimensions, EQ-5D). In a substudy (n=45), objective monitoring of cough and disturbance/movement during sleep were also available.Results122 participants (61/61 OPEP/control) were recruited, 40% female, 17% smokers, FEV1 38 (25–56)% predicted, and age 62±10 years. 103 completed the study (55/48 OPEP/control). Use of OPEP was associated with an improvement in LCQ compared with controls; MD (95% CI) 1.03 (0.71 to 2.10); (p=0.03), FACIT score 4.68 (1.34 to 8.02); (pConclusionsRegular use of an Acapella device improves symptoms and quality of life in people with COPD who produce sputum daily or most days.Trial registration numberISRCTN44651852.

BackgroundAround one in ten people who contract COVID-19 report persistent symptoms or ‘long COVID’. Impaired mental health and well-being is commonly reported, including anxiety, depression and reduced quality of life. However, there is limited in-depth research exploring why mental health and well-being are affected in people experiencing long COVID.AimsTo explore factors affecting mental health and well-being from the perspective of people with long COVID.MethodSemi-structured qualitative interviews were audio-recorded and transcribed. Data were analysed using reflexive thematic analysis. Twenty-one people with long COVID participated in the study. Participants were eligible if they self-reported a positive swab test/antibody test or one or more commonly reported COVID-19 symptoms at illness onset. and experiences of one or more long COVID symptoms ≥3 weeks following illness onset.ResultsFive themes were identified across participant accounts regarding factors affecting mental health and well-being, including symptoms causing severe disruption to daily life, lack of service and treatment options, uncertainty of illness trajectories, experiences of care and understanding from others and changes to identity.ConclusionsPeople with long COVID experience a range of factors that negatively affect their mental health and well-being. Providing patient-centred health services that integrate rapidly evolving research in this area is important, as are peer support groups and supported approaches to self-management.

SummaryObjectivesTo investigate the experience of people who continue to be unwell after acute COVID-19, often referred to as ‘long COVID’, both in terms of their symptoms and their interactions with healthcare.DesignWe conducted a mixed-methods analysis (quantitative and qualitative) of responses to a survey accessed through a UK online post-COVID support and information hub between April 2020 and December 2020 about people’s experiences after having acute COVID-19.ParticipantsOf 3290 respondents, 78% were female, median age range 45-54 years, 92.1% reported white ethnicity; 12.7% had been hospitalised. 494 respondents (16.5%) completed the survey between 4 and 8 weeks of the onset of their symptoms, 641 (21.4%) between 8 and 12 weeks and 1865 (62.1%) more than 12 weeks after.ResultsThe ongoing symptoms most frequently reported were; breathing problems (92.1%), fatigue (83.3%), muscle weakness or joint stiffness (50.6%), sleep disturbances (46.2%), problems with mental abilities (45.9%) changes in mood, including anxiety and depression (43.1%) and cough (42.3%). Symptoms did not appear to be related to the severity of the acute illness or to the presence of pre-existing medical conditions. Analysis of free text responses revealed three main themes (1) Experience of living with COVID-19 – physical and psychological symptoms that fluctuate unpredictably; (2) Interactions with healthcare; (3) Implications for the future – their own condition, society and the healthcare system and the need for researchConclusionPeople living with persistent problems after the acute phase of COVID-19 report multiple and varying symptoms that are not necessarily associated with initial disease severity or the presence of pre-existing health conditions. Many have substantial unmet needs and experience barriers to accessing healthcare. Consideration of patient perspective and experiences will assist in the planning of services to address this.Ethical approvalEthical approval was granted by Imperial College Research and Integrity Team (IREC; 20IC6625).What we already know on this subjectMany people who develop COVID-19 will go on to endure persistent symptoms past the acute phase of the disease, commonly termed long-COVID.Knowledge gaps exist regarding the lived experience and symptom frequency, in people with long-COVID, particularly in those who were not admitted to hospital during the acute phase of their illness.What this study addsThe findings from this large population, many of whom were not hospitalised during the acute phase of their illness, demonstrate the varying patterns and persistence of symptoms of long-COVID, which do not appear to be associated with severity of the acute phase of the disease or pre-existing medical conditions.Qualitative findings revealing the patient experience of long-COVID symptoms, healthcare, and suggestions for future research and service adaptation.

Aerosol particles of respirable size are exhaled when individuals breathe, speak and sing and can transmit respiratory pathogens between infected and susceptible individuals. The COVID-19 pandemic has brought into focus the need to improve the quantification of the particle number and mass exhalation rates as one route to provide estimates of viral shedding and the potential risk of transmission of viruses. Most previous studies have reported the number and mass concentrations of aerosol particles in an exhaled plume. We provide a robust assessment of the absolute particle number and mass exhalation rates from measurements of minute ventilation using a non-invasive Vyntus Hans Rudolf mask kit with straps housing a rotating vane spirometer along with measurements of the exhaled particle number concentrations and size distributions. Specifically, we report comparisons of the number and mass exhalation rates for children (12–14 years old) and adults (19–72 years old) when breathing, speaking and singing, which indicate that child and adult cohorts generate similar amounts of aerosol when performing the same activity. Mass exhalation rates are typically 0.002–0.02 ng s−1from breathing, 0.07–0.2 ng s−1from speaking (at 70–80 dBA) and 0.1–0.7 ng s−1from singing (at 70–80 dBA). The aerosol exhalation rate increases with increasing sound volume for both children and adults when both speaking and singing.

BackgroundAround one in 10 people who have COVID-19 report persistent symptoms or ‘long Covid’. Impaired mental health and wellbeing is commonly reported including anxiety, depression and reduced quality of life. There is however, limited in-depth research exploring why mental health and wellbeing have been impacted among people experiencing long Covid.AimsTo explore factors impacting mental health and wellbeing, from the perspective of people with long Covid.MethodSemi-structured qualitative interviews that were audio-recorded and transcribed. Data were analysed using reflexive thematic analysis. 21 people with long Covid participated in the study. Participants were eligible to take part if they self-reported a positive swab test/antibody test, or one or more commonly reported COVID-19 symptoms at illness onset and experiences of one or more long Covid symptom three or more weeks following illness onset.ResultsFive themes were identified across participant accounts regarding factors impacting mental health and wellbeing including i) experiences of care and understanding from others; ii) lack of service and treatment options; iii) severe disruption to daily life iv) uncertainty of illness trajectories and v) changes to identity.ConclusionsPeople with long Covid experience a range of factors that negatively impact their mental health and wellbeing. Providing patient centred health services that integrate the rapidly evolving research in this area is important, as are peer support groups and supported approaches to self-management.

Background Data on the long-term pulmonary sequelae in COVID-19 are lacking. Purpose To assess symptoms, functional impairment, and residual pulmonary abnormalities on serial chest CT scans in COVID-19 survivors discharged from hospital at up to 1-year follow-up. Materials and Methods Adult patients with COVID-19 discharged between March 2020 and June 2020 were prospectively evaluated at 3 months and 1 year through systematic assessment of symptoms, functional impairment, and thoracic CT scans as part of the PHENOTYPE study, an observational cohort study in COVID-19 survivors. Lung function testing was limited to participants with CT abnormalities and/or persistent breathlessness. Bonferroni correction was used. Results Eighty participants (mean age, 59 years ± 13 [SD]; 53 men) were assessed. At outpatient review, persistent breathlessness was reported in 37 of the 80 participants (46%) and cough was reported in 17 (21%). CT scans in 73 participants after discharge (median, 105 days; IQR, 95-141 days) revealed persistent abnormalities in 41 participants (56%), with ground-glass opacification (35 of 73 participants [48%]) and bands (27 of 73 participants [37%]) predominating. Unequivocal signs indicative of established fibrosis (ie, volume loss and/or traction bronchiectasis) were present in nine of 73 participants (12%). Higher admission serum C-reactive protein (in milligrams per liter), fibrinogen (in grams per deciliter), urea (millimoles per liter), and creatinine (micromoles per liter) levels; longer hospital stay (in days); older age (in years); and requirement for invasive ventilation were associated with CT abnormalities at 3-month follow-up. Thirty-two of 41 participants (78%) with abnormal findings at 3-month follow-up CT underwent repeat imaging at a median of 364 days (range, 360-366 days), with 26 (81%) showing further radiologic improvement (median, 18%; IQR, 10%-40%). Conclusion CT abnormalities were common at 3 months after COVID-19 but with signs of fibrosis in a minority. More severe acute disease was linked with CT abnormalities at 3 months. However, radiologic improvement was seen in the majority at 1-year follow-up. ClinicalTrials.gov identifier: NCT04459351. © RSNA, 2022

IntroductionMusic and dance are increasingly used as adjunctive arts-in-health interventions in high-income settings, with a growing body of research suggesting biopsychosocial benefits. Such low-cost, low-resource interventions may have application in low-resource settings such as Uganda. However, research on perceptions of patients and healthcare professionals regarding such approaches is lacking.MethodsWe delivered taster music and dance for chronic respiratory disease (CRD) sessions to patients and healthcare professionals. We then conducted an exploratory qualitative study, using thematic analysis of semi-structured interviews with the healthcare professionals and patients regarding i) the role of music and dance in Ugandan life and ii) the perceived acceptability and feasibility of using music and dance in CRD management in Uganda.ResultsEleven patients with long-term respiratory conditions and eight healthcare professionals were interviewed after selection by purposeful convenience sampling. Four key themes were identified from (interview) analysis: Music and dance: 1) were central components of daily life; 2) had an established role supporting health and wellbeing; 3) had strong therapeutic potential in respiratory disease management; 4) the importance of modulating demographic considerations of culture and religion, and age.ConclusionMusic and dance are central to life in Uganda, with established roles supporting health and wellbeing. These roles could be built on in the development of music and dance interventions as adjuncts to established components of CRD disease management like pulmonary rehabilitation. Through consideration of key contextual factors, and co-development and adaptation of interventions, such approaches are likely to be well received.Summary Box: Key QuestionsWhat is already known?Music and dance are increasingly being used as adjunctive components of CRD management in high resource settings, with a growing body of research suggesting such approaches are effective, well-received, and can be delivered at low cost. However, the perceptions of patients and healthcare professionals about potential application of such approaches in low-resource settings, such as Uganda, is not known.What are the new findings?Music and dance have central roles in the social, religious and cultural life in Uganda, including a clear view that participation supports both collective and individual health and wellbeing. In this study, both healthcare professionals and patients saw great potential for the use of music and dance as interventions for people with CRD, and highlighted important factors for consideration for successful implementation.What do the new findings imply?Music and dance interventions for people with long-term respiratory conditions in Uganda are likely to be accepted with enthusiasm due to the existing role of such activities in daily life. Delivery is likely to be feasible, but interventions would need to be co-developed with patients, their family members, and healthcare professionals, considering a number of key factors. Suggested approaches to address these considerations are provided. More generally, this study highlights how genuine co-design processes can provide valuable insights into health intervention development.

IntroductionParticipating in singing is considered to have a range of social and psychological benefits. However, the physiological demands of singing and its intensity as a physical activity are not well understood.MethodsWe compared cardiorespiratory parameters while completing components of Singing for Lung Health sessions, with treadmill walking at differing speeds (2, 4 and 6 km/hour).ResultsEight healthy adults were included, none of whom reported regular participation in formal singing activities. Singing induced acute physiological responses that were consistent with moderate intensity activity (metabolic equivalents: median 4.12, IQR 2.72–4.78), with oxygen consumption, heart rate and volume per breath above those seen walking at 4 km/hour. Minute ventilation was higher during singing (median 22.42 L/min, IQR 16.83–30.54) than at rest (11 L/min, 9–13), lower than 6 km/hour walking (30.35 L/min, 26.94–41.11), but not statistically different from 2 km/hour (18.77 L/min, 16.89–21.35) or 4 km/hour (23.27 L/min, 20.09–26.37) walking.ConclusionsOur findings suggest the acute metabolic demands of singing are comparable with walking at a moderately brisk pace, hence, physical effects may contribute to the health and well-being benefits attributed to singing participation. However, if physical training benefits result remains uncertain. Further research including different singing styles, singers and physical performance impacts when used as a training modality is encouraged.Trial registration numberClinicalTrials.gov registry (NCT04121351).

Interventions to prevent the spread of SARS-CoV-2 have been associated with substantial reductions in exacerbations of airways diseases, likely through reduced transmission of other respiratory viruses. We surveyed 4442 people with airways disease (asthma=3627, bronchiectasis=258, chronic obstructive pulmonary disease=557) to gauge attitudes and intentions towards continuing such measures after the COVID-19 pandemic. 47% intended to continue wearing a face mask in indoor public spaces, and 61% thought everyone should be required to do so during the ‘influenza season. Women, those with bronchiectasis, and older people were generally more cautious. Respiratory virus infection control measures should be considered in clinical guidelines and public health recommendations.

Rising hospital admissions due to respiratory disease (RD) are a major challenge to hospitals. This study explored modifiable social risk factors among 4478 older adults from the English Longitudinal Study of Ageing. Data were linked with administrative hospital records and mortality registry data (follow-up 9.6 years) and analysed using survival analysis accounting for competing risks. Living alone and social disengagement but not social contact or loneliness were associated with an increased risk of RD admissions, independent of socio-demographic, health and behaviour factors. Providing support for disengaged adults living alone who are at risk of RD admissions should be explored.

Arts in Health interventions show potential to improve the quality of life of people with chronic lung disease. Listening to music, making music, and dance have accepted and established roles in the lives of people without chronic disease. However, their potential utility in chronic disease management is infrequently considered by medical professionals. The aim of this review is to examine the use of music and dance in the treatment and self-management of chronic lung disease. Although the evidence base is currently limited, existing research suggests a range of biopsychosocial benefits. As personalised medicine and social prescribing become more prominent, further research is required to establish the role of arts interventions in chronic lung disease., Interest in the arts in health is growing, and initial research suggests that music and dance have a range of health benefits and show promise as tools to promote living well and self-management in people with chronic lung disease http://ow.ly/bFxd30o8t0X

IntroductionThere has been a substantial reduction in admissions to hospital with exacerbations of airways diseases during the COVID-19 pandemic, likely because measures introduced to prevent the spread of SARS-CoV-2 also reduced transmission of other respiratory viruses. The acceptability to patients of continuing such interventions beyond the pandemic as a measure to prevent exacerbations is not known.MethodAn online survey of people living with respiratory disease was created by the Asthma UK – British Lung Foundation Partnership. People were asked what infection control measures they expected to continue themselves, and what they thought should be policy for the population more generally in the future, once the COVID-19 pandemic had subsided.Results4442 people completed the survey: 3627 with asthma, 258 with bronchiectasis and 557 with COPD. Regarding personal behaviour, 79.5% would continue increased handwashing, 68.6% social distancing indoors, 46.9% would continue to wear a face covering in indoor public places (45.7% on public transport), and 59.3% would avoid friends and family who were unwell with a respiratory infection. 45.6% wanted healthcare professionals to continue wearing a mask when seeing patients. 60.7% thought that face coverings should continue to be worn by everyone in indoor public spaces during the ‘flu season. Women and older people were, in general, more cautious.ConclusionPeople living with airways diseases are supportive of infection control measures to reduce the risk of exacerbations and such measures should be considered for inclusion in guidelines. Further research to refine understanding of the most effective approaches is needed.

We were glad to see a news article1 highlighting research by Sjoding and colleagues2 which identifies a racial bias in pulse oximetry, with hypoxaemia identified less frequently in black people compared with white. The research is valuable, identifying an important matter; however, further details would aid clinical application of the findings. Useful, additional, commonly used metrics absent from the paper include bias, precision, limits of agreement, and accuracy value. A …

Background: Smoking is often colloquially considered “social”. However, the relationship between smoking with current and future social isolation and loneliness is unclear. Therefore, we examined these relationships over a 12-year follow-up. Methods: In this cohort study, we used a nationally representative sample of community dwelling adults aged 50 years and over from the English Longitudinal Study of Ageing (N=8780) (45% male, mean age of 67 years, standard deviation of 10). We examined associations of self-reported smoking status at baseline assessment, with social isolation (low social contact, social disengagement, domestic isolation), and loneliness (3-item UCLA loneliness scale), measured at baseline, and follow-up at 4, 8 and 12 years after. Findings: At baseline, smokers were more likely to be lonely and socially isolated than non-smokers, having less frequent social interactions with family and friends, having less frequent engagement with community and cultural activities, and being more likely to live alone. Smoking at baseline was associated with larger reductions in social contact, increases in social disengagement, and loneliness over time. No evidence was found for the association between smoking and changes in cohabitation status. These findings were independent of all identified confounders, including age, sex, social class and the presence of physical and mental health diagnoses. Interpretation: Smoking is associated with the development of increasing social isolation and loneliness in older adults. The idea that smoking might be prosocial appears a misconception. The intersection of these public health priorities requires further attention. Funding: UK Economic and Social Research Council & Imperial College London. Declaration of Interests: All authors have completed the ICMJE uniform disclosure form and declare: support from the National Institute of Ageing, a consortium of UK government departments coordinated by the Economic and Social Research Council; Imperial College London; and the Wellcome Trust for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work. Ethics Approval Statement: The study received ethical approval from the National Research Ethics Service and all participants provided informed consent.

Background: The impact of COVID-19 on people with asthma is a concern, with evidence that they are more likely to require intensive care if hospitalised. However, data regarding longer-term impacts is limited. Methods: Using data from an online UK-wide survey of 4,500 people with asthma (Median age 50-59 years, 81% female), conducted by the Asthma UK-British Lung Foundation partnership in October 2020, we undertook a mixed methods analysis of the characteristics and experience of those reporting that they had had COVID-19. Findings: The COVID-19 group (n=471, 10·5%) reported increased inhaler use and worse asthma management, compared to those not reporting COVID-19, but did not differ by gender, ethnicity, or household income. Among the COVID-19 group, 56·1% reported having long-COVID, 20·2% were ‘unsure’. Those with long-COVID were more likely than those without long-COVID to describe: their breathing as worse or much worse after their initial illness (73·7% Vs 34·8%, P

Preprint also available at Research Square: In Review. Scientific Reports, in press. doi: 10.21203/rs.3.rs-124158/v1. This work is licensed under a CC BY 4.0 License. Participating in singing is considered to have a range of social and psychological benefits. However, the physiological demands of singing, whether it can be considered exercise, and its intensity as a physical activity are not well understood. We therefore compared cardiorespiratory parameters while completing components of Singing for Lung Health (SLH) sessions, with treadmill walking at differing speeds (2, 4, and 6km/hr). Eight healthy adults were included, none of whom reported regular participation in formal singing activities. Singing induced physiological responses that were consistent with moderate intensity activity (METS: median 4.12, IQR 2.72 - 4.78), with oxygen consumption, heart rate, and volume per breath above those seen walking at 4km/hr. Minute ventilation was higher during singing (median 22.42L/min, IQR 16.83 - 30.54) than at rest (11L/min, 9 - 13), lower than 6km/hr walking (30.35L/min, 26.94 - 41.11), but not statistically different from 2km/hr (18.77L/min, 16.89 - 21.35) or 4km/hr (23.27L/min, 20.09 - 26.37) walking. Our findings suggest the metabolic demands of singing may contribute to the health and wellbeing benefits attributed to participation. However, if physical training benefits result remains uncertain. Further research including different singing styles, singers, and physical performance impacts when used as a training modality is encouraged. KP was supported by the Imperial College Clinician Investigator Scholarship. DF was supported by the Wellcome Trust [205407/Z/16/Z]. The funders had no say in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

IntroductionSinging for lung health (SLH) is a popular arts-in-health activity for people with long-term respiratory conditions. Participants report biopsychosocial benefits, however, research on impact is limited. The ‘SLH: Improving Experiences of Lung Disease trial’, a randomised controlled, single (assessor) blind, trial of 12 weeks SLH versus usual care for people with chronic obstructive pulmonary disease (COPD) (n=120) was setup to help to address this. The first group (n=18, nine singing and nine controls) started face-to-face (five sessions) before changing to online delivery (seven sessions) due to COVID-19-related physical distancing measures. As such, the experience of this group is here reported as a pilot study to inform further research in this area.MethodsWe conducted semistructured interviews and thematic analysis regarding barriers, facilitators and key considerations for transitioning from face-to-face to online delivery. Pilot quantitative outcomes include attendance, premeasures and postmeasures of quality of life and disease impact (Short Form 36 Health Survey, COPD Assessment Test score), breathlessness (Medical Research Council breathlessness scale, Dyspnoea-12), depression (Patient Health Questionnaire-9, PHQ-9), anxiety (Generalised Anxiety Disorder-7), balance confidence (Activity specific Balance Confidence, ABC scale) and physical activity (clinical visit PROactive physical activity in COPD tool, combining subjective rating and actigraphy).ResultsAttendance was 69% overall, (90% of the face-to-face sessions, 53% online sessions). Analysis of semistructured interviews identified three themes regarding participation in SLH delivered face to face and online, these where (1) perceived benefits; (2) digital barriers (online) and (3) digital facilitators (online). Findings were summarised into key considerations for optimising transitioning singing groups from face-to-face to online delivery. Pilot quantitative data suggested possible improvements in depression (treatment effect −4.78 PHQ-9 points, pDiscussionThis study identifies key considerations regarding the adaptation of SLH from face-to-face to online delivery. Pilot data suggest online group singing for people with COPD may deliver benefits related to reducing depression and improved balance confidence.

ObjectivesTo explore the experiences and perceived impact on health and well-being related to participation in a dance group for people with chronic respiratory disease (CRD).DesignAn exploratory qualitative study using thematic analysis of semistructured interviews.SettingA community dance group in a UK health centre.ParticipantsConvenience sample of long-term dance group participants.InterventionWeekly community dance sessions designed for people with breathlessness, lasting 75 min, led by a trained community dance leader.ResultsConvenience sample of eight participants, six females, aged 57–87 years (mean 75), with a median 2-year attendance at weekly dance sessions. Long-term attendance was driven by strongly held beliefs regarding the health and well-being benefits of participation. Four key themes were identified: dance as (1) a holistically beneficial activity, with physical and psychosocial health benefits including improved or maintained physical fitness and psychological well-being, and reduced need for healthcare; (2) an integral part of their life; (3) an enjoyable activity; and (4) a source of deep social cohesion.ConclusionsDance group participants perceived a broad range of health benefits of relevance to the biopsychosocial impacts of their respiratory disease. The themes identified are useful in the ongoing planning and evaluation of dance as a holistic complex intervention for people with CRD. Further research is required to assess the extent of health impacts identified, and how dance might be most effectively placed as an option in the management of CRD.Trial registration numberNCT04006015.

IntroductionUK guidelines suggest that pulse oximetry, rather than blood gas sampling, is adequate for monitoring of patients with COVID-19 if CO2 retention is not suspected. However, pulse oximetry has impaired accuracy in certain patient groups, and data are lacking on its accuracy in patients with COVID-19 stepping down from intensive care unit (ICU) to non-ICU settings or being transferred to another ICU.MethodsWe assessed the bias, precision and limits of agreement using 90 paired SpO2 and SaO2 from 30 patients (3 paired samples per patient). To assess the agreement between pulse oximetry (SpO2) and arterial blood gas analysis (SaO2) in patients with COVID-19, deemed clinically stable to step down from an ICU to a non-ICU ward, or be transferred to another ICU. This was done to evaluate whether the guidelines were appropriate for our setting.ResultsMean difference between SaO2 and SpO2 (bias) was 0.4%, with an SD of 2.4 (precision). The limits of agreement between SpO2 and SaO2 were as follows: upper limit of 5.2% (95% CI 6.5% to 4.2%) and lower limit of −4.3% (95% CI −3.4% to −5.7%).ConclusionsIn our setting, pulse oximetry showed a level of agreement with SaO2 measurement that was slightly suboptimal, although within acceptable levels for Food and Drug Authority approval, in people with COVID-19 judged clinically ready to step down from ICU to a non-ICU ward, or who were being transferred to another hospital’s ICU. In such patients, SpO2 should be interpreted with caution. Arterial blood gas assessment of SaO2 may still be clinically indicated.

People with long term respiratory conditions are at greater risk of serious disease and death from COVID-19. To reduce transmission among the most vulnerable in the UK, avoiding face-to-face contact – termed ‘shielding’ - was advised for the most vulnerable on March 20th 2020. However, shielding measures are likely to also have certain adverse consequences for health and wellbeing, which could result in a ‘third wave’ of COVID-19 related morbidity and mortality among people with long-term conditions. Two online surveys were carried out by the Asthma UK (AUK) and British Lung Foundation (BLF) Partnership for one week in April 2020 and May 2020 to assess shielding’s practical and psychological effects. The surveys gained 9,605 (April) and 14,312 (May) responses. Anonymised data was analysed using Stata V.14. Respondents in both surveys were asked to rate their anxiety about COVID-19 on a scale from 0-10. In April, high levels of anxiety about COVID-19 were reported; mean (SD) anxiety score 8.03 (2.07); slightly higher in women than men, 8.13 (1.99) vs 7.55 (2.28). In May anxiety levels about COVID-19 had decreased to 7.41 (2.08), again higher in women than men, 7.53 (2.00) vs 7.01 (2.26). Anxiety was higher in the lowest income quintile, 7.67 (2.19), than other quintiles, with a mean score of 7.04 (2.02) in the highest income quintile. While the decrease in anxiety levels from April to May is encouraging, they remain high and measures to reduce the risk of COVID-19 continue to have profound impacts on people with lung disease. There is an urgent need to adapt services to mitigate negative health consequences in this vulnerable group.

Isolation and loneliness are related to various aspects of health. Physical performance is a central component of health. However, its relationship with isolation and loneliness is not well understood. We therefore assessed the relationship between loneliness, different aspects of social isolation, and physical performance over time. 8,780 participants from the English Longitudinal Study of Ageing, assessed three times over 8 years of follow-up, were included. Measures included physical performance (Short Physical Performance Battery), loneliness (modified UCLA Loneliness Scale), and isolation considered in three ways (domestic isolation, social disengagement, low social contact). Fixed effects regression models were used to estimate the relationship between changes in these parameters. Missing data were imputed to account for variable response and ensure a representative sample. Loneliness, domestic isolation and social disengagement were longitudinally associated with poorer physical performance when accounting for both time-invariant and time-variant confounders (loneliness: coef = − 0.06, 95% CI − 0.09 to − 0.02; domestic isolation: coef = − 0.32, 95% CI − 0.46 to − 0.19; social disengagement: coef = − 0.10, 95% CI − 0.12 to − 0.07). Low social contact was not associated with physical performance. These findings suggest social participation and subjectively meaningful interpersonal interactions are related to physical performance, and highlight additional considerations regarding social distancing related to COVID-19 control measures.

IntroductionSinging for Lung Health (SLH) is a popular arts-in-health activity for people with long-term respiratory conditions, which participants report provides biopsychosocial benefits, however research on impact is limited. The ‘SHIELD trial’, a randomised controlled, single (assessor) blind, trial of 12 weeks SLH vs usual care for people with Chronic Obstructive Pulmonary Disease (COPD) (n=120) was set-up to help to address this. The first group started face-to-face (5 sessions) before changing to online delivery (7 sessions) due to COVID-19 related physical distancing measures. As such, the experience of this group is here reported as a pilot study to inform further research in this area.MethodsWe conducted semi-structured interviews and thematic analysis regarding barriers, facilitators and key considerations regarding transitioning from face-to-face to online delivery. Pilot quantitative outcomes include attendance, pre and post measures of quality of life and disease impact (SF-36, CAT score), breathlessness (MRC breathlessness scale, Dyspnoea-12), depression (PHQ9), anxiety (GAD-7), balance confidence (ABC scale) and physical activity (clinical visit PROactive physical activity in COPD tool, combining subjective rating and actigraphy).ResultsAttendance was 69% overall, (90% of the face-to-face sessions, 53% online sessions). Analysis of semi-structured interviews identified three themes regarding participation in SLH delivered face-to-face and online, these where 1) perceived benefits; 2) digital barriers (online); 3) digital facilitators (online). Findings were summarised into key considerations for optimising transitioning singing groups from face-to-face to online delivery. Pilot quantitative data suggested possible improvements in depression (treatment effect −4.78, p= 0.0487, MCID 5) balance confidence (treatment effect +17.21, p=0.0383, MCID 14.2), and anxiety (treatment effect −2.22, p=0.0659, MCID 2).DiscussionThis study identifies key considerations regarding the adaptation of SLH from face-to-face to online delivery. Pilot data suggest online group singing for people with COPD may deliver benefits related to reducing depression and anxiety, and improved balance confidence.KEY MESSAGESWhat is the key question?Can Singing for Lung Health (SLH) be delivered online for people with COPD? And if so, what are the practical issues and how does the experience compare with face-to-face participation?What is the bottom line?SLH appears safe and enjoyable both face-to-face and online. Access barriers for online sessions included digital access and literacy. However increasing access to those previous unable to physically access sessions is also important. In this pilot, depression, anxiety and balance confidence appear to show improvements related to participation in a SLH group that transitioned from face-to-face to online delivery.Why read on?To our knowledge this is the first study to assess health impacts of online group singing sessions. Given the physical distancing measures required by the response to COVID-19, there is a need for singing groups and other similar interventions to be delivered online such as pulmonary rehabilitation. This study helps to inform this and future research in the area.

Background The COVID-19 pandemic is having profound psychological impacts on populations globally, with increasing levels of stress, anxiety, and depression being reported, especially in people with pre-existing medical conditions who appear to be particularly vulnerable. There are limited data on the specific concerns people have about COVID-19 and what these are based on. Methods The aim of this study was to identify and explore the concerns of people with long-term respiratory conditions in the UK regarding the impact of the COVID-19 pandemic and how these concerns were affecting them. We conducted a thematic analysis of free text responses to the question “What are your main concerns about getting coronavirus?”, which was included in the British Lung Foundation/Asthma UK (BLF-AUK) partnership COVID-19 survey, conducted between the 1st and 8th of April 2020. This was during the 3rd week of the UK’s initial ‘social distancing measures’ which included advice to stay at home and only go outside for specific limited reasons. Results 7039 responses were analysed, with respondents from a wide range of age groups (under 17 to over 80), gender, and all UK nations. Respondents reported having asthma (85%), COPD (9%), bronchiectasis (4%), interstitial lung disease (2%), or ‘other’ lung diseases (e.g. lung cancer) (1%). Four main themes were identified: (1) vulnerability to COVID-19; (2) anticipated experience of contracting COVID-19; (3) pervasive uncertainty; and (4) inadequate national response. Conclusions The COVID-19 pandemic is having profound psychological impacts. The concerns we identified largely reflect contextual factors, as well as their subjective experience of the current situation. Hence, key approaches to reducing these concerns require changes to the reality of their situation, and are likely to include (1) helping people optimise their health, limit risk of infection, and access necessities; (2) minimising the negative experience of disease where possible, (3) providing up-to-date, accurate and consistent information, (4) improving the government and healthcare response.

Copyright © Author(s) (or their employer(s)) Singing is an increasingly popular activity for people with chronic obstructive pulmonary disease (COPD). Research to date suggests that ‘Singing for Lung Health’ may improve various health measures, including health-related quality-of-life. Singing and breathing are closely linked processes affecting one another. In this narrative review, we explore the physiological rationale for ‘Singing for Lung Health’ as an intervention, focusing on the abnormalities of pulmonary mechanics seen in COPD and how these might be impacted by singing. The potential beneficial physiological mechanisms outlined here require further in-depth evaluation.

BACKGROUND: Iron is central to multiple biological pathways, and treatment of non-anaemic absolute iron deficiency (NAID) is beneficial in certain conditions. However, it is unknown if NAID is associated with increased mortality in older-adults. METHODS: A nationally representative sample of 4451 older-adults from the English Longitudinal Study of Ageing was used. NAID was defined as serum ferritin

IntroductionThe British Lung Foundation (BLF) COPD Patient Passport (www.blf.org.uk/passport) was developed as a resource to help people with chronic obstructive pulmonary disease (COPD) and clinicians to consider the care received and identify essential omissions. We used the online data collected to evaluate the delivery of COPD care in the UK from a patient perspective.MethodsThe patient passport consists of 13 questions relating to key aspects of COPD care including: spirometry confirmation of diagnosis, understanding their diagnosis, support and a written management plan, vaccinations, smoking cessation, physical activity, exercise, eating well, pulmonary rehabilitation, exacerbations, medications and yearly reviews. Data were presented as proportions with an answer corresponding to good care, and plotted over time to identify trends.ResultsAfter removing identifiable duplicates, data from 41 769 entries, completed online between November 2014 and April 2019, remained (table 1). Twenty-four per cent reported getting support to manage their care and a written action plan; 53% could spot the signs of an acute exacerbation; 34% had discussed pulmonary rehabilitation and 41% stated they understood their COPD, and their doctor or nurse had explained where to find information, advice and emotional support. A quarter reported not receiving influenza vaccination and a third of those who smoke were not offered support to quit smoking. Even the strongest areas including spirometry-confirmed diagnosis, and knowing the importance of being active and eating well, achieved only around 80%. Response patterns remained stable or worsened over time.DiscussionResponses to the BLF COPD Patient Passport identify substantial gaps in patients’ experience of care, which did not appear to improve during the 5 years covered. These data provide a unique yet commonly overlooked perspective on care quality, and highlight that new approaches will be needed to meet the ambitions to improve respiratory care set out in the NHS Long Term Plan.

We read with great interest the paper by Hart et al,[1][1] recently published in Respiratory Care, regarding the impact of playing the harmonica on outcomes for people with COPD. As part of the FRESH AIR project,[2][2] we have been developing and delivering pulmonary rehabilitation programs in the

ObjectivesTo assess the experience of people with long-term respiratory conditions regarding the impact of measures to reduce risk of COVID-19.DesignAnalysis of data (n=9515) from the Asthma UK and British Lung Foundation partnership COVID-19 survey collected online between 1 and 8 April 2020.SettingCommunity.Participants9515 people with self-reported long-term respiratory conditions. 81% female, age ranges from ≤17 years to 80 years and above, from all nations of the UK. Long-term respiratory conditions reported included asthma (83%), chronic obstructive pulmonary disease (10%), bronchiectasis (4%), interstitial lung disease (2%) and ‘other’ (Outcome measuresStudy responses related to impacts on key elements of healthcare, as well as practical, psychological and social consequences related to the COVID-19 pandemic and social distancing measures.Results45% reported disruptions to care, including cancellations of appointments, investigations, pulmonary rehabilitation, treatment and monitoring. Other practical impacts such as difficulty accessing healthcare services for other issues and getting basic necessities such as food were also common. 36% did not use online prescriptions, and 54% had not accessed online inhaler technique videos. Psychosocial impacts including anxiety, loneliness and concerns about personal health and family were prevalent. 81% reported engaging in physical activity. Among the 11% who were smokers, 48% reported they were planning to quit smoking because of COVID-19.ConclusionsCOVID-19 and related social distancing measures are having profound impacts on people with chronic respiratory conditions. Urgent adaptation and signposting of services is required to mitigate the negative health consequences of the COVID-19 response for this group.

Introduction: Physical activity is a core component of COPD management, however, individuals often find standard pulmonary rehabilitation (PR) challenging, resulting in poor initial attendance and high levels of attrition. Our respiratory service provides a Tai Chi programme, which is primarily, but not exclusively, for individuals unable/unwilling to participate in standard PR. Methods: We compared baseline characteristics of participants from this programme with national PR participant baseline data, to assess similarities and differences between these groups. Results: Tai Chi programme baseline data included 88 participants, 59% female, 68% white British. Median values for key variables included age 68, FEV1%predicted 64%, FEV1/FVC ratio 0.64, 6MWT 185m, CAT score 29. Excluding individuals who attended no sessions (n=16), 50% completed the entire programme (median sessions attended 9). National PR baseline data included 47% female, 94% white British. Median values for the same variables included: age 70, FEV1% predicted 55, FEV1/FVC ratio 0.60, 6MWT 240m, CAT score 22, sessions attended 10. Conclusions: The Tai Chi group had had higher CAT scores and lower 6MWT results, however, median lung function results were similar compared with standard PR participants. The lower percentage of white British participants is representative of our local population. These data suggest people with more severe functional impairment, unable/unwilling to do standard PR, may consider and participate in Tai Chi as an alternative form of physical activity.

Dear Editors,We read with great interest the excellent review ‘Exercise Training Modalities for People with Chronic Obstructive Pulmonary Disease’ [1]. It was particularly good to see the inclusion...

It was a pleasure to read about the biopsychosocial benefits of group singing for people with chronic lung disease.1 The article reflects on how the author, and perhaps medical professionals more broadly, might increase the human warmth described in the singing group in their own clinical …

BACKGROUND: Patients on dialysis mount reduced immune responses compared with the general population. The Department of Health advises that these patients receive influenza and pneumococcal vaccinations at regular intervals-once yearly and every five years, respectively. This article investigates the uptake of these vaccinations in this patient population and seeks to examine factors that may influence vaccination status such as patient's language and presence of a general practitioner (GP) electronic vaccination reminder system. It also explores preferred site of vaccination for patients and GPs as these are primary care vaccinations yet patients have more frequent contact with their dialysis unit than their GP, blurring the boundaries between primary and specialized care. METHODS: This is a retrospective study of all patients registered as dialysing at the North Middlesex University Hospital NHS Trust (NMUH) in September 2011. Information was obtained through GP letters, GP and patient questionnaires. RESULTS: Of 154 patients, 133 were included in the data analysis. Nineteen per cent were up-to-date with both vaccinations and 67% with their influenza vaccination. Fifty per cent had received the influenza vaccination in the last two consecutive years. Thirty per cent were not up-to-date with either vaccination. There was no evidence of a difference in uptake in 2009 (P = 0.7564) and in 2010 (P = 0.7435) among those who could and could not speak English. Twenty-five per cent of GPs and 58.6% of patients preferred vaccination to occur in the dialysis unit. Unfortunately a high number of GPs did not provide information on whether they used an electronic vaccination reminder but the analysis from the information provided by the few respondents did not reveal any correlation between the presence of an electronic reminder and vaccination status. CONCLUSION: Most dialysis patients were not up-to-date with both vaccinations. They were, however, more up-to-date with their influenza than their pneumococcal vaccination. Non-English speakers did not appear to be disadvantaged. GP electronic reminder systems may have influenced influenza uptake but this study did not demonstrate a correlation and this is likely due to the lack of GP respondents; the effectiveness of electronic reminders merits further studies as a tool to improve vaccination rates in at-risk populations. Most patients visited their GP at least annually but preferred to receive their vaccinations at the hospital. Vaccinating in the dialysis unit and maintaining an electronic record accessible to GPs or generating a letter for GPs may help fill the vaccination gap in these patients. Overall, more evidence is required for the effectiveness of such vaccinations and their frequency, but in the meantime UK national guidelines were not being followed with a large proportion of patients remaining unvaccinated against influenza and in particular pneumococcal disease. This audit highlights the importance of local data collection, discussions around correlations influencing outcomes and publication of results to improve standards of care at a national level.

Current public health training infrastructure and facilitators in most developing nations are insufficient relative to public health service delivery needs. We examined five areas of student perceptions of a web-based public health learning initiative, the Peoples-uni, which focused on: reasons for enrolling, learning expectations; technical aspects of course modules; usefulness of prescribed learning materials; and encumbrances to participation in learning activities amongst the second cohort to enrol as students. Students were generally positive about the experience, with the majority wishing to gain academic credit, continue with the course, and recommend it to others. Other issues were identified on which the course organisers have subsequently acted, such as improved tutor training.

Background: Affordable, online public health education could assist health and development in low and middle-income countries. The Peoples-uni (www.Peoples-uni.org ) aims to provide this through a fully accredited, low cost, online Masters in Public Health. Although literature exists relating to online learners in general, we lack research regarding the characteristics of successful learners in this new student group. This study assessed which readily available information on learners could predict success in course modules. Methods: A descriptive survey method was used to assess correlations between pass rates with studentsâ?? personal characteristics (gender, nationality etc) and indicators of course engagement (discussion contributions, online profile etc). We sampled all students starting modules between September 2009 and March 2010 (n=218). Results: All indicators of engagement correlated strongly with pass rates, particularly online presence (photo/personal information on profile). Paying for modules correlated with higher pass rates than not. Interestingly, waiving fees correlated with lower pass rates than those who had not paid. Personal characteristics were not related to pass rates. Conclusion: Engagement is important for success, and indicators of which can predict pass rates, the personal characteristics investigated were not related to success. Further research is required to understand the nature of associations this study highlights.

We report the case of a 64-year-old woman, presenting with pleuritic chest pain and weight loss. She had a previous history of breast malignancy and no clear risk factors for tuberculosis (TB). Initial investigations showed a right-sided pleural effusion and pleural thickening suggestive of malignancy, which would have been in keeping with the clinical presentation. Initial pleural biopsy showed features suggestive of possible TB infection, though no growth on cultures. A repeat biopsy was negative on initial microscopy, but was culture positive for Mycobacterium tuberculosis, also identifying isoniazid resistance. This case highlights that TB remains an important differential even in the absence of classical risk factors, and illustrates the diagnostic challenges it poses. It also highlights the value of culture positivity in identification of drug resistance and facilitation of appropriate treatment.

Respiratory rate (RR) is one of the most sensitive markers of a patient condition and a core aspect of multiple clinical assessment tools. Doctors use a number of methods to assess RR, including formal measurement, and ‘spot’ assessments, although this is not recommended. This study aimed to assess the accuracy of the methods of RR measurement being used by doctors. A cross-sectional study assessing the accuracy (range, bias, and imprecision) of doctors’ ‘spot’ and ‘formal’ respiratory rate assessments, using videos of mock patients. 54 doctors in a London teaching hospital participated. Both methods showed high levels of inaccuracy, though formal methods were more accurate than ‘spot’ assessments. 52 and 19 % of doctors did not identify the respiratory rates shown as abnormal, using ‘spot’ and formal assessment methods respectively. We observed a trend towards decreasing accuracy of ‘spot’ assessments with increasing clinical experience (p = 0.0490). Current methods of RR assessment by doctors are inaccurate. This may be significantly delaying appropriate clinical care, or even misguiding treatment. Electronic supplementary material The online version of this article (doi:10.1007/s10877-014-9621-3) contains supplementary material, which is available to authorized users.

HIV co-receptor tropism determination is essential before prescribing the CCR5 antagonist maraviroc. British HIV Association guidelines suggest tropism testing may remain valid for only 90 days in antiretroviral-naïve patients. We aimed to determine the accuracy of this figure. Tropism was assessed in 26 antiretroviral-naïve patients with ongoing viral replication, sampled yearly from first clinic visit. The V3 region of HIV-1 was sequenced in triplicate, then tropism predicted using the Geno2Pheno system. Baseline tropism prediction remained valid for a median of 52 months (range 7–81). For 19/26 individuals baseline tropism remained unchanged throughout a median of 54 months follow-up; 18 R5 tropic and 1 X4 tropic. In seven patients (27%) baseline tropism switched at least once (range 1–4 switches) during follow-up; however, their baseline tropism prediction remained valid for a median of 45 months. Co-receptor tropism in treatment-naïve patients with ongoing viral replication appears highly stable over time, suggesting that baseline genotypic tropism prediction may be valid for a longer duration in patients delaying ART initiation. In this study, baseline tropism prediction remained valid for a median of 52 months, suggesting current guidelines recommending repeat testing after 90 days may be excessively conservative in their assessment of tropism stability.