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Objective Knowledgebases are needed to clarify correlations observed in real-world electronic health record (EHR) data. We posit design principles, present a unifying framework, and report a test of concept. Materials and Methods We structured a knowledge framework along 3 axes: condition of interest, knowledge source, and taxonomy. In our test of concept, we used hypertension as our condition of interest, literature and VanderbiltDDx knowledgebase as sources, and phecodes as our taxonomy. In a cohort of 832 566 deidentified EHRs, we modeled blood pressure and heart rate by sex and age, classified individuals by hypertensive status, and ran a Phenome-wide Association Study (PheWAS) for hypertension. We compared the correlations from PheWAS to the associations in our knowledgebase. Results We produced PhecodeKbHtn: a knowledgebase comprising 167 hypertension-associated diseases, 15 of which were also negatively associated with blood pressure (pos+neg). Our hypertension PheWAS included 1914 phecodes, 129 of which were in the PhecodeKbHtn. Among the PheWAS association results, phecodes that were in PhecodeKbHtn had larger effect sizes compared with those phecodes not in the knowledgebase. Discussion Each source contributed unique and additive associations. Models of blood pressure and heart rate by age and sex were consistent with prior cohort studies. All but 4 PheWAS positive and negative correlations for phecodes in PhecodeKbHtn may be explained by knowledgebase associations, hypertensive cardiac complications, or causes of hypertension independently associated with hypotension. Conclusion It is feasible to assemble a knowledgebase that is compatible with EHR data to aid interpretation of clinical correlation research.

In this work we analyse the local nonlinear electrochemical impedance spectroscopy (NLEIS) response of a lithium-ion battery and estimate model parameters from measured NLEIS data. The analysis assumes a single-particle model including nonlinear diffusion of lithium within the electrode particles and asymmetric charge transfer kinetics at their surface. Based on this model and assuming a moderately-small excitation amplitude, we systematically derive analytical formulae for the impedances up to the second harmonic response, allowing the meaningful interpretation of each contribution in terms of physical processes and nonlinearities in the model. The implications of this for parameterization are explored, including structural identifiability analysis and parameter estimation using maximum likelihood, with both synthetic and experimentally measured impedance data. Accurate fits to impedance data are possible, however inconsistencies in the fitted diffusion timescales suggest that a nonlinear diffusion model may not be appropriate for the cells considered. Model validation is also demonstrated by predicting time-domain voltage response using the parameterized model and this is shown to have excellent agreement with measured voltage time-series data (11.1 mV RMSE)., 40 pages (excluding supplementary material). Submitted to the Journal of the Electrochemical Society

Run-of-river (RoR) hydroelectric power provides renewable energy with potentially less impact on fish habitat productivity than large, reservoir-storage hydroelectric projects. This is the first empirical study of resident fish response to water diversion at RoR projects in BC, where the abundance of rainbow trout (Oncorhynchus mykiss) was monitored in four small streams using a before–after control–impact design. Although flows in the diversion reaches of these projects were reduced by 63% to 70%, the total biomass of rainbow trout increased from 35% to 157% across the streams compared with the “before period” and “control reaches”. The response to water diversion differed among age classes: adult biomass increased with reduced flows in the growing season; juvenile biomass increased with reduced flows in the winter, higher stream conductivity, and increased flows in late summer; and fry biomass increased with higher stream conductivity and temperatures. One novel way to contextualize these shifts in resident salmonid productivity and differential growth and (or) survival by age class is via a size–density approach, which we use here to demonstrate how the carrying capacity of a stream for rainbow trout is affected by water diversion.

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

Introduction Transient dry eye symptoms have been reported following laser in situ keratomileusis (LASIK). Very rarely, patients may present with debilitating symptoms of dry eye syndrome (DES) with limited or no evidence of ocular surface disease. These patients are diagnosed with a form of DES known as neuropathic corneal pain (NCP). Patients and Methods This study is a retrospective medical record review of a case series of 18 patients who developed NCP post-LASIK over the years 1996–2021. All patients who developed severe ocular pain following LASIK consistent with NCP were included. Patients with severe ocular pain who had evidence of severe ocular surface disease or other ophthalmic etiology to explain their debilitating symptoms were not included. Results The average age of patients in our study was 39.5 years. The majority of our patients were female (72.2%) and of Caucasian ancestry (83.3%). The average onset of symptoms was 9.6 months post-LASIK. Patients had past medical histories significant for neuropsychiatric conditions (50%), functional pain syndromes (22.2%), autoimmune diseases (33.3%), and hypothyroidism (27.8%), and the occurrence of these was higher than the national prevalence of these diseases. Symptoms were consistent with the severity and characteristics defining NCP. Treatment was multimodal, involved topical and systemic therapies, and was unique to each patient. Overall, the majority of patients had clinical improvement in symptoms following treatment with regular follow-up. Conclusion Although rare, the 26-year prevalence of NCP post-LASIK in our study was roughly 1 in 900 cases. The mean time to onset after surgery was delayed at 9.6 months. Certain risk factors such as neuropsychiatric conditions, history of functional pain syndromes, history of autoimmune conditions, and hypothyroidism may predispose patients to the development of this condition. Patients benefited from proper diagnosis and a multimodal approach to treatment.

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

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

This article is a preprint and has not been peer-reviewed [what does this mean?]. It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice. Copyright © 2021 The Authors. Introduction Pulmonary Rehabilitation (PR) is the gold standard, group-based intervention for individuals with Chronic Obstructive Pulmonary Disease (COPD). However, accessibility and adherence to PR is sub-optimal. Arts in Health interventions also improve health outcomes for people living with long term conditions. Playing the harmonica with COPD could be clinically beneficial. However, little is known about the patient experiences of playing the harmonica. Methods A qualitative, interpretivist, phenomenological study was undertaken, exploring COPD patient experiences of harmonica playing with a group of others living with chronic respiratory disease. Semi-structured interviews were completed, transcribed, and reflexive inductive thematic analysis performed. Results Eight people with COPD were interviewed. Thematic analysis generated five themes. Themes included “Hard in the beginning”, “Holding the condition”, “Breathing control”, “Gives you a high” and “Needing the Zoom class”. Playing the harmonica with COPD is difficult at first, particularly drawing a breath through the harmonica. With practice, experience in a fun activity, and quality teaching, individuals were able to become more attuned and embodied with their breathing. As breathing became easier the songs, rather than breathing, became the focus, and participants were able to escape living with respiratory disease when playing. The group was a priority in the weekly lives of participants, even though the buzz of being part of a group was lost. Discussion Playing the harmonica requires a different way of breathing and offers a breathing control strategy. Participants also reported the harmonica helped airway clearance and enabled a continued, regular social interaction through COVID-19. The results of this study compliment previous quantitative results and are relevant to physiotherapy. Further mechanistic studies and randomised controlled trials are needed to investigate the biopsychosocial benefits of playing the harmonica with COPD. Funding statement: No funding is associated with this work.

RationaleDietary nitrate supplementation improves skeletal muscle oxygen utilisation and vascular endothelial function. We hypothesised that these effects might be sufficient to improve exercise performance in patients with COPD and hypoxia severe enough to require supplemental oxygen.MethodsWe conducted a single-centre, double-blind, placebo-controlled, cross-over study, enrolling adults with COPD who were established users of long-term oxygen therapy. Participants performed an endurance shuttle walk test, using their prescribed oxygen, 3 hours after consuming either 140 mL of nitrate-rich beetroot juice (BRJ) (12.9 mmol nitrate) or placebo (nitrate-depleted BRJ). Treatment order was allocated (1:1) by computer-generated block randomisation.MeasurementsThe primary outcome was endurance shuttle walk test time. The secondary outcomes included area under the curve to isotime for fingertip oxygen saturation and heart rate parameters during the test, blood pressure, and endothelial function assessed using flow-mediated dilatation. Plasma nitrate and nitrite levels as well as FENOwere also measured.Main results20 participants were recruited and all completed the study. Nitrate-rich BRJ supplementation prolonged exercise endurance time in all participants as compared with placebo: median (IQR) 194.6 (147.5–411.7) s vs 159.1 (121.9–298.5) s, estimated treatment effect 62 (33–106) s (pConclusionAcute dietary nitrate supplementation increases exercise endurance in patients with COPD who require supplemental oxygen.Trial registration numberISRCTN14888729.

Many digital rock methodologies use a direct simulation approach, where only resolved pores are accounted for. This approach limits the types of rocks that can be analyzed, excluding some types of carbonates, unconventionals, and complex sandstones from the digital rock analysis. This is due to the challenge for single scale imaging to capture the full range of relevant pore sizes present in multiscale rocks. In this paper, a physical model is presented, within the context of an established direct simulation approach, to predict the production of hydrocarbons including the contribution of sub-resolution pores. The direct simulation component of the model employs a multiphase lattice Boltzmann method to simulate multiphase fluid flow displacement in resolved pores. In the production model, the amount of hydrocarbons present in the sub-resolution pores is identified and a physical description of the production behavior is provided. This allows a relative permeability curve to be predicted for rocks where mobile hydrocarbons are present in pores smaller than the image resolution. This simplified model for the oil movement in the unresolved pore space is based on a physical interpretation of different regions marked by simulation resolution limits in a USBM wettability test curve. The proposed methodology is applied to high-resolution microCT images of a sandstone that contains pores at multiple scales, some resolved and some not resolved. To allow for benchmarking, experimental routine and special core analysis data was also obtained. Good agreement to experimental results is observed, specifically in absolute and relative permeability. The presented multiscale model has the potential to extend the classes of reservoir rocks eligible for digital rock analysis and paves the way for further advancements in the modelling of multiscale rocks, particularly unconventionals and carbonates.

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

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).

Majid Moshirfar,1– 3 Adam L Lewis,4 James H Ellis,5 Shannon E McCabe,1,6 Yasmyne C Ronquillo,1 Phillip C Hoopes Sr1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4Kansas City University, Kansas City, MO, USA; 5University of Utah School of Medicine, Salt Lake City, UT, USA; 6Mission Hills Eye Center, Pleasant Hill, CA, USACorrespondence: Majid MoshirfarMedical Director Hoopes Vision Research Center, Hoopes Vision, 11820 S. State Street Suite #200, Draper, UT, 84020, USATel +1 801-568-0200Fax +1 801-563-0200Email cornea2020@me.comIntroduction: Retained lens fragments in the anterior chamber following cataract extraction (CE) with phacoemulsification are rare but can lead to significant patient morbidity. Our study aimed to identify risk factors associated with retained lens fragments.Methods: Patients who underwent cataract surgery and subsequently identified to have retained lens fragments in the anterior segment were included. Incidence per year, patient demographics, visual acuity, ocular biometrics, surgical technique, surgeon performing CE, and outcomes were collected retrospectively and compared to a control group.Results: Twenty-four patients were identified with retained lens fragments, with an incidence of 0.10%. The mean age was 76 years ± 6.72 (60– 80) compared to 63 ± 11.41 (22– 86) in the control group (p < 0.001). Patients with UDVA 20/150 or worse experienced a greater average improvement in visual acuity compared to patients with UDVA better than 20/150 (logMAR 0.46 vs logMAR 0.05). The mean intraocular pressures before (CE), after CE but before fragment removal, and following fragment removal were 14 mmHg ± 2.59, 19 mmHg ± 8.20, and 11 mmHg ± 2.75, respectively. Twenty-two patients presented with inferiorly located fragments. Statistically significant biometrics include mean anterior chamber depth (3.1 mm ± 0.37 vs 3.33 mm ± 0.39, p = 0.01) and lens thickness (4.77 mm ± 0.44 vs 4.35 mm ± 0.44, p = < 0.001). Yearly incidence rates per surgeon ranged from 0.00% to 0.85%. In 2003 and 2004, one surgeon had significantly higher incidence rates (0.31 and 0.40%) compared to the average combined rate of all surgeons throughout the study (0.10), with p values of 0.001 and 0.003, respectively. The mean number of days between CE and fragment removal was 26 ± 40 (1– 138).Conclusion: Increased patient age, shallow anterior chamber depth, and thick lens may be risk factors for retained lens fragments. There may be additional surgeon-specific risk factors. Phacoemulsification technique (Divide-and-Conquer versus Horizontal Chop) showed no significant difference.Keywords: retained lens fragments, phacoemulsification, cataract surgery, complications of cataract surgery, refractory corneal edema

Copyright © Author(s) (or their employer(s)) 2021. Introduction SARS-CoV-2 has restricted access to face-to-face delivery of Pulmonary Rehabilitation (PR). Evidence suggests that telehealth-PR is non-inferior to outpatient PR. However, it is unknown whether patients who have been referred to face-to-face programmes can feasibly complete an online-PR programme. Methods This service evaluation used a mixed-methods approach to investigate a rapid PR service remodelling using the University of Gloucestershire eLearn Moodle platform. Quantitative baseline demographic and PR outcome data were collected from online-PR participants, and semi-structured interviews were completed with PR staff and participants. Results Twenty-five individuals were eligible from a PR waiting list. Thirteen declined participation and fourteen completed PR. Significant Pre-post online PR improvements were achieved in 1-minute sit-to-stand (Confidence interval (CI) 2.1 - 9 (p = 0.004)), Generalised Anxiety Disorder (CI -0.3 - -2.6(p = 0.023)), Primary Health Questionnaire-9 (CI -5.1 - -0.3 (p = 0.029)), Chronic Respiratory Questionnaire dyspnoea (CI 0.5 - 1.3 (p = 0.001)), Fatigue (CI 0.7 - 2 (p = 0.0004)), Emotion (CI 0.7 - 1.7 (p = 0.0002)), Mastery (CI 0.4 - 1.3(p = 0.001)). Interviews indicated that patient PR inclusion was made possible with digital support and a PR introduction session improved participant engagement and safety. Incremental progression of exercise was perceived as more successful online compared to face-to-face PR. However, perceptions were that education sessions were less successful. Online-PR required significant staff time resource. Discussion Online-PR improves patient outcomes, is feasible and acceptable for individuals referred for face-to-face PR in the context of a requirement for social distancing. Face-to-face programmes can be adapted in a rapid fashion with both staff and participants perceiving benefit. Future pragmatic trials are now warranted comparing online-PR including remote assessments to centre-based PR with suitably matched outcomes, and patient and staff perceptions sought regarding barriers and facilitators of online delivery. The University of Gloucestershire, Sport, Exercise, Health and Wellbeing Internal Research Grant Programme 2019-2020 The University of Gloucestershire, Sport, Exercise, Health and Wellbeing Internal Research Grant Programme 2019-2020, for £8047.

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.

ObjectivesTo establish what proportion of patients completing a UK pulmonary rehabilitation (PR) programme meet the 2018 National Institute for Health and Care Excellence (NICE) chronic obstructive pulmonary disease (COPD) guideline (NG115) criteria to have a respiratory review to establish whether referral to a lung volume reduction multidisciplinary team would be appropriate. This respiratory review would include evaluation of the presence of hyperinflation and the presence of emphysema on CT scan. The NICE criteria include measures of breathlessness and exercise capacity but these parameters are not completely defined.DesignObservational study.SettingPR programmes across the UK in 2015 (210 centres) and 2017 (184 centres) entering data into the Royal College of Physicians’ National Asthma and COPD Audit Programme.Participants8295 (55.7%) of 14 889 patients in programmes using incremental shuttle walk test (ISWT) or 6-minute walk test (6MWT) as an outcome measure completed PR, and 4856 (32.6%) had complete data recorded (6MWT/ISWT, baseline spirometry, Medical Research Council (MRC) dyspnoea score).ResultsDepending on the walking test safety threshold adopted for the ISWT (≥140 m or ≥ 80 m) and the MRC dyspnoea score threshold used (MRC score ≥3 or ≥4 at the end of PR), between 4.9% and 18.1% of PR completers met the NICE criteria for a lung volume reduction-focused respiratory review.ConclusionsLung volume reduction therapies are beneficial in appropriately selected patients with COPD, but few procedures are performed, and treatment pathways are unclear. These data help to inform the feasibility of the approach recommended by NICE and highlight the need for future systematic pathways to reduce inequalities in patients being considered for effective treatments.

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.

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.