Experimental evidence for recovery of mercury-contaminated fish populations.

Anthropogenic releases of mercury (Hg)1-3 are a human health issue4 because the potent toxicant methylmercury (MeHg), formed primarily by microbial methylation of inorganic Hg in aquatic ecosystems, bioaccumulates to high concentrations in fish consumed by humans5,6. Predicting the efficacy of Hg pollution controls on fish MeHg concentrations is complex because many factors influence the production and bioaccumulation of MeHg7-9. Here we conducted a 15-year whole-ecosystem, single-factor experiment to determine the magnitude and timing of reductions in fish MeHg concentrations following reductions in Hg additions to a boreal lake and its watershed. During the seven-year addition phase, we applied enriched Hg isotopes to increase local Hg wet deposition rates fivefold. The Hg isotopes became increasingly incorporated into the food web as MeHg, predominantly from additions to the lake because most of those in the watershed remained there. Thereafter, isotopic additions were stopped, resulting in an approximately 100% reduction in Hg loading to the lake. The concentration of labelled MeHg quickly decreased by up to 91% in lower trophic level organisms, initiating rapid decreases of 38-76% of MeHg concentration in large-bodied fish populations in eight years. Although Hg loading from watersheds may not decline in step with lowering deposition rates, this experiment clearly demonstrates that any reduction in Hg loadings to lakes, whether from direct deposition or runoff, will have immediate benefits to fish consumers.

Factors influencing fatigue in UK nurses working in respiratory clinical areas during the second wave of the Covid-19 pandemic: An online survey.

AIMS AND OBJECTIVES: This study explores UK nurses' experiences of working in a respiratory clinical area during the COVID-19 pandemic over winter 2020. BACKGROUND: During the first wave of the pandemic, nurses working in respiratory clinical areas experienced significant levels of anxiety and depression. As the pandemic has progressed, levels of fatigue in nurses have not been assessed. METHODS: A cross-sectional e-survey was distributed via professional respiratory societies and social media. The survey included Generalised Anxiety Disorder Assessment (GAD7), Patient Health Questionnaire (PHQ9, depression), a resilience scale (RS-14) and Chalder mental and physical fatigue tools. The STROBE checklist was followed as guidance to write the manuscript. RESULTS: Despite reporting anxiety and depression, few nurses reported having time off work with stress, most were maintaining training and felt prepared for COVID challenges in their current role. Nurses reported concerns over safety and patient feedback was both positive and negative. A quarter of respondents reported wanting to leave nursing. Nurses experiencing greater physical fatigue reported higher levels of anxiety and depression. CONCLUSIONS: Nurses working in respiratory clinical areas were closely involved in caring for COVID-19 patients. Nurses continued to experience similar levels of anxiety and depression to those found in the first wave and reported symptoms of fatigue (physical and mental). A significant proportion of respondents reported considering leaving nursing. Retention of nurses is vital to ensure the safe functioning of already overstretched health services. Nurses would benefit from regular mental health check-ups to ensure they are fit to practice and receive the support they need to work effectively. RELEVANCE TO CLINICAL PRACTICE: A high proportion of nurses working in respiratory clinical areas have been identified as experiencing fatigue in addition to continued levels of anxiety, depression over winter 2020. Interventions need to be implemented to help provide mental health support and improve workplace conditions to minimise PTSD and burnout.

Oxygen alert wristbands (OxyBand) and controlled oxygen: a pilot study.

Despite the introduction of Oxygen Alert Cards, guidelines and audits, oxygen therapy remains overused in NHS practice, and this may lead to iatrogenic mortality. This pilot study aimed to examine the use of Oxygen Alert Wristbands (OxyBand) designed to alert health professionals who are delivering oxygen to patients to ensure that the oxygen is administered and titrated safely to the appropriate target saturations. Patients at risk of hypercapnic acidosis were asked to wear OxyBands while presenting to paramedics and health professionals in hospitals. Inappropriate prescription of oxygen reduced significantly after the OxyBands were used. A questionnaire-based assessment showed that the clinicians involved had a good understanding of the risks of uncontrolled oxygen. Forty-two patients found the wrist band comfortable to wear, and only two did not. OxyBands may have the potential to improve patient safety over Oxygen Alert Cards.

Self-management for bronchiectasis.

BACKGROUND: Bronchiectasis is a long term respiratory condition with an increasing rate of diagnosis. It is associated with persistent symptoms, repeated infective exacerbations, and reduced quality of life, imposing a burden on individuals and healthcare systems. The main aims of therapeutic management are to reduce exacerbations and improve quality of life. Self-management interventions are potentially important for empowering people with bronchiectasis to manage their condition more effectively and to seek care in a timely manner. Self-management interventions are beneficial in the management of other airways diseases such as asthma and COPD (chronic obstructive pulmonary disease) and have been identified as a research priority for bronchiectasis. OBJECTIVES: To assess the efficacy, cost-effectiveness and adverse effects of self-management interventions for adults and children with non-cystic fibrosis bronchiectasis. SEARCH METHODS: We searched the Cochrane Airways Specialised Register of trials, clinical trials registers, reference lists of included studies and review articles, and relevant manufacturers' websites up to 13 December 2017. SELECTION CRITERIA: We included all randomised controlled trials of any duration that included adults or children with a diagnosis of non-cystic fibrosis bronchiectasis assessing self-management interventions delivered in any form. Self-management interventions included at least two of the following elements: patient education, airway clearance techniques, adherence to medication, exercise (including pulmonary rehabilitation) and action plans. DATA COLLECTION AND ANALYSIS: Two review authors independently screened searches, extracted study characteristics and outcome data and assessed risk of bias for each included study. Primary outcomes were, health-related quality of life, exacerbation frequency and serious adverse events. Secondary outcomes were the number of participants admitted to hospital on at least one occasion, lung function, symptoms, self-efficacy and economic costs. We used a random effects model for analyses and standard Cochrane methods throughout. MAIN RESULTS: Two studies with a total of 84 participants were included: a 12-month RCT of early rehabilitation in adults of mean age 72 years conducted in two centres in England (UK) and a six-month proof-of-concept RCT of an expert patient programme (EPP) in adults of mean age 60 years in a single regional respiratory centre in Northern Ireland (UK). The EPP was delivered in group format once a week for eight weeks using standardised EPP materials plus disease-specific education including airway clearance techniques, dealing with symptoms, exacerbations, health promotion and available support. We did not find any studies that included children. Data aggregation was not possible and findings are reported narratively in the review.For the primary outcomes, both studies reported health-related quality of life, as measured by the St George's Respiratory Questionnaire (SGRQ), but there was no clear evidence of benefit. In one study, the mean SGRQ total scores were not significantly different at 6 weeks', 3 months' and 12 months' follow-up (12 months mean difference (MD) -10.27, 95% confidence interval (CI) -45.15 to 24.61). In the second study there were no significant differences in SGRQ. Total scores were not significantly different between groups (six months, MD 3.20, 95% CI -6.64 to 13.04). We judged the evidence for this outcome as low or very low. Neither of the included studies reported data on exacerbations requiring antibiotics. For serious adverse events, one study reported more deaths in the intervention group compared to the control group, (intervention: 4 of 8, control: 2 of 12), though interpretation is limited by the low event rate and the small number of participants in each group.For our secondary outcomes, there was no evidence of benefit in terms of frequency of hospital admissions or FEV1 L, based on very low-quality evidence. One study reported self-efficacy using the Chronic Disease Self-Efficacy scale, which comprises 10 components. All scales showed significant benefit from the intervention but effects were only sustained to study endpoint on the Managing Depression scale. Further details are reported in the main review. Based on overall study quality, we judged this evidence as low quality. Neither study reported data on respiratory symptoms, economic costs or adverse events. AUTHORS' CONCLUSIONS: There is insufficient evidence to determine whether self-management interventions benefit people with bronchiectasis. In the absence of high-quality evidence it is advisable that practitioners adhere to current international guidelines that advocate self-management for people with bronchiectasis.Future studies should aim to clearly define and justify the specific nature of self-management, measure clinically important outcomes and include children as well as adults.

Macrolide antibiotics for bronchiectasis.

BACKGROUND: Bronchiectasis is a chronic respiratory disease characterised by abnormal and irreversible dilatation and distortion of the smaller airways. Bacterial colonisation of the damaged airways leads to chronic cough and sputum production, often with breathlessness and further structural damage to the airways. Long-term macrolide antibiotic therapy may suppress bacterial infection and reduce inflammation, leading to fewer exacerbations, fewer symptoms, improved lung function, and improved quality of life. Further evidence is required on the efficacy of macrolides in terms of specific bacterial eradication and the extent of antibiotic resistance. OBJECTIVES: To determine the impact of macrolide antibiotics in the treatment of adults and children with bronchiectasis. SEARCH METHODS: We identified trials from the Cochrane Airways Trials Register, which contains studies identified through multiple electronic searches and handsearches of other sources. We also searched trial registries and reference lists of primary studies. We conducted all searches on 18 January 2018. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of at least four weeks' duration that compared macrolide antibiotics with placebo or no intervention for the long-term management of stable bronchiectasis in adults or children with a diagnosis of bronchiectasis by bronchography, plain film chest radiograph, or high-resolution computed tomography. We excluded studies in which participants had received continuous or high-dose antibiotics immediately before enrolment or before a diagnosis of cystic fibrosis, sarcoidosis, or allergic bronchopulmonary aspergillosis. Our primary outcomes were exacerbation, hospitalisation, and serious adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the titles and abstracts of 103 records. We independently screened the full text of 40 study reports and included 15 trials from 30 reports. Two review authors independently extracted outcome data and assessed risk of bias for each study. We analysed dichotomous data as odds ratios (ORs) and continuous data as mean differences (MDs) or standardised mean differences (SMDs). We used standard methodological procedures as expected by Cochrane. MAIN RESULTS: We included 14 parallel-group RCTs and one cross-over RCT with interventions lasting from 8 weeks to 24 months. Of 11 adult studies with 690 participants, six used azithromycin, four roxithromycin, and one erythromycin. Four studies with 190 children used either azithromycin, clarithromycin, erythromycin, or roxithromycin.We included nine adult studies in our comparison between macrolides and placebo and two in our comparison with no intervention. We included one study with children in our comparison between macrolides and placebo and one in our comparison with no intervention.In adults, macrolides reduced exacerbation frequency to a greater extent than placebo (OR 0.34, 95% confidence interval (CI) 0.22 to 0.54; 341 participants; three studies; I2 = 65%; moderate-quality evidence). This translates to a number needed to treat for an additional beneficial outcome of 4 (95% CI 3 to 8). Data show no differences in exacerbation frequency between use of macrolides (OR 0.31, 95% CI 0.08 to 1.15; 43 participants; one study; moderate-quality evidence) and no intervention. Macrolides were also associated with a significantly better quality of life compared with placebo (MD -8.90, 95% CI -13.13 to -4.67; 68 participants; one study; moderate-quality evidence). We found no evidence of a reduction in hospitalisations (OR 0.56, 95% CI 0.19 to 1.62; 151 participants; two studies; I2 = 0%; low-quality evidence), in the number of participants with serious adverse events, including pneumonia, respiratory and non-respiratory infections, haemoptysis, and gastroenteritis (OR 0.49, 95% CI 0.20 to 1.23; 326 participants; three studies; I2 = 0%; low-quality evidence), or in the number experiencing adverse events (OR 0.83, 95% CI 0.51 to 1.35; 435 participants; five studies; I2 = 28%) in adults with macrolides compared with placebo.In children, there were no differences in exacerbation frequency (OR 0.40, 95% CI 0.11 to 1.41; 89 children; one study; low-quality evidence); hospitalisations (OR 0.28, 95% CI 0.07 to 1.11; 89 children; one study; low-quality evidence), serious adverse events, defined within the study as exacerbations of bronchiectasis or investigations related to bronchiectasis (OR 0.43, 95% CI 0.17 to 1.05; 89 children; one study; low-quality evidence), or adverse events (OR 0.78, 95% CI 0.33 to 1.83; 89 children; one study), in those receiving macrolides compared to placebo. The same study reported an increase in macrolide-resistant bacteria (OR 7.13, 95% CI 2.13 to 23.79; 89 children; one study), an increase in resistance to Streptococcus pneumoniae (OR 13.20, 95% CI 1.61 to 108.19; 89 children; one study), and an increase in resistance to Staphylococcus aureus (OR 4.16, 95% CI 1.06 to 16.32; 89 children; one study) with macrolides compared with placebo. Quality of life was not reported in the studies with children. AUTHORS' CONCLUSIONS: Long-term macrolide therapy may reduce the frequency of exacerbations and improve quality of life, although supporting evidence is derived mainly from studies of azithromycin, rather than other macrolides, and predominantly among adults rather than children. However, macrolides should be used with caution, as limited data indicate an associated increase in microbial resistance. Macrolides are associated with increased risk of cardiovascular death and other serious adverse events in other populations, and available data cannot exclude a similar risk among patients with bronchiectasis.

An evaluation of National Health Service England's Care Maker Programme: A mixed-methods analysis.

AIMS AND OBJECTIVES: To investigate the impact and sustainability of the Care Maker programme across England from the perspective of those involved in its delivery. BACKGROUND: The Care Maker programme was launched in England in 2013. It aims to support the "Compassion in Practice" strategy, with particular emphasis on the 6Cs of care, compassion, competence, communication, courage and commitment. Care Makers were recruited in an ambassadorial role. The intention was to inspire individuals throughout the National Health Service in England to bridge national policy with those delivering care. DESIGN: A mixed methods design was chosen, but this article focuses on two of the four distinct empirical data collection phases undertaken as part of this evaluation: a questionnaire with Care Makers; and two case studies of separate National Health Service trust sites. METHOD: Data were collected for this evaluation in 2015. An online questionnaire was distributed to the total population of Care Makers across the National Health Service in England. It included a combination of open and closed questions. The case studies involved semistructured telephone interviews with a range of professionals engaged with the Care Maker programme across the trust sites. RESULTS: Care Makers reported that participation in the programme had offered opportunities in terms of improving the quality-of-care provision in the workplace as well as contributing towards their own professional development. CONCLUSION: The Care Maker programme has supported and helped underpin the nursing, midwifery and care strategy "Compassion in Practice". RELEVANCE TO CLINICAL PRACTICE: This model of using volunteers to embed strategy and policy could potentially be used in other areas of clinical practice and indeed in other countries.

Difficult decisions: An interpretative phenomenological analysis study of healthcare professionals' perceptions of oxygen therapy in palliative care.

BACKGROUND: The role of oxygen therapy to palliate dyspnoea is controversial. Without a clear evidence base oxygen is commonly prescribed, sometimes to the detriment of patients. This use of oxygen appears to be an entrenched culture, the roots of which remain obscure. AIM: To explore healthcare professionals' perceptions of oxygen therapy in palliative care. DESIGN: Interpretative phenomenological analysis study utilising semi-structured interviews to explore beliefs and behaviours of healthcare professionals regarding palliative oxygen therapy. Data were recorded, transcribed and analysed using interpretative phenomenological analysis. SETTING/PARTICIPANTS: A total of 34 healthcare professionals, including doctors, nurses, pharmacists and paramedics in the United Kingdom, who were involved in prescribing, or administering, oxygen therapy to palliate dyspnoea. RESULTS: Most healthcare professionals in this study were well informed about oxygen therapy; all recognised the role of oxygen in palliative care setting as important. The overarching theme of compassion identified sub-themes of 'comfort', 'do anything and everything' and 'family benefit'. However, the use of oxygen in the palliative care setting was not without its dilemmas, as additional sub-themes of 'controversy', 'doubt' and 'dependency' illustrated. CONCLUSION: Findings suggest that oxygen therapy in palliative care poses an on-going dilemma for healthcare professionals striving to provide optimum care. It seems patients and families often expect and welcome oxygen, but the perception of oxygen as a solution to dyspnoea can conflict with healthcare professionals' own doubt and experiences. There appears to be an emotional cost associated with this dilemma and the choices that need to be made.

How do health-care professionals perceive oxygen therapy? A critical interpretive synthesis of the literature.

Oxygen is one of the commonest health-care interventions worldwide. This might suggest that health-care professionals (HCPs) would be knowledgeable and familiar with its uses and limitations. Yet it is apparent, through clinical audit, that oxygen is probably misunderstood by many HCPs. The aim of this critical interpretive synthesis (CIS) is to explore qualitative and quantitative literature in relation to HCPs beliefs and perceptions of oxygen therapy. A systematic search in Medline, Cinahl, Embase, British Nursing Index and PsychInfo using search terms, such as, oxygen therapy, chronic respiratory disease, HCPs and perceptions yielded 1514 studies of which 12 contained data relevant to the review question. Two reviewers independently screened the articles for eligibility against inclusion and exclusion criteria, and data were selected and synthesized with an integrative and interpretive approach using CIS. This allowed diverse empirical evidence to be synthesized to develop existing and new interpretations of data.Three synthetic constructs were interpreted from the available literature, namely, oxygen for symptom relief, levels of knowledge and understanding and oxygen as a therapy for HCPs. The literature alludes to deep-seated beliefs that exist. In order to enhance practice, these beliefs and cultures need to be challenged. Further research is needed to explore HCPs' perceptions of oxygen therapy in order to inform the seemingly resistant adoption of evidence based practice in relation to oxygen.

How do respiratory patients perceive oxygen therapy? A critical interpretative synthesis of the literature.

Oxygen therapy is a common intervention in health care worldwide; yet, despite universal use, it is evident through poor practice that oxygen is often prescribed and administered injudiciously. It is proposed that possibly an influencing culture presides, whereby oxygen is often poorly understood and uncertainty regarding its use exists. It is unclear where the origins of this culture lie but exploring perceptions may enlighten the problem. A review of the literature was undertaken to establish what is already known about this elusive phenomenon. The paucity of any direct evidence regarding perceptions of oxygen directed the review to utilize a critical interpretative synthesis (CIS). The aim of this study was to explore how respiratory patients perceive oxygen therapy. A systematic search in Medline, Cinahl, Embase, British Nursing Index and PsychInfo yielded 1514 studies of which 42 were selected to consider the review question. The CIS allowed evidence from across studies to synthesize existing and new interpretations of data related to patients' perceptions of oxygen therapy. Synthetic constructs then informed the synthesizing arguments, namely positive - feeling safe, enabler and comforter; negative - fear, oxygen versus self, restriction and embarrassment; and impartiality - mixed blessings. The findings are divergent, and at times contradictory. There appears uncertainty among patients regarding the purpose and benefits of oxygen therapy, though an underlying faith in health-care professionals is apparent. This faith seems to foster acceptance of a life-changing therapy, despite the impact, burden and incomplete understanding. There is a clear need for further research regarding these elusive perceptions in order to improve clinical practice in respect of oxygen.

Improving Resident Hospital Discharge Communication by Changing Electronic Health Record Templates to Enhance Primary Care Provider Satisfaction.

BACKGROUND AND OBJECTIVES: Despite use of standardized electronic health record templates, the structure of discharge summaries may hinder communication from inpatient settings to primary care providers (PCPs). We developed an enhanced electronic discharge summary template to improve PCP satisfaction with written discharge summaries targeting diagnoses, medication reconciliation, laboratory test results, specialist follow-up, and recommendations. METHODS: Resident template usage was measured using statistical process control charts. PCP reviewers' discharge summary satisfaction was surveyed using 5-point Likert scales analyzed using the Mann-Whitney U test. Residents were surveyed for satisfaction. RESULTS: Resident template usage increased from 61% initially to 72% of discharge summaries at 6 months. The PCP reviewers reported increased satisfaction for summaries using the template compared with those without (4.3 vs 3.9, P = .003). Surveyed residents desired template inclusion in the default electronic discharge summary (93%). CONCLUSIONS: This system-level resident-initiated quality improvement initiative created a novel discharge summary template that achieved widespread usage among residents and significantly increased outpatient PCP satisfaction.

'The likes of me running and walking? No chance': Exploring the perceptions of adult patients with bronchiectasis towards exercise.

Objective: To explore the views and experiences of adult patients with bronchiectasis towards exercise. Methods: Semi-structured interviews with ten patients with bronchiectasis were conducted to explore perceptions of exercise, potential barriers and facilitators of exercise. Inductive thematic analysis was used to identify key themes. Findings: Five main themes: 1. The language of exercise 2. Facilitators to exercise 3. Barriers to exercise 4. Exercise has a positive impact on health and life expectancy 5. Grief regarding loss of ability Discussion: Participants perceived exercise as positive, but there was variance regarding what this entailed. Findings suggest healthcare professionals should consider the language used when prescribing exercise and provide clarity for patients and reflect on their own role in advising on exercise. There were both common and differing barriers and facilitators to exercise between participants. Holistic needs and the identification of these potential barriers and facilitators to exercise could aid compliance. Further research is needed to explore generalisability and the effectiveness of behaviour change models to improve engagement with exercise.

Outcomes of physiotherapy for people living with bronchiectasis: qualitative study to inform development of a core outcome set.

INTRODUCTION: Evidence of the effectiveness of physiotherapy for bronchiectasis is inconsistent, partly due to variation in the selection and reporting of outcomes in clinical trials. This qualitative study is a component of the development of a core outcome set (COS). The COS will identify a minimum group of outcomes for use in clinical trials of physiotherapy considering the views of researchers, patients, and clinicians. OBJECTIVES: To identify outcomes for use in physiotherapy research that are important to patients and physiotherapists and to explain their significance. METHODS: Semi-structured interviews were conducted with adult patients with bronchiectasis who received physiotherapy, in addition to physiotherapists clinically involved in bronchiectasis care. Interviews were audio recorded and transcribed verbatim. Thematic analysis was used to identify, classify, and explain the significance of outcomes. Outcomes were mapped into the list created from literature review and classified into domains. RESULTS: We interviewed 18 participants from four countries covering a range of experiences in different settings. Seventy outcomes were identified and grouped into 15 domains. Thirty-three outcomes were not previously reported in the literature. Thematic analysis revealed exacerbations, quality of life, use of healthcare resources, patient-reported symptoms, physical functioning, and sputum as the prominent themes reported by both patients and physiotherapists. CONCLUSIONS: This qualitative study highlighted the importance of considering stakeholder perspectives when planning research trials. Outcomes identified will be used to inform the next phase of COS development. REGISTRATION: This study is part of the COS development project registered with the Core Outcome Measures in Effectiveness Trials initiative (COMET) https://www.comet-initiative.org/Studies/Details/1931 CONTRIBUTION OF THE PAPER.

Evaluation of outcome reporting in clinical trials of physiotherapy in bronchiectasis: The first stage of core outcome set development.

INTRODUCTION: The aim of this study is to explore outcomes currently reported in physiotherapy trials for bronchiectasis and investigate the level of consistency in outcome reporting. This mapping of outcomes will be used to inform the development of a core outcome set (COS) for physiotherapy research in bronchiectasis. Outcomes reported in randomised clinical trials (RCTs) and RCT protocols were reviewed and evaluated. We included trials with physiotherapy as the main intervention, including pulmonary rehabilitation, exercise prescription, airway clearance, positive expiratory pressure devices, breathing training, self-management plans, and home exercise program. Medline, CINAHL, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and the physiotherapy evidence database (PEDro) were searched from inception using a prespecified search strategy. Records including adult patients with bronchiectasis were included. Outcomes were listed verbatim and categorised into domains based on a pre-specified system, frequency of reporting and sources of variation were inspected. RESULTS: Of 2158 abstracts screened, 37 trials (1202 participants) and 17 trial protocols were identified. Eighteen different physiotherapy techniques were investigated. A total of 331 outcomes were reported. No single outcome was reported by all trials. The most reported outcomes were lung function (27 trials, 50%), health related quality of life (26 trials, 48.1%), and dyspnoea (18 trials, 33.3%). A list of 104 unique outcomes covering 23 domains was created. Trials focus on physiological outcomes, mainly those related to respiratory system functions. Outcomes related to functioning and life impact are often neglected. CONCLUSION: Outcome reporting in physiotherapy research for bronchiectasis was found to be inconsistent in terms of choosing and defining outcomes. Developing a core outcome set in this area of research is needed to facilitate aggregation of future trial results in systematic reviews that will in turn inform the strength of evidence for the effectiveness of physiotherapy. Outcome choice should include all stakeholders, including patients. TRIAL REGISTRATION: This study is registered in the PROSPERO registry under the number CRD42021266247.

Patient information on nebulised antibiotics.

The importance of providing patients with high-quality information is highlighted in several government reports. The aim of this project was to develop written information specifically designed for patients with non-cystic fibrosis bronchiectasis who are prescribed nebulised colistimethate sodium. This involved evaluating current literature and best practice, which was achieved through multidisciplinary collaboration. The leaflet produced meets the recommendations of the British Thoracic Society and Department of Health, as well as NHS trusts' legal obligations to promote equality and diversity. It is available as a printed document in a variety of formats and languages, and can be downloaded from the hospital website.

Development of a core outcome set and outcome measurement set for physiotherapy trials in adults with Bronchiectasis (COS-PHyBE study): A protocol.

BACKGROUND: Bronchiectasis is a chronic respiratory disease characterised by airways widening and recurrent infections, resulting in episodes of chronic cough, sputum expectoration, and dyspnoea. This leads to deterioration in daily function, repeated hospital admissions and poor quality of life. The prevalence and mortality related to bronchiectasis is increasing worldwide with growing economic burden on healthcare systems. Physiotherapy for bronchiectasis aims to decrease accumulation of sputum, dyspnoea, and improve exercise capacity and daily function. A robust evidence base to support physiotherapy in bronchiectasis is currently lacking. This is partly because of inconsistency and poor reporting of outcomes in available studies. A core outcome set is the minimum acceptable group of outcomes that should be used in clinical trials for a specific condition. This decreases research waste by improving consistency and reporting of key outcomes and facilitates the synthesis of study outcomes in systematic reviews and guidelines. The aim of the study is therefore to develop a core outcome set and outcome measurement set for physiotherapy research in adults with bronchiectasis. This will ensure outcomes important to key stakeholders are consistently used and reported in future research. METHODS AND ANALYSIS: This project will use the COMET Initiative and COSMIN guidelines of core outcome set development and will include three phases. In the first phase, a comprehensive list of outcomes will be developed using systematic review of reported outcomes and qualitative interviews with patients and physiotherapists. Then consensus on key outcomes will be established in phase two using a Delphi survey and a consensus meeting. Finally, in phase three, we will identify appropriate instruments to measure the core outcomes by evaluating the psychometric properties of available instruments and a stakeholders' meeting to establish consensus. ETHICS: The study was reviewed and has received ethical approval from the health-related Research Ethics Committee- Edge Hill University (ETH2021-0217). REGISTRATION: This study is registered with the COMET database. https://www.comet-initiative.org/Studies/Details/1931. The full systematic review protocol is registered in PROSPERO under the number CRD42021266247.

Staff perceptions of patient safety in the NHS ambulance services: an exploratory qualitative study.

Objectives: Most research investigating staff perceptions of patient safety has been based in primary care or hospitals, with little research on emergency services. Therefore, this study aimed to explore staff perceptions of patient safety in the NHS ambulance services. Design: A stratified qualitative study using semi-structured interviews. Setting: Three urban or rural ambulance service NHS trusts in England. Participants: A total of 44 participants from three organisational levels, including executives, managers and operational staff. Methods: The semi-structured interviews explored the interpretation and definition of patient safety, perceived risks, incident reporting, communication and organisational culture. The framework method of qualitative data analysis was used to analyse the interviews and NVivo software was used to manage and organise the data. Results: We identified five dominant themes: varied interpretation of patient safety; significant patient safety risks; reporting culture shift; communication; and organisational culture. The findings demonstrated that staff perceptions of patient safety ranged widely across the three organisational levels, while they remained consistent within those levels across the participating ambulance service NHS trusts in England. Conclusions: The findings suggest that participants from all organisational levels perceive that the NHS ambulance services have become much safer for patients over recent years, which signifies an awareness of the historical issues and how they have been addressed. The inclusion of three distinct ambulance service NHS trusts and organisational levels provides deepened insight into the perceptions of patient safety by staff. As the responses of participants were consistent across the three NHS trusts, the identified issues may be generic and have application in other ambulance and emergency service settings, with implications for health policy on a national basis.

Self-management in chronic lung disease: what is missing?

Self-management, as a strategy to support those living with chronic respiratory conditions such as asthma and COPD, has been widely advocated in guidelines and adopted in practice. However, there can be a disconnect between the goals of patients and healthcare professionals. Goals and barriers to self-management are often compounded by the complex social, emotional and medical needs of patients. People living with chronic respiratory conditions also often have symptoms of anxiety and depression, which can impact on self-management. Self-management therefore requires patients and healthcare professionals to work together and it is essential to involve patients when designing, implementing and evaluating self-management interventions. Patient preferences are clearly important and goal setting needs an individual, flexible and responsive approach from healthcare professionals, which aligns to a more personalised approach to management of treatable traits and the burden of disease. To achieve these goals, healthcare professionals need education to support patients in self-management and behaviour change. This approach should lead to shared decision-making and partnership working that puts the patient right at the centre of their care.

Healthcare professionals' perceptions of pulmonary rehabilitation as a management strategy for patients with chronic obstructive pulmonary disease: a critical interpretive synthesis.

PURPOSE: To establish literature regarding healthcare professionals' perceptions of pulmonary rehabilitation as a management strategy for patients with chronic obstructive pulmonary disease. METHOD: A critical interpretive synthesis was conducted; CINAHL, PsychINFO and MEDLINE were searched between 1988 and August 2019, using MeSH headings and key terms. Reference lists of accepted papers were also searched. Qualitative, quantitative and mixed methods studies, written in English, including healthcare professionals' perceptions of pulmonary rehabilitation were included. The search yielded 133 papers which were assessed for eligibility; 20 met the inclusion criteria. RESULTS: Two themes were identified, the first explored "Barriers to Pulmonary Rehabilitation" from a healthcare professional's perspective. This incorporated a lack of knowledge, a lack of resources, practical barriers, patient barriers, and healthcare professional's being unsure it is their role to refer. The second entitled "General Perceptions of Pulmonary Rehabilitation", highlighted ways in which the programme could be improved, the perceived positives and negatives, facilitators to referral, and perceptions of patients referred. CONCLUSIONS: This is the first systematic review to encompass the perceptions of healthcare professionals with ability to refer and those who deliver pulmonary rehabilitation. Referral was low, highlighting potential influencing factors such as a lack of programme knowledge, pulmonary rehabilitation beliefs, and communication skills. Given inclusion of studies from multiple geographical locations, the findings provide implications for any healthcare system that develops and delivers pulmonary rehabilitation. With respect of a lack of referrals to the programme, further research should highlight healthcare professionals' perceptions of the referral process, and the views of those in Secondary Care.Implications for rehabilitationChronic obstructive pulmonary disease:•Pulmonary rehabilitation is a proven cost-effective management strategy for patients with chronic obstructive pulmonary disease, which reduces associated hospital admissions and increases quality of life.•Due to a lack of knowledge and negative perceptions surrounding pulmonary rehabilitation, further training and education is required for healthcare professionals surrounding non-pharmacological management strategies.•Pulmonary rehabilitation programmes should consider ways to increase awareness of the service amongst those with chronic obstructive pulmonary disease.•Those delivering pulmonary rehabilitation should consider ways to support healthcare professionals referring to the programme.

Self-management programmes for adult patients with bronchiectasis: a systematic review and realist synthesis.

PURPOSE: Self-management for patients with bronchiectasis has been identified as an important component that could potentially empower patients to manage their condition and improve their quality of life. Evidence was reviewed to investigate what self-management programmes work, why and in what circumstances. METHODS: A systematic review and realist synthesis were conducted. A comprehensive database search was performed on seven databases for evidence published up to July 2021. Leading candidate self-management programmes identified from the systematic review became the focus of the realist synthesis. A realist logic of analysis was applied to produce explanatory context-mechanism-outcome configurations. These explanations were consolidated into programme theories drawing on health behaviour change theory. RESULTS: By synthesising the data from eight eligible articles, programme theories articulated how three different self-management programmes work that included: (i) education and action planning, (ii) education and airway clearance techniques (ACT) and, (iii) education, exercise and ACT. Patient characteristics and collaborative partnership between healthcare professionals and patients were identified as important contexts that influenced the improvement in self-efficacy, health-related quality of life, and exercise capacity. CONCLUSIONS: This review contributes to a better understanding of how the complex interaction between contexts and mechanisms can improve outcomes of clinical interest.IMPLICATIONS FOR REHABILITATIONThis evidence synthesis has identified potentially important combinations of interventions to be considered in self-management programmes for adults with bronchiectasis.Collaborative partnership between patient and healthcare professionals should be considered to improve short-term self-efficacy.Targeting self-management programmes to increase short-term health-related quality of life and exercise capacity should consider the context of patient characteristics.

Need and baseline for harmonising nursing education in respiratory care: preliminary results of a global survey.

Background: The COVID-19 pandemic confirmed that respiratory nurses are critical healthcare providers. Limited knowledge is available about appropriate education to prepare nurses to deliver high-quality respiratory care. A survey was developed by the International Coalition for Respiratory Nursing (ICRN) group to identify the need for a respiratory nursing core curriculum. Method: A 39-item survey was distributed to 33 respiratory nursing experts in 27 countries. Questions asked about current roles, perception of need, expectations for a core curriculum project and respiratory content in nursing education in their countries. Results: 30 responses from 25 countries were analysed; participants predominantly worked in academia (53.3%, 16/30) and clinical practice (40%, 12/30). In total, 97% (29/30) confirmed a need for a core respiratory nursing curriculum. Post-registration nursing programmes at bachelor (83.3%, 25/30) and masters (63.3%, 19/30) levels include internal/medical nursing care; less than half identified separate respiratory nursing content. The core educational programme developed should include knowledge (70%, 21/30), skills (60%, 18/30), and competencies (50%, 15/30), with separate paediatric and adult content. Conclusion: Survey results confirm a wide variation in nursing education and respiratory nursing education across the world, with many countries lacking any formal educational programmes to prepare nurses capable of providing enhanced quality respiratory care. These findings support the need for a core respiratory curriculum. To advance this significant work the ICRN group plans to conduct a Delphi study to identify core curriculum requirements for respiratory nursing education at pre-registration and advanced educational levels to flexibly meet each country's specific educational requirements for recognition of respiratory nursing speciality practice.