Trans-Atlantic aeromedical repatriation of multiple COVID-19 patients: a hybrid military-civilian model.

Here, we report the first known transcontinental aeromedical evacuation of a large number (55) of patients with known and suspected positive COVID-19. These patients were evacuated from Havana, Cuba, to the UK through MOD Boscombe Down as part of Operation BROADSHARE, the British military's overseas response to COVID-19. We describe the safe transfer of patients with COVID-19 using a combined military-civilian model. In our view, we have demonstrated that patients with COVID-19 can be aeromedically transferred while ensuring the safety of patients and crew using a hybrid military-civilian model; this report contains lessons for future aeromedical evacuation of patients with COVID-19.

Delivering supervised group exercise to patients with cancer via telehealth: An implementation study using the RE-AIM framework

Aims: Assess the implementation of a telehealth supervised group exercise (tele-exercise) program for patients with cancer, using the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance). Method(s): Cancer patients with medical clearance and access to home internet participated in a physiotherapy-led tele-exercise program, comprising twice-weekly sessions for 12 weeks and featuring aerobic, resistance and balance exercises. A Garmin activity tracker was worn during sessions. Subjective (fatigue, quality of life) and objective (muscle strength, cardiorespiratory fitness, balance) measures were taken pre and post-program. Qualitative interviews (analysed using thematic and content analyses) and an online survey were completed post-program. Result(s): Reach: Twenty-six eligible participants consented and were enrolled. Twenty-four commenced the program, most of whom were female (92%), diagnosed with breast cancer (75%), treated with surgery (96%), chemotherapy (88%) or radiation therapy (54%). Effectiveness: FACIT-F scores indicated reduced fatigue (mean difference 5.8 [95% CI 1.9-9.8], p < 0.01). Improvements were seen across several strength, fitness and balance outcomes (e.g. upper body strength +5.6 [2.6-8.6] kg, p < 0.01). There were no changes to quality of life (FACT-G). Adoption: Participants found classes easy to integrate into daily routines and felt it helped avoid negative aspects of in-person exercise (e.g. COVID-19 exposure, parking). Recruitment improved after introducing a 6:30 am class. Most (78%) participants felt very confident using the technology. Viewing heart rate via the Garmin device contributed to feeling safe whilst exercising. Implementation: 21 of 24 participants completed the program. Mean number of sessions attended was 22. Maintenance: Participants suggested feasible improvements to program orientation, discharge, and the exercise classes. All felt comfortable using the internet for tele-exercise. The majority considered a telehealth class as equal to an in-person class (15 of 18, 83%). Conclusion(s): A telehealth group exercise program for people with cancer was successfully implemented. Further information is needed regarding non-breast cancer patients and non-tertiary hospital settings.

Are we sitting too comfortably? What evidence do we have regarding sedentary behaviour among GPs?

Background: Excessive sedentary behaviour is associated with several adverse health outcomes and increased all-cause mortality. GPs who are more physically active are more likely to recommend physical activity to their patients. Research question: What is the current evidence regarding levels of sedentary behaviour among GPs? Methods: A systematic review was conducted to establish the evidence regarding current levels of sedentary behaviour among GPs. Subsequently, a multi-item questionnaire survey (modified version of the International Sedentary Assessment Tool (ISAT)) was disseminated to GPs in Northern Ireland. A purposive, maximally varied sample of 20 survey participants was then recruited to wear thigh-worn accelerometers and complete a sleep/work log to obtain objective data regarding their sedentary behaviour. This allowed the comparison of subjective, self-reported data with objective, accelerometer data. Results: Systematic Review: Search criteria returned 1707 studies. 34 full texts were reviewed and two studies were included in the final review. Both were cross-sectional surveys of satisfactory methodological quality and a high risk of bias. Sedentary Behaviour Study: Out of 1999 GPs in Northern Ireland, the questionnaire received 352 valid responses (response rate of 18%). Overall mean workday sedentary time for GPs was 10 h 20 min. Overall mean non-workday sedentary time was 4 h 47 min. Only 6% of GPs had access to an active workstation, such as a standing desk, however, 61% of those who didn't have an active workstation would consider using one. 81% of GPs reported spending more time sitting at work now than before the COVID- 19 pandemic. 87% of GPs would prefer less time sitting at work. Conclusion: Sedentary behaviour among GPs has increased since the onset of the COVID-19 pandemic, with the vast majority of GPs exceeding the recommended daily levels of sedentary behaviour. Further research is required to identify ways of reducing sedentary behaviour and increasing physical activity among GPs.

Support for general practitoners during covid-19

Background: Evidence of initiatives to support General Practitioners (GPs) during the Covid-19 pandemic is scant. Aim: To understand the impact of a novel method of providing support in the early stages of the pandemic. Design and setting: A mixed-methods study of GPs working in a socially deprived area of Belfast. Method: A survey was distributed to GPs who had attended a series of educational meetings at the beginning of the COVID-19 pandemic. The survey incorporated the Warwick Edinburgh Mental Wellbeing Scale and questions about the virtual meetings. Follow-up interviews were undertaken with five GPs to further explore their lived experiences and their perceptions of the virtual support forum. Results: The Covid-19 pandemic resulted in a measurable diminution of emotional well-being in GPs in North and West Belfast. Attendees rated a series of virtual meetings highly and described the following themes (and subthemes): a sudden traumatic change (emotional response, fight or flight, painful reminders of the status of general practice in the NHS);a coming together (stepping up to take responsibility, sharing of information, feeling of affirmation);reflections on what worked (calming facilitation, careful selection of speakers, creating the right atmosphere, ownership and autonomy) and building future direction (defining future direction, capitalising on lesson learned). Conclusion: The virtual meetings harnessed the instinct to come together witnessed at the beginning of the pandemic, and as well as sharing valuable information, also provided emotional support along with a sense of comradeship, ownership and autonomy.

Mortality in patients requiring home mechanical ventilation during the COVID-19 pandemic: experiences of a regional specialist ventilation unit

P101 Figure 1(A) Monthly mortality of patients under Lane Fox Respiratory Service follow-up, dotted lines represent upper and lower bounds of 95% confidence intervals (B) Proportion of home mechanical ventilation (HMV) users in each disease category who died between 1st March and 30th ApriI by year[Figure omitted. See PDF]ConclusionsDeaths amongst HMV users at our regional ventilation centre were highest in the first two months following the onset of the COVID-19 pandemic. A subsequent fall in mortality may relate to effective shielding advice following national lockdown and departmental guidance offered. The majority of deaths were in patients with obesity-related respiratory failure. These data support previous observations that obesity is a major risk factor for adverse outcomes in patients with COVID-19.

The efficacy, challenges, and facilitators of telemedicine in post-treatment cancer survivorship care: an overview of systematic reviews.

BACKGROUND: Telemedicine services have been increasingly used to facilitate post-treatment cancer survivorship care, including improving access; monitoring health status, health behaviors, and symptom management; enhancing information exchange; and mitigating the costs of care delivery, especially since the COVID-19 pandemic. To inform guidance for the use of telemedicine in the post-COVID era, the aim of this overview of systematic reviews (SRs) was to evaluate the efficacy of, and survivor engagement in, telemedicine interventions in the post-treatment survivorship phase, and to consider implementation barriers and facilitators. METHODS: PubMed, Cochrane CENTRAL, CINAHL, Embase, and Web of Science databases were searched. SRs that examined the use of telemedicine in the post-treatment phase of cancer survivorship, published between January 2010 and April 2021, were included. Efficacy data were synthesized narratively. Implementation barriers and facilitators were synthesized using the Consolidated Framework for Implementation Research. RESULTS: Twenty-nine SRs were included. A substantive body of evidence found telemedicine to benefit the management of psychosocial and physical effects, particularly for improving fatigue and cognitive function. There was a lack of evidence on the use of telemedicine in the prevention and surveillance for recurrences and new cancers as well as management of chronic medical conditions. This overview highlights a range of diverse barriers and facilitators at the patient, health service, and system levels. CONCLUSIONS: This review highlights the benefits of telemedicine in addressing psychosocial and physical effects, but not in other areas of post-treatment cancer survivorship care. This large review provides practical guidance for use of telemedicine in post-treatment survivorship care.

Parasternal electromyography as a measure of respiratory muscle function in patients Recovering from severe covid-19 pneumonia

Introduction Conventional lung function testing involves forced expiratory manoeuvres which risk aerosolisation of respiratory droplets and nosocomial transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2/COVID-19). Between-patient decontamination procedures render routine testing impractical. Parasternal electromyography (EMGpara) is an effort-independent method of assessing inspiratory muscle activity that tracks clinical trajectory in COPD, cystic fibrosis and pulmonary fibrosis. We evaluated EMGpara as a method of monitoring respiratory muscle function during recovery from COVID-19 pneumonia in Post-COVID clinic. Methods Prospective single-centre observational cohort study (05/Q0703/82). All patients hospitalised with severe COVID-19 pneumonia (oxygen requirement-40% or critical care admission) were invited to clinic 6-8 weeks post-discharge. EMGpara was recorded in consecutive patients attending 12 clinic sessions using transcutaneous second intercostal space electromyography. Measurements were made over 2 minutes of tidal breathing followed by maximal inspiratory manoeuvres (inspiration to total lung capacity and maximal sniff manoeuvres) and the values for root mean square (RMS) EMGpara per breath, EMGpara%max (RMS EMGpara as a proportion of volitional maximum), Neural Respiratory Drive Index (NRDI) and sex-specific standardised residuals (z-scores) recorded. After each measurement, equipment was decontaminated using alcohol-based wipes and surface electrodes were disposed of. Symptom questionnaires and radiographic assessment of lung oedema (RALE) scores were recorded. Results Between 4th June and 2nd July 2020, EMGpara was measured in 25 patients. All approached patients consented to participate, no adverse events occurred. Mean±SD age 57.1 ±15.6 years, 64% male, BMI 29.4±5.6 kg/m2, 29% current/ex-smokers. mMRC was at pre-COVID baseline in 56%, 32% reported persistent burdensome breathlessness. Respiratory rate 15±3 breaths/minute, oxygen saturation 98±2.0%, heart rate 87±12 bpm. EMGpara measures are presented in table 1. Zscores of all EMGpara indices were raised. NRDI was associated with admission, worst inpatient and follow-up RALE scores (R=0.41 (p=0.04), R=0.40 (p=0.046) and R=0.49 (p=0.01), respectively), not mMRC (R=0.24, p=0.24 Conclusions Inspiratory muscle activation was high, which may reflect underlying interstitial pathology, critical illness myopathy, deconditioning or anxiety relating to clinic attendance. Parasternal electromyography is a well-tolerated technique that avoids aerosolisation of respiratory droplets and utilises equipment that is easily decontaminated between patients. This makes it a practical and informative measure of lung function during the COVID-19 pandemic.

P240 Parasternal electromyography as a measure of respiratory muscle function in patients recovering from severe COVID-19 pneumonia

P240 Table 1Measures of parasternal electromyography Measured value Z-score EMGpara (µV) 5.80 (3.91–12.26) 1.27 (0.73–2.10) EMGpara%max (%) 15.45 (11.41–23.27) 2.93 (1.91–4.34) NRDI (%.bpm) 224 (164–306) 2.68 (1.79–3.90) Data are presented as median (interquartile range). Abbreviations: z-score = standardised residual, EMGpara = mean root mean square parasternal electromyography per breath, µV = microvolts, EMGpara%max = EMGpara as a proportion of volitional maximum, NRDI = Neural Respiratory Drive Index.ConclusionsInspiratory muscle activation was high, which may reflect underlying interstitial pathology, critical illness myopathy, deconditioning or anxiety relating to clinic attendance. Parasternal electromyography is a well-tolerated technique that avoids aerosolisation of respiratory droplets and utilises equipment that is easily decontaminated between patients. This makes it a practical and informative measure of lung function during the COVID-19 pandemic.