Comparison of COVID-19 survival in relation to CPAP length of treatment and by comorbidity and transmission setting (community or hospital acquired) in a medium-sized UK hospital in 2020: a retrospective study.

OBJECTIVE: To estimate continuous positive airway pressure (CPAP) length of treatment effect on survival of hospitalised COVID-19 patients in a medium-sized UK Hospital, and how this effect changes according to the patient's comorbidity and COVID-19 route of acquisition (community or nosocomial) during the two waves in 2020. SETTING: The acute inpatient unit in Wrightington, Wigan and Leigh Teaching Hospitals National Health Service (NHS) Foundation Trust (WWL), a medium-sized NHS Trust in north-west of England. DESIGN: Retrospective cohort of all confirmed COVID-19 patients admitted in WWL during 2020. PARTICIPANTS: 1830 patients (568 first wave, 1262 s wave) with antigen confirmed COVID-19 disease and severe acute respiratory syndrome admitted between 17 March 2020 (first confirmed COVID-19 case) and 31 December 2020. OUTCOME MEASURE: COVID-19 survival rate in all patients and survival rate in potentially hospital-acquired COVID-19 (PHA) patients were modelled using a predictor set which include comorbidities (eg, obesity, diabetes, chronic ischaemic heart disease (IHD), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD)), wave, age, sex and care home residency, and interventions (remdesivir, dexamethasone, CPAP, intensive care unit (ICU), intubation). Secondary outcome measure was CPAP length, which was modelled using the same predictors of the survival rate. RESULTS: Mortality rate in the second wave was significantly lower than in the first wave (43.4% vs 28.1%, p<0.001), although for PHA COVID-19 patients mortality did not reduce, remaining at very high levels independently of wave and CPAP length. For all cohort, statistical modelling identified CPAP length (HR 95% CI 0.86 to 0.96) and women (HR 95% CI 0.71 to 0.81) were associated with improved survival, while being older age (HR 95% CI 1.02 to 1.03) admitted from care homes (HR 95% CI 2.22 to 2.39), IHD (HR 95% CI 1.13 to 1.24), CKD (HR 95% CI 1.14 to 1.25), obesity (HR 95% CI 1.18 to 1.28) and COPD-emphysema (HR 95% CI 1.18 to 1.57) were associated with reduced survival. Despite the detrimental effect of comorbidities, patients with CKD (95% CI 16% to 30% improvement in survival), IHD (95% CI 1% to 10% improvement in survival) and asthma (95% CI 8% to 30% improvement in survival) benefitted most from CPAP length, while no significant survival difference was found for obese and patients with diabetes. CONCLUSIONS: The experience of an Acute Trust during the COVID-19 outbreak of 2020 is documented and indicates the importance of care home and hospitals in disease acquisition. Death rates fell between the first and second wave only for community-acquired COVID-19 patients. The fall was associated to CPAP length, especially for some comorbidities. While uncovering some risk and protective factors of mortality in COVID-19 studies, the study also unravels how little is known about PHA COVID-19 and the interaction between CPAP and some comorbidities.

Development of the Warwick Axial Spondyloarthritis faTigue and Energy questionnaire (WASTEd)-a new patient-reported outcome measure.

Objective: The aim was to co-produce and test a potential new patient-reported outcome measure (PROM), the Warwick Axial Spondyloarthritis faTigue and Energy questionnaire (WASTEd), providing vital qualitative confirmation of conceptual relevance, clarity and acceptability. Methods: Informed by measurement theory, we collaborated with patient partners throughout a three-stage, iterative process of PROM development. In stage 1, informed by patient interviews, reviews exploring patients' fatigue experiences and existing PROMs of fatigue, an initial measurement framework of axial spondyloarthritis (axSpA) fatigue and energy and candidate items were defined. In stage 2, the relevance and acceptability of the measurement framework and candidate items were assessed qualitatively by focus group participants. In stage 3, patients participated in pre-testing interviews to assess item comprehensiveness, relevance, acceptability and comprehensibility. Results: Stage 1 informed the development of an initial five-domain measurement framework with 59 candidate items. In stage 2, five patients and seven health-care professionals participated in four focus groups to derive a 40-item model of fatigue and energy. Collaborative engagement with patient research partners supported refinement of questionnaire structure and content further. Pre-testing with ten patients across two interview rounds in stage 3 produced a four-domain, 30-item long-form questionnaire. Conclusion: An active collaboration with patients and health-care professionals has supported the co-production of a potential new PROM of axSpA fatigue, underpinned by strong evidence of face and content validity. The WASTEd extends the assessment of fatigue beyond severity, highlighting the importance of symptom frequency, energy and self-management. Future research will involve psychometric evaluation, supporting item reduction, structural refinement and confirmation of PROM validity.

CPAP management of COVID-19 respiratory failure: a first quantitative analysis from an inpatient service evaluation.

OBJECTIVE: To evaluate the role of continuous positive air pressure (CPAP) in the management of respiratory failure associated with COVID-19 infection. Early clinical management with limited use of CPAP (3% of patients) was compared with a later clinical management strategy which had a higher proportion of CPAP use (15%). DESIGN: Retrospective case-controlled service evaluation for a single UK National Health Service (NHS) Trust during March-June 2020 designed and conducted solely to estimate the effects of current care. SETTING: The acute inpatient unit in Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, a medium-sized English NHS Trust. PARTICIPANTS: 206 patients with antigen confirmed COVID-19 disease and severe acute respiratory syndrome admitted between 17 March 2020 and 3 April 2020 for the early group (controls), and between 10 April 2020 and 11 May 2020 for the late group (cases). Follow-up for all cases was until 11 June by which time all patients had a final outcome of death or discharge. Both groups were composed of 103 patients. Cases and controls were matched by age and sex. OUTCOME MEASURE: The outcome measure was the proportion of patients surviving at time t (time from the positive result of COVID-19 test to discharge/death date). The predictors were CPAP intervention, intubation, residence in care homes and comorbidities (renal, pulmonary, cardiac, hypertension and diabetes). A stratified Cox proportional hazard for clustered data (via generalised estimating equations) and model selection algorithms were employed to identify the effect of CPAP on patients' survival and the effect on gas exchange as measured by alveolar arterial (A-a) gradient and timing of CPAP treatment on CPAP patients' survival. RESULTS: CPAP was found to be significantly (HR 0.38, 95% CI 0.36 to 0.40) associated with lower risk of death in patients with hospital stay equal to, or below 7 days. However, for longer hospitalisation CPAP was found to be associated with increased risk of death (HR 1.72, 95% CI 1.40 to 2.12). When CPAP was initiated within 4 days of hospital admission, the survival probability was above 73% (95% CI 53% to 99%). In addition, lower A-a gradient was associated with lower risk of death in CPAP patients (HR 1.011, 95% CI 1.010 to 1.013). The selected model (best fit) was stratified by sex and clustered by case/control groups. The predictors were age, intubation, hypertension and the residency from care homes, which were found to be statistically significantly associated with patient's death/discharge. CONCLUSIONS: CPAP is a simple and cost-effective intervention. It has been established for care of other respiratory disorders but not for COVID-19 respiratory failure. This evaluation establishes that CPAP as a potentially viable treatment option for this group of patients during the first days of hospital admission. As yet there is limited availability of quantitative research on CPAP use for COVID-19. Whist this work is hampered by both the relatively small sample size and retrospective design (which reduced the ability to control potential confounders), it represents evidence of the significant benefit of early CPAP intervention. This evaluation should stimulate further research questions and larger study designs on the potential benefit of CPAP for COVID-19 infections. Globally, this potentially beneficial low cost and low intensity therapy could have added significance economically for healthcare provision in less developed countries.

Awareness of axial spondyloarthritis among chiropractors and osteopaths: findings from a UK Web-based survey.

OBJECTIVE: Chiropractors and osteopaths are important professional partners in the management of axial spondyloarthritis (axSpA). In view of recent advances in diagnosis and treatment, we sought to understand their current knowledge and working practices. METHODS: A Web-based survey was advertised to chiropractors and osteopaths via the Royal College of Chiropractors and the Institute of Osteopathy. RESULTS: Of 382 completed responses [237 chiropractors (62%) and 145 osteopaths (38%)], all were familiar with AS, but only 63 and 25% were familiar with the terms axSpA and non-radiographic axSpA, respectively. Seventy-seven per cent were confident with inflammatory back pain. Respondents routinely asked about IBD (91%), psoriasis (81%), acute anterior uveitis (49%), peripheral arthritis (71%), genitourinary/gut infection (56%), enthesitis (30%) and dactylitis (20%). Eighty-seven per cent were aware of the association between axSpA and HLA-B27. Only 29% recognized that axSpA was common in women. Forty per cent recommend an X-ray (pelvic in 80%) and, if normal, 27% would recommend MRI of the sacroiliac joints and whole spine. Forty-four per cent were aware of biologic therapies. Forty-three per cent were confident with the process of onward referral to rheumatology via the general practitioner (GP). The principal perceived barrier to onward referral was reluctance by the GP to accept their professional opinion. CONCLUSION: Overall knowledge of ankylosing spondylitis is good, but the term axSpA is poorly understood. Specific learning needs include gender preponderance, awareness of acute anterior uveitis and the availability of biological therapies. There is lack of confidence in the onward referral process to rheumatology via the GP.

The impact of ankylosing spondylitis/axial spondyloarthritis on work productivity.

Ankylosing spondylitis (AS) is a chronic inflammatory condition that has a significant impact on the quality of life and work productivity. New classification criteria have enabled earlier diagnosis of this condition. However, work productivity is an important issue that is still often overlooked during clinical assessments and consultations. This article focusses on the relationship between axial spondyloarthritis (axial SpA) and work productivity. It summarises the impact of this condition on work productivity, and it highlights the tools available to assess this. It also highlights the increasing role and potential of employers, health professionals and new treatments for enhancing work productivity for people with this condition.

Normative values for the Bath Ankylosing Spondylitis Metrology Index in a UK population.

OBJECTIVE: Spinal mobility is assessed frequently in patients with AS/axial SpA using the BASMI to provide baseline measurement and monitor change over time. The interpretation of BASMI scores has been hindered by the absence of normative values. We aimed to obtain normative values for the BASMI in healthy men and women in a UK population. METHODS: A cross-sectional study of 168 volunteers stratified by gender and age was completed. Exclusion criteria comprised factors potentially influencing spinal mobility. Each component of the BASMI was assessed, with the total score computed using the 10-point scoring system. Measurements were taken by physiotherapists following an agreed protocol. Data were summarized and analysed with age-specific centiles and CIs calculated. RESULTS: Total BASMI scores ranged from 0 to 4.4, with only 1.2% of the sample having a score of 0. The estimated median score for an individual age 25 years was 0.9, increasing with age to 2.1 for an individual age 65 years. There was a corresponding increase in component BASMI scores, which was more pronounced for some components than others. CONCLUSION: Our data indicate that it is unusual for healthy individuals to score zero on the BASMI, which has implications for the interpretation of scores, especially at baseline. The generation of normative values has the potential to inform clinical assessment of spinal mobility and assist patients in understanding how their spinal mobility compares with that of a healthy age-matched population.

An exploration of the inter- and intra-rater reliability of the Bath Ankylosing Spondylitis Metrology Index.

The aim of this study was to explore the inter- and intra-observer reliability of the Bath Ankylosing Spondylitis Metrology Index (BASMI) across raters from different clinical centres using a consensus-based standardised approach to assessment. One hundred thirty BASMI assessments were completed on the same day using a partially balanced incomplete block design. Thirteen physiotherapists from 10 hospitals assessed 26 participants (19 patients, 7 healthy volunteers). Each therapist assessed six participants and, to assess intra-observer reliability, performed repeat assessments on four. Overall, the mean (standard deviation; SD) BASMI total score was 3.11 (2.04). The constituent components of SD were 0.37 ('residual' inconsistency, i.e. between observer), 0.34 (between replicates), at least 0.06 (between observer means) and 2.03 (between participants). This suggests that the repeatability of BASMI assessments is 0.95 if the same observer is used and 1.05 if different observers are used. Inter-physiotherapist residual SDs for individual constituent component scores were largest for the modified Schober measurement and lumbar side flexion; intra-observer SDs showed similar patterns, although they were smaller for tragus to wall and lumbar side flexion. We found excellent inter-observer and intra-observer reliability, with most of the variability in BASMI scores being between participants. However, for repeat assessments of the same participant by the same physiotherapist, differences in BASMI of 1.0 or less are within bounds of error; likewise, differences of 1.0 or less are within the bounds of error if different physiotherapists perform the assessments. Only changes above these limits can be confidently interpreted as true clinical changes.