The circular paradox of including people with severe brain injuries and reduced decisional capacity in research: A feasibility study exploring randomized research, consent-based recruitment biases, and the resultant health inequities.

BACKGROUND: People with severe brain injuries (PSBI) and reduced capacity to consent (CTC) frequently develop muscle contractures. Standard care includes prolonged stretch (PS) but there is limited condition-specific evidence from randomized controlled trials (RCTs). PURPOSE: Identify factors affecting the inclusion of PSBI and reduced CTC in a PS RCT and methodologies more capable of generating condition-specific outcomes. METHODS: Mixed-method feasibility studies, including a pilot RCT (PSBI, adults with reduced CTC) comparing PS treatments (serial casting and splinting) and focus groups/interviews with physiotherapists involved in PS treatment. Reflexive thematic analysis developed themes. RESULTS: Two PSBI were included in the pilot RCT with no significant safety concerns or adverse effects. Twelve physiotherapists participated in two focus groups and two interviews. Four themes were identified: 1) complexity of contracture management; 2) burden of decision making; 3) lack of evidence and uncertainty; and 4) challenges to RCT acceptability and feasibility. CONCLUSIONS: Reduced CTC contributes to the exclusion of PSBI from experimental research, and a circular paradox where poor research inclusion contributes to generalized healthcare and "evidence-biased medicine." Due to the complexity of their condition, simply including PSBI in randomized research is unlikely to create meaningful health outcomes. Improving their care requires a paradigm shift toward pluralistic methods of knowledge generation.

Non-pharmacological Management in Palliative Care for Patients With Advanced COPD.

Chronic obstructive pulmonary disease (COPD) is a disabling condition associated with progressive airflow limitation and lung tissue damage; its main symptoms are breathlessness, fatigue, cough, and sputum production. In the advanced stage of the disease, these symptoms may severely impact on a person's physical and psychological functioning, with some also developing chronic respiratory failure, associated with blood gas abnormalities. Non-pharmacological interventions can improve quality of life and functioning in the management of people living with advanced COPD. This article will provide an overview of common non-pharmacological methods used in the symptomatic management of severe COPD, including: breathlessness and fatigue management strategies, anxiety management, pulmonary rehabilitation (PR) and physical activity (PA), neuromuscular electrical stimulation (NMES), airway clearance techniques (ACTs), nutrition and non-invasive ventilation (NIV). The importance of a holistic and multi-disciplinary approach to people living with COPD will be discussed.

Prevalence, severity, and risk factors of disability among adults living with HIV accessing routine outpatient HIV care in London, United Kingdom (UK): A cross-sectional self-report study.

BACKGROUND: The study objectives were to measure disability prevalence and severity, and examine disability risk factors, among adults living with HIV in London, United Kingdom (UK). METHODS: Self-reported questionnaires were administered: World Health Organization Disability Assessment Schedule 2.0 (WHODAS), HIV Disability Questionnaire (HDQ), Equality Act disability definition (EADD), and demographic questionnaire. We calculated proportion (95% Confidence Interval; CI) of "severe" and "moderate" disability measured using EADD and WHODAS scores ≥2 respectively. We measured disability severity with HDQ domain severity scores. We used demographic questionnaire responses to assess risk factors of "severe" and "moderate" disability using logistic regression analysis, and HDQ severity domain scores using linear regression analysis. RESULTS: Of 201 participants, 176 (87.6%) identified as men, median age 47 years, and 194 (96.5%) virologically suppressed. Severe disability prevalence was 39.5% (n = 79/201), 95% CI [32.5%, 46.4%]. Moderate disability prevalence was 70.5% (n = 141/200), 95% CI [64.2%, 76.8%]. Uncertainty was the most severe HDQ disability domain. Late HIV diagnosis was a risk factor for severe disability [Odds Ratio (OR) 2.71; CI 1.25, 5.87]. Social determinants of health, economic inactivity [OR 2.79; CI 1.08, 7.21] and receiving benefits [OR 2.87; CI 1.05, 7.83], were risk factors for "severe" disability. Economic inactivity [OR 3.14; CI 1.00, 9.98] was a risk factor for "moderate" disability. Economic inactivity, receiving benefits, and having no fixed abode were risk factors (P≤0.05) for higher HDQ severity scores in physical, mental and emotional, difficulty with day-to-day activities, and challenges to social participation domains. Personal factors, identifying as a woman and being aged <50 years, were risk factors (P≤0.05) for higher HDQ severity scores in mental and emotional, uncertainty, and challenges with social participation domains. CONCLUSIONS: People living with well-controlled HIV in London UK experienced multi-dimensional and episodic disability. Results help to better understand the prevalence, severity, and risk factors of disability experienced by adults living with HIV, identify areas to target interventions, and optimise health and functioning.

Therapeutic applications of capsaicin in humans to target conditions of the respiratory system: A scoping review.

BACKGROUND: Various studies have explored potential therapeutic applications of capsaicin in human medicine, for example in pain, obesity, cancer, cardiovascular and respiratory disease. The aim of this scoping review was to identify and chart available evidence on therapeutic applications of capsaicin in humans using any mode of capsaicin delivery to treat conditions of the respiratory system. METHODS: Electronic bibliographic databases (Web of Science, PubMed, Medline, ScienceDirect, Embase, Scopus) were searched from inception to 2021 to identify experimental studies reporting clinical outcomes of therapeutic applications of capsaicin. Studies with or without control group published in peer-reviewed journals were included. Animal studies, studies of human cell lines, and physiological proof of concept studies were excluded. Reviewer pairs independently double-screened 2799 search results for inclusion. RESULTS: Twenty-three original studies were included. Capsaicin has been investigated for the treatment of non-allergic rhinitis (n = 15), nasal polyposis (n = 3), allergic rhinitis (n = 2), unexplained chronic cough (n = 2), and prevention of aspiration pneumonia (n = 1). Modes of delivery included intranasal application (nasal spray, soaked pads, solution), inhalation, ingestion, and aural ointment. Seventeen studies reported positive effects of capsaicin on clinical outcomes for rhinitis, nasal polyposis, chronic cough, and pneumonia. Sixteen studies reported on the safety of capsaicin, with no reports of significant adverse events and overall fair to good patient acceptability. CONCLUSION: While the evidence identified in this review has limited implications for clinical practice, studies support the general safety of capsaicin as administered in these studies and highlight emerging strands of research and clinical hypotheses which warrant further examination.

Agreement and reliability of repeated bedside respiratory muscle strength measurements in acute and subacute stroke.

BACKGROUND AND PURPOSE: Many stroke trials include maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), and sniff nasal inspiratory pressure (SNIP) outcome measurements. However, data on agreement and reliability of repeated MIP, MEP, and SNIP measurements in acute and subacute stroke patients are scarce. METHODS: This study employed a test-retest design. Eighteen patients (seven female) with mean (SD) age 59 (14.5) years were recruited from neurological wards. Median (range) time since first stroke was 50.5 (21-128) days. MIP, MEP, and SNIP were measured repeatedly in three testing sessions (S1-3) conducted within 24 h and following international standards. Intra-rater agreement between testing sessions was analyzed using the Bland-Altman method. Test-retest reliability was analyzed using intra-class correlation coefficient (ICC). Association between individual measurement variability, time poststroke, and level of stroke impairment was analyzed using Spearman's rho. RESULTS: Mean difference and 95% limits of agreement for MIP were -0.40 (-23.02, 22.22) cmH2 O between S1 and S2, and 2.14 (-12.79, 16.99) cmH2 O between S2 and S3; for MEP, -4.56 (-29.01, 19.90) cmH2 O between S1 and S2, and 0.29 (-24.28, 24.87) cmH2 O between S2 and S3; and for SNIP, -10.56 (-38.48, 17.37) cmH2 O between S1 and S2, and -6.06 (-27.32, 15.20) cmH2 O between S2 and S3. ICCs for MIP, MEP, and SNIP were ≥0.9 throughout. There were no strong correlations between individual measurement variability and time poststroke or level of stroke impairment. DISCUSSION: MIP, MEP, and SNIP in acute and subacute stroke patients show good test-retest reliability for group averages; however, absolute agreement can vary considerably for some individuals.

Introduction of the harmonised respiratory physiotherapy curriculum.

Building on the core syllabus for postgraduate training in respiratory physiotherapy, published in 2014, the European Respiratory Society (ERS) respiratory physiotherapy task force has developed a harmonised and structured postgraduate curriculum for respiratory physiotherapy training. The curriculum outlines the knowledge, skills and attitudes which must be mastered by a respiratory physiotherapist working with adult or paediatric patients, together with guidance for minimal clinical exposures, and forms of learning and assessment. This article presents the rationale, methodology and content of the ERS respiratory physiotherapy curriculum. The full curriculum can be found in the supplementary material.

Evaluation of multidimensional COPD-related subjective fatigue following a pulmonary rehabilitation programme.

INTRODUCTION: Subjective fatigue has been recognised as an important, multi-component symptom in COPD. Pulmonary Rehabilitation (PR) improves fatigue component of the Chronic Respiratory Questionnaire, a quality of life (QoL) measure. However, it is not clear if all fatigue dimensions are affected equally. This study aims to evaluate changes in subjective multidimensional fatigue among people with COPD who participated in PR. METHODS: Thirty seven stable COPD patients were recruited; 23 patients (15 male) mean age 68.5 (range 49-86) yrs, mean (SD) %predicted FEV1 45.3 (19.8); completed 7 weeks of PR. Assessments (pre and post PR) consisted of the Multidimensional Fatigue Inventory (MFI-20), QoL (SGRQ), Anxiety and Depression (HADS), the London Chest Activity of Daily Living Scale (LCADL), muscle strength, incremental (ISWT) and endurance (ESWT) shuttle walk tests. The differences between pre and post PR fatigue were tested using Wilcoxon's test and relationships with other outcomes were examined using Spearman's correlation. RESULTS: There were statistically significant improvements in Reduced Activity (RA) (p = 0.01), General (GF) (p < 0.01) and Physical Fatigue (PF) (p = 0.03) components of MFI-20 after PR, but there were no differences in Motivation or Mental Fatigue (p > 0.05). There were significant improvements in ISWT (p < 0.05), ESWT (p < 0.01) and muscle strength (p = 0.03). Statistically significant correlations (p < 0.05) were found between changes in GF and in both ISWT (r = -0.43) and SGRQ impact (r = 0.46); and between RA and ESWT changes (r = -0.45). CONCLUSIONS: Some dimensions of fatigue in COPD are modifiable by a 7-week PR programme. Change in fatigue dimensions in COPD may be associated with a change in maximal or endurance walking distances or QoL.

Evaluation of psychological and physiological predictors of fatigue in patients with COPD.

BACKGROUND: Fatigue in COPD impairs functional status; however there are few studies examining mechanistic pathways of this symptom. The aims of this study are to compare fatigue between COPD patients and healthy age-matched subjects, and to identify predictors of fatigue in COPD. METHODS: Seventy four COPD patients, mean age 69.9 (49-87) yrs, mean (SD) % predicted FEV1 46.5 (20.0) % and FEV1/FVC ratio 0.45 (0.13) and 35 healthy subjects, mean age 67.1 (50-84) yrs completed the Multidimensional Fatigue Inventory (MFI 20). Patients' assessment included Depression (HADS), lung function, BMI, muscle strength, incremental shuttle walk test (ISWT), exercise oxygen saturation (SpO2), Borg breathlessness (CR-10) and exertion (RPE). Serum level of Interleukin 6 (IL-6) was recorded. Differences in MFI 20 between groups were examined and predictors of fatigue identified using logistic regression. RESULTS: Significant differences (p < 0.01) were found between the COPD and healthy subjects for all MFI 20 dimensions. There were significant differences when classified according to GOLD and dyspnoea stages for selected dimensions only. Predictors of General Fatigue were depression, muscle strength and end SpO2 (R2 = .62); of Physical Fatigue: depression, % predicted FEV1, ISWT and age (R2 = .57); Reduced Activity: % predicted FEV1, BMI and depression (R2 = .36); Reduced Motivation: RPE, depression and end SpO2 (R2 = .37) and Mental Fatigue: depression and end SpO2 (R2 = .38). CONCLUSION: All dimensions of fatigue were higher in COPD than healthy aged subjects. Predictive factors differ according to the dimension of fatigue under investigation. COPD-RF is a multi component symptom requiring further consideration.