BACKGROUND:Preexisting multiple (two or more) long-term conditions (MLTCs) may negatively affect recovery after COVID-19. We investigated how preexisting MLTCs, including different categorization and patterns of MLTCs, affect 1-year health outcomes after severe COVID-19. METHODS:Adults post-hospitalization after COVID-19 were recruited during 2020-2021. We compared recovery at 1 year after discharge using adjusted multivariable logistic regression in 1:1 propensity-matched adults (for age, sex, ethnicity, social deprivation, obesity, and smoking history) with and without preexisting MLTCs. In adults with MLTCs, different categorization such as number of conditions, number and types of body systems involved (e.g. respiratory, cardiovascular), and latent class analysis-derived patterns of condition co-occurrence were assessed for their association with recovery at 1 year. RESULTS:A total of 647 adults with MLTCs were matched with 647 adults without MLTCs (n = 1294; 61.9% male, 79.6% of White ethnicity, median age 59 [interquartile range 52-67] years). The presence of MLTCs was associated with lower odds of feeling fully recovered (odds ratio 0.66 [95% confidence interval 0.51-0.85], P = 0.001). In those with MLTCs, recovery was negatively affected by number and type of body systems involved (e.g. respiratory [odds ratio 0.49 (95% confidence interval 0.34-0.69), P <0.001]) but not by the number of conditions (P >0.1). Four latent classes of MLTC co-occurrence were estimated with different risks of recovery (P <0.01). CONCLUSION:Adults with preexisting MLTCs were 34% less likely to feel fully recovered at 1 year after COVID-19 hospitalization than adults without MLTCs. We describe prognostic classifications of MLTCs, with future work needed to understand whether they have prognostication in broader post-acute infection sequalae.

A scoping review was conducted using the Arksey and O'Malley framework to develop a comprehensive overview of how the experience of breathing pattern disorder (BPD) has been conceptualized and reported in the literature. The Applied Social Sciences Index and Abstracts (ASSIA), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Medline and PsycINFO electronic databases were searched from the earliest available reports until 13th May 2025. The reference lists of included reports were also screened for appropriate literature. Only reports relating to adults and published in English were included. Sixty-two reports were included in the final review. The following eight themes emerged; 1: Symptoms were diverse and frequently mimicked serious pathology. 2: Symptom triggers were often stress related. 3: Precipitating life experiences for BPD included physical or psychological trauma, chronic anxiety or stress. 4: The diagnostic pathway was often prolonged and complex. 5: Patient reaction to diagnosis varied from welcoming, sceptical or rejection. 6: Healthcare use was frequent due to symptoms mimicking serious pathology and a prolonged diagnostic pathway. 7: BPD was associated with panic, anxiety, fear, phobias and depression. 8: BPD was also associated with reduced quality of life and poorer asthma control. Evidence for the experience of BPD is poorly represented in the literature, mainly viewed from a Western perspective and found in simple case reports over 25 years old and snippets within empirical studies. Literature searching was confounded by the change in terminology over time, and the lack of agreed definition and diagnostic methods for BPD. Further research is required employing more diverse and rigorous study designs to clarify the definition and diagnostic methods for the condition, as well as explore experience of BPD, including experience from outside Europe and North America.

Identifying people with chronic obstructive pulmonary disease (COPD) who are at high risk of significant health events such as exacerbations and hospital admissions is clinically important to guide optimisation of preventative interventions. We evaluated the utility of the Global Initiative for Obstructive Lung Disease (GOLD) 2026 ABE assessment tool which stratifies based on exacerbations or symptoms to distinguish these patients at high risk. Methods 664 participants from the ERICA ( E valuation of the R ole of I nflammation in C hronic A irways Disease) COPD cohort were classified into GOLD ABE groups using both the Chronic Airways Assessment Tool (CAAT) score and the modified Medical Research Council (mMRC) breathlessness scale to define the degree of symptoms. National Health Service hospital episode statistics data were prospectively collected for a median follow-up of 4.75 years. Hospital admissions, including for acute exacerbations of COPD (H-AECOPD (hospitalised acute exacerbations of COPD)), were evaluated. Logistic regression analyses with ORs adjusted for potential confounding factors were performed. Results Using CAAT, n=43/182/439 (7%/27%/66%) of participants were in groups A, B and E, respectively. By mMRC, n=144/81/439 (22%/12%/66%) were in groups A, B and E. The ABE tool derived using both CAAT and mMRC predicted H-AECOPD over follow-up. For group B versus group A by CAAT, the OR was 3.72 (95% CI 1.09 to 12.73, p=0.04), and for group E versus group A the OR was 8.13 (95% CI 2.45 to 26.92, p<0.001). By mMRC, for group B versus group A the OR was 2.69 (95% CI 1.36 to 5.32, p=0.005) and for group E versus group A the OR was 4.05 (95% CI 2.38 to 6.05, p<0.001). Conclusions In this prospective real-world UK cohort, the simple GOLD 2026 ABE tool identified patients with high-risk COPD for severe exacerbations (H-AECOPD). The differences in groups A and B classification depending on whether the CAAT score or mMRC scale is used have clinical implications that need consideration.

Background:Despite strong evidence of benefit, in the UK only 40% of eligible patients are referred to Pulmonary Rehabilitation (PR) and there are poor levels of uptake and completion globally. Understanding how current interventions address reported barriers to PR referral and engagement can help understand intervention effectiveness and highlight opportunities for future policy and intervention. Methods:Two systematic reviews were conducted: 1) Review of studies reporting barriers/enablers to PR delivery and engagement behaviours, with extracted barriers/enablers inductively synthesized into themes and coded to the domains of the Theoretical Domains Framework (TDF). 2) Review of existing interventions to improve PR uptake/engagement, specifying component Behaviour Change Techniques (BCTs) using established taxonomies. Interventions were categorised for promise according to evidence of change in behaviour for one or more outcomes. Findings from both reviews were triangulated using the Theories and Techniques tool (TaTT), to assess the extent to which components in current interventions targeted key barriers/enablers. Results:Sixty-three studies were included in the analysis. Barriers and enablers to PR mainly fell under the TDF domains Environment, context and resources; Knowledge; Social Influences; Professional role and identity; and Memory, attention and decision making. There are opportunities to further support referral by considering interventions targeted at memory and decision making and by streamlining referral processes. For patient engagement with PR, the highly represented TDF domains were Environment, context and resources; Social influences; Emotions; Knowledge; and Beliefs about capabilities. Fifty-four percent of referral interventions and 15% of engagement interventions were considered very promising. BCTs in promising interventions targeting patient engagement included provision of social support and guidance on planning and goal setting. Opportunities for improving engagement include consideration of the emotional burden associated with COPD and attending PR. Conclusion:These findings can inform development of new, or refinement of existing, interventions targeting PR for people with COPD.

Background Researcher identity and positionality shape how studies of health inequalities are conceptualised, conducted, and interpreted, particularly within culturally diverse teams. Yet there is no consolidated map of how team-level identities influence research processes and outputs in High-Income Countries (HIC) settings. The purpose of this scoping review is to map out key definitions, theories, and methods used to examine team-level researcher identity/positionality in HIC health inequalities research, and to synthesise reported impacts on research processes, collaboration, and outputs. Methods This scoping review will be conducted following Arksey and O’Malley’s framework, with refinements by Levac and the Joanna Briggs Institute (JBI). It will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). The databases to be searched are MEDLINE (PubMed), Web of Science, and Scopus, using a JBI three-step strategy, supplemented by hand searching and citation tracking. Eligibility criteria are structured using the Participant Concept Context (PCC) framework. These will include studies involving culturally or demographically diverse research teams that explicitly address the researcher’s identity/positionality/reflexivity at the team level, as well as how these dynamics shape research processes and relationships between researchers and communities conducting health inequalities research in HIC. English-language, peer-reviewed empirical and conceptual/theoretical papers published from 2010 onwards will be included; grey literature and non-health contexts will be excluded. Two reviewers will independently screen titles, abstracts and full texts in Covidence, resolving disagreements through consensus procedures. Results will be presented in a PRISMA-ScR flow diagram and synthesised narratively, supported by tabulated summaries. Discussion This review will synthesise and provide important insights into how team-level researcher identity and positionality are defined and enacted within HIC health inequalities research, and where across the research cycle, these dynamics most influence study decisions, collaboration, and outputs. Review Registration Open Science Framework (OSF) ( https://doi.org/10.17605/OSF.IO/29KPT ).

There are difficulties with the standardisation of interpretative strategies for peak oxygen uptake (peak V ̇ O 2 ${\dot V_{{{\mathrm{O}}_2}}}$ ) related to the quality of reference equations. We aimed to investigate the utility of peak V ̇ O 2 Q ${\dot V_{{{\mathrm{O}}_2}{\mathrm{Q}}}}$ , a novel method reflecting how far a measured value is from the 1st percentile. We retrospectively analysed data from patients referred for a cardiopulmonary exercise test (CPET) at Cambridge University Hospital (CUH) and Royal Papworth Hospital (RPH). Data were included from those 18 years or older. We investigated the stability of the 1st percentile overall, then stratified by sex and age group. We calculated the peak V ̇ O 2 Q ${\dot V_{{{\mathrm{O}}_2}{\mathrm{Q}}}}$ (measured peak V ̇ O 2 ${\dot V_{{{\mathrm{O}}_2}}}$ /1st percentile) and investigated its association with all-cause mortality using Cox regression analysis. Data from 1377 patients were included in the analyses: 590 from CUH (mean age 55.5 (15.4) years, 47% female) and 787 from RPH (mean age 46.1 (15.3) years, 48% female). The 1st percentile value for peak V ̇ O 2 ${\dot V_{{{\mathrm{O}}_2}}}$ was 9.5 mL kg-1 min-1 (95% CI: 8.8-9.9) and was consistent across sex and age groups. The mean peak V ̇ O 2 Q ${\dot V_{{{\mathrm{O}}_2}{\mathrm{Q}}}}$ was 2.3 (0.8); it declined with age and was lowest in patients referred for heart transplant. Data on all-cause mortality were available for all patients from CUH. Median follow-up time was 3.8 (2.2-9.6) years, during which time 96 of 590 (16%) patients died. A 1-unit increase in peak V ̇ O 2 Q ${\dot V_{{{\mathrm{O}}_2}{\mathrm{Q}}}}$ was associated with a 60% reduction in risk of all-cause mortality. We propose the peak V ̇ O 2 Q ${\dot V_{{{\mathrm{O}}_2}{\mathrm{Q}}}}$ as an alternative means to interpret cardiorespiratory fitness estimates that does not require reference equations.

Specialised pro-resolving mediators (SPMs) are endogenously produced lipid mediators that regulate the propagation of inflammation and promote tissue repair. We hypothesised that SPM production is dysregulated in COPD; and associated with disease severity, defined by patients with stable COPD (no exacerbations)versuspatients with frequent exacerbations.MethodsLipid mediators were measured in plasma samples from patients with COPD (stable and frequent exacerbators) and age, sex, BMI-matched healthy controls using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Lipid mediator (LM) profiles were compared between controls and stable COPD patients, and stable COPD patients compared with frequent exacerbators. Exploratory association with ever occurrence of severe exacerbation over 4.1 years of follow up was examined. Data are presented as mean±semin pg·mL−1for LMs, or mean±sd.ResultsForty-nine stable COPD patients had increased levels of pro-inflammatory mediators and some SPMs compared with 28 controls (prostaglandin (PG)D2: 13.97±2.44versus0.53±0.13, p<0.001, lipoxins: 226.83±23.84versus59.84±20.25, p<0.01, respectively). Fifty-two frequent exacerbators had lower PGD2(3.07±0.97versus13.97±2.44, p<0.01) and SPMs (D-resolvins: 8.73±1.25versus34.53±8.95, p<0.01, lipoxins: 53.93±9.23versus226.83±23.84, p<0.01, respectively) compared with stable COPD patients, despite a higher neutrophil count (5.28±2.16versus4.28±1.60×109/L, p=0.004).In exacerbators, D-resolvins levels were independently, inversely associated with occurrence of severe exacerbation (OR:0.88 (95%CI: 0.79,0.97), p=0.03, over follow-up.ConclusionThese findings demonstrate distinct LM profiles of stable COPD and frequent exacerbator patients. In exacerbators, D-resolvins were downregulated compared with stable COPD patients and associated with future risk of severe exacerbations over follow up. Further work is needed to understand these findings.

Introduction Specialised pro-resolving mediators (SPMs) are endogenously produced lipid mediators (LMs) that regulate the propagation of inflammation and promote tissue repair. We hypothesised that SPM production is dysregulated in COPD and is associated with disease severity, defined by patients with stable COPD (no exacerbations) versus patients with frequent exacerbations. Methods LMs were measured in plasma samples from patients with COPD (stable patients and patients with frequent exacerbations) and from healthy controls, matched for age, sex and body mass index, using liquid chromatography-tandem mass spectrometry (LC-MS/MS). The LM profiles of controls were compared with those of stable COPD patients, and the LM profiles of stable COPD patients were compared with those of COPD patients with frequent exacerbations. We explored whether or not there was an association between LM profile and ever having a severe COPD exacerbation over 4.1 years of follow-up. Data are presented as mean +/- sem in pgmL(-1) for LMs, or mean +/- sd. Results 49 stable COPD patients had increased levels of pro-inflammatory mediators and some SPMs, compared with 28 controls (prostaglandin (PG)D-2: 13.97 +/- 2.44 versus 0.53 +/- 0.13; p<0.001; lipoxins: 226.83 +/- 23.84 versus 59.84 +/- 20.25; p<0.01, respectively). 52 patients with frequent exacerbations had lower levels of PGD(2) (3.07 +/- 0.97 versus 13.97 +/- 2.44; p<0.01) and SPMs (D-resolvins: 8.73 +/- 1.25 versus 34.53 +/- 8.95; p<0.01; lipoxins: 53.93 +/- 9.23 versus 226.83 +/- 23.84; p<0.01) than stable COPD patients, despite having a higher neutrophil count (5.28 +/- 2.16x10(9) L-1 versus 4.28 +/- 1.60x10(9) L-1; p=0.004). Among patients with frequent exacerbations, D-resolvin levels were independently inversely associated with occurrence of severe exacerbation (OR 0.88, 95% confidence interval (CI) 0.79-0.97; p=0.03) during follow-up. Conclusion These findings demonstrate distinct LM profiles of stable COPD patients and patients with frequent exacerbations. In those with exacerbations, D-resolvins were downregulated, compared with stable COPD patients, and associated with future risk of severe exacerbations during follow-up. Further work is needed to understand these findings.

Background: Recognising the importance of patient-reported outcomes in assessing COPD severity, the GOLD ABE assessment tool highlights the clinical priority of exacerbations and in those with infrequent exacerbations, symptoms. It has the potential to identify high-risk individuals with COPD which may be important for disease progression and to guide treatments. However, the GOLD ABE tool has not been validated in clinical research studies. Aim: To evaluate the utility of GOLD ABE assessment to predict severe exacerbations in a UK COPD cohort. Firstly, to evaluate across A-B-E within the cohort and then compare the tool to other established COPD severity indices (GOLD grade and BODE quartiles). Methods:664 participants from the ERICA (Evaluation of the Role of Inflammation in Chronic Airways Disease) COPD cohort with complete data to enable classification based on GOLD ABE, GOLD grade (2-4) and BODE quartiles were selected. The COPD Assessment Test (CAT) score was used to assess symptoms for A-B and repeat analysis with mMRC was also undertaken. NHS hospital episode statistics (HES) data were prospectively collected for a median 4.75 years of follow-up and hospital admissions for acute exacerbations of COPD (severe exacerbations, H-AECOPD) were extracted from hospital episode primary position ICD-10 codes. Cox proportional hazards regression, logistic regression and ROC analyses were undertaken. Models were performed unadjusted and then adjusted for age and sex (and FEV1 for ABE). Data are presented as median (IQR), average±SD, n (%). Results: Out of 664 participants, GOLD ABE stratification was as follows: A=60 participants (9%), B=277 (42%), E=327 (49%), 324 (49%) were on triple inhaled therapy. A total of 225 participants (34%) in the cohort had H-AECOPD over follow up with median time to first H-AECOPD being 525 (205-1071) days. 46% of group E, 25% in group B and 10% in group A had a H-AECOPD over follow-up. Group B had a higher risk of H-AECOPD and time to first H-AECOPD compared with group A (p<0.01 for both), despite both groups being infrequent exacerbators at baseline. Table 1 shows further data for ABE, GOLD grade and BODE quartiles. Conclusion: ABE was not more strongly associated with H-AECOPD than other COPD severity indices. Its utility from these data, however, seems to be across the A-B-E comparison to identify individuals at higher risk for future H-AECOPD. Table 1

Background In patients with COVID-19 requiring supplemental oxygen, dexamethasone reduces acute severity and improves survival, but longer-term effects are unknown. We hypothesised that systemic corticosteroid administration during acute COVID-19 would be associated with improved health-related quality of life (HRQoL) one year after discharge. Methods Adults admitted to hospital between February 2020 and March 2021 for COVID-19 and meeting current guideline recommendations for dexamethasone treatment were included using two prospective UK cohort studies. HRQoL, assessed by EQ-5D-5L utility index, pre-hospital and one year after discharge were compared between those receiving corticosteroids or not after propensity weighting for treatment. Secondary outcomes included patient reported recovery, physical and mental health status, and measures of organ impairment. Sensitivity analyses were undertaken to account for survival and selection bias. Findings In 1,888 participants included in the primary analysis, 1,149 received corticosteroids. There was no between-group difference in EQ-5D-5L utility index at one year (mean difference 0.004, 95% CI: -0.026 to 0.034, p = 0.77). A similar reduction in EQ-5D-5L was seen at one year between corticosteroid exposed and non-exposed groups (mean (SD) change -0.12 (0.22) vs -0.11 (0.22), p = 0.32). Overall, there were no differences in secondary outcome measures. After sensitivity analyses modelled using a larger cohort of 109,318 patients admitted to hospital with COVID-19, EQ-5D-5L utility index at one year remained similar between the two groups. Interpretation Systemic corticosteroids for acute COVID-19 have no impact on the large reduction in HRQoL one year after hospital discharge. Treatments to address this are urgently needed. ### Competing Interest Statement AART declares that their institute was awarded a fellowship from British Heart Foundation and grant funding from Heart Research UK and National Institute for Health and Care Research; payment for lectures and presentations received from Janssen-Cilag Ltd; support for attending meetings from Janssen-Cilag Ltd. AH​ declares that their institute was awarded funding from UK Research and Innovation (MR/V027859/1), National Institute of Health Research (COV0319) and NIHR Manchester BRC; leadership or fiduciary role as Chair for NIHR Translational Research Collaboration. AS declares that their institute was awarded joint funding from UKRI & NIHR (MR/V027859/1 and COV0319) to complete this work. AB declares consulting fees from Roche, Merck, Sanofi and GSK. ABD​ declares that they were awarded funding from Wellcome Clinical Research Career Development Fellowship (216606/Z/19/Z) to complete this work. ADS​ declares that their institute was awarded grant funding from AstraZeneca, Bayer, GSK, Chiesi, Novartis, Pfizer outside the submitted manuscript; consulting fees from AstraZeneca, Bayer, GSK, Chiesi, Novartis, Pfizer, Insmed, Gilead; payment for lectures and presentations received by AstraZeneca, Bayer, GSK, Chiesi, Novartis, Pfizer, Insmed, Gilead, 30T; participation on a Data Safety Monitoring Board or Advisory Board for Bayer; receipt of drugs from GSK outside the submitted manuscript. AShe declares that their institute was awarded grant funding from NIHR and UKRI to complete this work; participation on a Data Safety Monitoring Board or Advisory Board for Astra-Zenecas Thrombotic Thrombocytopenic Taskforce; leadership or fiduciary role for UK and Scottish Government COVID-19 advisory groups. CE declares a grant from GSK. CEB declares that their institute received grant funding from NIHR/UKRI and NIHR to complete this work; their institute received grant funding from Nottingham Hospitals Charity and University of Nottingham. CEBr declares that their institute received grant funding from MRC/NIHR and NIHR to complete this work; their institute received grant funding from GSK, AZ, Sanofi, Regeneron, Roche, Genentech, BI, Novartis, Chiesi, 4Dpharma, Mologic; consulting fees from GSK, AZ, Sanofi, Regeneron, Roche, Genentech, BI, Novartis, Chiesi, 4Dpharma, Mologic, Areteia. DP declares funding from NIHR and MRC; leadership or fiduciary role for Faculty of Intensive Care Medicine Board. GPM declares funding from NIHR (RP-2017-ST2-007) to complete this work; funding from British Heart Foundation, Wellcome Trust and NIHR; research support from Resonance Health, Circle CVi and Perspectum. RGJ declares that their institute received funding from Astra Zeneca, Biogen, Galecto, GlaxoSmithKline, Nordic Biosciences, RedX and Pliant; consulting fees from AstraZeneca, Brainomix, Bristol Myers Squibb, Chiesi, Cohbar, Daewoong, GlaxoSmithKline, Veracyte, Resolution Therapeutics and Pliant; payment for lectures and presentations received from Boehringer Ingelheim, Chiesi, Roche, PatientMPower, AstraZeneca; payment for expert testimony from Pinsent Masons LLP; participation on a Data Safety Monitoring Board or Advisory Board for Boehringer Ingelheim, Galapagos, Vicore; leadership or fiduciary role for NuMedii and president for Action for Pulmonary Fibrosis. GC declares funding from GlaxoSmithKline and AstraZeneca; received honoraria for delivering talks from GSK, AZ, Chiesi, BI; participation on a Data Safety Monitoring Board or Advisory Board as Chair on the Act on COPD Programme for AZ in Scotland; leadership or fiduciary role as Chair for the Lothian Respiratory Managed Clinical Network. JDC declares funding from AstraZeneca, Boehringer Ingelheim, Grifols, Gilead sciences, Insmed, Genentech, Glaxosmithkline; consulting fees from AstraZeneca, Boehringer Ingelheim, Grifols, Gilead sciences, Insmed, Genentech, Glaxosmithkline, Antabio, Zambon, Trudell; leadership or fiduciary roles as Chief Editor of European Respiratory Journal, Chair of British Thoracic Society Science and Research Committee and Trustee of the British Thoracic Society. JTS declares funding from UKRI. JKQ declares that their institute received funding from Industrial Strategy Challenge Fund, the Medical Research Council, Health Data Research, GSK, BI, asthma+lung UK, AZ; consulting fees from GlaxoSmithKline, Evidera, Chiesi, AstraZeneca, Insmed. JP declares funding from Breathing Matters and UCL/H BRC (NIHR); consulting fees from The Limbic. JJ declares funding from Gilead, Microsoft Research, GlaxoSmithKline; consulting fees from Boehringer Ingelheim, Roche, GlaxoSmithKline, NHSX; payment for lectures and presentations received from Boehringer Ingelheim, Roche, GlaxoSmithKline, Takeda; support for attending meetings and/or travel from Boehringer Ingelheim; patents planned, issued or pending (UK patent application number 2113765.8 and UK patent application number GB2211487.0); participation on a Data Safety Monitoring Board or Advisory Board for Boehringer Ingelheim and Roche. JRH declares funding from AstraZeneca; consulting fees from AstraZeneca and GSK; payment for lectures and presentations received from AstraZeneca, Boehringer Ingelheim, Chiesi, Sanofi, Takeda; support for attending meetings and/or travel from AstraZeneca; participation on a Data Safety Monitoring Board or Advisory Board for AstraZeneca; Receipt of equipment from Nonin. LGH declares that their institute received funding from GSK, Astra Zeneca, Roche/Genentech; payment for lectures received from Astra Zeneca, Novartis, Roche / Genentech, Sanofi, Circassia, GlaxoSmithKline, Chiesi, Teva; support to travel to meetings from AstraZeneca and GSK; participation on a Data Safety Monitoring Board or Advisory Board for Novartis, Roche/Genentech, GSK, Teva and Celltrion. LH-W declares funding from NIHR (RfPB grant PB-PG-0317-20032). LVW declares funding from UK Research and Innovation (MR/V027859/1), GSK/Asthma + Lung UK (Professorship (C17-1)) and National Institute of Health Research (COV0319) to complete this work; funding from Orion Pharma, GSK, Genentech, AstraZeneca, Nordic Bioscience, Sysmex (OGT); Consulting fees Galapagos, Boehringer Ingelheim, GSK; support for attending meetings and/or travel Genentech; participation on Advisory Board for Galapagos; leadership or fiduciary roles as Associate Editor for European Respiratory Journal and Medical Research Council Board member and Deputy Chair. MGS declares grant funding from National Institute of Health Research UK, Medical Research Council UK and Health Protection Research Unit in Emerging & Zoonotic Infections, University of Liverpool to complete this work; participation on a Data Safety Monitoring Board or Advisory Board for Pfizer; leadership or fiduciary roles as Chair of Infectious Disease Scientific Advisory Board Integrum Scientific LLC and Director of MedEx Solutions Ltd; Stock or stock options as minority owner of Integrum Scientific LLC and majority owner of MedEx Solutions Ltd; receipt of equipment, materials, drugs, medical writing, gifts or other services from Chiesi Farmaceutici S.p.A.; non-remunerated independent member of HMG UK Scientific Advisory Group for Emergencies (SAGE), COVID-19 Response (March 2020 to March 2022) and non-remunerated independent member of HMG UK New Emerging Respiratory Virus Threats Advisory Group (NERVTAG) (2014 to July 2023). MJ declares funding from MRC to complete this work; funding from MRC, British Lung Foundation and Boehringher Ingelheim; consulting fees from Skyhawk therapeutics; leadership or fiduciary role in AAIR Charity Scientific Committee. MT declares grant funding from NIHR Cambridge BRC and NIHR HTA to complete this work; consulting fees from Jansen; support for attending meetings and/or travel from GSK, Jansen; participation on a Data Safety Monitoring Board or Advisory Board for ComCov and FluCov. MJR declares support for attending meetings and/or travel from Novartis Pharmaceuticals; stock or stock options from Novartis Pharmaceuticals and Roche Pharmaceuticals; employed full time as a Senior Clinical Development Medical Director at Novartis Pharmaceuticals. MJD declares grant funding from Novo Nordisk, Sanofi-Aventis, Lilly, Boehringer Ingelheim, AstraZeneca and Janssen; consulting fees from Eli Lilly, Boehringer Ingelheim, Novo Nordisk and Sanofi; payment for speaking for Boehringer Ingelheim, Lilly, Novo Nordisk, Sanofi, AstraZeneca, Amgen, Napp Pharmaceuticals and Novartis; advisory Board Member for Boehringer Ingelheim, Lilly, Novo Nordisk, Sanofi, Lexicon, Pfizer, Medtronic and ShouTi Pharma Inc., Zealand Pharma. MM declares that their institute received joint funding from UKRI & NIHR to complete this work. NDB declares they have received non-restrictive educational grants from Chiesi, AZ, and Teva for attending conferences; honoraria from TEVA, AZ, and GSK; support for attending meetings and/or travel from Chiesi and AZ; participation on a Data Safety Monitoring Board or Advisory Board for TEVA. NE declares receipt of equipment from Global Access Diagnostics (previously Mologic Inc). OCL declares that their institute received joint funding from UKRI & NIHR- grant (MR/V027859/1 and COV0319) to complete this work. PEP declares funding from NIHR. PJMO declares funding from UKRI-MRC/DHSC NIHR and UKRI-BEIS. RAE declares funding from UKRI/MRC/NIHR to complete this work; funding from Wolfson Foundation and Genentech/Roche; consulting fees from AstraZeneca/Evidera; payment for speaking fees from Boeringher and Moderna; support for attending meetings from Chiesi; leadership or fiduciary role as ERS Group 01.02 Pulmonary Rehabilitation and Chronic Care Secretary and ATS Pulmonary Rehabilitation Assembly Chair. RA declares lecture fees from Boehringer Ingelheim; support for attending meeting from Boehringer Ingelheim. SJS declares grants or contracts from NIHR (programme Grant (NIHR 202020)_, Wellcome Doctoral Training Programme, HTA Project Grant (NIHR: 131015), NIHR DHSC/UKRI COVID-19 Rapid Response Initiative, NIHR Global Research Group (NIHR 17/63/20), Actegy Limited and NIHR Senior Investigator; payment for presentations for GSK, Ministry of Justice, CIPLA, Sherbourne Gibbs; participation on NICE Expert Adviser Panel (long COVID), Wales Long COVID Advisory Board and NHS-E Long Covid Your Covid Recovery working group; leadership or fiduciary role as ATS Pulmonary Rehabilitation Assembly Chair, Clinical Lead RCP Pulmonary Rehabilitation Accreditation Scheme and Clinical Lead NACAP Audit for Pulmonary Rehabilitation. SR-J declares that their institute received funding from UKRI to complete this work; their institute received funding from NIHR Sheffield Biomedical Research centre, Bill & Melinda Gates Foundation, UKRI (MRC) and EDCTP. SH declares consulting fees from NovoNordisk; participation on a Data Safety Monitoring Board or Advisory Board for Eli Lilly with payments made Institution. SN declares grant funding from Oxford NIHR Biomedical Research centre. WD-CM declares that their institute received funding from National Institute for Health Research and NHS Accelerated Access Collaborative; leadership or fiduciary role as Honorary President of the Association for Respiratory Technology and Physiology. ### Clinical Protocols ### Funding Statement PHOSP-COVID is supported by a grant from the MRC-UK Research and Innovation and the Department of Health and Social Care through the National Institute for Health Research (NIHR) rapid response panel to tackle COVID-19. The funder had no role in study design, data collection, data analysis, data interpretation, or writing of the report. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: PHOSP-COVID was approved by the Leeds West Research Ethics Committee (20/YH/0225) and is registered on the ISRCTN Registry ([ISRCTN10980107][1]). ISARIC was approved by the South Central - Oxford C Research Ethics Committee in England and the Scotland A Research Ethics Committee. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The PHOSP-COVID study website (https://www.phosp.org) contains an overview of the study, resources, information about people involved, and publications. Research activity using the study is organised across a series of Working Groups. These were established at the outset of the study to coordinate research, minimise duplication of efforts, and facilitate communication across research and clinical specialties. Researchers interested in undertaking research using PHOSP-COVID are encouraged to contact the relevant Working Group leads (https://www.phosp.org/working-group/) in the first instance. The data are currently held in the Outbreak Data Analysis Platform (ODAP, https://odap.ac.uk/). Researchers seeking to access these data are directed to https://www.phosp.org/resource/ for information and forms. Correspondence to be directed to Dr Rachael A Evans, the Co-Principal Investigator of PHOSP-COVID study phosp@leicester.ac.uk. [1]: /external-ref?link_type=ISRCTN&access_num=ISRCTN10980107

### Competing Interest Statement Full COI statement included in the submitted manuscript. ### Clinical Protocols ### Funding Statement This work was supported by a joint funding from the UK Research and Innovation and National Institute of Health Research [grant references: MR/V027859/1 and COV0319]. The views expressed in the publication are those of the author(s) and not necessarily those of the National Health Service (NHS), the NIHR or the Department of Health and Social Care. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was approved by the Leeds West Research Ethics Committee (20/YH/0225) and is registered on the ISRCTN Registry ([ISRCTN10980107][1]). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The PHOSP-COVID study website () contains an overview of the study, resources, information about people involved, and publications. Research activity using the study is organised across a series of Working Groups ([Figure 3][2]). These were established at the outset of the study to coordinate research, minimise duplication of efforts, and facilitate communication across research and clinical specialties. Researchers interested in undertaking research using PHOSP-COVID are encouraged to contact the relevant Working Group leads () in the first instance. The data are currently held in the Outbreak Data Analysis Platform (ODAP, ). Researchers seeking to access these data are directed to for information and forms. Correspondence to be directed to Dr Rachael A Evans, the Co-Principal Investigator of PHOSP-COVID study phosp{at}leicester.ac.uk. [1]: /external-ref?link_type=ISRCTN&access_num=ISRCTN10980107 [2]: #F3

Chronic Obstructive Pulmonary Disease is a progressive lung disease associated with anxiety, depression, and reduced health-related quality of life. Pulmonary rehabilitation (PR) is a cost-effective and transformative treatment, but 31% of referred patients do not take up their PR appointment. The study aimed to develop user requirements for an intervention to increase PR uptake. A systems approach, the Engineering Better Care framework, was used to develop a system map of the PR pathway, translate evidence-based user needs into user requirements, and validate the user requirements in a stakeholder workshop. Eight user requirements addressed patient and health care practitioner needs to understand what PR entails, understand the benefits of PR and have positive conversations about PR to address patient concerns. The solution-independent user requirements can be applied to the development of any intervention sharing similar goals. The study demonstrates potential in taking a systems approach to more challenges within respiratory medicine.

BACKGROUND: The rising prevalence of electronic cigarette (e-cigarette) and hookah use among youth raises questions about medical trainees’ views of these products. We aimed to investigate medical trainees’ knowledge and attitudes toward e-cigarette and hookah use. METHODS: We used data from a large cross-sectional survey of medical trainees in Brazil, the United States, and India. We investigated demographic and mental health aspects, history of e-cigarettes and tobacco use, knowledge and attitudes toward e-cigarettes and hookah, and sources of information on e-cigarettes and hookah. Although all medical trainees were eligible for the original study, only senior students and physicians-in-training were included in the present analysis. RESULTS: Of 2,036 senior students and physicians-in-training, 27.4% believed e-cigarette use to be less harmful than tobacco smoking. As for hookah use, 14.9% believed it posed a lower risk than cigarettes. More than a third of trainees did not acknowledge the risks of passive e-cigarette use (42.9%) or hookah smoking (35.1%). Also, 32.4% endorsed e-cigarettes to quit smoking, whereas 22.5% felt ill equipped to discuss these tobacco products with patients. Fewer than half recalled attending lectures on these topics, and their most common sources of information were social media (54.5%), Google (40.8%), and friends and relatives (40.3%). CONCLUSIONS: Medical trainees often reported incorrect or biased perceptions of e-cigarettes and hookah, resorted to unreliable sources of information, and lacked the confidence to discuss the topic with patients. An expanded curriculum emphasis on e-cigarette and hookah use might be necessary because failing to address these educational gaps could risk years of efforts against smoking normalization.

Background In patients with coronavirus disease 2019 (COVID-19) requiring supplemental oxygen, dexamethasone reduces acute severity and improves survival, but longer-term effects are unknown. We hypothesised that systemic corticosteroid administration during acute COVID-19 would be associated with improved health-related quality of life (HRQoL) 1 year after discharge. Methods Adults admitted to hospital between February 2020 and March 2021 for COVID-19 and meeting current guideline recommendations for dexamethasone treatment were included using two prospective UK cohort studies (Post-hospitalisation COVID-19 and the International Severe Acute Respiratory and emerging Infection Consortium). HRQoL, assessed by the EuroQol-Five Dimensions-Five Levels utility index (EQ-5D-5L UI), pre-hospital and 1 year after discharge were compared between those receiving corticosteroids or not after propensity weighting for treatment. Secondary outcomes included patient-reported recovery, physical and mental health status, and measures of organ impairment. Sensitivity analyses were undertaken to account for survival and selection bias. Findings Of the 1888 participants included in the primary analysis, 1149 received corticosteroids. There was no between-group difference in EQ-5D-5L UI at 1 year (mean difference 0.004, 95% CI -0.026-0.034). A similar reduction in EQ-5D-5L UI was seen at 1 year between corticosteroid exposed and nonexposed groups (mean +/- SD change -0.12 +/- 0.22 versus -0.11 +/- 0.22). Overall, there were no differences in secondary outcome measures. After sensitivity analyses modelled using a cohort of 109 318 patients admitted to hospital with COVID-19, EQ-5D-5L UI at 1 year remained similar between the two groups. Interpretation Systemic corticosteroids for acute COVID-19 have no impact on the large reduction in HRQoL 1 year after hospital discharge. Treatments to address the persistent reduction in HRQoL are urgently needed.

The increased use of E-cigarettes and hookah among young consumers represents a public health concern. This study aimed to investigate the frequency and patterns of use of E-cigarettes and hookah among medical trainees. This cross-sectional multinational online survey included medical students, residents, and fellows in Brazil, the U.S., and India between October 2020 and November 2021. Information on sociodemographics; mental health; and E-cigarettes, hookah, tobacco, marijuana, and alcohol use were collected. Generalized structural equation models were used in 2022 to explore the factors associated with current vaping and current hookah use (ongoing monthly/ weekly/daily use). People reporting previous sporadic/frequent use or those who never used/only tried it once were the reference group. Overall, 7,526 participants were recruited (Brazil=3,093; U.S.= 3,067; India=1,366). The frequency of current vaping was 20% (Brazil), 11% (U.S.), and <1% (India), and current hookah use was 10% (Brazil), 6% (U.S.), and 1% (India). Higher family income (OR=6.35, 95% CI=4.42, 9.12), smoking cigarettes (OR=5.88, 95% CI=4.88, 7.09) and marijuana (OR=2.8, 95% CI=2.35, 3.34), and binge drinking (OR=3.03, 95% CI=2.56, 3.59) were associated with current vaping. The same was true for hookah use: higher family income (OR=2.69, 95% CI=1.75, 4.14), smoking cigarettes (OR=3.20, 95% CI=2.53, 4.06), smoking marijuana (OR=4.17, 95% CI=3.35, 4.19), and binge drinking (OR=2.42, 95% CI=1.96, 2.99). In conclusion, E-cigarettes and hookah were frequently used by Brazilian and American trainees, sharply contrasting with data from India. Cultural aspects and public health policies may explain the differences among countries. Addressing the problems of hookah and E-cigarette smoking in this population is relevant to avoid the renormalization of smoking.

Medical students in Ukraine have faced extraordinary disruption to their clinical studies with both the COVID-19 pandemic and subsequent Russian military invasion forcing a majority of their learning to be conducted remotely. Over the summer of 2022, the School of Clinical Medicine, University of Cambridge hosted 20 medical students from Kharkiv National Medical University for a seven-week intensive clinical elective programme. The aim was to provide an immersive clinical placement that would help students to attain the necessary knowledge and experience to become competent and confident practising doctors. This perspective piece aims to support the development of future equivalent exchanges through outlining the placement's context, its planning and implementation, evidence of placement impact, and finally reflections and learning points.

AIMS:To determine the lived experiences of people with COPD who isolated at home during the coronavirus disease 2019 (COVID-19) pandemic, and explore how these experiences affected health and patient-reported outcomes.METHODS:Keyword searches were performed in five bibliographic databases. Critical interpretative synthesis (CIS) methods were used to interrogate and understand patterns across studies.RESULTS:23 studies were identified; three employed qualitative methods and 20 quantitative methods. Application of CIS methods highlighted a core synthetic concept that appeared to underpin experiences and outcomes, that of a heightened perception of risk. Using the Risk Perception Model as a framework, we found that cognitive factors such as knowledge of underlying health status and the transmissibility of COVID-19; experiential factors including previous episodes of breathlessness and hospitalisation; and sociocultural factors such as access to trusted sources of information, influenced perceptions of risk. In turn, this influenced behaviour, which translated to outcomes such as reduced hospitalisations, deconditioning and social isolation as people avoided "high-risk" situations and settings.CONCLUSIONS:Patients with COPD who isolated at home during the COVID-19 pandemic had a heightened perception of risk which was influenced by cognitive, experiential and sociocultural factors. The consequences of this were varied and included both positive (reduced exacerbations and hospitalisations) and negative (social isolation, deconditioning, diminished capacity for self-care) outcomes. Understanding risk and the impacts it can have could help clinicians to support people with COPD return to their pre-pandemic way of living and enable better communication of ongoing risk from respiratory viral illness.

Introduction: The lack of referral constitutes a major problem for the participation of COPD patients in pulmonary rehabilitation (PR). We were interested in framing the barriers to referral reported by clinicians and patients using behaviour-related framework, in the primary care setting. Methods: Scoping review using the Joanna Briggs Institute methodology. Records from Embase, Medline, Scopus, Web of Science, and PsycINFO databases were analysed - and one manually identified. Pilot and peer review for records screening and selection. Inclusion criteria: in context, primary quantitative and qualitative studies on barriers to referral. Results: 9 out of 861 studies analysed - all from high-income countries (1-9). Two survey-based studies and seven interview-based studies. Two studies conducted among COPD patients and seven studies conducted among clinicians. 62 barriers framed in total; 21 reported by COPD patients and 41 by clinicians. Barriers related to knowledge on PR and the environmental context and resources were the most frequently reported. Unknown delivery location of PR and inconvenient timing were the most frequently cited barriers in these framework domains by COPD patients. Insufficient publicity, practical difficulties in making referrals, limited understanding of patient eligibility, the treatment itself and its delivery site were barriers frequently mentioned by clinicians in these domains. Conclusions: Original review that showed multiple barriers to referral of COPD patients for PR in the primary care setting. Further studies are needed to understand how these barriers operate in the referral process.

Background Although 1 billion people live in informal (slum) settlements, the consequences for respiratory health of living in these settlements remain largely unknown. This study investigated whether children living in an informal settlement in Nairobi, Kenya are at increased risk of asthma symptoms. Methods Children attending schools in Mukuru (an informal settlement in Nairobi) and a more affluent area (Buruburu) were compared. Questionnaires quantified respiratory symptoms and environmental exposures; spirometry was performed; personal exposure to particulate matter (PM 2.5 ) was estimated. Results 2373 children participated, 1277 in Mukuru (median age, IQR 11, 9–13 years, 53% girls), and 1096 in Buruburu (10, 8–12 years, 52% girls). Mukuru schoolchildren were from less affluent homes, had greater exposure to pollution sources and PM 2.5 . When compared with Buruburu schoolchildren, Mukuru schoolchildren had a greater prevalence of symptoms, ‘current wheeze’ (9.5% vs 6.4%, p=0.007) and ‘trouble breathing’ (16.3% vs 12.6%, p=0.01), and these symptoms were more severe and problematic. Diagnosed asthma was more common in Buruburu (2.8% vs 1.2%, p=0.004). Spirometry did not differ between Mukuru and Buruburu. Regardless of community, significant adverse associations were observed with self-reported exposure to ‘vapours, dusts, gases, fumes’, mosquito coil burning, adult smoker(s) in the home, refuse burning near homes and residential proximity to roads. Conclusion Children living in informal settlements are more likely to develop wheezing symptoms consistent with asthma that are more severe but less likely to be diagnosed as asthma. Self-reported but not objectively measured air pollution exposure was associated with increased risk of asthma symptoms.