Cerebral perfusion is not impaired in persons with moderate obstructive sleep apnoea when awake.

PURPOSE: It is well established that, together with a multitude of other adverse effects on health, severe obstructive sleep apnoea causes reduced cerebral perfusion and, in turn, reduced cerebral function. Less clear is the impact of moderate obstructive sleep apnoea (OSA). Our aim was to determine if cerebral blood flow is impaired in people diagnosed with moderate OSA. METHODS: Twenty-four patients diagnosed with moderate OSA (15 ≤ apnoea-hypopnea index (AHI) < 30) were recruited (aged 32-72, median 59 years, 10 female). Seven controls (aged 42-73 years, median 62 years, 4 female) with an AHI < 5 were also recruited. The OSA status of all participants was confirmed at baseline by unattended polysomnography and they had an MRI arterial-spin-labelling scan of cerebral perfusion. RESULTS: Neither global perfusion nor voxel-wise perfusion differed significantly between the moderate-OSA and control groups. We also compared the average perfusion across three regional clusters, which had been found in a previous study to have significant perfusion differences with moderate-severe OSA versus control, and found no significant difference in perfusion between the two groups. The perfusions were also very close, with means of 50.2 and 51.8 mL/100 g/min for the moderate-OSAs and controls, respectively, with a negligible effect size (Cohen's d = 0.10). CONCLUSION: We conclude that cerebral perfusion is not impaired in people with moderate OSA and that cerebral flow regulatory mechanisms can cope with the adverse effects which occur in moderate OSA. This is an important factor in clinical decisions for prescription of continuous positive airway pressure therapy (CPAP).

Reasons for why Medical Students Prefer Specific Sleep Management Strategies.

OBJECTIVES: Insomnia symptoms are common among medical students. This study explored the perspectives of medical students about which sleep management strategies to use. METHODS: Medical students responded to an online survey on their thoughts about the use of various sleep management strategies. RESULTS: Of the 828 respondents, 568 (69%) provided responses to questions about the most preferred strategies and 450 (54%) provided responses about their least preferred strategies. About 48.5% felt their insomnia symptoms were too mild to see a clinician and 23.9% did not think their symptoms warranted sleep medication. Over 40% of students could not avoid work before sleep, have consistent sleep/wake times, or engage in regular exercise because of their busy and inconsistent schedules. Approximately 40-60% could not improve their sleep environment (e.g. better heating and bed) because of the associated costs. Over 80% reported an inability to change their pre-sleep habits (e.g. using electronics close to bedtime, using bed for activities other than sleep or sex). Half of the students disliked relaxation techniques or felt they would not help. Around 30-50% did not believe that changing caffeine and/or alcohol intake would affect their sleep. CONCLUSIONS: Medical students may benefit from additional sleep education. Clinicians may need to discuss which strategies individual students prefer and modify their recommendations accordingly.

Symptom persistence and recovery among COVID-19 survivors during a limited outbreak in Canterbury, New Zealand: a prospective cohort study.

BACKGROUND: In Canterbury, near complete identification of coronavirus disease 2019 (COVID-19) cases during a limited outbreak provides unique insights into sequelae. AIMS: The current study aimed to measure symptom persistence, time to return to normal activity, generalised anxiety and health-related quality of life (HrQoL) among COVID-19 survivors compared with uninfected participants. METHODS: The authors conducted a prospective cohort study of people tested for COVID-19 by reverse transcriptase polymerase chain reaction of nasopharyngeal swabs from 1 March to 30 June 2020. They enrolled participants who tested positive and negative at a 1:2 ratio, and administered community-acquired pneumonia, 7-item generalised anxiety disorder (GAD-7) and HrQoL (RAND-36) questionnaires. RESULTS: The authors recruited 145 participants, 48 with COVID-19 and 97 without COVID-19. The mean time from COVID-19 testing to completing the health questionnaire was 306 days. The mean age of patients was 46.7 years, and 70% were women. Four (8%) COVID-19-positive and eight (8%) COVID-19-negative participants required hospitalisation. Fatigue (30/48 [63%] vs 13/97 [13%]; P < 0.001), dyspnoea (13/48 [27%] vs 6/97 [6%]; P < 0.001) and chest pain (10/48 [21%] vs 1/97 [1%]; P < 0.001) were persistent in those with COVID-19. Fewer COVID-19-positive participants returned to normal activity levels (35/48 [73%] vs 94/97 97%; P < 0.001), with longer times taken (median 21 vs 14 days; P = 0.007). The GAD-7 and RAND-36 scores of both groups were similar across all anxiety and HrQoL subscales. CONCLUSIONS: Persistent symptoms and longer recovery times were found in COVID-19 survivors, but not impaired generalised anxiety levels or HrQoL compared with COVID-19-uninfected participants.

Sleep Management Strategies Among Medical Students At the University of Otago.

OBJECTIVES: We aim to investigate factors which might affect the sleep of medical students, and how they currently manage their sleep. METHODS: An online survey was sent to medical students at the University of Otago. RESULTS: After adjusting for gender, ethnicity and age, depressive symptoms (Mild: odds ratio (OR) = 6.3; Moderate: OR = 18.1; Severe: OR = 15.6), and sleep hygiene (OR = 1.07) were associated with insomnia symptoms. Commonly endorsed strategies for sleep management by students were undertaking regular exercise (80.1%), having consistent sleep-wake time (71.3%), and limiting caffeine intake (70.3%). Few were willing to see a clinician (23.4%) or take medication (22.3%). Participants with insomnia symptoms were more likely to prefer limiting their alcohol intake (OR = 1.8), limiting daytime naps (OR = 1.5), seeing clinicians (OR = 1.9), and taking sleep medication (OR = 4.0), but less likely to prefer avoiding intense work (OR = .71) or minimizing using electronics (OR = .60) close to bedtime than those without insomnia symptoms. High sleep self-efficacy was associated with lower odds for having insomnia symptoms (OR = .74 (.70, .77)). CONCLUSIONS: Increased awareness and greater resources are needed to support the sleep health of medical students.

'People that suffer or have been through it know the answers': stakeholders' perspectives on improving healthcare systems for end-of-life care in chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a progressive and disabling lung condition with a high mortality. Our research has shown that health care for end-of-life COPD is poorly integrated. The aim of this study was to involve people with end-of-life COPD, their support people and health professionals in the design of healthcare services to help improve the delivery of care for advanced COPD, including informing system-level quality improvement. DESIGN: We conducted a focus group study involving stakeholders of healthcare services: people with end-of life COPD, support people, bereaved support people, and community- and hospital-based health care professionals. METHODS: We conducted qualitative analysis using deductive structural coding, and then inductive descriptive and pattern coding. Analyses were triangulated by investigators. The research positioned people with end-of-life COPD, their support people and health professionals as experts in healthcare services. Critical theory and Actor-Network theory informed the analysis. RESULTS: Seven focus groups involving 74 participants reported their experiences of end-of-life care for COPD. Five themes related to healthcare systems responses to improving care quality were identified: governance, system integration, resource design and development, standardisation of processes, and communication. CONCLUSION: Stakeholders provided multiple healthcare system-level responses to end-of-life care in COPD that could inform healthcare service design and clinical quality improvement.

Evaluation of pleural fluid cytology for the diagnosis of malignant pleural effusion: a retrospective cohort study.

BACKGROUND: Cytological examination of pleural fluid has good specificity, but imperfect sensitivity for the diagnosis of malignant pleural effusion (MPE). Published estimates of sensitivity vary and predictors of false negative cytology are not well established. AIMS: To estimate pleural fluid cytology sensitivity and identify risk factors for false negative cytology. METHODS: We conducted a retrospective cohort study of patients who had cytology testing of pleural fluid at Christchurch Hospital, New Zealand, from July 2017 to October 2019. Data on clinical and pleural fluid characteristics were collected. MPE was defined by positive pleural fluid cytology, tissue histology or multidisciplinary meeting consensus. We estimated sensitivity of the first pleural cytology assessment. We performed multivariate logistic regression to ascertain patient groups at greatest risk of false negative results. RESULTS: Initial pleural fluid cytology was diagnostic in 117 of 156 patients, providing a sensitivity (95% confidence interval (CI)) of 75.0% (67.4-81.6%). The sensitivity was 79.0% (66.8-88.3%) for lung cancer, 91.3% (72.0-98.9%) for breast cancer and 33.3% (95% CI 11.8-61.6%) for mesothelioma. Cloudy appearance of pleural fluid (odds ratio (OR) 0.12; 95% CI 0.03-0.54) and yellow/gold pleural fluid (OR 0.24; 95% CI 0.06-0.96) reduced the odds of false negative pleural cytology. Pleural thickening on computed tomography scan (OR 3.3; 95% CI 1.2-9.4) was a risk factor for false negative cytology. CONCLUSION: Sensitivity of pleural fluid cytology was greatest in primary lung and breast cancer, and lowest in mesothelioma. Clinicians should be alert to false negative results when suspecting mesothelioma or if pleural thickening is present.

Long-term outcomes in patients with pulmonary embolism: results from a longitudinal cohort study.

BACKGROUND: Patients with pulmonary embolism (PE) have increased mortality in short-term; however, long-term prognosis is not well defined. AIM: In this long-term cohort study, we aimed to determine if PE was associated with increased risk of mortality or serious clinical events (SCE). Secondary aims were to ascertain predictors of mortality and SCE. METHODS: Patients admitted with clinical suspicion of PE were prospectively recruited from July 2002 to May 2003 and followed up until March 2015. Clinical outcomes in patients with PE were compared to those without PE. SCE was defined as composite of mortality, malignancy, cardiovascular events, recurrent venous thromboembolism and chronic thromboembolic pulmonary hypertension. RESULTS: A total of 501 patients with median follow up of 11.9 years (interquartile range 3.91-12.28) was included. PE was diagnosed in 104 (20.7%) patients. Overall, 45.9% died and 57.1% developed SCE during follow up, with no significant difference in PE and no-PE groups (both P > 0.5). Major determinants of mortality were age (hazard ratio (HR) 1.06 per year, 95% confidence interval (CI) 1.05-1.08), malignancy (HR 2.19, 95% CI 1.64-2.91) and congestive heart failure (HR 1.72, 95% CI 1.23-2.42). Factors associated with increased risk of SCE were age (HR 1.05 per year, 95% CI 1.04-1.06), malignancy (HR 1.93, 95% CI 1.48-2.52) and congestive heart failure (HR 1.77, 95% CI 1.29-2.43). In patients without PE, elevated D-dimer concentration was not found to be associated with diagnosis of malignancy during follow up (HR 1.31, 95% CI 0.55-3.12). CONCLUSIONS: In this prospective study, we did not find association between PE and risk of all-cause mortality or SCE. Major determinants of poor clinical outcomes were advancing age and underlying comorbidities.

Reported sources of health inequities in Indigenous Peoples with chronic kidney disease: a systematic review of quantitative studies.

BACKGROUND: To summarise the evidentiary basis related to causes of inequities in chronic kidney disease among Indigenous Peoples. METHODS: We conducted a Kaupapa Maori meta-synthesis evaluating the epidemiology of chronic kidney diseases in Indigenous Peoples. Systematic searching of MEDLINE, Google Scholar, OVID Nursing, CENTRAL and Embase was conducted to 31 December 2019. Eligible studies were quantitative analyses (case series, case-control, cross-sectional or cohort study) including the following Indigenous Peoples: Maori, Aboriginal and Torres Strait Islander, Métis, First Nations Peoples of Canada, First Nations Peoples of the United States of America, Native Hawaiian and Indigenous Peoples of Taiwan. In the first cycle of coding, a descriptive synthesis of the study research aims, methods and outcomes was used to categorise findings inductively based on similarity in meaning using the David R Williams framework headings and subheadings. In the second cycle of analysis, the numbers of studies contributing to each category were summarised by frequency analysis. Completeness of reporting related to health research involving Indigenous Peoples was evaluated using the CONSIDER checklist. RESULTS: Four thousand three hundred seventy-two unique study reports were screened and 180 studies proved eligible. The key finding was that epidemiological investigators most frequently reported biological processes of chronic kidney disease, particularly type 2 diabetes and cardiovascular disease as the principal causes of inequities in the burden of chronic kidney disease for colonised Indigenous Peoples. Social and basic causes of unequal health including the influences of economic, political and legal structures on chronic kidney disease burden were infrequently reported or absent in existing literature. CONCLUSIONS: In this systematic review with meta-synthesis, a Kaupapa Maori methodology and the David R Williams framework was used to evaluate reported causes of health differences in chronic kidney disease in Indigenous Peoples. Current epidemiological practice is focussed on biological processes and surface causes of inequity, with limited reporting of the basic and social causes of disparities such as racism, economic and political/legal structures and socioeconomic status as sources of inequities.

Electronic cigarettes: A position statement from the Thoracic Society of Australia and New Zealand.

The TSANZ develops position statements where insufficient data exist to write formal clinical guidelines. In 2018, the TSANZ addressed the question of potential benefits and health impacts of electronic cigarettes (EC). The working party included groups focused on health impacts, smoking cessation, youth issues and priority populations. The 2018 report on the Public Health Consequences of E-Cigarettes from the United States NASEM was accepted as reflective of evidence to mid-2017. A search for papers subsequently published in peer-reviewed journals was conducted in August 2018. A small number of robust and important papers published until March 2019 were also identified and included. Groups identified studies that extended, modified or contradicted the NASEM report. A total of 3793 papers were identified and reviewed, with summaries and draft position statements developed and presented to TSANZ membership in April 2019. After feedback from members and external reviewers, a collection of position statements was finalized in December 2019. EC have adverse lung effects and harmful effects of long-term use are unknown. EC are unsuitable consumer products for recreational use, part-substitution for smoking or long-term exclusive use by former smokers. Smokers who require support to quit smoking should be directed towards approved medication in conjunction with behavioural support as having the strongest evidence for efficacy and safety. No specific EC product can be recommended as effective and safe for smoking cessation. Smoking cessation claims in relation to EC should be assessed by established regulators.

A multicentre prospective observational study comparing arterial blood gas values to those obtained by pulse oximeters used in adult patients attending Australian and New Zealand hospitals.

BACKGROUND: Pulse oximetry is widely used in the clinical setting. The purpose of this validation study was to investigate the level of agreement between oxygen saturations measured by pulse oximeter (SpO2) and arterial blood gas (SaO2) in a range of oximeters in clinical use in Australia and New Zealand. METHODS: Paired SpO2 and SaO2 measurements were collected from 400 patients in one Australian and two New Zealand hospitals. The ages of the patients ranged from 18 to 95 years. Bias and limits of agreement were estimated. Sensitivity and specificity for detecting hypoxaemia, defined as SaO2 < 90%, were also estimated. RESULTS: The majority of participants were recruited from the Outpatient, Ward or High Dependency Unit setting. Bias, oximeter-measured minus arterial blood gas-measured oxygen saturation, was - 1.2%, with limits of agreement - 4.4 to 2.0%. SpO2 was at least 4% lower than SaO2 for 10 (2.5%) of the participants and SpO2 was at least 4% higher than the SaO2 in 3 (0.8%) of the participants. None of the participants with a SpO2 ≥ 92% were hypoxaemic, defined as SaO2 < 90%. There were no clinically significant differences in oximetry accuracy in relation to clinical characteristics or oximeter brand. CONCLUSIONS: In the majority of the participants, pulse oximetry was an accurate method to assess SaO2 and had good performance in detecting hypoxaemia. However, in a small proportion of participants, differences between SaO2 and SpO2 could have clinical relevance in terms of patient monitoring and management. A SpO2 ≥ 92% indicates that hypoxaemia, defined as a SaO2 < 90%, is not present. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ACTRN12614001257651). Date of registration: 2/12/2014.

Consolidated criteria for strengthening reporting of health research involving indigenous peoples: the CONSIDER statement.

BACKGROUND: Research reporting guidelines are increasingly commonplace and shown to improve the quality of published health research and health outcomes. Despite severe health inequities among Indigenous Peoples and the potential for research to address the causes, there is an extended legacy of health research exploiting Indigenous Peoples. This paper describes the development of the CONSolIDated critERtia for strengthening the reporting of health research involving Indigenous Peoples (CONSIDER) statement. METHODS: A collaborative prioritization process was conducted based on national and international statements and guidelines about Indigenous health research from the following nations (Peoples): Australia (Aboriginal and Torres Strait Islanders), Canada (First Nations Peoples, Métis), Hawaii (Native Hawaiian), New Zealand (Maori), Taiwan (Taiwan Indigenous Tribes), United States of America (First Nations Peoples) and Northern Scandinavian countries (Sami). A review of seven research guidelines was completed, and meta-synthesis was used to construct a reporting guideline checklist for transparent and comprehensive reporting of research involving Indigenous Peoples. RESULTS: A list of 88 possible checklist items was generated, reconciled, and categorized. Eight research domains and 17 criteria for the reporting of research involving Indigenous Peoples were identified. The research reporting domains were: (i) governance; (ii) relationships; (iii) prioritization; (iv) methodologies; (v) participation; (vi) capacity; (vii) analysis and findings; and (viii) dissemination. CONCLUSIONS: The CONSIDER statement is a collaborative synthesis and prioritization of national and international research statements and guidelines. The CONSIDER statement provides a checklist for the reporting of health research involving Indigenous peoples to strengthen research praxis and advance Indigenous health outcomes.

Reported Maori consumer experiences of health systems and programs in qualitative research: a systematic review with meta-synthesis.

BACKGROUND: Persistent inequities in health experiences and outcomes are observed for Maori compared to non-Maori in Aotearoa New Zealand. We conceptualised factors associated with Maori consumer experiences of health programs and services and characterise how the recommendations arising from qualitative research inform strategies to address inequities. METHODS: In this systematic review, electronic literature searching was conducted in February 2018. Qualitative studies reporting Maori consumer experiences of health services and programs in Aotearoa New Zealand were eligible. Maori consumer experiences of health services were mapped to the WHO Commission of Social Determinants of Health (CSDH) conceptual framework on health inequities as related to: (i) the socioeconomic and political context; (ii) socioeconomic positioning; or (iii) intermediary factors that increase exposure to health-compromising conditions. Recommendations to improve consumer experiences were mapped to the CSDH framework for tackling social determinants of health inequities as policy directions on: (i) unequal consequences of illness (individual interaction); (ii) risks of exposure to health-damaging factors (community); (iii) exposures to health-damaging factors (public policies); and (iv) mitigating effects of socioeconomic and political stratification (environment). RESULTS: Fifty-four studies were included. Maori consumer experiences mapped to social determinants of health inequities were most frequently related to direct interactions with health services and programs, particularly patient-clinician interactions (communication, relationships) and cultural competencies of clinicians and the system. Key recommendations by researchers mapped to potential strategies to address inequity were identified at all levels of the political, social and health system from individual interactions, community change, and broader public and system-level strategies. Recommendations were predominantly focused on actions to reduce risks of exposure to health-damaging factors including health literacy interventions, increased resources in cultural competencies and Maori capacity in health service development and workforce. CONCLUSIONS: Maori consumer experiences of health services and programs are an important informer of variables that impact health inequity. Strategies to tackle health inequities informed by Maori consumer experiences can be drawn from existing empirical research. Future qualitative exploration of how socioeconomic, political and public policies influence Maori consumer experiences of health services and programs could inform a broader range of structural policies to address health inequities.

Inequity in dialysis related practices and outcomes in Aotearoa/New Zealand: a Kaupapa Maori analysis.

BACKGROUND: In Aotearoa/New Zealand, Maori, as the indigenous people, experience chronic kidney disease at three times the rate of non-Maori, non-Pacific New Zealanders. Maori commence dialysis treatment for end-stage kidney disease at three times the rate of New Zealand European adults. To examine for evidence of inequity in dialysis-related incidence, treatment practices, and survival according to indigeneity in Aotearoa/New Zealand, utilising a Kaupapa Maori approach. METHODS: We conducted a retrospective cohort study involving adults who commenced treatment for end-stage kidney disease in Aotearoa/New Zealand between 2002 and 2011. We extracted data from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) linked to the New Zealand National Health Index (NHI). Propensity score methods were used to assemble a cohort of 1039 Maori patients matched 1:1 on clinical and socio-demographic characteristics with a cohort of 1026 non-Maori patients. We compared incidence of end-stage kidney disease and treatment practices. Differences in the risks of all-cause mortality during treatment between propensity-matched cohorts were estimated using Cox proportional hazards and generalised linear models. RESULTS: Non-Maori patients were older, more frequently lived in urban areas (83% versus 67% [standardised difference 0.38]) and bore less socioeconomic deprivation (36% living in highest decile areas versus 14% [0.53]). Fewer non-Maori patients had diabetes (35% versus 69%, [- 0.72]) as a cause of kidney failure. Non-Maori patients were more frequently treated with peritoneal dialysis (34% versus 29% [0.11]), received a pre-emptive kidney transplant (4% vs 1% [0.19]), and were referred to specialist care < 3 months before treatment (25% vs 19% [0.15]) than Maori patients. Fewer non-Maori started dialysis with a non-tunnelled dialysis vascular catheter (43% versus 47% [- 0.08]). The indigenous-age standardised incidence rate ratio for non-Maori commencing renal replacement therapy in 2011 was 0.50 (95% CI, 0.40-0.61) compared with Maori. Propensity score matching generated cohorts with similar characteristics, although non-Maori less frequently started dialysis with a non-tunnelled venous catheter (30% versus 47% [- 0.35]) or lived remotely (3% versus 14% [- 0.50]). In matched cohorts, non-Maori experienced lower all-cause mortality at 5 yr. after commencement of treatment (risk ratio 0.78, 95% CI 0.72-0.84). New Zealand European patients experienced lower mortality than Maori patients in indigenous age-standardised analyses (age-standardised mortality rate ratio 0.58, 95% CI 0.51-0.67). CONCLUSIONS: Non-Maori patients are treated with temporary dialysis vascular access less often than Maori, and experience longer life expectancy with dialysis, even when socioeconomic, demographic, and geographical factors are equivalent. Based on these disparities, health services should monitor and address inequitable treatment practices and outcomes in end-stage kidney disease care.

Is higher population-level use of ICS/LABA combination associated with better asthma outcomes? Cross-sectional surveys of nationally representative populations in New Zealand and Australia.

BACKGROUND AND OBJECTIVE: New Zealand (NZ) and Australia (AU) have similarly high asthma prevalence; both have universal public health systems, but different criteria for subsidized medicines. We explored differences in asthma management and asthma-related outcomes between these countries. METHODS: A web-based survey was administered in AU (2012) and NZ (2013) to individuals aged ≥16 years with current asthma, drawn randomly from web-based panels, stratified by national population proportions. Symptom control was assessed with the Asthma Control Test (ACT). Healthcare utilization was assessed from reported urgent doctor/hospital visits in the previous year. RESULTS: NZ (n = 537) and Australian (n = 2686) participants had similar age and gender distribution. More NZ than Australian participants used inhaled corticosteroid (ICS)-containing medication (68.8% vs 60.9%; P = 0.006) but ICS/long-acting ß2 -agonist (LABA) constituted 44.4% of NZ and 81.5% of Australian total ICS use (P < 0.0001). Adherence was higher with ICS/LABA than ICS-alone (P < 0.0001), and higher in NZ than in AU (P < 0.0001). ACT scores were similar (P = 0.41), with symptoms well controlled in 58.6% and 54.4% participants, respectively. More NZ participants reported non-urgent asthma reviews (56.6% vs 50.4%; P = 0.009). Similar proportions had urgent asthma visits (27.9% and 28.6%, respectively, P = 0.75). CONCLUSION: This comparison, which included the first nationally representative data for asthma control in NZ, showed that poorly controlled asthma is common in both NZ and AU, despite subsidized ICS-containing medications. The greater use of ICS-alone in NZ relative to ICS/LABA does not appear to have compromised population-level asthma outcomes, perhaps due to better adherence in NZ. Different ICS/LABA subsidy criteria and different patient copayments may also have contributed to these findings.

Indigenous health: designing a clinical orientation program valued by learners.

BACKGROUND: Indigenous health programs are seen as a curriculum response to addressing health disparities and social accountability. Several interrelated teaching approaches to cultural competency curricula have been recommended, however evidence of the impact of these on learner outcomes including engagement and self-reported competencies is limited. We aimed to explore undergraduate medical student perspectives of an indigenous health orientation program to inform curriculum strategies that promote learning and development of clinical skills. METHODS: We analyzed quantitative and qualitative student evaluations (n = 602) of a three-day immersed indigenous health orientation program between 2006 and 2014 based on Likert-scale responses and open-text comments. We conducted a thematic analysis of narrative student experiences (n = 426). RESULTS: Overall, 509 of 551 respondents (92%) rated the indigenous health orientation program as extremely or highly valuable and most (87%) reported that the course strongly increased their interest in indigenous health. The features of the clinical course that enhanced value for learners included situated learning (learning environment; learning context); teaching qualities (enthusiasm and passion for Maori health; role-modelling); curriculum content (re-presenting Maori history; exploring Maori beliefs, values and practices; using a Maori health framework in clinical practice); teaching methodologies (multiple teaching methods; simulated patient interview); and building relationships with peers (getting to know the student cohort; developing professional working relationships). CONCLUSIONS: Undergraduate medical students valued an indigenous health program delivered in an authentic indigenous environment and that explicitly reframed historical notions of indigenous health to contextualize learning. Content relevant to clinical practice, faculty knowledge, and strengthened peer interactions combined to build learner confidence and self-reported indigenous health competencies. These findings suggest empirical evidence to support a curriculum approach to indigenous health teaching that enhances clinical learning.

Doctors learn new tricks, but do they remember them? Lack of effect of an educational intervention in improving Oxygen prescribing.

BACKGROUND AND OBJECTIVE: The 'audit cycle' is a fundamental part of improving clinical performance. For this to be effective, improvements made must be sustained. We observed that the prescription of Oxygen is often poor. Our aim was to audit Oxygen prescription before and after an educational intervention, and then again 4 years on. We hypothesized that improvements made immediately after the intervention would not be sustained over a longer period of time. METHODS: Oxygen prescription was assessed in 102 inpatients between June and August 2009. Following this, an educational intervention to improve Oxygen prescription was staged. Oxygen prescription was then re-audited in a further 102 inpatients between September 2009 and February 2010. A third audit of 72 inpatients took place between February and May 2014. RESULTS: One-way analysis of variance showed significant variance between audit groups (F 8.74, F-crit 4.26, P = 0.008). Post-hoc analysis with paired t-tests confirmed significant improvement in the rate of Oxygen prescription in the second audit (24.5-58.8%, P = 0.01), immediately after the intervention. Four years on in the third audit, there was significant deterioration in the rate of Oxygen prescription compared with the second audit (58.8-13.9%, P = 0.01). CONCLUSIONS: The rate of Oxygen prescription improves significantly after an educational intervention; however, this improvement is not sustained. This observation is likely reflected in a range of areas where the audit cycle is used to improve performance. It is important to be aware of this potential for regression to ensure that improvements are maintained over time.

Clinical use of pulse oximetry: official guidelines from the Thoracic Society of Australia and New Zealand.

Pulse oximetry provides a simple, non-invasive approximation of arterial oxygenation in a wide variety of clinical settings including emergency and critical-care medicine, hospital-based and ambulatory care, perioperative monitoring, inpatient and outpatient settings, and for specific diagnostic applications. Pulse oximetry is of utility in perinatal, paediatric, adult and geriatric populations but may require use of age-specific sensors in these groups. It plays a role in the monitoring and treatment of respiratory dysfunction by detecting hypoxaemia and is effective in guiding oxygen therapy in both adult and paediatric populations. Pulse oximetry does not provide information about the adequacy of ventilation or about precise arterial oxygenation, particularly when arterial oxygen levels are very high or very low. Arterial blood gas analysis is the gold standard in these settings. Pulse oximetry may be inaccurate as a marker of oxygenation in the presence of dyshaemoglobinaemias such as carbon monoxide poisoning or methaemoglobinaemia where arterial oxygen saturation values will be overestimated. Technical considerations such as sensor position, signal averaging time and data sampling rates may influence clinical interpretation of pulse oximetry readings.