Sample representativeness and influence of attrition on longitudinal data collected as part of a national medical career tracking project.

BACKGROUND: The Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) in New Zealand is one example of a national survey-based resource of medical student experiences and career outcomes. Longitudinal studies of medical students are valuable for evaluating the outcomes of medical programs against workforce objectives. As a prospective longitudinal multiple-cohort study, survey response rates at each collection point of MSOD vary. This paper assesses the effects of participant non-response rates on MSOD data. METHODS: Demographic variables of MSOD respondents between 2012 and 2018 were compared to the distribution of the demographic variables in the population of all NZ medical graduates to ascertain whether respondent samples at multiple survey collection points were representative of the population. Analysis using logistic regression assessed the impact of participant non-response on variables at collection points throughout MSOD. RESULTS: 2874 out of a total population of 2939 domestic medical students graduating between 2012 and 2018 responded to MSOD surveys. Entry and exit surveys achieved response rates around 80% and were broadly representative of the total population on demographic variables. Post-graduation survey response rates were around 50% of the total population of graduates and underrepresented graduates from the University of Auckland. Between the entry and exit and the exit and postgraduation year three samples, there was a significant impact of non-response on ascribed variables, including age at graduation, university, gender and ethnic identity. Between the exit and postgraduation year one sample, non-response significantly impacted ascribed and non-ascribed variables, including future practice intentions. CONCLUSION: Samples collected from MSOD at entry and exit are representative, and findings from cross-sectional studies using these datasets are likely generalisable to the wider population of NZ medical graduates. Samples collected one and three years post-graduation are less representative. Researchers should be aware of this bias when utilizing these data. When using MSOD data in a longitudinal manner, e.g. comparing the change in career intentions from one collection point to the next, researchers should appropriately control for bias due to non-response between collection points. This study highlights the value of longitudinal career-tracking studies for answering questions relevant to medical education and workforce development.

Women's interest in surgery as a career in the early postgraduate period: a national longitudinal study.

BACKGROUND: Women remain underrepresented in Surgery in Aotearoa New Zealand (AoNZ). This study described interest in surgical careers by gender in the early postgraduate period and associated influencing factors. METHODS: AoNZ medical graduates between 2012 and 2016 responding to an Exit Questionnaire (EQ) at graduation and 3 years later (PGY3) as part of the Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) were included. Analyses of specialty preferences and influences by gender were performed. RESULTS: Of 992 participants, 58% were women. At EQ, 158 participants (16%) had a surgical preference: 21% of men and 14% of women (P < 0.01). By PGY3, this was 20% of men and 10% of women (P < 0.01). A logistic regression found women were half as likely as men to have a surgical preference at PGY3. Those with a surgical preference at EQ were over 23 times more likely to have a surgical preference at PGY3, irrespective of gender. There were significant differences in self-reported career influencing factors between women and men at EQ and PGY3, as well as between PGY3 women with a surgical and those with a non-surgical preference. These included nature of the specialty, training requirements, lifestyle, family and personal factors. CONCLUSIONS: Increasing the proportion of women in Surgery requires a multifaceted approach starting during medical school and continuing through early postgraduate years. More needs to be done to make surgical experiences as an undergraduate and junior doctor appealing to women.

Immunostimulants versus placebo for preventing exacerbations in adults with chronic bronchitis or chronic obstructive pulmonary disease.

BACKGROUND: Individuals with chronic obstructive pulmonary disease (COPD) or chronic bronchitis may experience recurrent exacerbations, which negatively impact prognosis and quality of life, and can impose a significant socioeconomic burden on the individual and wider society. Immunostimulants are a broad category of therapies that may theoretically enhance non-specific immunity against several respiratory insults, thereby reducing exacerbation risk and severity. However, evidence to date for their use in this population is limited. OBJECTIVES: To determine the efficacy of immunostimulants in preventing respiratory exacerbations in adults with chronic obstructive pulmonary disease, chronic bronchitis, or both. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest literature search was conducted on 25 January 2022.  SELECTION CRITERIA: We included parallel randomised controlled trials (RCTs) that compared immunostimulant therapy, administered by any method and with the intention of preventing (rather than treating) exacerbations, with placebo for a minimum treatment duration of one month in adults with chronic bronchitis or COPD, or both. We excluded participants with other respiratory conditions.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were number of participants with no exacerbations during the study period and all-cause mortality, secondary outcomes were respiratory-related mortality, quality of life, number of participants requiring antibiotics, exacerbation duration, respiratory-related hospitalisation duration and adverse events/side effects. We used GRADE to assess certainty of evidence for each outcome. MAIN RESULTS: This review included 36 studies involving 6192 participants. Studies were published between 1981 and 2015. Duration ranged from three to 14 months. The mean age of study participants varied between 35.2 and 82 years. Twelve studies examined participants with COPD only. Seventeen studies reported baseline lung function values; most indicated a moderate-to-severe degree of airflow limitation. Nineteen studies indicated inclusion of participants with a mean baseline exacerbation frequency of two or more in the preceding year. Immunostimulants investigated were OM-85, AM3, RU41740 (Biostim), Ismigen, Diribiotine CK, thymomodulin, pidotimod, D53 (Ribomunyl), Lantigen B, Symbioflor, and hyaluronan; routes of administration were oral, sublingual, and subcutaneous. The risk of bias of the included studies was mostly low or unclear. Participants receiving immunostimulants for a mean duration of six months were slightly more likely to be free of exacerbations during that time (odds ratio (OR) 1.48, 95% confidence interval (CI) 1.15 to 1.90; 15 RCTs, 2961 participants; moderate-certainty evidence). The overall number needed to treat with immunostimulants for a mean of six months, to prevent one participant from experiencing an exacerbation, was 11 (95% CI 7 to 29). This outcome was associated with a moderate degree of unexplained heterogeneity (I2 = 53%). Type of immunostimulant, baseline lung function, baseline exacerbation frequency, treatment duration, and follow-up duration did not modify the effect size, although due to heterogeneity and limited study and participant numbers within some subgroups, the validity of the subgroup treatment effect estimates were uncertain. Immunostimulants probably result in little to no difference in all-cause mortality (OR 0.64, 95% CI 0.37 to 1.10; 5 RCTs, 1558 participants; moderate-certainty evidence) and respiratory-related mortality (OR 0.40, 95% CI 0.15 to 1.07; 2 RCTs, 735 participants; low-certainty evidence) compared to placebo; however, the effects were imprecise and data quality limited the certainty of these results.  There was a small improvement in health-related quality of life, as measured by the St George's Respiratory Questionnaire (SGRQ), with immunostimulant compared to placebo (mean difference -4.59, 95% CI -7.59 to -1.59; 2 RCTs, 617 participants; very-low certainty evidence). The effect estimate just met the minimum clinically important difference (MCID) score of 4 units; however, the CI width means the possibility of a non-meaningful difference cannot be excluded. The pooled result from five studies indicated that immunostimulants likely reduce the number of participants requiring antibiotics over a mean duration of six months (OR 0.34, 95% CI 0.18 to 0.63; 542 participants; moderate-certainty evidence). This outcome had a low-to-moderate degree of heterogeneity (I2 = 38%), but the direction of effect was consistent across all studies. There was no evidence of a difference in the odds of experiencing an adverse event with immunostimulant compared to placebo, over a mean duration of six months (OR 1.01, 95% CI 0.84 to 1.21; 20 RCTs, 3780 participants; high-certainty evidence). The CI limits for the associated risk ratio (RR) did not cross thresholds for appreciable harm or benefit (RR 1.02, 95% CI 0.92 to 1.13). An additional seven studies reported no events rates in either study arm. Meta-analyses were not performed for the outcomes of exacerbation duration and respiratory-related hospitalisation duration, due to high levels of heterogeneity across the included studies (exacerbation duration: I2 = 92%; respiratory-related hospitalisation duration: I2 = 83%). Results from an effect direction plot and binomial probability test for exacerbation duration indicated that a significant proportion of studies (94% (95% CI 73% to 99%); P = 0.0002) favoured intervention, possibly indicating that immunostimulants are efficacious in reducing the mean exacerbation duration compared to placebo. However, the degree of uncertainty associated with this estimate remained high due to data quality and heterogeneity. Three studies reported mean duration of respiratory-related hospitalisation, two of which demonstrated a direction of effect that favoured immunostimulant over placebo. AUTHORS' CONCLUSIONS: In participants with chronic bronchitis or COPD, we are moderately confident that treatment with immunostimulants is associated with a small reduction in the likelihood of having an exacerbation and a moderate reduction in the requirement for antibiotics. Low numbers of events limit interpretation of the effect of immunostimulants on all-cause and respiratory-related mortality. We are uncertain whether immunostimulants improve quality of life, and whether they are associated with a reduction in exacerbation and respiratory-related hospitalisation durations, although immunostimulants were generally associated with a positive effect direction in the studies that examined these outcomes. Immunostimulants appear to be safe and well-tolerated, and are not associated with an increased risk of adverse events.

Effects of a regional-rural immersion program in Northland, New Zealand, on returning to work in that region.

INTRODUCTION: It is well established that rural workforce outcomes are more likely among medical graduates who spend time training in non-urban areas; however, fewer studies have assessed whether graduates are more likely to return to the specific area where they undertook rural training. OBJECTIVE: This study aimed to determine whether graduates who had undertaken a regional-rural immersion program in Northland, NZ, were more likely to have returned to work in Northland as of mid-2021, relative to peers who did not participate. DESIGN: This prospective cohort study used longitudinal tracking survey responses, medical school administrative data and workforce outcome information. A multinomial model, accounting for other covariates, was built to determine the association between graduates practising in Northland (population ⟨ 100 000), which encompasses both rural (population ⟨ 25 000) and regional (25 000 ⟩ population ⟨ 100 000) areas, and having participated in a Northland-based immersion program during medical school. The study population was University of Auckland domestic medical students graduating between 2009 and 2018, inclusive. Immersion program participants who responded to longitudinal career tracking surveys were included in the study sample. FINDINGS: The final sample size was 1320 students (80% of population of interest). Graduates who undertook the Northland immersion program (n = 169) were more likely than non-participants (n = 1151) to be working in Northland as of 2020-2021 (relative risk: 3.2). DISCUSSION AND CONCLUSION: Regional-rural immersion programs might preferentially build workforces in that specific region; however, further research is required to understand whether these findings are generalizable, and the main reasons for this effect.

How rural is rural? The relationship between rural background of medical students and their career location intentions.

OBJECTIVE: Rural background is associated with greater interest in rural practice. However, there is no universally agreed definition of 'rural' background used in medical school selection. This study explored the association between definitions of 'rural' background and students' intended career locations. DESIGN: Prospective cohort study using survey data on career intention, hometown size, rurality of background, home address, high school and intended career location. SETTING: University of Auckland, New Zealand (NZ). PARTICIPANTS: Commencing medical students 2009-2017, inclusive. MAIN OUTCOME MEASURES: Univariate associations between student background according to 7 definitions of 'rural', and 3 definitions of intended practice location based on population size: urban intention (>100 000); regional intention (25 000-100 000); rural intention (<25 000). RESULTS: The sample size was 1592 students. 27.4% had a rural background by at least one definition. All definitions of rural background were associated with a greater rural intention. Applying a restrictive definition of rural (population<25 000) was associated with a higher likelihood of rural intention, but captured a smaller number of students. There was strong agreement between the population size of a student's background and intended practice location (chi-square P < .0001). CONCLUSION: Rural intention varies by definition, but the number of students captured by each definition is important. Applying a binary or overly restrictive definition may limit interested students. Medical schools should adopt a definition of 'rural' that optimises the number of eligible students and their propensity to work rurally. Further, alternative ways of identifying students with rural intentions without a rural background should be explored.

National study of the impact of rural immersion programs on intended location of medical practice in New Zealand.

INTRODUCTION: New Zealand (NZ) faces an ongoing shortage of rural medical professionals. In an effort to increase interest in rural practice, both of the medical schools in NZ offer rural immersion programs as well as rural entry pathways. The aim of this study was to compare the effect of long (>33-week) rural immersion with a short (5-week interprofessional) rural immersion or no rural immersion on the career location intentions of NZ medical students. METHODS: This observational study used linked data from the Commencing Medical Students Questionnaire (CMSQ) and Exit Questionnaire (EQ), collected between 2011 and 2017 as part of the Medical Schools Outcomes Database project, along with information on whether or not a student undertook a rural immersion program. The main outcome measure was EQ career location intention (Rural (population 100 000)). The explanatory variables were rural immersion (long, short, none), age, ethnicity, background, CMSQ career location intention, gender, specialisation preferences and interest in rural medicine. In addition to univariate analysis, data were used to build a multinomial model to determine relative associations of these variables with the outcome. RESULTS: Full data were available for 1367 NZ medical students (47% of all students during the time period). Of these, 17.4% had undertaken a long or short rural immersion program. In univariate analysis, age was the only variable that did not significantly predict EQ rural intention outcome. In the multivariate model, rural immersion was a significant independent predictor of EQ career location intention. Students taking a long rural immersion were 6.4 and 4.4 times more likely to select a Rural or Regional intention, respectively, than those with no rural immersion. This strong effect on rural intentions was seen regardless of background. CMSQ career location intention, background, ethnicity, rural club membership and preference for general practice were also significant predictors. While short rural immersion did not have an independent effect, this finding should be interpreted with caution given the smaller number of students and the response rate. CONCLUSIONS: Long rural immersion is highly beneficial for increasing interest in rural work, increasing the likelihood that medical students will intend to work outside an urban setting. Students who signal an early rural intention are strong candidates for such programs later in their course, regardless of their background. A three-category classification for geographic background and career location intention permitted a more detailed understanding of the interplay among demographic variables and rural immersion in influencing career intentions. Following cohorts into their postgraduate years is needed to ascertain if these career location intentions persist.

Phosphodiesterase-4 inhibitors for chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with cough, sputum production or dyspnoea, and a reduction in lung function, quality of life, and life expectancy. Apart from smoking cessation, no other treatments that slow lung function decline are available. Roflumilast and cilomilast are oral phosphodiesterase-4 (PDE4) inhibitors proposed to reduce the airway inflammation and bronchoconstriction seen in COPD. This Cochrane Review was first published in 2011, and was updated in 2017 and 2020. OBJECTIVES: To evaluate the efficacy and safety of oral PDE4 inhibitors for management of stable COPD. SEARCH METHODS: We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register (date of last search 9 March 2020). We found other trials at web-based clinical trials registers. SELECTION CRITERIA: We included RCTs if they compared oral PDE4 inhibitors with placebo in people with COPD. We allowed co-administration of standard COPD therapy. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Two independent review authors selected trials for inclusion, extracted data, and assessed risk of bias. We resolved discrepancies by involving a third review author. We assessed our confidence in the evidence by using GRADE recommendations. Primary outcomes were change in lung function (minimally important difference (MID) = 100 mL) and quality of life (scale 0 to 100; higher score indicates more limitations). MAIN RESULTS: We found 42 RCTs that met the inclusion criteria and were included in the analyses for roflumilast (28 trials with 18,046 participants) or cilomilast (14 trials with 6457 participants) or tetomilast (1 trial with 84 participants), with a duration between six weeks and one year or longer. These trials included people across international study centres with moderate to very severe COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades II to IV), with mean age of 64 years. We judged risks of selection bias, performance bias, and attrition bias as low overall amongst the 39 published and unpublished trials. Lung function Treatment with a PDE4 inhibitor was associated with a small, clinically insignificant improvement in forced expiratory volume in one second (FEV1) over a mean of 40 weeks compared with placebo (mean difference (MD) 49.33 mL, 95% confidence interval (CI) 44.17 to 54.49; participants = 20,815; studies = 29; moderate-certainty evidence). Forced vital capacity (FVC) and peak expiratory flow (PEF) were also improved over 40 weeks (FVC: MD 86.98 mL, 95% CI 74.65 to 99.31; participants = 22,108; studies = 17; high-certainty evidence; PEF: MD 6.54 L/min, 95% CI 3.95 to 9.13; participants = 4245; studies = 6; low-certainty evidence). Quality of life Trials reported improvements in quality of life over a mean of 33 weeks (St George's Respiratory Questionnaire (SGRQ) MD -1.06 units, 95% CI -1.68 to -0.43; participants = 7645 ; moderate-certainty evidence). Incidence of exacerbations Treatment with a PDE4 inhibitor was associated with a reduced likelihood of COPD exacerbation over a mean of 40 weeks (odds ratio (OR) 0.78, 95% CI 0.73 to 0.84; participants = 20,382; studies = 27; high-certainty evidence), that is, for every 100 people treated with PDE4 inhibitors, five more remained exacerbation-free during the study period compared with those given placebo (number needed to treat for an additional beneficial outcome (NNTB) 20, 95% CI 16 to 27). No change in COPD-related symptoms nor in exercise tolerance was found. Adverse events More participants in the treatment groups experienced an adverse effect compared with control participants over a mean of 39 weeks (OR 1.30, 95% CI 1.22 to 1.38; participants = 21,310; studies = 30; low-certainty evidence). Participants experienced a range of gastrointestinal symptoms such as diarrhoea, nausea, vomiting, or dyspepsia. Diarrhoea was more commonly reported with PDE4 inhibitor treatment (OR 3.20, 95% CI 2.74 to 3.50; participants = 20,623; studies = 29; high-certainty evidence), that is, for every 100 people treated with PDE4 inhibitors, seven more suffered from diarrhoea during the study period compared with those given placebo (number needed to treat for an additional harmful outcome (NNTH) 15, 95% CI 13 to 17). The likelihood of psychiatric adverse events was higher with roflumilast 500 µg than with placebo (OR 2.13, 95% CI 1.79 to 2.54; participants = 11,168; studies = 15 (COPD pool data); moderate-certainty evidence). Roflumilast in particular was associated with weight loss during the trial period and with an increase in insomnia and depressive mood symptoms. Participants treated with PDE4 inhibitors were more likely to withdraw from trial participation; on average, 14% in the treatment groups withdrew compared with 8% in the control groups. Mortality No effect on mortality was found (OR 0.98, 95% CI 0.77 to 1.24; participants = 19,786; studies = 27; moderate-certainty evidence), although mortality was a rare event during these trials. AUTHORS' CONCLUSIONS: For this current update, five new studies from the 2020 search contributed to existing findings but made little impact on outcomes described in earlier versions of this review. PDE4 inhibitors offered a small benefit over placebo in improving lung function and reducing the likelihood of exacerbations in people with COPD; however, they had little impact on quality of life or on symptoms. Gastrointestinal adverse effects and weight loss were common, and the likelihood of psychiatric symptoms was higher, with roflumilast 500 µg. The findings of this review provide cautious support for the use of PDE4 inhibitors in COPD. In accordance with GOLD 2020 guidelines, they may have a place as add-on therapy for a subgroup of people with persistent symptoms or exacerbations despite optimal COPD management (e.g. people whose condition is not controlled by fixed-dose long-acting beta2-agonist (LABA) and inhaled corticosteroid (ICS) combinations). More longer-term trials are needed to determine whether or not PDE4 inhibitors modify FEV1 decline, hospitalisation, or mortality in COPD.

Enhancing Maori and Pasifika graduate interest in ophthalmology surgical training in New Zealand/Aotearoa: Barriers and opportunities.

IMPORTANCE: Improving the representation of indigenous ophthalmologists in New Zealand. BACKGROUND: Maori, indigenous to New Zealand/Aotearoa and Pacific Peoples indigenous to Pacific Island Nations living in New Zealand, experience poorer health outcomes across several ophthalmic conditions. The Royal Australian and New Zealand College of Ophthalmologists have identified indigenous workforce development as a priority. DESIGN: Mixed-methods study, utilizing retrospective analysis of Medical Schools Outcomes Database and Longitudinal Tracking Project responses, and prospective interviews with Maori/Pasifika medical graduates. PARTICIPANTS: This study involved 64 medical graduates from the University of Auckland (UoA) and the University of Otago, and six Maori/Pasifika medical postgraduates in New Zealand. METHODS: Retrospective analysis of medical graduate responses who ranked ophthalmology among their top-three preferred specialties in the Medical Schools Outcomes Database and Longitudinal Tracking Project. Prospective semi-structured interviews with Maori/Pasifika medical postgraduates. MAIN OUTCOME MEASURES: Specialty training influencing factors and prevocational ophthalmology experience. RESULTS: A total of 64 (6.7%) out of 954 medical graduates from the UoA and University of Otago ranked ophthalmology among their top-three preferred training specialties (2012-2017). Of the 64 graduates, six (9.3%) identified as Maori/Pasifika. No significant difference in influencing factors between Maori/Pasifika and non-Maori/Pasifika students was identified. Both groups ranked intellectual content, procedural skills, specialty exposure and mentorship as highly influential. Qualitative interviews with Maori/Pasifika graduates highlighted positive experiences in ophthalmology but limited exposure overall. Negative anecdotes and unclear training pathways discouraged Maori/Pasifika interest in Ophthalmology training. CONCLUSIONS AND RELEVANCE: Maori/Pasifika graduate interest in ophthalmology training was relatively low. Valuable insights include enhancing specialty exposure, mentor development, promoting Maori/Pasifika connections and clarifying training pathways for future graduates.

The employment gap: the relationship between medical student career choices and the future needs of the New Zealand medical workforce.

AIMS: To determine the career decision intentions of graduating doctors, and the relationship between these intentions and the predicted medical workforce needs in New Zealand in 10 years' time. METHODS: A workforce forecasting model developed by the Ministry of Health (MOH) has been used to predict the proportion of doctors required in each medical specialty in 2028 in New Zealand. The future work intentions of recently graduated doctors at the Universities of Auckland and Otago were collected from the Medical Student Outcomes Data (MSOD), and compared with these predicted needs. RESULTS: Between 2013 and 2017, 2,292 doctors graduated in New Zealand, of whom 1,583 completed the MSOD preferences section (response rate 69%). Of these only 50.1% had decided on a future medical specialty. The most popular were surgical specialties (26.2%), general practice (20.7%), and internal medicine (11.0%). Compared to the MOH workforce forecast model there appears to be insufficient interest in general practice at the time of graduation. CONCLUSIONS: To shape the medical workforce to meet forecast needs, multiple stakeholders will need to collaborate, with a special focus on the early postgraduate years, as many doctors have yet to decide on specialisation.

Developing New Zealand's medical workforce: realising the potential of longitudinal career tracking.

For over a decade, the Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) has collected data from medical students in Australia and New Zealand. This project aims to explore how individual student background or attributes might interact with curriculum or early postgraduate training to affect eventual career choice and location. In New Zealand, over 4,000 students have voluntarily provided information at various time points, and the project is at a stage where some firm conclusions are starting to be drawn. This paper presents the background to the project along with some early results and future directions.

Mucolytic agents versus placebo for chronic bronchitis or chronic obstructive pulmonary disease.

BACKGROUND: Individuals with chronic bronchitis or chronic obstructive pulmonary disease (COPD) may suffer recurrent exacerbations with an increase in volume or purulence of sputum, or both. Personal and healthcare costs associated with exacerbations indicate that therapies that reduce the occurrence of exacerbations are likely to be useful. Mucolytics are oral medicines that are believed to increase expectoration of sputum by reducing its viscosity, thus making it easier to cough it up. Improved expectoration of sputum may lead to a reduction in exacerbations of COPD. OBJECTIVES: Primary objective• To determine whether treatment with mucolytics reduces exacerbations and/or days of disability in patients with chronic bronchitis or COPDSecondary objectives• To assess whether mucolytics lead to improvement in lung function or quality of life• To determine frequency of adverse effects associated with use of mucolytics SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register and reference lists of articles on 12 separate occasions, most recently on 23 April 2019. SELECTION CRITERIA: We included randomised studies that compared oral mucolytic therapy versus placebo for at least two months in adults with chronic bronchitis or COPD. We excluded studies of people with asthma and cystic fibrosis. DATA COLLECTION AND ANALYSIS: This review analysed summary data only, most derived from published studies. For earlier versions, one review author extracted data, which were rechecked in subsequent updates. In later versions, review authors double-checked extracted data and then entered data into RevMan 5.3 for analysis. MAIN RESULTS: We added four studies for the 2019 update. The review now includes 38 trials, recruiting a total of 10,377 participants. Studies lasted between two months and three years and investigated a range of mucolytics, including N-acetylcysteine, carbocysteine, erdosteine, and ambroxol, given at least once daily. Many studies did not clearly describe allocation concealment, and we had concerns about blinding and high levels of attrition in some studies. The primary outcomes were exacerbations and number of days of disability.Results of 28 studies including 6723 participants show that receiving mucolytics may be more likely to be exacerbation-free during the study period compared to those given placebo (Peto odds ratio (OR) 1.73, 95% confidence interval (CI) 1.56 to 1.91; moderate-certainty evidence). However, more recent studies show less benefit of treatment than was reported in earlier studies in this review. The overall number needed to treat with mucolytics for an average of nine months to keep an additional participant free from exacerbations was eight (NNTB 8, 95% CI 7 to 10). High heterogeneity was noted for this outcome (I² = 62%), so results need to be interpreted with caution. The type or dose of mucolytic did not seem to alter the effect size, nor did the severity of COPD, including exacerbation history. Longer studies showed smaller effects of mucolytics than were reported in shorter studies.Mucolytic use was associated with a reduction of 0.43 days of disability per participant per month compared with use of placebo (95% CI -0.56 to -0.30; studies = 9; I² = 61%; moderate-certainty evidence). With mucolytics, the number of people with one or more hospitalisations was reduced, but study results were not consistent (Peto OR 0.68, 95% CI 0.52 to 0.89; participants = 1788; studies = 4; I² = 58%; moderate-certainty evidence). Investigators reported improved quality of life with mucolytics (mean difference (MD) -1.37, 95% CI -2.85 to 0.11; participants = 2721; studies = 7; I² = 64%; moderate-certainty evidence). However, the mean difference did not reach the minimal clinically important difference of -4 units, and the confidence interval includes no difference. Mucolytic treatment was associated with a possible reduction in adverse events (OR 0.84, 95% CI 0.74 to 0.94; participants = 7264; studies = 24; I² = 46%; moderate-certainty evidence), but the pooled effect includes no difference if a random-effects model is used. Several studies that could not be included in the meta-analysis reported high numbers of adverse events, up to a mean of five events per person during follow-up. There was no clear difference between mucolytics and placebo for mortality, but the confidence interval is too wide to confirm that treatment has no effect on mortality (Peto OR 0.98, 95% CI 0.51 to 1.87; participants = 3527; studies = 11; I² = 0%; moderate-certainty evidence). AUTHORS' CONCLUSIONS: In participants with chronic bronchitis or COPD, we are moderately confident that treatment with mucolytics leads to a small reduction in the likelihood of having an acute exacerbation, in days of disability per month and possibly hospitalisations, but is not associated with an increase in adverse events. There appears to be limited impact on lung function or health-related quality of life. Results are too imprecise to be certain whether or not there is an effect on mortality. Our confidence in the results is reduced by high levels of heterogeneity in many of the outcomes and the fact that effects on exacerbations shown in early trials were larger than those reported by more recent studies. This may be a result of greater risk of selection or publication bias in earlier trials, thus benefits of treatment may not be as great as was suggested by previous evidence.

Keeping them interested: a national study of factors that change medical student interest in working rurally.

INTRODUCTION: In most countries it remains a challenge to sustain the rural medical workforce. Based on evidence that medical students with rural backgrounds are more likely than their urban peers to enter rural practice, medical schools may have rural entry pathways. It is less well established what happens to career intentions during medical school. This study assessed how rural intentions persist or change during medical school and sought factors associated with either persistence or change in rural intention. METHODS: Students who participate in the Medical Schools Outcomes Database and Longitudinal Tracking project complete surveys at entry to and exit from medical school. They are asked about demographics, career intentions and influencing factors. This study used data from students at both of New Zealand's medical schools from 2006 to 2016. Participants were placed into one of four groups: rural intention at entry and rural intention at exit (R-R), urban at entry and rural at exit (U-R), rural at entry and urban at exit (R-U) or urban at entry and urban at exit (U-U). 'Rural' was defined as an area with a population of 100 000 or fewer. Differences among the groups in demographics and influencing factors were analysed. RESULTS: Overall, 4368 students completed an entry survey (response rate 85.9%), and 2243 students completed an exit survey (response rate 66.4%). A third intended to work in a rural area; of these, 49% had a rural background and 51% an urban background. From the linked entry and exit data (n=1114), there were 239 (21.4%), 188 (16.8%), 135 (12.1%) and 552 (49.5%) students in the R-R, U-R, R-U and U-U groups respectively (p<0.001). Most students had a stable geographical career intention. Of those who changed, more moved towards a rural intention than away from it. Medical students with a persistent rural pattern had characteristics of a rural background (70%), being female (68%), New Zealand European (76%) or having involvement with a rural club for at least 1 year (45%). These students were also more likely to express a GP career intention as their first choice (25%). There were small differences in age, but otherwise no particular demographic factors were associated with students who changed intention. Similarly there were only small differences in perceived career influencing factors among groups. CONCLUSION: This large national study shows a stability of career location intention for the majority of students. It confirms earlier findings of the importance of rural background in rural career preference, but shows that women may have a higher propensity for a persisting rural interest. Apart from providing quality experience in rural areas for all students, and facilitating rural clubs, the study did not reveal any other strategies that might be used by medical schools to either increase or prevent the loss of rural interest.

Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD).

BACKGROUND: There has been renewal of interest in the use of prophylactic antibiotics to reduce the frequency of exacerbations and improve quality of life in chronic obstructive pulmonary disease (COPD). OBJECTIVES: To determine whether or not regular (continuous, intermittent or pulsed) treatment of COPD patients with prophylactic antibiotics reduces exacerbations or affects quality of life. SEARCH METHODS: We searched the Cochrane Airways Group Trials Register and bibliographies of relevant studies. The latest literature search was performed on 27 July 2018. SELECTION CRITERIA: Randomised controlled trials (RCTs) that compared prophylactic antibiotics with placebo in patients with COPD. DATA COLLECTION AND ANALYSIS: We used the standard Cochrane methods. Two independent review authors selected studies for inclusion, extracted data, and assessed risk of bias. We resolved discrepancies by involving a third review author. MAIN RESULTS: We included 14 studies involving 3932 participants in this review. We identified two further studies meeting inclusion criteria but both were terminated early without providing results. All studies were published between 2001 and 2015. Nine studies were of continuous macrolide antibiotics, two studies were of intermittent antibiotic prophylaxis (three times per week) and two were of pulsed antibiotic regimens (e.g. five days every eight weeks). The final study included one continuous, one intermittent and one pulsed arm. The antibiotics investigated were azithromycin, erythromycin, clarithromycin, doxycyline, roxithromycin and moxifloxacin. The study duration varied from three months to 36 months and all used intention-to-treat analysis. Most of the pooled results were of moderate quality. The risk of bias of the included studies was generally low.The studies recruited participants with a mean age between 65 and 72 years and mostly at least moderate-severity COPD. Five studies only included participants with frequent exacerbations and two studies recruited participants requiring systemic steroids or antibiotics or both, or who were at the end stage of their disease and required oxygen. One study recruited participants with pulmonary hypertension secondary to COPD and a further study was specifically designed to asses whether eradication of Chlamydia pneumoniae reduced exacerbation rates.The co-primary outcomes for this review were the number of exacerbations and quality of life.With use of prophylactic antibiotics, the number of participants experiencing one or more exacerbations was reduced (odds ratio (OR) 0.57, 95% CI 0.42 to 0.78; participants = 2716; studies = 8; moderate-quality evidence). This represented a reduction from 61% of participants in the control group compared to 47% in the treatment group (95% CI 39% to 55%). The number needed to treat for an additional beneficial outcome with prophylactic antibiotics given for three to 12 months to prevent one person from experiencing an exacerbation (NNTB) was 8 (95% CI 5 to 17). The test for subgroup difference suggested that continuous and intermittent antibiotics may be more effective than pulsed antibiotics (P = 0.02, I² = 73.3%).The frequency of exacerbations per patient per year was also reduced with prophylactic antibiotic treatment (rate ratio 0.67; 95% CI 0.54 to 0.83; participants = 1384; studies = 5; moderate-quality evidence). Although we were unable to pool the result, six of the seven studies reporting time to first exacerbation identified an increase (i.e. benefit) with antibiotics, which was reported as statistically significant in four studies.There was a statistically significant improvement in quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) with prophylactic antibiotic treatment, but this was smaller than the four unit improvement that is regarded as being clinically significant (mean difference (MD) -1.94, 95% CI -3.13 to -0.75; participants = 2237; studies = 7, high-quality evidence).Prophylactic antibiotics showed no significant effect on the secondary outcomes of frequency of hospital admissions, change in forced expiratory volume in one second (FEV1), serious adverse events or all-cause mortality (moderate-quality evidence). There was some evidence of benefit in exercise tolerance, but this was driven by a single study of lower methodological quality.The adverse events that were recorded varied among the studies depending on the antibiotics used. Azithromycin was associated with significant hearing loss in the treatment group, which was in many cases reversible or partially reversible. The moxifloxacin pulsed study reported a significantly higher number of adverse events in the treatment arm due to the marked increase in gastrointestinal adverse events (P < 0.001). Some adverse events that led to drug discontinuation, such as development of long QTc or tinnitus, were not significantly more frequent in the treatment group than the placebo group but pose important considerations in clinical practice.The development of antibiotic resistance in the community is of major concern. Six studies reported on this, but we were unable to combine results. One study found newly colonised participants to have higher rates of antibiotic resistance. Participants colonised with moxifloxacin-sensitive pseudomonas at initiation of therapy rapidly became resistant with the quinolone treatment. A further study with three active treatment arms found an increase in the degree of antibiotic resistance of isolates in all three arms after 13 weeks treatment. AUTHORS' CONCLUSIONS: Use of continuous and intermittent prophylactic antibiotics results in a clinically significant benefit in reducing exacerbations in COPD patients. All studies of continuous and intermittent antibiotics used macrolides, hence the noted benefit applies only to the use of macrolide antibiotics prescribed at least three times per week. The impact of pulsed antibiotics remains uncertain and requires further research.The studies in this review included mostly participants who were frequent exacerbators with at least moderate-severity COPD. There were also older individuals with a mean age over 65 years. The results of these studies apply only to the group of participants who were studied in these studies and may not be generalisable to other groups.Because of concerns about antibiotic resistance and specific adverse effects, consideration of prophylactic antibiotic use should be mindful of the balance between benefits to individual patients and the potential harms to society created by antibiotic overuse. Monitoring of significant side effects including hearing loss, tinnitus, and long QTc in the community in this elderly patient group may require extra health resources.

Influence of student debt on health career location and specialty.

INTRODUCTION In New Zealand (NZ), there are shortages of health professionals in rural areas and in primary care. AIM This study aims to examine the association of student debt levels of medical, nursing, pharmacy and optometry students with: (1) preferred geographical location of practice, specifically preference to work in urban vs. rural areas; and (2) preferred career specialties, specifically interest in primary health care. METHODS Medical, nursing, pharmacy and optometry students completed a questionnaire at graduation that included questions about levels of New Zealand Government Student Loan debt and preferences regarding location of practice and career specialty. In an additional survey, medical students were asked to self-rate the effect of financial factors on their career choices. RESULTS Debt patterns varied across programmes. Medical and pharmacy students with high debt were significantly more likely than students with low debt to prefer rural over urban practice (P = 0.003). There was no difference in level of interest in a primary care specialty by debt level for any programme. Medical students reported little influence of debt on career choice, although students with high debt levels were less concerned over career financial prospects than students with lower levels of debt. DISCUSSION Current levels of student debt do not deter students from planning a career in rural or primary care settings. Somewhat surprisingly, higher levels of debt are associated with greater rural practice intentions for medical and pharmacy students, although the underlying reasons are uncertain.

Influenza vaccine for chronic obstructive pulmonary disease (COPD).

BACKGROUND: Influenza vaccinations are currently recommended in the care of people with COPD, but these recommendations are based largely on evidence from observational studies, with very few randomised controlled trials (RCTs) reported. Influenza infection causes excess morbidity and mortality in people with COPD, but there is also the potential for influenza vaccination to cause adverse effects, or not to be cost effective. OBJECTIVES: To determine whether influenza vaccination in people with COPD reduces respiratory illness, reduces mortality, is associated with excess adverse events, and is cost effective. SEARCH METHODS: We searched the Cochrane Airways Trials Register, two clinical trials registries, and reference lists of articles. A number of drug companies we contacted also provided references. The latest search was carried out in December 2017. SELECTION CRITERIA: RCTs that compared live or inactivated virus vaccines with placebo, either alone or with another vaccine, in people with COPD. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data. All entries were double-checked. We contacted study authors and drug companies for missing information. We used standard methods expected by Cochrane. MAIN RESULTS: We included 11 RCTs with 6750 participants, but only six of these included people with COPD (2469 participants). The others were conducted on elderly and high-risk individuals, some of whom had chronic lung disease. Interventions compared with placebo were inactivated virus injections and live attenuated intranasal virus vaccines. Some studies compared intra-muscular inactivated vaccine and intranasal live attenuated vaccine with intra-muscular inactivated vaccine and intranasal placebo. Studies were conducted in the UK, USA and Thailand.Inactivated vaccine reduced the total number of exacerbations per vaccinated participant compared with those who received placebo (mean difference (MD) -0.37, 95% confidence interval (CI) -0.64 to -0.11; P = 0.006; two RCTs, 180 participants; low quality evidence). This was due to the reduction in 'late' exacerbations, occurring after three or four weeks (MD -0.39, 95% CI -0.61 to -0.18; P = 0.0004; two RCTs, 180 participants; low quality evidence). Both in people with COPD, and in older people (only a minority of whom had COPD), there were significantly more local adverse reactions in people who had received the vaccine, but the effects were generally mild and transient.There was no evidence of an effect of intranasal live attenuated virus when this was added to inactivated intramuscular vaccination.Two studies evaluating mortality for influenza vaccine versus placebo were too small to have detected any effect on mortality. However, a large study (N=2215) noted that there was no difference in mortality when adding live attenuated virus to inactivated virus vaccination, AUTHORS' CONCLUSIONS: It appeared, from the limited number of RCTs we were able to include, all of which were more than a decade old, that inactivated vaccine reduced exacerbations in people with COPD. The size of effect was similar to that seen in large observational studies, and was due to a reduction in exacerbations occurring three or more weeks after vaccination, and due to influenza. There was a mild increase in transient local adverse effects with vaccination, but no evidence of an increase in early exacerbations. Addition of live attenuated virus to the inactivated vaccine was not shown to confer additional benefit.

Cut-scores revisited: feasibility of a new method for group standard setting.

BACKGROUND: Standard setting is one of the most contentious topics in educational measurement. Commonly-used methods all have well reported limitations. To date, there is not conclusive evidence suggesting which standard setting method yields the highest validity. METHODS: The method described and piloted in this study asked expert judges to estimate the scores on a real MCQ examination that they consider indicated a clear pass, clear fail, and pass mark for the examination as a whole. The mean and SD of the judges responses to these estimates, Z scores and confidence intervals were used to derive the cut-score and the confidence in it. RESULTS: In this example the new method's cut-score was higher than the judges' estimate. The method also yielded estimates of statistical error which determine the range of the acceptable cut-score and the estimated level of confidence one may have in the accuracy of that cut-score. CONCLUSIONS: This new standard-setting method offers some advances, and possibly advantages, in that the decisions being asked of judges are based on firmer constructs, and it takes into account variation among judges.

The efficacy of medical student selection tools in Australia and New Zealand.

OBJECTIVES: To estimate the efficacy of selection tools employed by medical schools for predicting the binary outcomes of completing or not completing medical training and passing or failing a key examination; to investigate the potential usefulness of selection algorithms that do not allow low scores on one tool to be compensated by higher scores on other tools. DESIGN, SETTING AND PARTICIPANTS: Data from four consecutive cohorts of students (3378 students, enrolled 2007-2010) in five undergraduate medical schools in Australia and New Zealand were analysed. Predictor variables were student scores on selection tools: prior academic achievement, Undergraduate Medicine and Health Sciences Admission Test (UMAT), and selection interview. Outcome variables were graduation from the program in a timely fashion, or passing the final clinical skills assessment at the first attempt. MAIN OUTCOME MEASURES: Optimal selection cut-scores determined by discriminant function analysis for each selection tool at each school; efficacy of different selection algorithms for predicting student outcomes. RESULTS: For both outcomes, the cut-scores for prior academic achievement had the greatest predictive value, with medium to very large effect sizes (0.44-1.22) at all five schools. UMAT scores and selection interviews had smaller effect sizes (0.00-0.60). Meeting one or more cut-scores was associated with a significantly greater likelihood of timely graduation in some schools but not in others. CONCLUSIONS: An optimal cut-score can be estimated for a selection tool used for predicting an important program outcome. A "sufficient evidence" selection algorithm, founded on a non-compensatory model, is feasible, and may be useful for some schools.

Phosphodiesterase 4 inhibitors for chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with cough, sputum production or dyspnoea and a reduction in lung function, quality of life and life expectancy. Apart from smoking cessation, there are no other treatments that slow lung function decline. Roflumilast and cilomilast are oral phosphodiesterase 4 (PDE4) inhibitors proposed to reduce the airway inflammation and bronchoconstriction seen in COPD. This is an update of a Cochrane review first published in 2011 and updated in 2013. OBJECTIVES: To evaluate the efficacy and safety of oral PDE4 inhibitors in the management of stable COPD. SEARCH METHODS: We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register (date of last search October 2016). We found other trials from web-based clinical trials registers. SELECTION CRITERIA: We included RCTs if they compared oral PDE4 inhibitors with placebo in people with COPD. We allowed co-administration of standard COPD therapy. DATA COLLECTION AND ANALYSIS: One review author extracted data and a second review author checked the data. We reported pooled data in Review Manager as mean differences (MD), standardised mean differences (SMD) or odds ratios (OR). We converted the odds ratios into absolute treatment effects in a 'Summary of findings' table. MAIN RESULTS: Thirty-four separate RCTs studying roflumilast (20 trials with 17,627 participants) or cilomilast (14 trials with 6457 participants) met the inclusion criteria, with a duration of between six weeks and one year. These included people across international study centres with moderate to very severe COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades II-IV), with a mean age of 64 years.We considered that the methodological quality of the 34 published and unpublished trials was acceptable overall. Treatment with a PDE4 inhibitor was associated with a significant improvement in forced expiratory volume in one second (FEV1) over the trial period compared with placebo (MD 51.53 mL, 95% confidence interval (CI) 43.17 to 59.90, 27 trials with 20,585 participants, moderate-quality evidence due to moderate levels of heterogeneity and risk of reporting bias). There were small improvements in quality of life (St George's Respiratory Questionnaire (SGRQ), MD -1.06 units, 95% CI -1.68 to -0.43, 11 trials with 7645 participants, moderate-quality evidence due to moderate levels of heterogeneity and risk of reporting bias) and COPD-related symptoms, but no significant change in exercise tolerance. Treatment with a PDE4 inhibitor was associated with a reduced likelihood of COPD exacerbation (OR 0.78, 95% CI 0.73 to 0.83; 23 trials with 19,948 participants, high-quality evidence). For every 100 people treated with PDE4 inhibitors, five more remained exacerbation-free during the study period compared with placebo (number needed to treat for an additional beneficial outcome (NNTB) 20, 95% CI 16 to 26). More participants in the treatment groups experienced non-serious adverse events compared with controls, particularly a range of gastrointestinal symptoms such as diarrhoea, nausea, vomiting or dyspepsia. For every 100 people treated with PDE4 inhibitors, seven more suffered from diarrhoea during the study period compared with placebo (number needed to treat for an additional harmful outcome (NNTH) 15, 95% CI 13 to 17). Roflumilast in particular was associated with weight loss during the trial period and an increase in insomnia and depressive mood symptoms. There was no significant effect of treatment on non-fatal serious adverse events (OR 0.99, 95% CI 0.91 to 1.07) or mortality (OR 0.97, 95% CI 0.76 to 1.23), although mortality was a rare event during the trials. Participants treated with PDE4 inhibitors were more likely to withdraw from the trials because of adverse effects; on average 14% in the treatment groups withdrew compared with 8% in the control groups. AUTHORS' CONCLUSIONS: In people with COPD, PDE4 inhibitors offered benefit over placebo in improving lung function and reducing the likelihood of exacerbations; however, they had little impact on quality of life or symptoms. Gastrointestinal adverse effects and weight loss were common, and safety data submitted to the US Food and Drug Administration (FDA) have raised concerns over psychiatric adverse events with roflumilast. The findings of this review give cautious support to the use of PDE4 inhibitors in COPD. They may be best used as add-on therapy in a subgroup of people with persistent symptoms or exacerbations despite optimal COPD management. This is in accordance with the GOLD 2017 guidelines. Longer-term trials are needed to determine whether or not PDE4 inhibitors modify FEV1 decline, hospitalisation or mortality in COPD.

Examining the predictors of academic outcomes for indigenous Maori, Pacific and rural students admitted into medicine via two equity pathways: a retrospective observational study at the University of Auckland, Aotearoa New Zealand.

OBJECTIVE: To determine associations between admission markers of socioeconomic status, transitioning, bridging programme attendance and prior academic preparation on academic outcomes for indigenous Maori, Pacific and rural students admitted into medicine under access pathways designed to widen participation. Findings were compared with students admitted via the general (usual) admission pathway. DESIGN: Retrospective observational study using secondary data. SETTING: 6-year medical programme (MBChB), University of Auckland, Aotearoa New Zealand. Students are selected and admitted into Year 2 following a first year (undergraduate) or prior degree (graduate). PARTICIPANTS: 1676 domestic students admitted into Year 2 between 2002 and 2012 via three pathways: GENERAL admission (1167), Maori and Pacific Admission Scheme-MAPAS (317) or Rural Origin Medical Preferential Entry-ROMPE (192). Of these, 1082 students completed the programme in the study period. MAIN OUTCOME MEASURES: Graduated from medical programme (yes/no), academic scores in Years 2-3 (Grade Point Average (GPA), scored 0-9). RESULTS: 735/778 (95%) of GENERAL, 111/121 (92%) of ROMPE and 146/183 (80%) of MAPAS students graduated from intended programme. The graduation rate was significantly lower in the MAPAS students (p<0.0001). The average Year 2-3 GPA was 6.35 (SD 1.52) for GENERAL, which was higher than 5.82 (SD 1.65, p=0.0013) for ROMPE and 4.33 (SD 1.56, p<0.0001) for MAPAS. Multiple regression analyses identified three key predictors of better academic outcomes: bridging programme attendance, admission as an undergraduate and admission GPA/Grade Point Equivalent (GPE). Attending local urban schools and higher school deciles were also associated with a greater likelihood of graduation. All regression models have controlled for predefined baseline confounders (gender, age and year of admission). CONCLUSIONS: There were varied associations between admission variables and academic outcomes across the three admission pathways. Equity-targeted admission programmes inclusive of variations in academic threshold for entry may support a widening participation agenda, however, additional academic and pastoral supports are recommended.