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Combination inhaled corticosteroid–formoterol reliever monotherapy reduces the rate of asthma attacks compared to short-acting β2-agonist (SABA) reliever monotherapy in adults. Its comparative efficacy in children has not been established. CARE was a 52-week, open-label, parallel-group, multicentre, superiority, randomised controlled trial in children aged 5–15 years with asthma using SABA reliever monotherapy at 15 clinical trials sites in New Zealand. Participants were randomly assigned (1:1) to either budesonide 50 μg–formoterol 3 μg, two actuations as needed, or salbutamol 100 μg, two actuations as needed. The primary outcome was asthma attacks as rate per participant per year. This trial was registered with the Australian New Zealand Clinical Trials Registry, ACTRN12620001091998. From Jan 28, 2021, to June 23, 2023, we assessed 382 participants for eligibility. We randomly assigned 360 (94%) participants to treatment (179 [50%] to the budesonide–formoterol group and 181 [50%] to the salbutamol group). The annualised rate of asthma attacks was lower in the budesonide–formoterol group than in the salbutamol group—cluster-adjusted rates 0·23 versus 0·41 per participant per year (relative rate 0·55 [95% CI 0·35–0·86]; p=0·012). The number of participants with at least one adverse event was 162 (91%) in the budesonide–formoterol group and 167 (92%) in the salbutamol group (odds ratio 0·79 [95% CI 0·35–1·79]). In children aged 5–15 years with mild asthma, budesonide–formoterol reliever monotherapy is superior to salbutamol for preventing asthma attacks, with a similar safety profile. Health Research Council of New Zealand, Cure Kids New Zealand, and the Barbara Basham Medical Charitable Trust (managed by Perpetual Guardian).

Dedifferentiated chordoma is a rare, aggressive, chemoresistant and radioresistant malignancy arising from notochord remnants that can occur anywhere along the spine. Incidence in patients under 20 years of age is 1 per 250 million. We report a case of dedifferentiated clival chordoma presenting in a 3-year-old boy with pulmonary metastasis, which responded unusually well to chemotherapy, achieving complete metastatic clearance and debulking of the primary tumour. Proton beam therapy achieved further tumour control, with excellent quality of life for multiple years. On disease relapse, an atypical lateral transcondylar surgical approach achieved complete macroscopic clearance but there was cutaneous seeding. This, and continued primary site activity, failed to be controlled with targeted therapy, traditional chemotherapy and photon radiation, resulting in gradual neurological decline and death. Intensive management resulted in above-average survival despite diagnosis late in the disease course, which may be of value directing investigation into optimal management.

To estimate thresholds for Body Mass Index (BMI) and arm circumference above which a longer needle is needed to ensure intramuscular (IM) delivery of a vaccine in the deltoid muscle at the site recommended by New Zealand (NZ) immunization guidelines. A combined analysis of two studies, including 442 adults, with measurements of arm circumference, BMI and skin to deltoid muscle distance (SDMD) at the NZ immunization guideline-recommended IM injection site. Receiver Operator Characteristic curves identified arm circumference and BMI cut-points that gave 100% sensitivity for SDMD thresholds. These thresholds were: SDMD of 20 mm, accounting for a minimal penetration of 5 mm into muscle with the standard needle; and 25 mm, which is the length of a standard needle for IM injection, representing the depth this can reach. Cut-point values for arm circumference, at which a longer needle would be required, were higher for males than females: 35 cm versus 30 cm for the 20 mm cut-point, and 40 cm versus 36.7 cm for the 25 mm cut-point respectively. The BMI cut-points were also higher for male than females: 24.6 kg/m2 versus 23.7 kg/m2 for the 20 mm cut-point, and 38.2 kg/m2 vs 31.6 kg/m2 for the 25 mm cut-point respectively. Arm circumference and BMI cut-points provide practical measures from which to choose a needle length that increases the chance of successful IM vaccination. Based on our data, an arm circumference of 35 cm for men and 30 cm for women should prompt selection of a longer needle to ensure intramuscular injection at the deltoid site. Thresholds for the different skin to deltoid sites proposed internationally should be determined to enable successful IM vaccination in clinical practice beyond NZ.

ObjectiveTo compare bronchodilator response after to salbutamol and budesonide/formoterol in adults with stable asthma.MethodsA double-blind, cross-over, single-centre, placebo-controlled, non-inferiority trial. Adults with stable asthma were randomised to different orders of two treatment regimens: two actuations of placebo via MDI and one actuation of budesonide/formoterol 200/6 µg via turbuhaler; and one actuation of placebo turbuhaler and two actuations of salbutamol 100 µg via MDI. The primary outcome measure was FEV1 after 2 min. Secondary outcome measures included FEV1, mBorg Dyspnoea Scale score and visual analogue score for breathlessness over 30 min.ResultsForty-nine of 50 potential participants were randomised. One participant withdrew following the first intervention visit and another could not be randomised due to COVID-19 restrictions. The mean (SD) change from baseline FEV1 2 min after treatment administration for budesonide/formoterol and salbutamol was 0.08 (0.14) L, n=49, and 0.17 (0.18) L, n=48, respectively, mean (95% CI) paired difference of −0.097 L (−0.147 to −0.047), p=0.07, against a non-inferiority bound of −0.06 L. In the secondary analysis, FEV1 over 30 min was lower for budesonide/formoterol compared with salbutamol, difference (95% CI): −0.10 (−0.12 to −0.08) L, p<0.001. There were no differences in Visual Analogue Scale score or mBorg Dyspnoea Scale score between treatments.ConclusionThe results do not support the primary hypothesis of non-inferiority at the boundary of −0.06 L for the difference between budesonide/formoterol 200/6 µg compared with salbutamol 200 µg for FEV1 at 2 min, and could be consistent with inferiority with a p value of 0.07. For the secondary analysis of FEV1 measurements over time, the FEV1 was higher with salbutamol.Trial registration numberAustralian and New Zealand Clinical Trials Registry (ACTRN 12619001387112).

ObjectiveTo characterise the self-isolating household units (bubbles) during the COVID-19 Alert Level 4 lockdown in New Zealand.Design, setting and participantsIn this cross-sectional study, an online survey was distributed to a convenience sample via Facebook advertising and the Medical Research Institute of New Zealand’s social media platforms and mailing list. Respondents were able to share a link to the survey via their own social media platforms and by email. Results were collected over 6 days during Alert Level 4 from respondents living in New Zealand, aged 16 years and over.Main outcomes measuresThe primary outcome was the mean size of a self-isolating household unit or bubble. Secondary outcomes included the mean number of households in each bubble, the proportion of bubbles containing essential workers and/or vulnerable people, and the mean number of times the home was left each week.Results14 876 surveys were included in the analysis. The mean (SD) bubble size was 3.58 (4.63) people, with mean (SD) number of households 1.26 (0.77). The proportion of bubbles containing one or more essential workers, or one or more vulnerable persons was 45.3% and 42.1%, respectively. The mean number of times individual bubble members left their home in the previous week was 12.9 (12.4). Bubbles that contained at least one vulnerable individual had fewer outings over the previous week compared with bubbles that did not contain a vulnerable person. The bubble sizes were similar by respondent ethnicity.ConclusionIn this New Zealand convenience sample, bubble sizes were small, mostly limited to one household, and a high proportion contained essential workers and/or vulnerable people. Understanding these characteristics from a country which achieved a low COVID-19 infection rate may help inform public health interventions during this and future pandemics.

Correspondence to Professor Richard Beasley, Medical Research Institute of New Zealand, Wellington 6242, New Zealand; richard.beasley@mrinz.ac.nz Recognition that there are risks associated with hyperoxaemia, as well as hypoxaemia, with the use of oxygen therapy in critically ill patients, has led to a paradigm shift in clinical practice, from the traditional approach of liberal administration to titration within a target oxygen saturation range.1 This paradigm shift, colloquially referred to as ‘swimming between the flags’,2 particularly applies to the use of oxygen in severe exacerbations of chronic obstructive pulmonary disease (COPD), in which guidelines now recommend that oxygen is titrated to a target oxygen saturation range of 88%–92%.2–4 This recommendation is based on the landmark randomised controlled trial in patients with acute exacerbations of COPD, in which oxygen therapy titrated to maintain oxygen saturations between 88% and 92% in the prehospital setting reduced the risk of mortality by 58%, when compared with high concentration oxygen therapy.5 While this randomised controlled trial provides the evidence base for the recommended 88%–92% target range, it raises the important question as to whether a ‘physiologically normal’ target of 93%–96%, that also avoids hyperoxaemia, may result in better outcomes than the 88%–92% target. In support of this higher target range, the nadir within the U-shaped risk of a serious adverse outcome with oxygen saturation in COPD extends from 88% to 96%, with insufficient delineation of risk within this range.6 The U-shaped association between oxygen saturations and risk of mortality in exacerbations of COPD has been examined further by Echevarria et al in a study published in this journal, and which provides data directly relevant to clinical practice.7 The strengths of their observational study are the power with 2645 consecutive admissions, data obtained on whether oxygen was administered and the ability to control for mortality risk through use of validated mortality prediction scores. External validity of this calculation is obtained from the number needed to cause one death of 14 calculated from the landmark randomised controlled trial of liberal versus titrated oxygen therapy in COPD.5 It may be that the period of grace, in which tolerance to excessive administration of high concentration oxygen to patients with COPD is accepted as entrenched behaviour that is understandable when treating a breathless distressed patient, should now be over.

Abstract This article reports an effective strategy for recruiting patients with asthma to a qualitative study using an animated comic advertised on social media. An ad spend of NZ$432 on Facebook resulted in 101 study enquiries, and 27 participants taking part in the focus groups, of which 16 (56%) were Māori, the Indigenous Peoples of New Zealand. Representation of Māori amongst participants was over five times higher than their proportion in the local population (9.7%), resulting in data fulfilling the principle of equal explanatory power, an approach to research which can help advance Māori health development and address inequity. The success of this campaign is of particular interest for health researchers in New Zealand where Māori continue to be disproportionately affected by poorer health outcomes compared with non-Māori, particularly those with asthma. Approaches that better engage and support participation of under-represented communities in clinical research are of wider global interest. We reflect on the recruitment strategy and outcomes within a Kaupapa Māori framework, explore how this can be applied more widely in healthcare, and suggest direction for future study and implementation. Lay summary We designed an animated comic to advertise a study for patients with asthma. This was shared locally with a Facebook ad. The approach was highly engaging with the public, and resulted in rapid recruitment. Interestingly, participation of Māori (the Indigenous People of New Zealand) was over five times higher than their proportion in the local population. Māori have poorer health outcomes and increased barriers to healthcare access compared with non-Māori, particularly those with asthma. Approaches which can engage and support under-represented communities to participate in clinical research are of wider global interest. In this article, we reflect on the recruitment strategy and outcomes, and suggest direction for future study and implementation.