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Many women experience pelvic floor disorders which may require medical intervention such as transvaginal mesh implant surgeries (TVM; the abdominal or vaginal insertion of woven netting to support pelvic tissue). We examined women's perceptions of communication with their health professionals concerning TVM.We analysed 153 women's written submissions to an Australian Government Inquiry regarding their experiences of transvaginal mesh surgery to explore their perceptions of TVM-related doctor-patient communication. Data were analysed using deductive and inductive reflexive thematic analysis.Women expressed several challenges in their communication with their health professionals. Three themes regarding communication were generated: Insufficient information was abundant; Normalisation and minimisation of the procedure and risks; and, Desired communication interactions.According to women's accounts, doctor-patient communication was poor. Health professionals must be knowledgeable about medical procedures and their potential complications and provide their patients with adequate, accurate information to make informed choices about their health. Health professionals should also document informed consent.Health professionals should be well-informed about TVM, including best-practice treatments for pelvic floor disorders, indications for TVM, the risks, outcomes and potential complications from various forms of TVM, and ways to adequately communicate sufficient information to women.

Abstract Background Early onset fetal growth restriction secondary to placental insufficiency can lead to severe maternal and neonatal morbidity and mortality. Pre-clinical studies and a few small randomised clinical trials have suggested that phosphodiesterase type 5 (PDE-5) inhibitors may have protective effects against placental insufficiency in this context; however, robust evidence is lacking. The STRIDER Consortium conducted four randomised trials to investigate the use of a PDE-5 inhibitor, sildenafil, for the treatment of early onset fetal growth restriction. We present a protocol for the pre-planned systematic review with individual participant data meta-analysis, aggregate meta-analysis, and trial sequential analysis of these and other eligible trials. The main objective of this study will be to evaluate the effects of PDE-5 inhibitors on neonatal morbidity compared with placebo or no intervention among pregnancies with fetal growth restriction. Methods We will search the following electronic databases with no language or date restrictions: OVID MEDLINE, OVID EMBASE, the Cochrane Controlled Register of Trials (CENTRAL), and the clinical trial registers Clinicaltrials.gov and World Health Organisation International Clinical Trials Registry Platform (ICTRP). We will identify randomised trials of PDE-5 inhibitors in singleton pregnancies with growth restriction. Two reviewers will independently screen all citations, full-text articles, and abstract data. Our primary outcome will be infant survival without evidence of serious adverse neonatal outcome. Secondary outcomes will include gestational age at birth and birth weight z-scores. We will assess bias using the Cochrane Risk of Bias 2 tool. We will conduct aggregate meta-analysis using fixed and random effects models, Trial Sequential Analysis, and individual participant data meta-analysis using one- and two-stage approaches. The certainty of evidence will be assessed with GRADE. Discussion This pre-defined protocol will minimise bias during analysis and interpretation of results, toward the goal of providing robust evidence regarding the use of PDE-5 inhibitors for the treatment of early onset fetal growth restriction. Systematic review registration PROSPERO (CRD42017069688).

During a period of intensified exercise (e.g. training/identification camps), often undertaken by competitive youth athletes, the maintenance of muscle function and peak performance can become challenging due to an accumulation of fatigue. The provision of post-exercise dairy protein in adults has been previously shown to accelerate recovery; however, its efficacy in youth athletes is currently unknown. Therefore, the purpose of this study was to examine the effects of increased dairy protein consumption with plain Greek yogurt (GY) on performance and recovery indices during an intensified soccer training camp in adolescent female soccer players.Thirteen players (14.3 ± 1.3 years) participated in a randomized, double blinded, crossover design study where they received 3 servings/day of either GY (~115 kcal, 17 g protein, ~11.5 g carbohydrates) or an isoenergetic carbohydrate control (CHO, ~115 kcal, 0.04 g protein, ~28.6 g carbohydrates) during two 5-day soccer-specific training camps. Performance was assessed before and after each training camp. Fasted, morning, creatine kinase (CK), insulin-like growth factor-1 (IGF-1), C-reactive protein (CRP), interleukin 6 (IL6), interleukin 10 (IL10) and tumor necrosis factor-α (TNFα) were measured in plasma pre- and post-training.Training led to decrements in counter-movement jump (These results demonstrate that consumption of GY did not offer any added recovery benefit with respect to measures of performance and in the attenuation of exercise-induced muscle damage above that achieved with energy-matched carbohydrate in this group of young female soccer players. However, regular consumption of GY may assist with the acute anti-inflammatory response during periods of intensified training in adolescent athletes.

Background Young people need equitable access to high-quality sexual and reproductive health care to enjoy good sexual health. Methods This online survey of people aged 15–24 years in a defined region of New Zealand asked about unmet need for sexual health care and sought views on improving access to sexual health care. Results Five hundred participants took part in the study between August and October 2020, of whom 60% were female, 25% were of Māori (indigenous) ethnicity, and 21.4% were gender and/or sexuality diverse. Sixty percent had ever received sexual health care (300/500), and 74.3% received it from a general practice clinic (223/300). Overall, 41% (204/500) reported they needed, but had not received sexual health care in the past (‘unmet need’). Reasons for unmet need included being shy, embarrassed or ashamed (74.5%, 152/204), fear of judgment by clinic staff (42.6%, 87/204), cost (32.8%, 67/204), concerns about confidentiality (28.9%, 59/204), and not knowing where to go (24%, 49/204). Māori participants were more likely to report not knowing where to go (32.1% vs 20%, P = 0.04). Participants identified the need to reduce stigma, normalise sexual health care, improve convenience, affordability and awareness of services as key to improving access. Reassurance about confidentiality and being treated with kindness, empathy and respect were deemed critical to service acceptability. Conclusions Action is urgently needed at policy, funding and practice levels to improve access to services by: reducing societal stigma, normalising discussions around sexual health, improving affordability and raising awareness of services. Quality improvement is also needed in general practice to ensure young people can routinely access youth-friendly sexual and reproductive health care.

Background The COVID-19 pandemic and associated restrictions caused major global disruption. Individuals with long-term physical health conditions (LTCs) are at higher risk of severe illness and often subject to the strictest pandemic guidance, so may be disproportionally affected. The aim of this study was to qualitatively explore how living with a LTC during the COVID-19 pandemic affected people’s mental health and wellbeing. Methods Participants were people living with LTCs who participated in telephone/video call interviews based on a semi-structured topic guide. Key themes and subthemes were determined using deductive and inductive thematic analysis. Results The sample included 32 participants with LTCs (most commonly cancer, respiratory conditions or cardiovascular diseases), mean age 57 (SD 13) years, 66% female and 72% white British. There were four overarching themes specific to living with a LTC. These were 1) high levels of fear and anxiety related to perceived consequences of catching COVID-19, 2) impact of shielding/isolation on mental health and wellbeing, 3) experience of healthcare during the pandemic and 4) anxiety created by uncertainty about the future. Fourteen subthemes were identified, including concerns about accessing essential supplies and the importance of social support. Individuals who lived alone and were advised to shield could be profoundly negatively affected. Conclusions This study found that there were a number of aspects of living with a LTC during the pandemic that had a significant impact on mental health and well-being. There should be focus on how best to provide practical and social support to people with LTCs during a pandemic, particularly if they have to shield or isolate.

ImportanceNeonatal hypoglycemia is common, but its association with later neurodevelopment is uncertain.ObjectiveTo examine associations between neonatal hypoglycemia and neurocognitive outcomes at corrected age 2 years.Design, Setting, and ParticipantsExploratory cohort analysis of the Hypoglycaemia Prevention With Oral Dextrose (hPOD) randomized clinical trial was conducted. The trial recruited participants from January 9, 2015, to May 5, 2019, with follow-up between January 26, 2017, and July 31, 2021. Infants were recruited from 9 maternity hospitals in New Zealand and assessed at home or in a research clinic. Children born late preterm and at term at risk of neonatal hypoglycemia but without evidence of acute or imminent illness in the first hour after birth were screened and treated to maintain blood glucose concentrations greater than or equal to 47 mg/dL.ExposuresHypoglycemia was defined as any blood glucose concentration less than 47 mg/dL, recurrent as 3 or more episodes, and severe as less than 36 mg/dL.Main Outcomes and MeasuresNeurologic examination and tests of development (Bayley III) and executive function. The primary outcome was neurosensory impairment (any of the following: blindness, deafness, cerebral palsy, developmental delay, or executive function total score worse than 1.5 SD below the mean).ResultsA total of 1197 of 1321 (91%) eligible children were assessed at a mean of corrected age 24 months; 616 (52%) were male. Compared with the normoglycemia group, children who experienced hypoglycemia were more likely to have neurosensory impairment (111 [23%] vs 125 [18%]; adjusted risk ratio [aRR], 1.28; 95% CI, 1.01-1.60), particularly if they experienced severe episodes (30 [28%] vs 125 [18%]; aRR, 1.68; 95% CI, 1.20-2.36), but not recurrent episodes (12 [19%] vs 125 [18%]; aRR, 1.06; 95% CI, 0.63-1.80). The risk of cognitive, language, or motor delay was similar between groups, but children who experienced hypoglycemia had lower Bayley-III composite cognitive (adjusted mean difference [aMD], −1.48; 95% CI, −2.79 to −0.18) and motor scores (aMD, −2.05; 95% CI, −3.30 to −0.79).Conclusions and RelevanceIn children born at risk of hypoglycemia but otherwise well, those who experienced neonatal hypoglycemia were more likely to have neurosensory impairment at corrected age 2 years, with higher risks after severe episodes. Further research is required to determine causality.

Treatment of gestational diabetes improves maternal and infant health, although diagnostic criteria remain unclear.We randomly assigned women at 24 to 32 weeks' gestation in a 1:1 ratio to be evaluated for gestational diabetes with the use of lower or higher glycemic criteria for diagnosis. The lower glycemic criterion was a fasting plasma glucose level of at least 92 mg per deciliter (≥5.1 mmol per liter), a 1-hour level of at least 180 mg per deciliter (≥10.0 mmol per liter), or a 2-hour level of at least 153 mg per deciliter (≥8.5 mmol per liter). The higher glycemic criterion was a fasting plasma glucose level of at least 99 mg per deciliter (≥5.5 mmol per liter) or a 2-hour level of at least 162 mg per deciliter (≥9.0 mmol per liter). The primary outcome was the birth of an infant who was large for gestational age (defined as a birth weight above the 90th percentile according to Fenton-World Health Organization standards). Secondary outcomes were maternal and infant health.A total of 4061 women underwent randomization. Gestational diabetes was diagnosed in 310 of 2022 women (15.3%) in the lower-glycemic-criteria group and in 124 of 2039 women (6.1%) in the higher-glycemic-criteria group. Among 2019 infants born to women in the lower-glycemic-criteria group, 178 (8.8%) were large for gestational age, and among 2031 infants born to women in the higher-glycemic-criteria group, 181 (8.9%) were large for gestational age (adjusted relative risk, 0.98; 95% confidence interval, 0.80 to 1.19; P = 0.82). Induction of labor, use of health services, use of pharmacologic agents, and neonatal hypoglycemia were more common in the lower-glycemic-criteria group than in the higher-glycemic-criteria group. The results for the other secondary outcomes were similar in the two trial groups, and there were no substantial between-group differences in adverse events. Among the women in both groups who had glucose test results that fell between the lower and higher glycemic criteria, those who were treated for gestational diabetes (195 women), as compared with those who were not (178 women), had maternal and infant health benefits, including fewer large-for-gestational-age infants.The use of lower glycemic criteria for the diagnosis of gestational diabetes did not result in a lower risk of a large-for-gestational-age infant than the use of higher glycemic criteria. (Funded by the Health Research Council of New Zealand and others; GEMS Australian New Zealand Clinical Trials Registry number, ACTRN12615000290594.).

BACKGROUND: Treatment of gestational diabetes improves maternal and infant health, although diagnostic criteria remain unclear. METHODS: We randomly assigned women at 24 to 32 weeks' gestation in a 1:1 ratio to be evaluated for gestational diabetes with the use of lower or higher glycemic criteria for diagnosis. The lower glycemic criterion was a fasting plasma glucose level of at least 92 mg per deciliter (≥5.1 mmol per liter), a 1-hour level of at least 180 mg per deciliter (≥10.0 mmol per liter), or a 2-hour level of at least 153 mg per deciliter (≥8.5 mmol per liter). The higher glycemic criterion was a fasting plasma glucose level of at least 99 mg per deciliter (≥5.5 mmol per liter) or a 2-hour level of at least 162 mg per deciliter (≥9.0 mmol per liter). The primary outcome was the birth of an infant who was large for gestational age (defined as a birth weight above the 90th percentile according to Fenton-World Health Organization standards). Secondary outcomes were maternal and infant health. RESULTS: A total of 4061 women underwent randomization. Gestational diabetes was diagnosed in 310 of 2022 women (15.3%) in the lower-glycemic-criteria group and in 124 of 2039 women (6.1%) in the higher-glycemic-criteria group. Among 2019 infants born to women in the lower-glycemic-criteria group, 178 (8.8%) were large for gestational age, and among 2031 infants born to women in the higher-glycemic-criteria group, 181 (8.9%) were large for gestational age (adjusted relative risk, 0.98; 95% confidence interval, 0.80 to 1.19; P = 0.82). Induction of labor, use of health services, use of pharmacologic agents, and neonatal hypoglycemia were more common in the lower-glycemic-criteria group than in the higher-glycemic-criteria group. The results for the other secondary outcomes were similar in the two trial groups, and there were no substantial between-group differences in adverse events. Among the women in both groups who had glucose test results that fell between the lower and higher glycemic criteria, those who were treated for gestational diabetes (195 women), as compared with those who were not (178 women), had maternal and infant health benefits, including fewer large-for-gestational-age infants. CONCLUSIONS: The use of lower glycemic criteria for the diagnosis of gestational diabetes did not result in a lower risk of a large-for-gestational-age infant than the use of higher glycemic criteria. (Funded by the Health Research Council of New Zealand and others; GEMS Australian New Zealand Clinical Trials Registry number, ACTRN12615000290594.).

BackgroundNew Zealand’s response to the COVID-19 pandemic involved a nationwide stay-at-home lockdown in March–April 2020 that restricted access to primary healthcare services.MethodsAn online survey of 15–24-year-olds in a high deprivation region of New Zealand asked about the need for, and receipt of, sexual healthcare during lockdown. Experience of telehealth and preferences for future receipt of sexual healthcare were also explored. Social media advertising was used to recruit participants over five weeks in August and October 2020.ResultsThe survey sample included 500 respondents comprising 58.8% females, 25.4% Māori (indigenous) ethnicity and 21.4% LGBTQI+ (lesbian, gay, bisexual, transgender, queer, intersex +) young people. During lockdown, 22.2% of respondents reported sexual health needs (111/500), but fewer than half this group got help (45%, 50/111), believing their issue could wait, or due to barriers contacting services and lack of information about service availability. Experience of telehealth consultations (by 28/50 participants) was mostly favourable though only 46% agreed it was easier than going to the clinic. Telehealth methods were the preferred option by some participants for future receipt of sexual healthcare; but for most scenarios suggested, respondents favoured in-person clinic visits.ConclusionsYoung people experienced unmet need for sexual healthcare during lockdown in New Zealand, but not because services were unavailable. Findings point to the need for targeted information dissemination to young people about available services and the importance of seeking help during lockdown. More research is needed to understand the advantages and disadvantages of sexual healthcare delivered via telehealth to inform future service provision.

Background: Bariatric surgery leads to long-term remission and reduced incidence of diabetes, hypertension, and dyslipidemia. Short-term studies suggest reduction in specific fat depots may be more predictive of health improvement than reduced body mass index (BMI). Visceral, subcutaneous, epicardial, and liver fat, measured 11 years after bariatric surgery, were associated with long-term remission and incidence of diabetes, dyslipidemia, and hypertension. Methods: Fat depots an average of 11 (maximum 14) years after surgery were quantified by noncontrast computed tomography in subjects who did (N = 261; 86% gastric bypass) or did not (N = 243) have bariatric surgery. Multiple regression related fat depots to disease endpoints with and without adjustment for change in BMI and surgical status. Results: Visceral fat was 42% lower, subcutaneous fat 20% lower, epicardial fat 30% lower, and liver-to-spleen density ratio 9% higher at follow-up in the bariatric surgery group compared with the nonsurgery group (all P

Background: We recently introduced the myocardial-ischemic-injury-index (MI3), a machine learning algorithm that predicts the likelihood of myocardial infarction in patients with suspected acute coronary syndrome. Whether this algorithm performs well in routine clinical practice or predicts subsequent events is unknown.Methods: MI3 was validated in a prespecified exploratory analysis from a multi-centre randomised trial that included consecutive patients with suspected acute coronary syndrome undergoing serial high-sensitivity cardiac troponin I measurement. Patients with ST-segment elevation myocardial infarction were excluded. MI3 incorporates age, sex, and two troponin measurements to compute a value (0-100) reflecting an individual’s likelihood of myocardial infarction during the index visit and estimates diagnostic performance metrics at the computed score. Model performance for an index diagnosis of myocardial infarction, and for subsequent myocardial infarction or cardiovascular death at one year was determined using previously defined low- and high-probability MI3 thresholds (1·6 and 49·7, respectively). Findings: In total, 20,761 patients (64±16 years, 46% women) were included of whom 3,272 (15·8%) had myocardial infarction. MI3 had an area under the receiver-operating-characteristic curve of 0·949 (95% confidence interval 0·946-0·952) identifying 12,983 (62·5%) patients as low-probability (sensitivity 99·3% [99·0-99·6%], negative predictive value 99·8% [99·8-99·9%]), and 2,961 (14·3%) as high-probability (specificity 95·0% [94·6-95·3%], positive predictive value 70·4% [68·7-72·0%]). At one year, subsequent myocardial infarction or cardiovascular death occurred more often in high-probability compared to low-probability patients (17·6% [520/2,961] versus 1·5% [197/12,983], PInterpretation: In consecutive patients undergoing serial cardiac troponin measurement for suspected acute coronary syndrome, the MI3 algorithm accurately estimates the likelihood of myocardial infarction and predicts subsequent adverse cardiovascular events.

Background People using maternity services in the United Kingdom (UK) have faced significant changes brought on by the COVID-19 pandemic and social distancing regulations. We focused on the experiences of pregnant women using UK maternity services during the pandemic and the impact of social distancing rules on their mental health and wellbeing. Methods We conducted 23 qualitative semi-structured interviews from June 2020 to August 2021, with women from across the UK who experienced a pregnancy during the pandemic. Nineteen participants in the study carried their pregnancy to term and four had experienced a miscarriage during the pandemic. Interviews took place remotely over video or telephone call, discussing topics such as mental health during pregnancy and use of UK maternity services. We used reflexive thematic analysis to analyse interview transcripts. Results We generated six higher order themes: [1] Some pregnancy discomforts alleviated by social distancing measures, [2] The importance of relationships that support coping and adjustment, [3] Missed pregnancy and parenthood experiences, [4] The mental health consequences of birth partner and visitor restrictions, [5] Maternity services under pressure, and [6] Lack of connection with staff. Many participants felt a sense of loss over a pregnancy experience that differed so remarkably to what they had expected because of the pandemic. Supportive relationships were important to help cope with pregnancy and pandemic-related changes; but feelings of isolation were compounded for some participants because opportunities to build social connections through face-to-face parent groups were unavailable. Participants also described feeling alone due to restrictions on their partners being present when accessing UK maternity services. Conclusions Our findings highlight some of the changes that may have affected pregnant women’s mental health during the COVID-19 pandemic. Reduced social support and being unable to have a partner or support person present during maternity service use were the greatest concerns reported by participants in this study. Absence of birth partners removed a protective buffer in times of uncertainty and distress. This suggests that the availability of a birth partner or support person must be prioritised wherever possible in times of pandemics to protect the mental health of people experiencing pregnancy and miscarriage.

Timely detection of small for gestational age (SGA) fetuses is important for reducing severe perinatal morbidity and mortality, and better tools are needed to detect SGA in maternity care.We evaluated the effect of the introduction of the Perinatal Institute's Growth Assessment Protocol (GAP) in the Counties Manukau Health region, South Auckland, New Zealand, on antenatal detection of SGA and maternal and perinatal outcomes.Uncontrolled before and after study in women booked under hospital community midwife care with a singleton, non-anomalous pregnancy. Antenatal detection of SGA (birthweight10th customised centile) was compared pre-GAP (2012, N = 1105) and post-GAP (2017, N = 1082). Composite adverse neonatal outcome was defined as neonatal unit admission48 h, five-minute Apgar score7, and/or any ventilation. Analyses were adjusted for maternal age, body mass index, deprivation, smoking and ethnicity.SGA rates were similar across epochs (13.8% vs 12.9%) but antenatal detection of SGA increased from 22.9% (35/153) to 57.9% (81/140) post-GAP (adjusted odds ratio (aOR) = 4.8, 95% CI 2.82-8.18). Rates of induction of labour and caesarean section increased between epochs but were similar in SGA, non-SGA, and detected and non-detected SGA subgroups. Among SGA babies, there was some evidence that antenatal detection of SGA may be associated with lower composite adverse neonatal outcome (detected SGA: aOR 0.44 95% CI 0.17-1.15; non-detected SGA: aOR = 1.81 95% CI 0.73-4.48; interaction P = 0.03). Pre-term birth did not appear to be influenced by GAP.Implementation of GAP was associated with a nearly five-fold increase in SGA detection without increasing obstetric intervention for SGA.

ObjectiveTo determine the effect of prophylactic dextrose gel for prevention of neonatal hypoglycaemia on neurodevelopment and executive function at 2 years’ corrected age.DesignProspective follow-up of a randomised trial.SettingNew Zealand.PatientsParticipants from the pre-hypoglycaemia Prevention with Oral Dextrose (pre-hPOD) trial randomised to one of four dose regimes of buccal 40% dextrose gel or equivolume placebo.Main outcome measuresCoprimary outcomes were neurosensory impairment and executive function. Secondary outcomes were components of the primary outcomes, neurology, anthropometry and health measures.ResultsWe assessed 360 of 401 eligible children (90%) at 2 years’ corrected age. There were no differences between dextrose gel dose groups, single or multiple dose groups, or any dextrose and any placebo groups in the risk of neurosensory impairment or low executive function (any dextrose vs any placebo neurosensory impairment: relative risk (RR) 0.77, 95% CI 0.50 to 1.19, p=0.23; low executive function: RR 0.50, 95% CI 0.24 to 1.06, p=0.07). There were also no differences between groups in any secondary outcomes. There was no difference between children who did or did not develop neonatal hypoglycaemia in the risk of neurosensory impairment (RR 1.05, 95% CI 0.68 to 1.64, p=0.81) or low executive function (RR 0.73, 95% CI 0.34 to 1.59, p=0.43).ConclusionProphylactic dextrose gel did not alter neurodevelopment or executive function and had no adverse effects to 2 years’ corrected age, but this study was underpowered to detect potentially clinically important effects on neurosensory outcomes.

Summary Background Very low birthweight or preterm infants are at increased risk of adverse outcomes including sepsis, necrotising enterocolitis, and death. We assessed whether supplementing the enteral diet of very low-birthweight infants with lactoferrin, an antimicrobial protein, reduces all-cause mortality or major morbidity. Methods We did a multicentre, double-blind, pragmatic, randomised superiority trial in 14 Australian and two New Zealand neonatal intensive care units. Infants born weighing less than 1500 g and aged less than 8 days, were eligible and randomly assigned (1:1) using minimising web-based randomisation to receive once daily 200 mg/kg pasteurised bovine lactoferrin supplements or no lactoferrin supplement added to breast or formula milk until 34 weeks' post-menstrual age (or for 2 weeks, if longer), or until discharge from the study hospital if that occurred first. Designated nurses preparing the daily feeds were not masked to group assignment, but other nurses, doctors, parents, caregivers, and investigators were unaware. The primary outcome was survival to hospital discharge or major morbidity (defined as brain injury, necrotising enterocolitis, late-onset sepsis at 36 weeks' post-menstrual age, or retinopathy treated before discharge) assessed in the intention-to-treat population. Safety analyses were by treatment received. We also did a prespecified, PRISMA-compliant meta-analysis, which included this study and other relevant randomised controlled trials, to estimate more precisely the effects of lactoferrin supplementation on late-onset sepsis, necrotising enterocolitis, and survival. This trial is registered with the Australian and New Zealand Clinical Trials Registry, ACTRN12611000247976. Findings Between June 27, 2014, and Sept 1, 2017, we recruited 1542 infants; 771 were assigned to the intervention group and 771 to the control group. One infant who had consent withdrawn before beginning lactoferrin treatment was excluded from analysis. In-hospital death or major morbidity occurred in 162 (21%) of 770 infants in the intervention group and in 170 (22%) of 771 infants in the control group (relative risk [RR] 0·95, 95% CI 0·79–1·14; p=0·60). Three suspected unexpected serious adverse reactions occurred; two in the lactoferrin group, namely unexplained late jaundice and inspissated milk syndrome, but were not attributed to the intervention and one in the control group had fatal inspissated milk syndrome. Our meta-analysis identified 13 trials completed before Feb 18, 2020, including this Article, in 5609 preterm infants. Lactoferrin supplements significantly reduced late-onset sepsis (RR 0·79, 95% CI 0·71–0·88; p Interpretation Lactoferrin supplementation did not improve death or major morbidity in this trial, but might reduce late-onset sepsis, as found in our meta-analysis of over 5000 infants. Future collaborative studies should use products with demonstrated biological activity, be large enough to detect moderate and clinically important effects reliably, and assess greater doses of lactoferrin in infants at increased risk, such as those not exclusively receiving breastmilk or infants of extremely low birthweight. Funding Australian National Health and Medical Research Council.

Background This study examined the effects of whey protein supplementation, compared with an isocaloric carbohydrate beverage and water, consumed immediately following an intense swimming trial on bone turnover in adolescent swimmers. Methods Fifty-eight (31 female, 27 male) swimmers (14.1 ± 0.4 years) were stratified into three groups matched for age, sex and body mass. The protein and carbohydrate groups consumed two isocaloric post-exercise beverages each containing 0.3 g.kg− 1 of whey protein (with ~ 6 mg of calcium) or maltodextrin while the control group consumed water. Participants provided a morning, fasted, resting blood sample, then performed an intense swimming trial consisting of a maximal 200 m swim followed by a high intensity interval swimming protocol (5x100m, 5x50m and 5x25m; 1:1 work-to-rest ratio). Following swimming, they consumed their first respective post-exercise beverage, and 2 h later, they performed a second maximal swim immediately followed by the second beverage. Approximately 3 h after the second beverage, two post-consumption blood samples were collected at 8 h and 24 h from baseline. Procollagen type 1 intact N-terminal propeptide (PINP) and carboxy-terminal collagen crosslinks (CTXI) were measured in serum. The multiples of medians of PINP and CTXI were also used to calculate bone turnover rate and balance. Results No significant changes were observed in PINP. CTXI increased (+ 11%) at 8 h in all groups, but then significantly decreased (− 22%) at 24 h in the protein group only. The protein group also had a significantly higher calculated rate of bone turnover at 8 h and 24 h compared to baseline, which was not observed in the other groups. Conclusions These results shed light on the potential importance of protein consumed shortly after intense swimming in promoting positive bone turnover responses up to 24 h following exercise in adolescent athletes. Clinical trial registration ClinicalTrials.gov PRS; NCT04114045 . Registered 1 October 2019 - Retrospectively registered.

Enhanced recovery after surgery (ERAS) is a constant motivation. There is growing evidence that an endoscopic (rather than microscopic) transsphenoidal approach to pituitary tumours can play a role, facilitating faster recovery and a commensurate reduction in length of stay (LOS). Reducing LOS is beneficial to both patients and healthcare systems. We sought to assess the safety, patient feedback, and resource implications of adopting an enhanced recovery and accelerated discharge policy for elective pituitary surgery. We retrospectively assessed two consecutive cohorts of patients undergoing elective surgery for pituitary adenoma in a single UK centre between July 2016 and November 2019. The pre-ERAS cohort included 52 sequential patients operated prior to protocol change. The ERAS cohort included 55 sequential patients operated after a protocol change. Patient demographic data, tumour characteristics, intra- and post-operative CSF leak, the rate and cause of readmission (within 30 days), and the mean and median LOS were recorded. Patient feedback was collected from a subset of patients (n = 23) in the ERAS group. The two cohorts were well-matched with respect to their demographic, pathological, and operative characteristics. The rates of readmission within 30 days of discharge were similar between the two groups (8% pre-ERAS cohort, 9% ERAS cohort, p = 0.75). In the pre-ERAS cohort, the mean LOS was 4.5 days and median LOS was 3 days. This compares with significant reduction in LOS for the ERAS group: mean of 1.7 days and median of 1 day (p

Most doctors working in New Zealand general practice undertake vocational training through the Royal New Zealand College of General Practitioners. We aimed to explore general practice registrar views on their academic learning needs during and following vocational training. An online survey of all current NZ GP trainees in 2019 was completed by 314 registrars (54% response rate). The majority (88%, 275/314) were completing RNZCGP Fellowship only, and of these half (55%, 152/275) were planning a further postgraduate qualification. A minority (12%, 33/275) indicated a desire to undertake a masters or PhD degree. Almost all (99%, 310/314) intended to work in general practice; 9% (8/314) intending to also work as rural hospital doctors. The five most common areas of interest for further training were clinical skills (68%), practice-based teaching (66%), specific clinical conditions (63%), age or life-stage specific (47%) and non-clinical areas (41%). There is a considerable gap between completing RNZCGP Fellowship, intending to undertake further (formal postgraduate) education and actually enrolling. This is concerning given the need for lifelong learning and critical evaluation of practice and health service delivery. The future New Zealand general practice workforce needs GPs to be diverse and highly skilled members or leaders of expert teams.

IMPORTANCE: Prophylactic oral dextrose gel reduces neonatal hypoglycemia, but later benefits or harms remain unclear. OBJECTIVE: To assess the effects on later development of prophylactic dextrose gel for infants born at risk of neonatal hypoglycemia. DESIGN, SETTING, AND PARTICIPANTS: Prospective follow-up of a multicenter randomized clinical trial conducted in 18 Australian and New Zealand hospitals from January 2015 to May 2019. Participants were late preterm or term at-risk infants; those randomized in 9 New Zealand centers (n = 1359) were included and followed up between January 2017 and July 2021. INTERVENTIONS: Infants were randomized to prophylactic 40% dextrose (n = 681) or placebo (n = 678) gel, 0.5 mL/kg, massaged into the buccal mucosa 1 hour after birth. MAIN OUTCOMES AND MEASURES: The primary outcome of this follow-up study was neurosensory impairment at 2 years’ corrected age. There were 44 secondary outcomes, including cognitive, language, and motor composite Bayley-III scores (mean [SD], 100 [15]; higher scores indicate better performance). RESULTS: Of eligible infants, 1197 (91%) were assessed (581 females [49%]). Neurosensory impairment was not significantly different between the dextrose and placebo gel groups (20.8% vs 18.7%; unadjusted risk difference [RD], 2.09% [95% CI, −2.43% to 6.60%]; adjusted risk ratio [aRR], 1.13 [95% CI, 0.90 to 1.41]). The risk of cognitive and language delay was not significantly different between the dextrose and placebo groups (cognitive: 7.6% vs 5.3%; RD, 2.32% [95% CI, −0.46% to 5.11%]; aRR, 1.40 [95% CI, 0.91 to 2.17]; language: 17.0% vs 14.7%; RD, 2.35% [95% CI, −1.80% to 6.50%]; aRR, 1.19 [95% CI, 0.92 to 1.54]). However, the dextrose gel group had a significantly higher risk of motor delay (2.5% vs 0.7%; RD, 1.81% [95% CI, 0.40% to 3.23%]; aRR, 3.79 [95% CI, 1.27 to 11.32]) and significantly lower composite scores for cognitive (adjusted mean difference [aMD], −1.30 [95% CI, −2.55 to −0.05]), language (aMD, −2.16 [95% CI, −3.86 to −0.46]), and motor (aMD, −1.40 [95% CI, −2.60 to −0.20]) performance. There were no significant differences between groups in the other 27 secondary outcomes. CONCLUSIONS AND RELEVANCE: Among late preterm and term infants born at risk of neonatal hypoglycemia, prophylactic oral 40% dextrose gel at 1 hour of age, compared with placebo, resulted in no significant difference in the risk of neurosensory impairment at 2 years’ corrected age. However, the study may have been underpowered to detect a small but potentially clinically important increase in risk, and further research including longer-term follow-up is required. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12614001263684

This study aimed to examine patterns of injury, the impact of these injuries on patients and identification of potentially modifiable contributing factors through industry regulation reforms and education.Food delivery rider (FDR)-related presentations to the Royal Brisbane and Women's Hospital Emergency and Trauma Centre for a year from September 2020 were identified. Data collected included patient and incident demographics: time, type and location of injuries, investigations and care required, length of stay, admission requirements and follow up.The cohort included 81.8% male with a mean age of 25.2 years. Most injuries occurred on the road from a collision with a vehicle. The most common injury was fractures. Incidence increased on weekends and during the evening. More than half the cohort were admitted to hospital. Only 22.7% of patients were eligible for workers compensation and less than half were covered by Medicare. The majority (72.7%) of cases involved non-resident riders from other countries.The majority of FDRs presenting with injuries are not Australian citizens and less than half were Medicare eligible potentially contributing to inadequate access to care especially fracture follow up. There were spikes in injuries occurring at night, weekends and during periods of pandemic associated lockdowns demonstrating an increased usage of delivery services during these times. Results highlight injury patterns experienced by delivery riders and potentially modifiable risk factors for this rapidly growing area of employment within the gig economy.

BACKGROUND Salivary measures are advantageous in conducting large paediatric studies involving repeated measures. However, research measuring salivary cytokines in youth is limited. AIM Compare salivary with plasma concentrations of inflammatory cytokines at rest and following exercise in adolescent swimmers (21 male, 22 female). METHODS Following collection of resting saliva and blood samples, participants performed a bout of high-intensity interval swimming, with samples taken again ∼15 min post-swimming and analysed for interleukin-6 (IL-6), interleukin 10 (IL-10), and tumour necrosis factor-alpha (TNF-α). RESULTS Resting IL-10 was significantly lower, while IL-6 and TNF-α were significantly higher in saliva compared with plasma. IL-10 increased from pre- to post-swimming in plasma, but less so in saliva (51% vs. 29%; p = 0.02). TNF-α decreased post-swimming in saliva, but not in plasma (-27% vs -1%; p = 0.01). IL-6 decreased post-swimming in saliva compared with plasma (-21% vs. -3%; p = 0.06). Intraclass correlation coefficients (ICC) revealed no association between salivary and plasma IL-6 and TNF-α, while IL-10 showed a weak correlation only at rest (ICC = 0.39; p = 0.05). CONCLUSIONS Differences in concentrations and exercise responses, along with weak correlations, suggest that salivary cytokine levels are not an accurate representation of blood cytokine levels, and should not be used as a surrogate measure in paediatric studies.

ObjectiveTo evaluate the effectiveness of a junior high school-based sports injury prevention programme to reduce injuries through neuromuscular training (NMT).MethodsThis was a cluster randomised controlled trial. Students were recruited from 12 Calgary junior high schools (2014–2017). iSPRINT is a 15 min NMT warm-up including aerobic, agility, strength and balance exercises. Following a workshop, teachers delivered a 12-week iSPRINT NMT (six schools) or a standard-of-practice warm-up (six schools) in physical education classes. The definition of all recorded injuries included injuries that resulted in participants being unable to complete a sport and recreation (S&R) session, lost time from sport and/or seek medical attention. Incidence rate ratios (IRRs) were estimated based on multiple multilevel Poisson regression analyses (adjusting for sex (considering effect modification) and previous injury, offset by S&R participation hours, and school-level and class-level random effects were examined) for intent-to-treat analyses.Results1067 students (aged 11–16) were recruited across 12 schools (6 intervention schools (22 classes), 6 control schools (27 classes); 53.7% female, 46.3% male). The iSPRINT programme was protective of all recorded S&R injuries for girls (IRR=0.543, 95% CI 0.295 to 0.998), but not for boys (IRR=0.866, 95% CI 0.425 to 1.766). The iSPRINT programme was also protective of each of lower extremity injuries (IRR=0.357, 95% CI 0.159 to 0.799) and medical attention injuries (IRR=0.289, 95% CI 0.135 to 0.619) for girls, but not for boys (IRR=1.055, 95% CI 0.404 to 2.753 and IRR=0.639, 95% CI 0.266 to 1.532, respectively).ConclusionThe iSPRINT NMT warm-up was effective in preventing each of all recorded injuries, lower extremity injuries and medically treated S&R injuries in female junior high school students.Trial registration numberNCT03312504

Background The rates of pre-diabetes and type 2 diabetes mellitus are increasing worldwide, producing significant burdens for individuals, families, and healthcare systems. In New Zealand, type 2 diabetes mellitus and pre-diabetes disproportionally affect Māori, Pacific, and South Asian peoples. This research evaluates the efficacy, acceptability, and economic impact of a probiotic capsule and a prebiotic cereal intervention in adults with pre-diabetes on metabolic and mental health and well-being outcomes. Methods Eligible adults (n = 152) aged 18–80 years with pre-diabetes (glycated haemoglobin 41–49 mmol/mol) will be enrolled in a 2 × 2 factorial design, randomised, parallel-group, placebo-controlled trial. Computer-generated block randomization will be performed independently. Interventions are capsulated Lactobacillus rhamnosus HN001 (6 × 109 colony-forming units/day) (A) and cereal containing 4 g β-glucan (B), placebo capsules (O1), and calorie-matched control cereal (O2). Eligible participants will receive 6 months intervention in the following groups: AB, AO1, BO2, and O1O2. The primary outcome is glycated haemoglobin after 6 months. Follow-up at 9 months will assess the durability of response. Secondary outcomes are glycated haemoglobin after 3 and 9 months, fasting glucose, insulin resistance, blood pressure, body weight, body mass index, and blood lipid levels. General well-being and quality of life will be measured by the Short-Form Health Survey 36 and Depression Anxiety Stress Scale 21 at 6 and 9 months. Outcome assessors will be blind to capsule allocation. An accompanying qualitative study will include 24 face-to-face semistructured interviews with an ethnically balanced sample from the β-glucan arms at 2 months, participant focus groups at 6 months, and three health professional focus groups. These will explore how interventions are adopted, their acceptability, and elicit factors that may support the uptake of interventions. A simulation model of the pre-diabetic New Zealand population will be used to estimate the likely impact in quality-adjusted life years and health system costs of the interventions if rolled out in New Zealand. Discussion This study will examine the efficacy of interventions in a population with pre-diabetes. Qualitative components provide rich description of views on the interventions. When combined with the economic analysis, the study will provide insights into how to translate the interventions into practice. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12617000990325. Prospectively registered on 10 July 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3553-7) contains supplementary material, which is available to authorized users.

The current study tested a new interpersonal model of disordered eating behaviours, whereby maladaptive schemas and theory of mind decoding (ToM-decoding) were related with disordered eating attitudes (body dissatisfaction) and behaviours (binging/purging and food restriction) through the mediating variable appearance-based rejection-sensitivity. A secondary aim was to test whether this model differed between two cultural groups: Caucasian Australian women (N = 197, ages ranging 17-43, M = 19.25, SD = 3.10), and Asian women living in East-Asia (N = 195, ages ranging 18-40, M = 28.60, SD = 5.15). Participants completed an online survey assessing the variables of interest. While the model showed acceptable fit for both groups, invariance testing demonstrated that the model worked differently in each group. Appearance-based rejection-sensitivity mediated the effect of maladaptive schemas on body dissatisfaction and disordered eating in both groups, but only mediated the effect of ToM-decoding on body dissatisfaction in the East-Asian group. Overall, the significant indirect pathways were greater in strength and number for the Caucasian-Australian group. These findings indicate that while the relationships between maladaptive schemas, appearance-based rejection-sensitivity, and disordered eating attitudes and behaviours are present in both cultures, ToM-decoding may only play a role for East-Asian participants.

Background Traumatic Brain Injury (TBI) is a major health problem for adults aged 50-65 years. Mild/moderate TBI in older adults has implications for the workforce and the individual's quality of life (QOL). Objective To compare changes in life roles, QOL, daily activity performance, perceptions of support available and rehabilitative experiences among older adults with predominantly mTBI and orthopaedic injury (OI). Methods The study included 15 individuals with TBI (13 mild, 2 moderate) and 15 with OI (50-65 years), with injuries sustained more than 6 months prior to. A semi-structured interview retrieved background information, and satisfaction with life roles and daily activities. The World Health Organisation Quality of Life Questionnaire - 100 Version was used to examine QOL, and The Role Checklist was administered to assessed change in life roles. Results Independent samples t-tests revealed older adults with mTBI experienced more role losses, had lower QOL, and were less satisfied with daily activity performance than those with OI. Regression analysis revealed mTBI significantly predicts QOL (except physical domain) when controlling for gender, age at injury and time since injury. Conclusions Findings demonstrate the detrimental impact of predominantly mild TBI on older adults' life roles and QOL, and highlights need for services that adequately support older adults who have experienced mTBI, so they can return to their pre-injury life roles and maintain QOL.

We aimed to evaluate the impact of diabetes mellitus (DM) and insulin treatment on clinical outcomes in patients with heart failure and preserved left ventricular ejection fraction enrolled in the TOPCAT study. We investigated the influence of DM status (insulin-treated [ITDM], non-insulin treated [NITDM], and no diabetes [non-DM]) at baseline on time to development of the primary end point, a composite of cardiovascular (CV) mortality, heart failure hospitalization, and aborted cardiac arrest. Secondary end points included the individual components of the primary end point, myocardial infarction, stroke, all-cause mortality, hyperkalemia, and worsened renal function. Due to marked regional differences in characteristics and outcomes of the TOPCAT patients, with much lower events in patients enrolled in Russia/Georgia, we restricted our analyses on findings from patients enrolled from the Americas. Compared to patients without DM, patients with ITDM had approximately 2-fold increased risk for the primary end point, heart failure hospitalization, and myocardial infarction (hazard ratios: 1.80, 1.97, and 2.27, respectively) and approximately 50% increases in all-cause and CV mortality. The risks for these outcomes were also increased in patients with ITDM in comparison to patients with NITDM as well (hazard ratios: 1.63, 1.65, and 2.73, respectively, and approximately 40% increases in all-cause and CV mortality). Patients with NITDM had similar risks for the primary end point and all secondary end points as patients without DM. In conclusion, the apparent increased risk of adverse outcomes in patients with heart failure and preserved left ventricular ejection fraction and ITDM merits future research to improve the prognosis of these high-risk patients.

Introduction While cognitive impairment is a recognised feature of Parkinson's disease (PD), few studies have evaluated the validity of brief cognitive screening measures compared to a comprehensive neuropsychological assessment. This studies aim was to evaluate the sensitivity and specificity of the Mini-Mental State Examination (MMSE), Modified Mini-Mental State Examination and Dementia Rating Scale (DRS-2) to detect cognitive impairment in individuals with PD. Method Fifty-eight participants were administered the MMSE, 3MS, DRS-2 and a neuropsychological battery. ROC analyses were conducted to assess their effectiveness in classifying cognitive impairment. Results None of the three measures demonstrated good sensitivity or specificity to detect single domain cognitive impairment. For detecting impairment on two or more cognitive domains, the MMSE and DRS-2 yielded excellent sensitivity (88%) and specificity (78% and 76% respectively), at cut-off scores of 28 and 136 respectively. The 3MS demonstrated excellent sensitivity (88%) and good specificity (60%) at cut off score of 94. Conclusion The MMSE and DRS-2 have excellent discriminant ability to classify multi-domain cognitive impairment in PD, however, their ability to detect more focal cognitive impairment is limited. Given that focal domain may be an indicator that could be useful in early detection of cognitive impairment for people with PD, this finding has implication for the use of these measures as screening tools in clinical practice.

IntroductionInfants with severe or recurrent transitional hypoglycaemia continue to have high rates of adverse neurological outcomes and new treatment approaches are needed that target the underlying pathophysiology. Diazoxide is one such treatment that acts on the pancreatic β-cell in a dose-dependent manner to decrease insulin secretion.Methods and analysisPhase IIB, double-blind, two-arm, parallel, randomised trial of diazoxide versus placebo in neonates ≥35 weeks’ gestation for treatment of severe (blood glucose concentration (BGC)Ethics and disseminationThis trial has been approved by the Health and Disability Ethics Committees of New Zealand (19CEN189). Findings will be disseminated in peer-reviewed journals, to clinicians and researchers at local and international conferences and to the public.Trial registration numberACTRN12620000129987.

Introduction Prediabetes is the asymptomatic precursor to type two diabetes mellitus, a significant and growing public health problem in New Zealand (NZ). Little is known about how general practitioners (GPs) and nurses view prediabetes care, and similarly little is known about how people with prediabetes view their condition and care. Aim This study aimed to investigate the views of NZ GPs and nurses, and people with prediabetes about prediabetes and its management. Methods This was a mixed qualitative methods study that is part of a randomised control trial of a prediabetes intervention. Results Three key themes emerged from the health professional data (GPs and nurses) and another three themes emerged from people with prediabetes data. GPs and nurses were uncertain about the progression of prediabetes; they felt prediabetes was not a priority and they were unsure about what to advise. People with prediabetes were uncertain about the diagnosis and information given to them; they were unsure about what to do about prediabetes and they found lifestyle change hard. Discussion GPs, nurses and people with prediabetes, expressed much uncertainty, but also some certainty about prediabetes. All were certain that prediabetes is common and increasing and that sustained lifestyle change was very difficult. But uncertainty prevailed about whether, in reality, prediabetes could be stopped, who would be most likely to benefit from lifestyle interventions and how best to achieve these. Older Māori and Pacific women were keen to promote lifestyle change and this appeared best done through Māori and Pacific peoples' organisations by means of co-designed interventions.

BACKGROUND Treatment of heart failure with preserved ejection fraction (HFpEF) with spironolactone is associated with lower risk of heart failure hospitalization (HFH) but increased risk of worsening renal function (WRF). The prognostic implications of spironolactone-associated WRF in HFpEF patients are not well understood.OBJECTIVES The purpose of this study was to investigate the association between WRF, spironolactone treatment, and clinical outcomes in patients with HFpEF.METHODS In 1,767 patients randomized to spironolactone or placebo in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial)-Americas study, we examined the incidence of WRF (doubling of serum creatinine) by treatment assignment. Associations between incident WRF and subsequent risk for the primary study endpoint of cardiovascular (CV) death, HFH, or aborted cardiac arrest and key secondary outcomes, including CV death, HFH, and all-cause mortality according to treatment assignment, were examined in time-updated Cox proportional hazards models with an interaction term.RESULTS WRF developed in 260 (14.7%) patients with higher rates in those assigned to spironolactone compared to placebo (17.8% vs. 11.6%; odds ratio: 1.66; 95% confidence interval: 1.27 to 2.17; p < 0.001). Regardless of treatment, incident WRF was associated with increased risk for the primary endpoint (hazard ratio: 2.04; 95% confidence interval: 1.52 to 2.72; p < 0.001) after multivariable adjustment. Although there was no statistical interaction between treatment assignment and WRF regarding the primary endpoint (interaction p = 0.11), spironolactone-associated WRF was associated with lower risk of CV death (interaction p = 0.003) and all-cause mortality (interaction p = 0.001) compared with placebo-associated WRF.CONCLUSIONS Among HFpEF patients enrolled in TOPCAT-Americas, spironolactone increased risk of WRF compared with placebo. Rates of CV death were lower with spironolactone in both patients with and without WRF. (c) 2021 the American College of Cardiology Foundation. Published by Elsevier. All rights reserved.

Objective: An indeterminate thyroid nodule fine-needle aspiration (FNA) presents a unique dilemma. We evaluated our institution’s experience with Bethesda III thyroid nodules, including the risk of malignancy (ROM) of these nodules removed for diagnostic lobectomy and radiologic and clinical risk factors for malignancy. Study design: Retrospective chart review. Setting: San Antonio Military Medical Center (SAMMC; 483 bed Military Treatment Facility and Level 1 Trauma Center). Methods: We identified all patients with a Bethesda III thyroid FNA at our institution from 2010 to 2018 and determined which nodules were removed. The final histological diagnosis was recorded. Whether or not age, gender, body mass index (BMI), race, nodule size, margin regularity, rate of nodule growth, vascularity, internal calcifications, family history of thyroid cancer, personal history of radiation, and history of repeated AUS/FLUS on FNA had a significant impact on malignancy risk was evaluated with chi square and rank sum Wilcoxon tests. Results: 492 patients had 1 or more AUS result. 52% (258/492) underwent repeat FNA. This resulted in Bethesda II or III in 90% (232/258). In 10% (26/258), the repeat FNA resulted in a higher Bethesda grade. 183 lobectomies were performed on the side containing an AUS nodule. The malignancy percentage was 38.3% (70/183). Age less than 30 was the only variable showing statistical significance for increased risk of malignancy ( P = .04). Conclusion: The ROM of nodules characterized as AUS/FLUS on FNA may be higher than expected. Age may be a better predictor of malignancy than repeat FNA.

ObjectivesTo explore the psychosocial well-being of health and social care professionals working during the COVID-19 pandemic.DesignThis was a qualitative study deploying in-depth, individual interviews, which were audio-recorded and transcribed verbatim. Thematic analysis was used for coding.ParticipantsThis study involved 25 participants from a range of frontline professions in health and social care.SettingInterviews were conducted over the phone or video call, depending on participant preference.ResultsFrom the analysis, we identified 5 overarching themes: communication challenges, work-related stressors, support structures, personal growth and individual resilience. The participants expressed difficulties such as communication challenges and changing work conditions, but also positive factors such as increased team unity at work, and a greater reflection on what matters in life.ConclusionsThis study provides evidence on the support needs of health and social care professionals amid continued and future disruptions caused by the pandemic. It also elucidates some of the successful strategies (such as mindfulness, hobbies, restricting news intake, virtual socialising activities) deployed by health and social care professionals that can support their resilience and well-being and be used to guide future interventions.

Background Health services internationally have been compelled to change their methods of service delivery in response to the global COVID-19 pandemic, to mitigate the spread of infection amongst health professionals and patients. In Aotearoa/New Zealand, widespread electronic delivery of prescriptions (e-prescribing) was enabled. The aim of the research was to explore patients’ experiences of how lockdown, changes to prescribing and the interface between general practices and community pharmacy affected access to prescription medications. Method The research employed a mixed-method approach. This included an online survey (n = 1,010) and in-depth interviews with a subset of survey respondents (n = 38) during the first COVID-19 lockdown (March–May 2020). Respondents were recruited through a snowballing approach, starting with social media and email list contacts of the research team. In keeping with the approach, descriptive statistics of survey data and thematic analysis of qualitative interview and open-ended questions in survey data were combined. Results For most respondents who received a prescription during lockdown, this was sent directly to the pharmacy. Most people picked up their medication from the pharmacy; home delivery of medication was rare (4%). Survey and interview respondents wanted e-prescribing to continue post-lockdown and described where things worked well and where they encountered delays in the process of acquiring prescription medication. Conclusions E-prescribing has the potential to improve access to prescription medication and is convenient for patients. The increase in e-prescribing during lockdown highlighted how the system could be improved, through better feedback about errors, more consistency across practices and pharmacies, more proactive communication with patients, and equitable prescribing costs.

Purpose: This study examined the effect of whey protein consumption following high-intensity interval swimming (HIIS) on muscle damage, inflammatory cytokines and performance in adolescent swimmers. Methods: Fifty-four swimmers (11&ndash, 17 years-old) were stratified by age, sex and body mass to a whey protein (PRO), isoenergetic carbohydrate (CHO) or a water/placebo (H2O) group. Following baseline blood samples (06:00 h) and a standardised breakfast, participants performed a maximal 200 m swim, followed by HIIS. A total of two post-exercise boluses were consumed following HIIS and ~5 h post-baseline. Blood and 200 m performance measurements were repeated at 5 h, 8 h and 24 h from baseline. Muscle soreness was assessed at 24 h. Creatine kinase (CK), interleukin-6 (IL-6), interleukin-10 (IL-10) and tumor necrosis factor-alpha (TNF-&alpha, ) were measured in plasma. Results: No difference in 200 m swim performance was observed between groups. CK activity was elevated at 5 h compared to baseline and 24 h and at 8 h compared to all other timepoints, with no differences between groups. Muscle soreness was lower in PRO compared to H2O (p = 0.04). Anti-inflammatory IL-10 increased at 8 h in PRO, while it decreased in CHO and H2O. Conclusions: Post-exercise consumption of whey protein appears to have no additional benefit on recovery indices following HIIS compared to isoenergetic amounts of carbohydrate in adolescent swimmers. However, it may assist with the acute-inflammatory response.

Neonatal hypoglycaemia is associated with adverse development, particularly visual-motor and executive function impairment, in childhood. As neonatal hypoglycaemia is common and frequently asymptomatic in at-risk babies-ie, those born preterm, small or large for gestational age, or to mothers with diabetes, it is recommended that these babies are screened for hypoglycaemia in the first 1-2 days after birth with frequent blood glucose measurements. Neonatal hypoglycaemia can be prevented and treated with buccal dextrose gel, and it is also common to treat babies with hypoglycaemia with infant formula and intravenous dextrose. However, it is uncertain if screening, prophylaxis, or treatment improves long-term outcomes of babies at risk of neonatal hypoglycaemia. This narrative review assesses the latest evidence for screening, prophylaxis, and treatment of neonates at risk of hypoglycaemia to improve long-term neurodevelopmental outcomes.

Background During the first COVID-19 pandemic ‘lockdown’ in Aotearoa/New Zealand (March–May 2020, in which strict ‘stay at home’ measures were introduced), general practices were advised to use telephone and video consultations (telehealth) wherever possible instead of the usual in-person visits. This was a sudden change for most practices and patients. This research aimed to explore how patients accessed general practice during lockdown and evaluate their experiences with telehealth, to inform how telehealth could be most effectively used in the future. Methods Using a mixed-method approach, we undertook an online survey and in-depth interviews with adults (> 18 years) who had contact with practices during lockdown, recruited through social media and email lists. We present descriptive statistics from the survey data (n = 1010) and qualitative analysis of interview data (n = 38) and open-ended survey questions, using a framework of access to health care, from the patient’s perspective. Results In general, patients reported high satisfaction with telehealth in general practice during lockdown. Telehealth was convenient and allowed patients to safely access health care without having to weigh-up the fear of COVID-19 infection against the need to be seen. Telehealth worked best for routine and familiar health issues and when rapport was established between patients and clinicians. This was easier with a pre-existing clinical relationship, but not impossible without one. Telehealth was less suitable when a physical examination was needed, when the diagnosis was unknown or for patients who had a strong preference to be seen in-person. Conclusions Even in this disruptive lockdown period, that prompted an unexpected and rapid implementation of telehealth services in general practices, most patients had positive experiences with telehealth. In the future, patients want the choice of consultation type to match their needs, circumstances, and preferences. Technological issues and funding barriers may need to be addressed, and clear communication for both patients and clinicians is needed about key aspects of telehealth (e.g. cost, appropriateness, privacy). Maintaining telehealth as an option post-lockdown has the potential to increase timely and safe access to primary health care for many patients.

Background Gestational diabetes mellitus (GDM) has lifelong implications for the woman and her infant. Treatment reduces adverse maternal and perinatal outcomes although uncertainty remains about the optimal diagnostic criteria. The GEMS Trial aims to assess whether detection and treatment of women with GDM using the lower International Association of Diabetes in Pregnancy Study Groups diagnostic criteria compared with the higher criteria recommended in New Zealand reduces infant morbidity without increasing maternal morbidity. Methods GEMS is a multicentre, randomised trial. Women with a singleton pregnancy at 24 to 34 weeks’ gestation are eligible who give written informed consent. Women are randomly allocated to the Lower Criteria Group or the Higher Criteria Group. Women with a normal OGTT by their allocated criteria receive routine care (Higher criteria: fasting plasma glucose 90th centile). Secondary outcomes for the infant include a composite of serious outcomes, gestational age, anthropometry, Apgar score Discussion The GEMS Trial will provide high-level evidence relevant for clinical practice. If use of the lower diagnostic criteria results in significantly fewer large for gestational age infants and/or improves maternal and perinatal outcomes these criteria should be recommended for diagnosis of gestational diabetes. Trial registration Australian New Zealand Clinical Trials Registry registration number ACTRN12615000290594. Date registered: 27th March 2015.

BACKGROUND: Antenatal corticosteroids (ACSs) administered to women before preterm birth improve neonatal health. Proportionately more women are obese or overweight in current obstetric populations than those who were included in the original trials of ACSs, and it remains uncertain if higher doses are required for such women. AIM: Our aim was to assess the association between maternal body mass index (BMI) and infant morbidity after the administration of ACSs. METHODS: In the secondary analysis of the ASTEROID trial cohort, women at risk of preterm birth at

Background Progressive cardiac remodeling and worsening myocardial function over time have been proposed as potential mediators of heart failure in obesity. Methods and Results We serially assessed cardiac structure and function in 254 subjects participating in a longitudinal study of obesity. Demographic, clinical, laboratory, and echocardiographic features were determined at baseline and 2‐, 6‐, and 11‐year follow‐up. We measured body mass index ( BMI ) exposure as the area under the curve of the BMI at each of the 4 visits. At enrollment, mean age of the subjects was 47 years, 79% were women, mean BMI was 44 kg/m 2 , 26% had diabetes mellitus, 48% had hypertension, and 53% had hyperlipidemia. Between baseline and 11 years, BMI increased by 1.1 and 0.3 kg/m 2 in men and women, respectively. There were modest increases in left ventricular ( LV ) end‐diastolic volume, LV mass, and left atrial volume, and significant decreases in early/late mitral diastolic flow velocity ratio and E wave deceleration time. However, there were no significant changes in LV ejection fraction or ratio of early mitral diastolic flow velocity/early mitral annular velocity, whereas right ventricular fractional area change increased. Significant predictors of the change in LV mass were male sex, baseline BMI , BMI area under the curve, and change in LV stroke volume, but not smoking, hypertension, or diabetes mellitus. Conclusions In long‐standing, persistent severe obesity, there was evidence of cardiac remodeling over a period of 11 years, but no clear worsening of systolic or diastolic function. Measures of remodeling were most strongly related to BMI . The observed changes might predispose to heart failure with preserved ejection fraction, but are not classic for an evolving dilated cardiomyopathy.

Measurement of body composition is increasingly important in research and clinical settings but is difficult in very young children. Bioelectrical impedance analysis (BIA) and air displacement plethysmography (ADP) are well-established but require specialist equipment so are not always feasible. Our aim was to determine if anthropometry and skinfold thickness measurements can be used as a substitute for BIA or ADP for assessing body composition in very young New Zealand children. We used three multi-ethnic cohorts: 217 children at a mean age of 24·2 months with skinfold and BIA measurements; seventy-nine infants at a mean age of 20·9 weeks and seventy-three infants at a mean age of 16·2 weeks, both with skinfold and ADP measurements. We used Bland–Altman plots to compare fat and fat-free mass calculated using all potentially relevant equations with measurements using BIA or ADP. We also calculated the proportion of children in the same tertile for measured fat or fat-free mass and tertiles (i) calculated using each equation, (ii) each absolute skinfold, and (iii) sum of skinfold thicknesses. We found that even for the best equation for each cohort, the 95 % limits of agreement with standard measures were wide (25–200 % of the mean) and the proportion of children whose standard measures fell in the same tertile as the skinfold estimates was ≤69 %. We conclude that none of the available published skinfold thickness equations provides good prediction of body composition in multi-ethnic cohorts of very young New Zealand children with different birth history and growth patterns.

An updated Cochrane Review showed that maternal supplementation with omega-3 fatty acids reduced preterm birth, offering a potential strategy for prevention. We hypothesised that pregnant women with obesity, at higher risk of preterm birth, would have low omega-3 fatty acid levels and may benefit from supplementation. Our study measured the omega-3 fatty acid levels of 142 participants from the Healthy Mums and Babies study, Counties Manukau, Auckland, New Zealand. Counties Manukau is a multi-ethnic community with high rates of socio-economic deprivation, obesity, and preterm birth. Red blood cell omega-3 fatty acid levels were measured from samples collected between 12

Gestational diabetes mellitus (GDM) is a major health problem, with increased risks of obesity and diabetes in offspring. However, little is known about the effect of GDM on infant feeding, nutrition and growth, and whether these factors play a role in mediating these risks. We systematically reviewed evidence for the effect of GDM on infant feeding, nutrition and growth. We searched MEDLINE, Web-of-Science, Embase, CINAHL and CENTRAL for studies that reported outcomes in infants

In this secondary analysis of six qualitative studies, we found that approximately one-quarter of individuals with fragility fracture were serving as informal caregivers. The caregiving role appeared to be a cause of the fracture for some and was prioritized over bone health, acting as a barrier to bone health management. Among fragility fracture patients serving as informal caregivers, our objective was to examine how caregiving responsibilities were associated with, and possibly impacted by, the fracture experience and the resulting management of bone health. We conducted a secondary analysis (amplified analysis) of six qualitative studies to understand caregiver responsibilities and the relationship between these responsibilities and patients’ management of the fracture and bone health. The primary studies and the secondary analysis were conducted from a phenomenological approach. Eligible individuals in the primary studies were English-speaking men and women who were 45+ years old recruited from three settings (local, provincial, and national). Without being prompted to talk about their experience of caregiving, 33 of 145 (23%) individuals reported they were providing care to a family member or friend at the time of their fracture or during recovery post-fracture. The experience of having caregiving responsibilities was related to the fracture and bone health in two ways: (1) the caregiving role appeared to be a cause of the fracture in some participants and (2) caregiving was prioritized over participants’ own bone health and was a barrier to bone health management. Fragility fracture is associated with, and potentially leads to an impairment of, an important social role in patients providing physical and emotional support and supervision for dependents as caregivers. Further, an important cause of fragility fracture can occur in the act of caregiving.

Introduction Inhaled methoxyflurane is an analgesic used for the emergency relief of moderate to severe pain in conscious adult patients with trauma and associated pain that is increasingly being used in hospital emergency departments to provide rapid analgesia. It is widely accepted that effective pain relief can facilitate patient care and flow through the emergency department (ED). The main aim of this evaluation was to assess the impact of inhaled methoxyflurane on patient length of stay (LOS) in the ED compared with standard care. Methods Adult patients with moderate to severe trauma pain and Glasgow coma score of 15 were included in the evaluation. Evaluation forms were completed for 79 patients who received methoxyflurane and were matched with 80 patients who received standard care. Results Overall the mean time spent in the ED was reduced by 71 min in those patients who were administered methoxyflurane compared with patients who received standard care. Furthermore, analysis of LOS by injury type demonstrated a reduction in ED LOS by 183 min for patients with shoulder dislocation who were treated with methoxyflurane compared with patients who received standard care. There was no reduction in ED LOS for patients with lower limb, hip or pelvic injuries between the two treatment groups. Conclusion Use of methoxyflurane in adult patients with trauma pain significantly reduced the ED LOS and may potentially improve patient flow through the ED.

In 2020, in the first COVID-19 pandemic lockdown, Aotearoa New Zealand consistently maintained stringent public health measures including stay-at-home lockdowns and distancing responses. Considering the widespread disruption to social functioning caused by the pandemic, this paper aimed to explore environmental and social factors that influenced the wellbeing of individuals during the first lockdown in Aotearoa New Zealand. Our mixed-methods study involved a survey (n = 1010) and semi-structured interviews of a subset of surveyed individuals undertaken at the tail end of the first 2020 lockdown. Survey participants were recruited through social media-driven snowball sampling, less than 50% were aged under 45 years and 85% identified as female. Of those interviewed, 63% identified as female. Qualitative interview findings and open-ended survey results were analysed thematically. Participants described a variety of factors influencing wellbeing, largely related to the community and household; physical, behavioural, and lifestyle factors; access to health services; and social and economic foundations. While much of the focus of COVID-19 recovery was on reversing the economic and physical toll of the pandemic, our findings emphasise the need to empower individuals, families, and communities to mitigate the pandemic’s negative implications on wellbeing.

AIM The aim was to survey the Australian and New Zealand Neonatal Network (ANZNN) member units regarding current services and management guidelines for the ex-premature infant with severe chronic lung disease (CLD) still requiring significant respiratory support at term. METHODS A 16-question survey was sent to clinical directors of all Level 3 units in Australia and New Zealand via the network. Reminder emails were sent, as required, to prompt a satisfactory response rate. RESULTS Survey responses were received from 26 of the 29 (90%) ANZNN Level 3 units. At 37 weeks' corrected gestation, over 90% of the units provide ongoing respiratory support in the neonatal intensive care unit (NICU). However, by 50 weeks, ongoing care is provided in several settings, including NICU, high dependency unit (HDU)/paediatric intensive care unit or respiratory wards. The majority (76%) of units arrange transfer on an ad hoc basis, but six units (24%) have set criteria for transfer based on gestation, workload and respiratory requirement. Three units declared a maximum age in NICU (44, 46 or 48 weeks). A variety of approaches were used to identify infants who were likely to require transfer, and 78% of units had a staff member assigned to assist transition. Three units stated that they had a home ventilation programme suitable for these infants. No unit supplied a guideline on tracheostomy or specific respiratory management post-term. CONCLUSION Despite a significant number of babies requiring ongoing support for severe CLD, the location of the service appears very variable, and there is a lack of specific written guidelines.

Social networks are informal relationships often with social ties and voluntary or mandatory obligations that can positively support a patient with multimorbidity. This exploratory study sought insights into the social networks of New Zealand people with multimorbidity and also the work of those nominated as providing significant support. Ten participants were recruited from general practice as part of an education programme in which health professional students discussed living with multimorbidity and completed a social network template together with patients. Each patient nominated an individual from their social network whom they considered provided significant support. A researcher interviewed each supporter about their experience of providing support, and their view of the patient's social network. Significant supporters included three classified as 'lay' supporters (sister, wife and daughter) and seven classified as 'professional' supporters (exercise physiologist, general practitioners, nurse, medical specialists). The activities described by supporters was classified according to Vassilev et al.'s expansion of Corbin and Strauss's 1985 classification of work in chronic illness, including the categories of "illness," "everyday" and "emotional" work. Irrespective of whether supporters were lay or professional, they gave examples of each category. While this is expected of lay supporters, it is not expected of professional supporters who are typically viewed as undertaking illness work. Lay supporters described a complex array of activities sometimes impacting on their own personal well-being, making them more akin to meeting the formal definition of being a carer, while professional supports gave objective yet professionally invested descriptions. The work of lay and professional supporters is complementary in the provision of support for those with multimorbidity. Consideration should be given to the role of lay supporters and to their own needs if they are to be able to sustain their support work with patients.

In patients with heart failure and preserved ejection fraction (HF-PEF) randomized in the Americas as part of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial, treatment with spironolactone enhanced the risk of hyperkalemia but reduced the risk of hypokalemia. We examined the clinical correlates and prognostic implications of incident hypo- and hyperkalemia during study follow-up.We defined the region-specific incidence of hypokalemia (potassium [KIn the Americas, assignment to spironolactone increased risk for hyperkalemia (hazard ratio 3.21, 95% confidence interval 2.46-4.20, P .001) and reduced risk of hypokalemia (hazard ratio 0.43, 95% confidence interval 0.34-0.55, P .001). Assignment to spironolactone, lower estimated glomerular filtration rate, higher baseline KBoth hyperkalemia and hypokalemia are associated with heightened risk for mortality in HF-PEF. Use of spironolactone in this population requires careful laboratory surveillance of K