Journal Articles

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General practitioner and nurse experiences of type 2 diabetes management and prescribing in primary care: a qualitative review following the introduction of funded SGLT2i/GLP1RA medications in Aotearoa New Zealand.
(Cambridge University Press, 2024-09-16) Norman K; Mustafa ST; Cassim S; Mullins H; Clark P; Keenan R; Te Karu L; Murphy R; Paul R; Kenealy T; Chepulis L
AIM: To explore the views of general practitioners (GPs) and nurses on type 2 diabetes (T2D) management, including the use of recently funded T2D medications in New Zealand (NZ) and their perceived barriers to providing optimal care. BACKGROUND: T2D is a significant health concern in NZ, particularly among Māori and Pacific adults. Characterised by prolonged hyperglycaemia, T2D is generally a progressive condition requiring long-term care. METHODS: Semi-structured interviews were conducted between July and December 2022 with 21 primary care clinicians (10 GPs and 11 nurses/nurse prescribers) from nine different general practice clinics across the Auckland and Waikato regions of NZ. Framework analysis was conducted to identify common themes in clinicians' perceptions and experiences with T2D management. FINDINGS: Three themes were identified: health-system factors, new medications, and solution-based approaches. Lack of clinician time, healthcare funding, staff shortages, and burn-out were identified as barriers to T2D management under health-system factors. The two newly funded medications, empagliflozin and dulaglutide, were deemed to be a positive change for T2D care in that they improved patient satisfaction and clinical outcomes, but several clinicians were hesitant to prescribe these medications. Participants suggested that additional education and specialist diabetes support would be helpful to inform optimal medication prescribing and that better use of a multi-disciplinary team (clinical and support staff) could support T2D care by reducing workload, addressing cultural gaps in healthcare delivery, and reducing burnout. An improved primary care work environment, including appropriate professional development to support prescribing of new medications and the value of collaboration with a non-regulated workforce, may be required to facilitate optimal T2D management in primary care. Future research should focus on interventions to increase support for both clinical teams and patients while adopting a culturally appropriate approach to increase patient satisfaction and improve health outcomes.
Effects of intranasal maropitant on clinical signs of naturally acquired upper respiratory disease in shelter cats
(SAGE Publications on behalf of the nternational Cat Care Veterinary Society and Feline Veterinary Medical Association, 2025-02-26) Parncutt J; Johnson LR; Subharat S; Oke B; Hill KE
OBJECTIVES: The aim of this study was to test the hypothesis that intranasally administered maropitant citrate would reduce the severity of clinical signs of feline upper respiratory disease (FURD) in shelter cats with naturally acquired disease. METHODS: Shelter cats with clinical signs of FURD were randomly assigned to receive either intranasal maropitant diluted in saline (maropitant citrate 10 mg/ml q12h, diluted 1:10 with sterile 0.9% saline) or intranasal 0.9% saline q12h for 7 days. Clinical disease severity was measured at entry into the study and again after completion of 7 days of treatment using a visual analogue scale to assess four separate clinical signs: conjunctivitis, blepharospasm, ocular discharge and nasal discharge. Total disease severity was also calculated. Cats received other medications for FURD as per standard shelter protocols, and all investigators were masked to group assignments. A Mann-Whitney U-test was performed to compare the clinical improvement score (CIS) between the treatment and control groups. RESULTS: There were 34 cats in the maropitant treatment group; 27 cats served as placebo controls. Groups did not differ in age, sex distribution, nature of disease, administration of other medications for FURD or baseline clinical disease severity. There was no significant difference in CIS between the maropitant treatment and control groups for conjunctivitis, blepharospasm, ocular discharge, nasal discharge or total disease severity after 7 days. CONCLUSIONS AND RELEVANCE: This study found no significant difference in outcomes for cats with FURD when treated with intranasal maropitant compared with treatment with intranasal saline. Further investigations would be required before intranasal maropitant could be recommended as the standard of care for FURD.
Antibiotic Use In Utero and Early Life and Risk of Chronic Childhood Conditions in New Zealand: Protocol for a Data Linkage Retrospective Cohort Study
(JMIR Publications, 2025-02-28) Ram S; Corbin M; 't Mannetje A; Eng A; Kvalsig A; Baker M; Douwes J
Background: The incidence of many common chronic childhood conditions has increased globally in the past few decades, which has been suggested to be potentially attributed to antibiotic overuse leading to dysbiosis in the gut microbiome. Objective: This linkage study will assess the role of antibiotic use in utero and in early life in the development of type 1 diabetes (T1D), attention-deficit/hyperactive disorder (ADHD), and inflammatory bowel disease. Methods: The study design involves several retrospective cohort studies using linked administrative health and social data from Statistics New Zealand’s Integrated Data Infrastructure. It uses data from all children who were born in New Zealand between October 2005 and December 2010 (N=334,204) and their mothers. Children’s antibiotic use is identified for 4 time periods (at pregnancy, at ≤1 year, at ≤2 years, and at ≤5 years), and the development of T1D, ADHD, and inflammatory bowel disease is measured from the end of the antibiotic use periods until death, emigration, or the end of the follow-up period (2021), whichever came first. Children who emigrated or died before the end of the antibiotic use period are excluded. Cox proportional hazards regression models are used while adjusting for a range of potential confounders. Results: As of September 2024, data linkage has been completed, involving the integration of antibiotic exposure and outcome variables for 315,789 children. Preliminary analyses show that both prenatal and early life antibiotic consumption is associated with T1D. Full analyses for all 3 outcomes will be completed by the end of 2025. Conclusions: This series of linked cohort studies using detailed, complete, and systematically collected antibiotic prescription data will provide critical new knowledge regarding the role of antibiotics in the development of common chronic childhood conditions. Thus, this study has the potential to contribute to the development of primary prevention strategies through, for example, targeted changes in antibiotic use.
Acceptance and commitment therapy for mild traumatic brain injury (ACTion-mTBI): a quasiexperimental feasibility study
(BMJ Publishing Group Ltd, 2025-02-16) Faulkner J; Prouty D; Devlin L; Appleton D; Roche M; Below K; Moffat J; Snell D; Williams MN; Barker-Collo S; Theadom A
OBJECTIVES: This study aimed to determine the feasibility of recruiting, implementing and delivering an acceptance and commitment therapy (ACT) intervention for mild traumatic brain injury (mTBI) (ACTion-mTBI) within a multidisciplinary outpatient mTBI rehabilitation services. The study also aimed to conduct a preliminary investigation of group differences between ACTion-mTBI and an equivalent cognitive behavioural therapy (CBT) intervention on various outcome measures and psychological treatment targets. DESIGN: A two-arm quasiexperimental feasibility study. SETTING: Five mTBI rehabilitation clinics throughout New Zealand. INTERVENTION: Psychologists working in mTBI rehabilitation clinics throughout New Zealand were trained to deliver ACTion-mTBI or CBT. Eligible participants were assigned to either of these interventions based on the psychologist available at the clinic they were referred to. ACTion-mTBI is a five sessions intervention that incorporates all six components of the ACT model. The CBT intervention is an equivalent intervention and incorporating all four components of the CBT model. Both interventions are adapted for an mTBI context. PRIMARY OUTCOME MEASURES: The primary outcomes were related to the feasibility of ACTion-mTBI. This included recruitment, retention and treatment adherence of participants, study procedure and fidelity of treatment delivery. SECONDARY OUTCOME MEASURES: To explore group differences between ACTion-mTBI and CBT on functional disability, postconcussion symptoms, mental health, valued living and psychological flexibility. RESULTS: The intervention proved feasible to implement with community-based mTBI rehabilitation services. Attrition rates were comparable between the two psychological interventions and fidelity to the treatments was high. At post-treatment, when covarying pretreatment scores, ACTion-mTBI had a significantly greater improvement in functional disability than CBT (moderate effect). ACTion-mTBI also had a significantly greater reduction in postconcussion symptoms, anxiety and stress. Promisingly, significant improvements in psychological flexibility was also found post-treatment. There were no group differences on depressive symptoms and valued living. CONCLUSION: We conclude that a full clinical trial of ACTion-mTBI for individuals with mTBI is feasible and warranted. TRIAL REGISTRATION NUMBER: ACTRN1262100059482.
Dropping the baton: Cognitive biases in emergency physicians.
(PLOS, 2025-01-02) Ng M; Wong E; Sim GG; Heng PJ; Terry G; Yann FY
Introduction Clinical medicine is becoming more complex and increasingly requires a team-based approach to deliver healthcare needs. This dispersion of cognitive reasoning across individuals, teams and systems (termed “distributed cognition”) means that our understanding of cognitive biases and errors must expand beyond traditional “in-the-head” individual mental models and focus on a broader “out-in-the-world” context instead. To our knowledge, no qualitative studies thus far have examined cognitive biases in clinical settings from a team-based sociocultural perspective. Our study therefore seeks to explore how cognitive biases and errors among emergency physicians (EPs) arise due to sociocultural influences and lapses in team cognition. Methodology Our study team comprised four EPs of different seniorities from three different institutions and local and international academics who provided qualitative methodological guidance. We adopted a constructivist paradigm and employed a reflexive thematic analysis approach which acknowledged our researcher reflexivity. We conducted seven focus group discussions with 25 EPs who were purposively sampled for maximum variation. Our research question was: How do sociocultural factors lead to cognitive biases and medical errors among EPs? Results Our themes coalesce around sociocultural pressures related to team psychology. In theme one, the EP is compelled by sociocultural pressures to blindly trust colleagues. In the second, the EP is obliged by cultural norms to be “nice” and neatly summarise cases into illness scripts during handovers. In the last, the EP is under immense pressure to follow conventional wisdom, comply with clinical protocols and not challenge inpatient specialists. Conclusion Cognitive biases and errors in clinical decision-making can arise due to lapses in distributed team cognition. Although this study focuses on emergency medicine, these pitfalls in team-based cognition are relevant across the entire continuum of care and across all specialties of medicine. The hyperacute nature of emergency medicine merely exacerbates and condenses these into a compressed timeframe. Indeed, similar relays are run every day in every discipline of medicine, with the same unified goal of doing the best for our patients while not committing cognitive errors and dropping the baton.
Healthcare performance of leprosy management in peripheral health facilities of Dhanusa and Mahottari, Nepal.
(BioMed Central Ltd, 2025-12) Mahato RK; Ghimire U; Bajracharya B; K C B; Bam D; Ghimire D; Pyakurel UR; Hayman DTS; Pandey BD; Das CL; Paudel KP
BACKGROUND: The global elimination of leprosy transmission by 2030 is a World Health Organization (WHO) target. Nepal's leprosy elimination program depends on early case diagnosis and the performance of health workers and facilities. The knowledge and skills of paramedical staff (Leprosy Focal Person, LFP) and case documentation and management by health facilities are therefore key to the performance of health care services. METHODS: The performance of health workers and facilities was evaluated through a combined cross-sectional and retrospective study approach of 31 health facilities and their LFPs in Dhanusa and Mahottari Districts in Madhesh Province, Nepal. An average of 6 patients (paucibacillary, PB, or multibacillary, MB) per health facility registered within the 2018/2019 fiscal year were also enrolled in the study. LFP knowledge (e.g., of the three cardinal signs) and skills (e.g., nerve palpation) and facility processes (e.g., record keeping) were scored (e.g., 0, 1) and then rescaled to a proportion, where 1 is perfect. Internal benchmarking was used to guide performance management. RESULTS: Overall LFP knowledge and skill scores of health workers ranged from 0.16 to 0.63 (median 0.53, 95% confidence interval (CI), 0.46-0.6). Case documentation scores ranged from 0.15 to 0.87 (median 0.37, 95% CI 0.36-0.38), case management scores from 0.38 to 0.79 (median 0.54, 95% CI 0.53-0.55) and overall healthcare scores from 0.36-0.62 (median 0.48, 95% CI 0.47-0.49). Leprosy-related training was significantly related to the knowledge and skills of the health workers. All identified cases (n = 187) adhered to the complete treatment and release after treatment (RFT) scheme, out of which 84.5% were satisfied with the service they were provided. Leprosy disability and ear hand and feet (EHF) scores were not significantly reduced in treated patients during the study period, but counseling by LFPs significantly improved cases' positive beliefs and practices regarding self-care. CONCLUSION: Overall leprosy care median performance was low (53%) and can be improved by evidenced-based training, onsite coaching, monitoring, and supervision to facilitate leprosy transmission elimination. The results highlight many of the challenges facing leprosy elimination programs.
Case-Control Study of Congenital Anomalies: Study Methods and Nonresponse Bias Assessment.
(Wiley Periodicals LLC, 2025-02-20) Eng A; Mannetje AT; Ellison-Loschmann L; Borman B; Cheng S; Lawlor DA; Douwes J; Pearce N
BACKGROUND: To describe the methods of a congenital anomalies case-control study conducted in New Zealand, discuss the encountered methodological difficulties, and evaluate the potential for nonresponse bias. METHODS: The potential cases (n = 2710) were New Zealand live births in 2007-2009 randomly selected from the New Zealand Congenital Anomalies Registry. The potential controls (n = 2989) included live births identified from the Maternity and Newborn Information System, frequency matched to cases by the child's year of birth and sex. Mothers were invited to complete an interview covering demographic, lifestyle, and environmental factors. Response probabilities for case and control mothers were evaluated in relation to maternal age, deprivation, occupation, and ethnicity, available from the Electoral Roll, and inverse probability weights (IPWs) for participation were calculated. Odds ratios (ORs) for key demographic and selected risk factors were estimated through unconditional logistic regression, with and without IPW. RESULTS: A total of 652 (24%) of case mothers and 505 (17%) of control mothers completed the interview. Younger and more deprived mothers were underrepresented among the participants, particularly for controls, resulting in inflated ORs of associations with congenital anomalies for younger age, Māori ethnicity, deprivation, and risk factors under study, such as blue-collar occupations and smoking, indicative of nonresponse bias. Nonresponse bias was minimized through IPW, resulting in ORs and exposure prevalence estimates similar to those based on the prerecruitment sample. CONCLUSIONS: Attaining high participation rates was difficult in this study that was conducted in new mothers, particularly for the controls. The resulting nonresponse bias was minimized through IPW.
Campylobacter colonization and undernutrition in infants in rural eastern Ethiopia - a longitudinal community-based birth cohort study.
(Frontiers Media S.A., 2025-01-07) Chen D; McKune SL; Yang Y; Usmane IA; Ahmed IA; Amin JK; Ibrahim AM; Seran AJ; Shaik N; Ojeda A; Hassen BM; Deblais L; Ahmedo BU; Hassen KA; Bhrane M; Li X; Singh N; Roba KT; French NP; Rajashekara G; Manary MJ; Hassen JY; Havelaar AH; CAGED Research Team
Background: Campylobacter is associated with environmental enteric dysfunction (EED) and malnutrition in children. Campylobacter infection could be a linchpin between livestock fecal exposure and health outcomes in low-resource smallholder settings. Methods: We followed a birth cohort of 106 infants in rural smallholder households in eastern Ethiopia up to 13 months of age. We measured anthropometry, surveyed sociodemographic determinants, and collected stool and urine samples. A short survey was conducted during monthly visits, infant stool samples were collected, and Campylobacter spp. was quantified using genus-specific qPCR. In month 13, we collected stool and urine samples to assay for EED biomarkers. We employed regression analyses to assess the associations of household determinants with Campylobacter colonization, EED, and growth faltering. Results: The Campylobacter load in infant stools increased with age. The mean length-for-age Z-score (LAZ) decreased from −0.45 at 3–4 months of age to −2.06 at 13 months, while the prevalence of stunting increased from 3 to 51%. The prevalence of EED at 13 months of age was 56%. A higher Campylobacter load was associated with more frequent diarrhea. Prelacteal feeding significantly increased Campylobacter load in the first month of life. Over the whole follow-up period, Campylobacter load was increased by keeping chickens unconfined at home and unsanitary disposal of infant stools while decreased by mothers’ handwashing with soap. Longitudinally, Campylobacter load was positively associated with food insecurity, introduction of complementary foods, and raw milk consumption. There were no significant associations between Campylobacter load, EED, and LAZ. Conclusion: This study found that most determinants associated with increased Campylobacter infection were related to suboptimal feeding practices and hygiene. The findings related to livestock-associated risks were inconclusive. Although stunting, EED, and Campylobacter prevalence rates all increased to high levels by the end of the first year of life, no significant association between them was identified. While additional research is needed to investigate whether findings from this study are replicable in other populations, community efforts to improve infant and young child feeding practices and food hygiene, and water, sanitation, and hygiene (WaSH) at the household level, could reduce (cross-)contamination at the point of exposure.
Comparing the Effects of Collagen Hydrolysate and Dairy Protein on Recovery from Eccentric Exercise: A Double Blind, Placebo-Controlled Study.
(MDPI (Basel, Switzerland), 2024-12-20) Barclay R; Coad J; Schraders K; Barnes MJ; Driss T
Background: Consuming collagen hydrolysate (CH) may improve symptoms of exercise-induced muscle damage (EIMD); however, its acute effects have not been compared to dairy protein (DP), the most commonly consumed form of protein supplement. Therefore, this study compared the effects of CH and DP on recovery from EIMD. Methods: Thirty-three males consumed either CH (n = 11) or DP (n = 11), containing 25 g of protein, or an isoenergetic placebo (n = 11) immediately post-exercise and once daily for three days. Indices of EIMD were measured before and 30 min and 24, 48, and 72 h after 30 min of downhill running on a −15% slope at 80% of VO2max speed. Results: Downhill running induced significant EIMD, with time effects (all p < 0.001) for the delayed onset of muscle soreness (visual analogue scale), countermovement jump height, isometric midthigh pull force, maximal voluntary isometric contraction force, running economy, and biomarkers of muscle damage (creatine kinase) and inflammation (interleukin-6, high-sensitivity C-reactive protein). However, no group or interaction effects (all p > 0.05) were observed for any of the outcome measures. Conclusions: These findings suggest that the post-exercise consumption of CH or DP does not improve indices of EIMD during the acute recovery period in recreationally active males.
Nicotine exacerbates exertional heat strain in trained men: A randomized, placebo-controlled, double-blind study.
(American Physiological Society, 2024-08-16) Moyen NE; Barnes MJ; Perry BG; Fujii N; Amano T; Kondo N; Mundel T
To determine whether using nicotine exacerbates exertional heat strain through an increased metabolic heat production (Hprod) or decreased skin blood flow (SkBF), 10 nicotine-naïve trained males [37 ± 12 yr; peak oxygen consumption (V̇o2peak): 66 ± 10 mL·min−1·kg−1] completed four trials at 20°C and 30°C following overnight transdermal nicotine (7 mg·24 h−1) and placebo use in a crossover, double-blind design. They cycled for 60 min (55% V̇o2peak) followed by a time trial (∼75% V̇o2peak) during which measures of gastrointestinal (Tgi) and mean weighted skin (̅Tsk) temperatures, SkBF, Hprod, and mean arterial pressure (MAP) were made. The difference in ΔTgi between nicotine and placebo trials was greater during 30°C (0.4 ± 0.5°C) than 20°C (0.1 ± 0.7°C), with ̅Tsk higher during nicotine than placebo trials (0.5 ± 0.5°C, P = 0.02). SkBF became progressively lower during nicotine than placebo trials (P = 0.01) and progressively higher during 30°C than 20°C trials (P < 0.01); MAP increased from baseline (P < 0.01) and remained elevated in all trials. The difference in Hprod between 30°C and 20°C trials was lower during nicotine than placebo (P = 0.01) and became progressively higher during 30°C than 20°C trials with exercise duration (P = 0.03). Mean power output during the time trial was lower during 30°C than 20°C trials (24 ± 25 W, P = 0.02), and although no effect of nicotine was observed (P > 0.59), two participants (20%) were unable to complete their 30°C nicotine trials as one reached the ethical limit for Tgi (40.0°C), whereas the other withdrew due to “nausea and chills” (Tgi = 39.7°C). These results demonstrate that nicotine use increases thermal strain and risk of exertional heat exhaustion by reducing SkBF. NEW & NOTEWORTHY In naïve participants, acute nicotine use exerts a hyperthermic effect that increases the risk of heat exhaustion during exertional heat strain, which is driven by a blunted skin blood flow response. This has implications for 1) populations that face exertional heat strain and demonstrate high nicotine use (e.g., athletes and military, 25%–50%) and 2) study design whereby screening and exclusion for nicotine use or standardization of prior use (e.g., overnight abstinence) is encouraged.

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