INTRODUCTION:Management of type 2 diabetes (T2D) occurs predominantly in primary health care in Aotearoa New Zealand. Optimising the delivery of clinical diabetes management by upskilling healthcare professionals can reduce the strain on the healthcare system and improve patient care. AIM:This study aimed to qualitatively evaluate the importance of an education programme delivered by a non-physician diabetes specialist on nurses' knowledge and confidence of T2D management in primary care. METHODS:Semi-structured interviews with nurses enrolled in the programme for at least 6 months and their nurse leads across two clinics in the Waikato region were conducted to assess their confidence and knowledge in T2D management, as well as the acceptability of the programme. Transcripts were analysed using quantitative content analysis. RESULTS:Four nurses and two nurse leads were interviewed, lasting between 15 and 60 min. Nurses reported improved knowledge of diabetes medications and interpreting clinical measures. Nurses also felt more confident in their communication skills with patients, advocating for their patients, and improved patient engagement. Further education was needed on administering diabetes medication, knowledge of medical devices such as continuous glucose monitoring, and understanding the pathophysiology of diabetes. DISCUSSION:Self-efficacy and self-reported skills of nurses in T2D management improved following the diabetes mentoring programme. Further research is needed to assess quantitative clinical measures and whether the programme is effective in improving patient health outcomes.

AIM:We aimed to validate the interRAI Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) scale in predicting unplanned hospital admissions following emergency department (ED) visits among community-dwelling older adults in an urban Aotearoa New Zealand population. METHODS:We conducted a retrospective cohort study of adults aged ≥55 years who underwent interRAI home care (HC) version 9.1 assessment between May 2021 and April 2022. The DIVERT score, derived from HC assessment data, categorised patients into risk levels. Hospital records were reviewed for unplanned hospital admissions via ED within 90 days of assessment. Statistical analyses, including survival and regression models, were used to evaluate predictive validity and explore risk factors. RESULTS:Between May 2021 and April 2022, 2,006 patients were assessed, with a mean age of 79.8 years (range 55-103). Admission rates within 90 days increased with higher DIVERT scores, from 18.2% (score 1) to 41.9% (score 6). Among high-risk groups (scores 5-6), a higher comorbidity burden was significantly associated with admission (p<0.001), while age, ethnicity and deprivation showed no statistically significant association. Primary causes of admission included infections, heart failure and falls. Mortality rates were notably higher in admitted patients at both 30 and 90 days. CONCLUSIONS:This study confirms the predictive validity of the interRAI DIVERT scale for unplanned hospital admissions among community-dwelling older adults in urban Aotearoa New Zealand. The strong association between higher scores and increased admission rates supports its use in risk-stratification within this population.

BACKGROUND:Hospital discharge codes can be used to identify possible Adverse Events of Special Interest (AESI) following COVID-19 vaccinations. AIM:We sought to estimate the positive predictive value (PPV) and level of certainty of ICD-10-AM and SNOMED coding for meeting Brighton Collaboration case definitions of AESIs in Aotearoa, New Zealand. METHODS:Our expert panel identified 24 ICD-10-AM codes and 2 SNOMED codes expected to identify 9 AESIs. We sought codes likely to be specific rather than sensitive. Medical record reviews were conducted by an experienced coder, adjudicated by medical specialists, for the level of certainty that each case met the target case definition. Admissions coded to an explicit alternative diagnosis were classified as Not a Case. RESULTS:Our data covered over 3 million people. Reviews were conducted on 761 medical records, randomly selected from admissions principally in calendar years 2016 to 2019. We report the PPV of each code with respect to its level of certainty of meeting the case definition. Only Guillain-Barré had a single code specific to a single AESI. Several neurological conditions had overlapping codes, conditions and case definitions. PPVs for individual codes to meet case definitions ranged from 11% to 100%. Level of certainty of each code and PPV are specified. CONCLUSION:PPVs of codes for each AESI need to be assessed on a case-by-case basis. Many codes are arguably insufficiently 'accurate' to identify a target AESI. We did not assess PPVs for combinations of codes. Our method did not allow us to estimate the number of cases missed by the coding.

In a multinational randomized controlled trial, we previously showed that maternal supplementation with myo-inositol, probiotics, and micronutrients was associated with reduced incidence of rapid infant weight gain and high body mass index (BMI) at two years among offspring. It was unclear whether these differences in weight gain and body mass were due to reduced adiposity. Therefore, we aimed to determine whether there were any differences in body composition. Body composition was measured using bioelectrical impedance spectroscopy at six weeks, six months, one year, and two years among offspring born to mothers who received a nutritional intervention (n = 268) or control (n = 264) supplement preconception and during pregnancy. There were no group-level differences in body composition, except at two years, when fat-free mass was greater among control offspring [adjusted mean difference (aMD) 0.14 kg, 95

IMPACT:Body composition estimates in infancy differ substantially depending on the tool used (ADP, DXA, or BIA) and on within-tool factors (e.g. DXA software version). This study systematically compares three widely used infant body composition tools, demonstrating that the choice of tool and analysis approach can markedly affect the results. These findings underscore the need for caution when comparing infant body composition measurements across studies or over time where a change in tool type has been required. Standardized protocols and transparent reporting will be crucial for improving paediatric nutrition and growth assessments.

The prevalence of childhood obesity is increasing globally(1). While BMI is commonly used to define obesity, it is unable to differentiate between fat and muscle mass, leading to calls to measure body composition specifically(2). While several tools are available to assess body composition in infancy, it is unclear if they are directly comparable. Among a subset of healthy infants born to mothers participating in a randomised controlled trial of a preconception and antenatal nutritional supplement(3), measurements were made at ages 6 weeks (n = 58) and 6 months (n = 70) using air displacement plethysmography (ADP), whole-body dual-energy X-ray absorptiometry (DXA), and bioelectrical impedance spectroscopy (BIS). Estimates of percentage fat mass (%FM) were compared using Cohen’s kappa statistic (κ) and Bland-Altman analysis (4,5). There was none to weak agreement when comparing tertiles of %FM (κ = 0.15–0.59). When comparing absolute values, the bias (i.e., mean difference) was smallest when comparing BIS to ADP at 6 weeks (+1.7%). A similar bias was observed at 6 months when comparing DXA to ADP (+1.8%). However, when comparing BIA to DXA at both ages, biases were much larger (+7.6% and +4.7% at 6 weeks and 6 months, respectively). Furthermore, there was wide interindividual variance (limits of agreement [LOA] i.e., ± 1.96 SD) for each comparison. At 6 weeks, LOA ranged from ± 4.8 to ± 6.5% for BIA vs. DXA and BIA vs. ADP, respectively. At 6 months, LOA were even wider, ranging from ± 7.3 to ± 8.1% (DXA vs. ADP and BIA vs. DXA, respectively). Proportional biases were apparent when comparing BIS to the other tools at both ages, with BIS generally overestimating %FM more among infants with low adiposity. In addition to differences according to tool type, within-tool factors impacted body composition estimation. For ADP measurements, the choice of FFM density reference (Fomon vs. Butte) had minimal impact; however, choice of DXA software version (GE Lunar enCORE basic vs. enhanced) and BIS analysis approach (empirical equation vs. mixture theory prediction) led to very different estimates of body composition. In conclusion, when comparing body composition assessment tools in infancy, there was limited agreement between three commonly used tools. Therefore, researchers and clinicians must be cautious when conducting longitudinal analyses or when comparing findings across studies, as estimates are not comparable across tools.

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.

Abstract Background For more than a century, Māori have experienced poorer health than non-Māori. In 2019 an independent Tribunal found the Government had breached Te Tiriti o Waitangi by “failing to design and administer the current primary health care system to actively address persistent Māori health inequities”. Many Māori (44%) have unmet needs for primary care. Seven models of primary care were identified by the funders and the research team, including Māori-owned practices. We hypothesised patient health outcomes for Māori would differ between models of care. Methods Cross-sectional primary care data were analysed at 30 September 2018. National datasets were linked to general practices at patient level, to measure associations between practice characteristics and patient health outcomes. Primary outcomes: polypharmacy (≥ 55 years), HbA1c testing, child immunisations, ambulatory sensitive hospitalisations (0–14, 45–64 years) and emergency department attendances. Regressions include only Māori patients, across all models of care. Results A total of 660,752 Māori patients were enrolled in 924 practices with 124,854 in 65 Māori-owned practices. Māori practices had: no significant association with HbA1c testing, ambulatory sensitive hospitalisations or ED attendances, and a significant association with lower polypharmacy (3.7% points) and lower childhood immunisations (13.4% points). Māori practices had higher rates of cervical smear and cardiovascular risk assessment, lower rates of HbA1c tests, and more nurse (46%) and doctor (8%) time (FTE) with patients. The average Māori practice had 52% Māori patients compared to 12% across all practices. Māori practices enrolled a higher percentage of children and young people, five times more patients in high deprivation areas, and patients with more multimorbidity. More Māori patients lived rurally (21.5% vs 15%), with a greater distance to the nearest ED. Māori patients were more likely to be dispensed antibiotics or tramadol. Conclusions Māori practices are an expression of autonomy in the face of enduring health system failure. Apart from lower immunisation rates, health outcomes were not different from other models of care, despite patients having higher health risk profiles. Across all models, primary care need was unmet for many Māori, despite increased clinical input. Funding must support under-resourced Māori practices and ensure accountability for the health outcomes of Māori patients in all models of general practice.

Purpose Indigenous peoples from high income countries experience health disparities attributable to the ongoing legacy of colonisation and racism, including higher rates of diabetes and associated complications, including diabetes foot disease, in comparison to the relevant resident population. Providing culturally safe care through well-organised diabetes foot interventions can improve outcomes. This scoping review describes the range of publications detailing diabetes foot interventions that incorporated Indigenous peoples. Methods This scoping review followed the PRISMA-Scoping Review guide. Indigenous Māori perspectives were included in all stages of the review. Eligible publications described diabetes foot interventions that included Indigenous peoples from high-income countries. Key study characteristics included country, Indigenous population, intervention description, foot-related outcomes, and alignment with the CONSIDER statement domains for reporting on Indigenous involvement in health research. Main findings A total of 32 publications met the eligibility criteria, with publications from Australia (n = 14), Canada (n = 6), USA (n = 6), New Zealand (n = 2), Greenland (n = 2) and Nauru (n = 2). Primary prevention interventions were predominant (n=20) with a focus on increasing foot screening rates (n=16). Other interventions included health promotion and education (n=4), comprehensive foot interventions (n=5), foot care services embedded in undergraduate podiatry education, a diabetic foot ulcer management protocol, and a service brokerage model. Only 2 studies of the 29 evaluated reported all the CONSIDER statement domains. Principal conclusions Few publications described improved outcomes for Indigenous peoples and most interventions for diabetes-related foot disease overlooked Indigenous perspectives and health beliefs concerning feet. The CONSIDER statement provides useful guidance for all stages of research with Indigenous peoples and our findings suggest reporting Indigenous engagement could be strengthened.

Objective This review aimed to assess the effectiveness of interventions for type 2 diabetes (T2D) management in New Zealand on clinical outcomes, and explore the factors impacting their feasibility and acceptability. Study design Scoping review. Methods Three databases (PubMed, Web of Science and Scopus) were searched between January 2000 and July 2023. Reference lists of included studies were hand searched to identify additional articles. Results The search yielded 550 publications, of which 11 were included in the final review. Most interventions (n = 10) focussed on education and seven were delivered by health professionals. Supporting factors for interventions included clinical/peer support (n = 8) and whānau (family) involvement (n = 6). Hindering factors included non-adherence (n = 4) and high drop-out (n = 4). Most studies reported modest improvement in HbA1c and weight at six months, but minimal change in HbA1c, weight, lipids, renal profile, and blood pressure by two years. Conclusion Future interventions should involve culturally appropriate approaches to improve engagement and acceptability while addressing lifestyle and medication adherence for T2D management. T2D interventions not widely disseminated via academic channels need to be further identified.

Background Nutritional intervention preconception and throughout pregnancy has been proposed as an approach to promoting healthy postnatal weight gain in the offspring but few randomised trials have examined this. Methods Measurements of weight and length were obtained at multiple time points from birth to 2 years among 576 offspring of women randomised to receive preconception and antenatally either a supplement containing myo -inositol, probiotics, and additional micronutrients (intervention) or a standard micronutrient supplement (control). We examined the influence on age- and sex-standardised BMI at 2 years (WHO standards, adjusting for study site, sex, maternal parity, smoking and pre-pregnancy BMI, and gestational age), together with the change in weight, length, BMI from birth, and weight gain trajectories using latent class growth analysis. Results At 2 years, there was a trend towards lower mean BMI among intervention offspring (adjusted mean difference [aMD] − 0.14 SD [95% CI 0.30, 0.02], p = 0.09), and fewer had a BMI > 95th percentile (i.e. > 1.65 SD, 9.2% vs 18.0%, adjusted risk ratio [aRR] 0.51 [95% CI 0.31, 0.82], p = 0.006). Longitudinal data revealed that intervention offspring had a 24% reduced risk of experiencing rapid weight gain > 0.67 SD in the first year of life (21.9% vs 31.1%, aRR 0.76 [95% CI 0.58, 1.00], p = 0.047). The risk was likewise decreased for sustained weight gain > 1.34 SD in the first 2 years of life (7.7% vs 17.1%, aRR 0.55 [95% CI 0.34, 0.88], p = 0.014). From five weight gain trajectories identified, there were more intervention offspring in the “normal” weight gain trajectory characterised by stable weight SDS around 0 SD from birth to 2 years (38.8% vs 30.1%, RR 1.29 [95% CI 1.03, 1.62], p = 0.029). Conclusions Supplementation with myo -inositol, probiotics, and additional micronutrients preconception and in pregnancy reduced the incidence of rapid weight gain and obesity at 2 years among offspring. Previous reports suggest these effects will likely translate to health benefits, but longer-term follow-up is needed to evaluate this. Trial registration ClinicalTrials.gov, NCT02509988 (Universal Trial Number U1111-1171–8056). Registered on 16 July 2015.

Aim: Myo-inositol supplementation from similar to 13 weeks' gestation reportedly improves glycaemia regulation in metabolically at-risk women, with speculation that earlier supplementation might bring further improvement. However, the NiPPeR trial of a myo-inositol-containing supplement starting preconception did not lower gestational glycaemia in generally healthy women. We postulated that the earlier timing of supplementation influences the maternal metabolic adaptation for gestational glycaemia regulation. Methods: In total, 585 women were recruited from Singapore, UK and New Zealand for the NiPPeR study. We examined associations of plasma myo-inositol concentrations at 7 and 28 weeks' gestation with 28 weeks plasma glucose (PG; fasting, and 1 h and 2 h in 75 g oral glucose tolerance test) and insulin indices using linear regression adjusting for covariates. Results: Higher 7-week myo-inositol, but not 28-week myo-inositol, associated with higher 1 h PG [beta(adj) (95% confidence intervals) 0.05 (0.01, 0.09) log(e) mmol/L per log(e) mu mol/L, p = .022] and 2 h PG [0.08 (0.03, 0.12), p = .001]; equivalent to 0.39 mmol/L increase in 2 h PG for an average 7-week myo-inositol increase of 23.4 mu mol/L with myo-inositol supplementation. Higher 7-week myo-inositol associated with a lower 28-week Stumvoll index (first phase), an approximation of insulin secretion [-0.08 (-0.15, -0.01), p = .020] but not with 28-week Matsuda insulin sensitivity index. However, the clinical significance of a 7-week myo-inositol-related increase in glycaemia was limited as there was no association with gestational diabetes risk, birthweight and cord C-peptide levels. In-silico modelling found higher 28-week myo-inositol was associated with lower gestational glycaemia in White, but not Asian, women after controlling for 7-week myo-inositol effects. Conclusion: To our knowledge, our study provides the first evidence that increasing first trimester plasma myo-inositol may slightly exacerbate later pregnancy post-challenge glycaemia, indicating that the optimal timing for starting prenatal myo-inositol supplementation needs further investigation.

Background Māori are over-represented in Aotearoa New Zealand morbidity and mortality statistics. Other populations with high health needs include Pacific peoples and those living with material deprivation. General practice has evolved into different models of primary care. We describe nurse work in relation to these models of care; populations with high health need; and patient health outcomes. Methods Cross-sectional study (30 September 2018), data from national datasets and practices at patient level. Six primary outcome measures were selected because they could be improved by primary care: polypharmacy (≥65 years), HbA1c testing in adults with diabetes, immunisations (6 months), ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Analysis adjusted for patient and practice characteristics. Results Nurse FTE, and combined nurse, nurse practitioner and general practitioner FTE, were substantially higher in Trust/NGO, Māori, and Pacific practices than Traditional, Corporate, or Health Care Home practices. A progressive increase of clinically complex patients was associated with more clinical input and higher scores on all outcome measures. The highest rates of nurse consultations afterhours and with unenrolled patients, improving access, were in PHO/DHB, Pacific, Trust/NGO and Māori practices. Compared to general practitioners, nurses undertook more cardiovascular risk assessment in all models of care except PHO/DHB, and more cervical screening in Pacific, Trust/NGO and Māori practices. The highest rates of preventative care by nurses (cervical screening, cardiovascular risk assessment, PHQ9 assessment, HbA1c testing) were in Māori, Trust/NGO and Pacific practices. There was an 8-fold difference, across models of care, in percentage of PHQ9 undertaken by nurses and a 5-fold difference in cervical screening and HbA1c testing. Work not attributed to nurses in the practice records meant nurse work was underestimated to an unknown degree. Conclusions Transferring work to nurses in Traditional, Health Care Home, and Corporate practices, would release GP FTE to be utilised for other work. Worse patient health outcomes were associated with higher patient need and higher clinical input. It is plausible that there is insufficient clinical input to meet the degree of patient need. More practitioner FTE is required, especially in practices with high volumes of complex patients.

Background Bioimpedance devices are practical for measuring body composition in preschool children, but their application is limited by the lack of validated equations. Objectives To develop and validate fat-free mass (FFM) bioimpedance prediction equations among New Zealand 3.5-year olds, with dual-energy X-ray absorptiometry (DXA) as the reference method. Methods Bioelectrical impedance spectroscopy (SFB7, ImpediMed) and DXA (iDXA, GE Lunar) measurements were conducted on 65 children. An equation incorporating weight, sex, ethnicity, and impedance was developed and validated. Performance was compared with published equations and mixture theory prediction. Results The equation developed in ~70% ( n = 45) of the population (FFM [kg] = 1.39 + 0.30 weight [kg] + 0.39 length 2 /resistance at 50 kHz [cm 2 /Ω] + 0.30 sex [M = 1/F = 0] + 0.28 ethnicity [1 = Asian/0 = non-Asian]) explained 88% of the variance in FFM and predicted FFM with a root mean squared error of 0.39 kg (3.4% of mean FFM). When internally validated ( n = 20), bias was small (40 g, 0.3% of mean FFM), with limits of agreement (LOA) ±7.6% of mean FFM (95% LOA: –0.82, 0.90 kg). Published equations evaluated had similar LOA, but with marked bias (>12.5% of mean FFM) when validated in our cohort, likely due to DXA differences. Of mixture theory methods assessed, the SFB7 inbuilt equation with personalized body geometry values performed best. However, bias and LOA were larger than with the empirical equations (–0.43 kg [95% LOA: –1.65, 0.79], p < 0.001). Conclusions We developed and validated a bioimpedance equation that can accurately predict FFM. Further external validation of the equation is required.

BackgroundMaternal vitamin status preconception and during pregnancy has important consequences for pregnancy outcome and offspring development. Changes in vitamin status from preconception through early and late pregnancy and postpartum have been inferred from cross-sectional data, but longitudinal data on vitamin status from preconception throughout pregnancy and postdelivery are sparse. As such, the influence of vitamin supplementation on vitamin status during pregnancy remains uncertain. This study presents one prespecified outcome from the randomized controlled NiPPeR trial, aiming to identify longitudinal patterns of maternal vitamin status from preconception, through early and late pregnancy, to 6 months postdelivery, and determine the influence of vitamin supplementation.Methods and findingsIn the NiPPeR trial, 1,729 women (from the United Kingdom, Singapore, and New Zealand) aged 18 to 38 years and planning conception were randomized to receive a standard vitamin supplement (control; n = 859) or an enhanced vitamin supplement (intervention; n = 870) starting in preconception and continued throughout pregnancy, with blinding of participants and research staff. Supplement components common to both treatment groups included folic acid, β-carotene, iron, calcium, and iodine; components additionally included in the intervention group were riboflavin, vitamins B6, B12, and D (in amounts available in over-the-counter supplements), myo-inositol, probiotics, and zinc. The primary outcome of the study was glucose tolerance at 28 weeks' gestation, measured by oral glucose tolerance test. The secondary outcome reported in this study was the reduction in maternal micronutrient insufficiency in riboflavin, vitamin B6, vitamin B12, and vitamin D, before and during pregnancy. We measured maternal plasma concentrations of B-vitamins, vitamin D, and markers of insufficiency/deficiency (homocysteine, hydroxykynurenine-ratio, methylmalonic acid) at recruitment, 1 month after commencing intervention preconception, in early pregnancy (7 to 11 weeks' gestation) and late pregnancy (around 28 weeks' gestation), and postdelivery (6 months after supplement discontinuation). We derived standard deviation scores (SDS) to characterize longitudinal changes among participants in the control group and measured differences between the 2 groups. At recruitment, the proportion of patients with marginal or low plasma status was 29.2% for folate (<13.6 nmol/L), 7.5% and 82.0% for riboflavin (<5 nmol/L and ≤26.5 nmol/L, respectively), 9.1% for vitamin B12 (<221 pmol/L), and 48.7% for vitamin D (<50 nmol/L); these proportions were balanced between the groups. Over 90% of all participants had low or marginal status for one or more of these vitamins at recruitment. Among participants in the control group, plasma concentrations of riboflavin declined through early and late pregnancy, whereas concentrations of 25-hydroxyvitamin D were unchanged in early pregnancy, and concentrations of vitamin B6 and B12 declined throughout pregnancy, becoming >1 SDS lower than baseline by 28 weeks gestation. In the control group, 54.2% of participants developed low late-pregnancy vitamin B6 concentrations (pyridoxal 5-phosphate <20 nmol/L). After 1 month of supplementation, plasma concentrations of supplement components were substantially higher among participants in the intervention group than those in the control group: riboflavin by 0.77 SDS (95% CI 0.68 to 0.87, p < 0.0001), vitamin B6 by 1.07 SDS (0.99 to 1.14, p < 0.0001), vitamin B12 by 0.55 SDS (0.46 to 0.64, p < 0.0001), and vitamin D by 0.51 SDS (0.43 to 0.60, p < 0.0001), with higher levels in the intervention group maintained during pregnancy. Markers of vitamin insufficiency/deficiency were reduced in the intervention group, and the proportion of participants with vitamin D insufficiency (<50 nmol/L) during late pregnancy was lower in the intervention group (35.1% versus 8.5%; p < 0.0001). Plasma vitamin B12 remained higher in the intervention group than in the control group 6 months postdelivery (by 0.30 SDS (0.14, 0.46), p = 0.0003). The main limitation is that generalizability to the global population is limited by the high-resource settings and the lack of African and Amerindian women in particular.ConclusionsOver 90% of the trial participants had marginal or low concentrations of one or more of folate, riboflavin, vitamin B12, or vitamin D during preconception, and many developed markers of vitamin B6 deficiency in late pregnancy. Preconception/pregnancy supplementation in amounts available in over-the-counter supplements substantially reduces the prevalence of vitamin deficiency and depletion markers before and during pregnancy, with higher maternal plasma vitamin B12 maintained during the recommended lactational period.Trial registrationClinicalTrials.gov NCT02509988; U1111-1171-8056.

Objective: To determine whether a combined myo-inositol, probiotics and micronutrient nutritional supplement impacts time-tonatural-conception and clinical pregnancy rates. Design: Secondary outcomes of a double-blind randomized controlled trial. Setting: Community recruitment. Patients: Women aged 18 to 38 years planning to conceive in the United Kingdom, Singapore, and New Zealand, excluding those with diabetes mellitus or receiving fertility treatment. Intervention: A standard (control) supplement (folic acid, iron, calcium, iodine, beta-carotene), compared with an intervention additionally containing myo-inositol, probiotics, and other micronutrients (vitamins B2, B6, B12, D, zinc). Main Outcome Measures: Number of days between randomization and estimated date of natural conception of a clinical pregnancy, as well as cumulative pregnancy rates at 3, 6, and 12 months. Results: Of 1729 women randomized, 1437 (83%; intervention, n=736; control, n=701) provided data. Kaplan-Meier curves of conception were similar between intervention and control groups; the time at which 20% achieved natural conception was 90.5 days (95% confidence interval: 80.7, 103.5) in the intervention group compared with 92.0 days (76.0, 105.1) in the control group. Cox's proportional hazard ratios (HRs) comparing intervention against control for cumulative achievement of pregnancy (adjusted for site, ethnicity, age, body mass index, and gravidity) were similar at 3, 6, and 12 months. Among both study groups combined, overall time-to-conception lengthened with higher preconception body mass index, and was longer in non-White than in White women. Among women who were overweight the intervention shortened time-to-conception compared with control regardless of ethnicity (12-month HR=1.47 [1.07, 2.02], P=.016; 20% conceived by 84.5 vs. 117.0 days) and improved it to that comparable to nonoverweight/nonobese women (20% conceived by 82.1 days). In contrast, among women with obesity, time-to-conception was lengthened with intervention compared with control (12-month HR=0.69 [0.47, 1.00]; P=.053; 20% conceived by 132.7 vs. 108.5 days); an effect predominantly observed in non-White women with obesity. Conclusions: Time-to-natural-conception and clinical pregnancy rates within a year were overall similar in women receiving the intervention supplement compared with control. Overweight women had a longer time-to-conception but there was suggestion that the supplement may shorten their time-to-conception to that comparable to the nonoverweight/nonobese women. Further studies are required to confirm this.

isual changes are a common presentation to the emergency department and appropriate work-up is paramount.This case shows how fundoscopy findings alone alerted the medical practitioners to a life-changing, exceedingly rare systemic illness.Preretinal haemorrhages form between the hyaloid face and the inner limiting membrane of the retina, and may occur in cases of diabetes, trauma or older age. 1 However, in younger patients it is an uncommon clinical finding.This is the first reported case of B-cell prolymphocytic leukaemia (B-PLL) presenting with visual symptoms.