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Purpose of Review We give an overview of recent developments on psychological treatments of depression in primary care. Recent Findings In recent years, it has become clear that psychotherapies can effectively be delivered through e-health applications. Furthermore, several studies in low and middle income countries have shown that lay health counselors can effectively deliver psychological therapies. Behavioral activation, a relatively simple form of therapy, has been found to be as effective as cognitive behavior therapy. Treatment of subthreshold depression has been found to not only reduce depressive symptoms but also prevent the onset of major depression. In addition, therapies are effective in older adults, patients with general medical disorders and in perinatal depression. Summary Psychological therapies are effective in the treatment of depression in primary care, have longer lasting effects than drugs, are preferred by the majority of patients, and can be applied flexibly with different formats and across different target groups.

Probiotics may be helpful in preventing upper respiratory tract infections, but the interventions and evidence are inconsistent. A systematic review of 14 RCTs included 10 trials (n = 3451) that provided sufficient data for pooling.34 Pediatric and adult populations from a wide variety of countries were included. Probiotic prophylaxis reduced the number of participants who had one or more upper respiratory tract infections (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.36 to 0.92) and the number of upper respiratory tract infections per person-year (rate ratio 0.88, 95% CI 0.81 to 0.96). Both outcomes had inconsistent results in the individual studies, reflected in estimates of heterogeneity (I2 = 69% and 44%, respectively). However, use of probiotics reduced antibiotic use (risk ratio 0.67, 95% CI 0.45 to 0.98). In all but two studies, the probiotics varied in types of organisms, combinations of organisms, formulations (e.g., pills, liquids) and quantity (colonyforming units). These inconsistencies limit the clinical application of the study findings. Inhaled ipratropium bromide appears to improve cold symptoms, particularly rhinorrhea, with a moderate increase in adverse events such as epistaxis and dryness of the nose and mouth. A systematic review and meta-analysis of intranasal ipratropium bromide spray did not pool data because of variability in scales, measurements and other parameters.58 Four RCTs identified in the systematic review reported statistically significant improvement in rhinorrhea symptoms compared with placebo. However, four other RCTs found no improvement in nasal congestion compared with placebo. Two RCTs found a statistically significant improvement in the global assessment of symptoms, with 10%-15% more patients in the ipratropium group reporting themselves as \"good or better\" or \"much better or better\" on day 1 or 2 (e.g., in one study, 74% of patients using ipratropium and 61% of those using placebo rated themselves \"much better or better\" [p = 0.02]). Pooled data on adverse events (from up to six RCTs) showed significantly increased epistaxis (OR 3.21, 95% CI 1.68 to 6.13), nasal dryness (OR 2.55, 95% CI 1.50 to 4.33) and dry mouth (OR 3.59, 95% CI 1.38 to 9.38). Inconsistent evidence from a meta-analysis suggests that orally administered zinc reduces the duration and severity of the common cold in adults.74 A 23-mg zinc gluconate lozenge every two hours was the most commonly studied regimen, although there was considerable variability across studies in dose (4.5 to 23.7 mg), frequency (twice daily to 10 times daily) and formulations (gluconate, sulfate or acetate).74 Zinc shortened the course of colds significantly (mean difference -1.65 d, 95% CI -2.5 to -0.8, compared with placebo),74 a finding similar to but somewhat better than the Cochrane review31 (standardized mean difference -0.97 d, 95% CI -1.56 to -0.38). However, zinc was found to have no significant effect on the duration of colds in children (mean difference -0.26, 95% CI -0.78 to 0.25), but the effect was significant in adults (mean difference -2.63, 95% CI -3.69 to -1.58).74 Higher doses appeared to be more effective than lower doses. Zinc did not significantly affect symptom severity in children (standard mean difference -0.05, 95% CI -0.27 to 0.17) but did reduce severity in adults (standard mean difference -0.64, 95% CI -1.05 to -0.24).74 Although the data were positive for adults, heterogeneity was consistently high in all results (I2 = 55% to 95%), which reflected a high level of inconsistency, even in subgroup testing.74 Use of oral zinc supplements was associated with an increased risk of adverse events such as bad taste and nausea (risk ratio 1.24, 95% CI 1.05 to 1.46).74 It is unclear why oral zinc treatment seems to benefit adults more than children.

Background Aging leads to a decline in muscle mass and strength, contributing to frailty and decreased quality of life. Sirolimus (rapamycin) , an mTOR inhibitor, has shown potential in preclinical studies to extend lifespan and improve health span. This study evaluates the safety and efficacy of once-weekly sirolimus (rapamycin) administration on muscle strength and endurance in older adults engaged in a 13-week exercise program. Methods This randomized, double-blind, placebo-controlled trial will enroll 40 participants aged 65–85. Participants will be randomly assigned to receive either sirolimus (rapamycin) 6 mg/week or placebo for 13 weeks, in conjunction with an at-home exercise program. The primary outcome measure is the change in muscle strength and endurance, assessed by the 30-Second Chair-Stand Test. Secondary outcome measures include adverse events, changes in muscle strength and endurance as measured by the 6-min walk test, handgrip strength, and participant-reported outcomes using the SF-36 survey. Assessments will be conducted at baseline, mid-intervention (week 6), and post-intervention (week 13). Blood samples will be collected for hematology and biochemistry analyses, including full blood count, urea and electrolytes, liver function tests, HbA1c, lipids, serum IGF-1, and hs-CRP. DNA methylation will be analyzed using TruDiagnostic™ to explore changes in biological age. Discussion This study aims to provide insights into the potential benefits of intermittent sirolimus (rapamycin) administration on muscle performance in older adults. By alternating periods of mTOR inhibition through rapamycin and activation via exercise, this study will explore a novel approach to enhancing muscle strength and endurance in the aging population. The results could have significant implications for developing interventions to improve physical function and overall health outcomes in older adults. Safety and tolerability will also be closely monitored to ensure the feasibility of this regimen for wider application. Trial registration Australia New Zealand Clinical Trials Registry, ACTRN12624000790549. Registered on 26 June 2024 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12624000790549 .

ObjectivesTo identify what changes in the prescribing of isotretinoin have occurred since funded prescriber access was widened in 2009 from ‘dermatologist only’ prescribing to include ‘general practitioners (GPs) and nurse practitioners working within their scope of practice’.DesignEvaluation of isotretinoin dispensing data from 2008 to 2023 using the national annual prescribing data obtained from the New Zealand Pharmaceutical National Collection database.SettingAll New Zealand citizens prescribed and dispensed funded isotretinoin for acne from 2008 to 2023 were included.Main outcome measuresThe prescribing data were analysed to identify the total number of prescriptions per year by prescribing clinician type, patient ethnicity and deprivation levels.ResultsIn 2008, nearly 100% (26 897) of dispensed prescriptions were written by a dermatologist, while in 2023, 79% (39 432) were written by primary care clinicians. Annual isotretinoin prescriptions increased by 87%, from 26 897 (2008) to 50 613 (2023). Prescriptions for Māori increased from 1750 in 2008 to 4374 in 2023, with similar increases for other ethnic minorities.ConclusionExpanding the prescriber cohort has resulted in a substantial increase in prescriptions, with primary care now issuing the majority of isotretinoin prescriptions. These data demonstrate that the GP workforce can absorb and manage the additional acne workload from the increasing population. Enhanced access for patients suggests an unmet need. An absolute number of prescriptions have risen faster for Māori and Asian patients than for Europeans. Pacific people were generally lower than Europeans. This suggests the longstanding ethnic disparity in access to isotretinoin is partially reduced.Many countries have restrictions on patient access to isotretinoin, similar to New Zealand in 2008. This is the first study demonstrating that, given appropriate postgraduate education and support, the isotretinoin risk–benefit profile may be enhanced to safely deliver high-quality, timely, equitable patient access to isotretinoin in primary care.

Background This systematic review aims to investigate the extent to which preoperative conditioning (PREHAB) improves physiologic function and whether it correlates with improved recovery after major surgery. Methods An electronic database search identified randomized controlled trials (RCTs) investigating the safety and efficacy of PREHAB. The outcomes studied were changes in cardiorespiratory physiologic function, clinical outcomes (including length of hospital stay and rates of postoperative complications), and measures of changes in functional capacity (physical and psychological). Results Eight low- to medium-quality RCTs were included in the final analysis. The patients were elderly (mean age >60 years), and the exercise programs were significantly varied. Adherence to PREHAB was low. Only one study found that PREHAB led to significant improvement in physiologic function correlating with improved clinical outcomes. Conclusion There are only limited data to suggest that PREHAB confers any measured physiologic improvement with subsequent clinical benefit. Further data are required to investigate the efficacy and safety of PREHAB in younger patients and to identify interventions that may help improve adherence to PREHAB.

Insufficient data exist on population-based trends in morbidity and mortality to determine the success of prevention strategies and improvements in health care delivery in stroke. The aim of this study was to determine trends in incidence and outcome (1-year mortality, 28-day case-fatality) in relation to management and risk factors for stroke in the multi-ethnic population of Auckland, New Zealand (NZ) over 30-years. Four stroke incidence population-based register studies were undertaken in adult residents (aged ≥15 years) of Auckland NZ in 1981-1982, 1991-1992, 2002-2003 and 2011-2012. All used standard World Health Organization (WHO) diagnostic criteria and multiple overlapping sources of case-ascertainment for hospitalised and non-hospitalised, fatal and non-fatal, new stroke events. Ethnicity was consistently self-identified into four major groups. Crude and age-adjusted (WHO world population standard) annual incidence and mortality with corresponding 95% confidence intervals (CI) were calculated per 100,000 people, assuming a Poisson distribution. 5400 new stroke patients were registered in four 12 month recruitment phases over the 30-year study period; 79% were NZ/European, 6% Māori, 8% Pacific people, and 7% were of Asian or other origin. Overall stroke incidence and 1-year mortality decreased by 23% (95% CI 5%-31%) and 62% (95% CI 36%-86%), respectively, from 1981 to 2012. Whilst stroke incidence and mortality declined across all groups in NZ from 1991, Māori and Pacific groups had the slowest rate of decline and continue to experience stroke at a significantly younger age (mean ages 60 and 62 years, respectively) compared with NZ/Europeans (mean age 75 years). There was also a decline in 28-day stroke case fatality (overall by 14%, 95% CI 11%-17%) across all ethnic groups from 1981 to 2012. However, there were significant increases in the frequencies of pre-morbid hypertension, myocardial infarction, and diabetes mellitus, but a reduction in frequency of current smoking among stroke patients. In this unique temporal series of studies spanning 30 years, stroke incidence, early case-fatality and 1-year mortality have declined, but ethnic disparities in risk and outcome for stroke persisted suggesting that primary stroke prevention remains crucial to reducing the burden of this disease.

Introduction: Counties Manukau Health Otolaryngology programme for general practitioners with special interest (GPwSI) was developed to provide a group of GPs with tools to manage low complexity, secondary otolaryngology (ORL) problems in their local communities. After clinical triaging, the medical records were retrieved to assess patient outcomes from community (GPwSI) review. This programme provides an example of how the aims of the Health NZ reforms may work in practice, by bridging primary and secondary services.Aim: To assess whether the GPwSI programme provides patients with suitable specialty care in the community, compared to a specialised, hospital outpatient otolaryngology clinic (OPC).Methods: This is a retrospective study of patients with an assigned priority of three (non-urgent) referred to Middlemore Hospital for a first specialist assessment (FSA) during 2018–19.Results: Of the 6231 patients referred, one-fifth (22%) were directed to the GPwSI service, and the remainder (78%) were arranged to be seen in the OPC. GPwSI patients were more likely to be seen for their FSA earlier than OPC patients (RR 1.55, 95% CI 1.46–1.64, P < 0.05). Most patients (99%) referred for surgery by GPwSIs and about one-quarter (23%) of GPwSI patients (315/1345; 23%) were assigned to GPwSI follow up, of which almost all (95%) were managed within the GPwSI programme.Discussion: Patients being seen through the GPwSI programme are suitably managed in the community, more efficiently than if they were to be seen in an outpatient specialist clinic.

INTRODUCTION: Gout remains a health equity issue; Māori and Pacific peoples are disproportionately afflicted, with increased burden and loss of quality of life, yet are less likely to receive appropriate management, which mainly occurs in primary care.AIM: This study aims to understand the perspectives of the mainly Māori and Pacific clinicians and staff at an urban marae practice about barriers and challenges to delivering effective care to a Māori and Pacific community with high burden of gout.METHODS: Semi-structured interviews were conducted with 10 staff members delivering health care to a mostly Indigenous community. Interviews sought to ascertain staff views of enablers and barriers to optimal gout management and analyse them thematically.RESULTS: Three themes were identified: community disadvantage; demands unique to Indigenous providers; and challenges and opportunities for optimising gout management. High prevalence and heavy impact of gout on wellbeing in the community was intertwined with socioeconomic disadvantage, precariousness of employment and entrenched inaccurate (yet pliable) patient views on gout, to the detriment of focused, effective care. Structural and funding demands on providers inhibited staff focus on the clear community need. Providers saw the culturally safe and competent approach necessary for improvement as requiring community empowerment with appropriate clinical tools and adequate resourcing.DISCUSSION: Despite provider intent to deliver culturally appropriate and safe care and equitable health outcomes for patients suffering from gout, general practice initiatives without aligned resourcing or incentives are inhibited when inequity is pervasive. Simply asking Māori providers to do more for the same amount of resource may not be effective.