Clinical Snippets May 2022

Clinical Snippets – May 2022

1.  ACC Treatment Injury

• Refusal to provide or delays in lodging a Treatment Injury claim with ACC is not an uncommon source of patient complaints.  However, on average a third of Treatment Injury claims are declined each year

• ACC has a provider resource (to which a patient could also be referred) clarifying the process

• The principles of a claim are:
  • An injury has occurred that has resulted in physical harm or damage to the patient
  • The injury has been caused by the treatment (probability rather than possibility considered)
  • The injury is not a necessary part or an ordinary consequence of treatment, having regard to the clinical knowledge at the time of treatment and the underlying health condition of the patient

• A precipitating event can include when treatment has not been given by mistake or has been given unreasonably late

• Lack of evidence of physical injury caused by treatment is the most common reason for a claim to be declined

• If review of an ACC Treatment Injury claim results in concern there is a risk to the public, the details may be forwarded to HDC

2.  Concussion

BPAC has recently published a comprehensive overview of concussion management for primary healthcare professionals – audiovisual and written resources including a summary sheet.  Key practice points include:

• Recognising concussion in primary care can be challenging as symptoms and signs are often subtle, non-specific, and can progress over time.  Initial loss of consciousness only occurs in one in ten people with concussion
• The Brain Injury Screening Tool (BIST) is a standardised and validated assessment tool to evaluate patients with suspected concussion; this is specifically tailored for use in time-limited clinical consultations (takes 5-6 minutes to complete)
• Initial management of patients with concussion involves physical and mental rest for 24 – 48 hours; in most cases patients should then progressively re-engage in normal activities after this rest period, assuming the degree of engagement does not significantly worsen symptoms – excessive rest can prolong recovery.
• Patients who have sustained a sports-related concussion should be immediately removed from play, and not return until they have been medically cleared after completing a graduated return-to-play protocol
• Patients can be reassured that most people who experience a concussion will fully recover within two to four weeks. However, recovery is strongly influenced by the timeliness of clinical review and follow-up, effective education delivered at an appropriate level of health literacy (and whether the advice given is culturally appropriate/relevant), as well as other patient-specific factors, e.g. initial symptom burden, ‘yellow flags’
• On-line educational resources are available from ACC for adult patients (English and Te Reo Maori) and for carers of an affected child
• Post-concussion syndrome is no longer a recognised as a diagnosis in DSM-5. ICD-11 or by ACC.  The preferred term is ‘persistent concussion symptoms’ (beyond three months). 

The article covers all aspects of assessment, education, recovery and rehabilitation,  complications, return to work and sport advice etc. 

3.  Calcium for hypertension?

A recent PEARL published in NZ Doctor referenced a Cochrane review noting several studies have shown an inverse association between calcium intake and blood pressure, and small reductions in blood pressure have been shown to produce rapid reductions in cardiovascular disease risk even in individuals with normal blood pressure. A 2 mmHg lower systolic blood pressure is predicted to produce about 10% lower stroke mortality and about 7% lower mortality from ischaemic heart disease.

An increase in calcium intake slightly reduced both systolic and diastolic blood pressure in normotensive people. The effect was confirmed in multiple prespecified subgroups, including a possible dose–response effect (1500mg per day being more efficacious than 1000mg), reinforcing the efficacy of the intervention. The effects were observed after only 3.5 months of intervention and were more pronounced in younger patients.

Most of the studies used calcium supplements and there is some suggestion that the effect might be lost over time in populations with adequate calcium intake.

Conversely, a 2021 meta-analysis in the journal Nutrients reported that dietary calcium intake of 700–1000 mg per day or supplementary calcium intake of 1000 mg per day increased the risk of CVD by about 15% in healthy postmenopausal women.

4.  Dog bites

Starship Hospital has updated its guidance on management of dog bite injuries which are increasing in frequency.  Practice points include:

• In serious incidents police or animal management may require photos or DNA collection from the wound prior to washout or closure. Encourage patients to take their own photos of injuries to keep for future reference.

• Consider imaging (Xray/CT) in even seemingly simple dog-bite injuries. Significant force (>1000N) can be involved, with deep penetration or crush injuries not initially obvious.
• Examination and copious irrigation should be done if the dermis has been penetrated or if the wound is in the proximity of joints
• Primary wound closure is recommended if early presentation (<4-6hours) AND absence of non-viable/heavily damaged tissue/contamination.  Delayed wound closure or healing by secondary intention is recommended for all other wounds.
• There is evidence that prophylactic antibiotics are associated with a statistically significant reduction in infection in dog-bites to hands.  There is conflicting evidence for other wounds. Antibiotics are also indicated for any infected wound, or as prophylaxis for puncture wounds, bite-injuries to hands, feet, face or genitalia, immunocompromised patients, those requiring surgery or who have an underlying structural injury, or if presenting >8 hours after the bite. 
• Amoxicillin/clavulanic acid is the antibiotic of choice with alternative for penicillin allergic patients being metronidazole plus co-trimoxazole (≥1 month – 11 years) or metronidazole plus doxycycline ( ≥ 12 years)
• It is strongly recommended that health professionals notify all dog-bite and serious non-bite dog-related injuries to the Animal Management Service of the council where the dog bite occurred, and do not require patient consent. Dogs pose a serious health risk to vulnerable people, including children, who are more likely to receive serious bites to the head/face/neck, and the potential for significant psychological harm in any age group
•   Any serious risk to a child or the public also needs to be referred to Social Work, Oranga Tamariki and/or Police. Animal Management Officers have limitations on what they can do in situations where a dog has bitten a family member, and may require further input from these services to ensure safety measures are put in place.
• Offer psychological support to all victims, and to whānau who have witnessed an attack. ACC can provide support with counselling or therapy sessions. 
• The Starship website has a printable information sheet for carers of affected children which includes reference to notification to Animal Control Officers, and a Council Notification form (currently Auckland specific – Hamilton details are Ph 07 8386632, email: animalweb@hcc.govt.nz  ) 

5.  Avocados

• A recent BPAC update references a recent paper published in the Journal of the American Heart Association that has found higher avocado intake is associated with a significantly lower risk of cardiovascular disease (CVD) and coronary heart disease.

• In a study of almost 70,000 women and over 40,000 men who did not have a history of cancer, coronary heart disease or stroke at baseline, followed up for thirty years, it was found that those who had two or more servings of avocado per week had a 16% lower risk of CVD and 21% lower risk of coronary heart disease. There was no significant association with a lower risk of stroke.

• The authors concluded that CVD risk could be lowered by 16 – 22% by replacing half a serving per day of high fat content foods such as margarine, butter, egg, yoghurt, cheese or processed meat with the equivalent amount of avocado.