January 2023

Clinical Snippets – January 2023 – Shownotes

1.  Goodfellow Gem – Diagnosing sleep conditions 

A recent Goodfellow Gem includes a straightforward screening tool for common sleep conditions:  the Goodfellow Unit Short Sleep Questionnaire.¹

Two lesser-known issues are:

• Primary insomnia (chronic insomnia), when patients spend more time in bed than they need to. The Australian Sleep Association² has tools for how to diagnose and treat this and other sleep conditions.
• Delayed sleep phase disorder – those who prefer to go to bed late [after midnight] and get up late in the morning is the other less common issue; this is a teenage sleep pattern seen in 25% of University students. This group need melatonin at night and light boxes or sunlight early in the morning.
  
  References:

1. Short Sleep questionnaire View
2. Australian Sleep Association Website

2.  Topiramate and pregnancy

A BPAC bulletin refers to a recently published study in JAMA Neurology which has identified an increased risk of neurodevelopmental disorders in children exposed in utero to topiramate.  The results of this study suggest that topiramate poses a similar risk of neurodevelopmental adverse effects as sodium valproate (or potentially higher) and the same level of caution should therefore be applied. In New Zealand, topiramate is indicated for epilepsy and migraine prophylaxis in adults and is also used off-label in restless leg syndrome, as a mood stabiliser (BPAD, PTSD) and neuropathic pain. 

Key points for prescribing any anti-epileptic medicines to females of child-bearing potential include:

• Women of child-bearing age should be made aware of the potential risks of anti-epileptic medicines, but also of the risk of seizures during pregnancy, i.e. if an appropriate anti-epileptic medicine is not taken
• Two forms of effective contraception should be used by women of child-bearing age who are taking an anti-epileptic medicine; N.B. Some hormonal contraceptives interact with enzyme-inducing anti-epileptic medicines
• Pregnancy should be planned so that an anti-epileptic medicine regimen with the lowest risk, while balancing treatment efficacy, can be put in place
• If an anti-epileptic medicine is being considered for a condition such as migraine prophylaxis or neuropathic pain, consider other suitable treatment options first in a woman of child-bearing age

3.  New ACE inhibitor available from December: ramipril

Ramipril (Tryzan), an angiotensin-converting enzyme (ACE) inhibitor, will be funded from 1 December, 2022, without restrictions. Ramipril is indicated for people with hypertension, heart failure, progressive kidney disease and for the prevention of cardiovascular events in people with heart disease. Ramipril will be available in 1.25 mg, 2.5 mg, 5 mg and 10 mg capsules (see dosing information on NZF).

4.  Cellulitis Pathway updated on HealthPathways

Important assessment points include checking for signs of sepsis and determining the severity of cellulitis which in turn guides therapy. 

Wound swabs are not usually necessary.  If you are taking a sample, do not swab skin, wound ooze or wound surfaces. Send only aspirate or swab of pus from a drained or draining abscess for microbiology.  Chronic wound swabs should never be taken.

For mild to moderate cellulitis, start oral antibiotics according to the presentation and the patient’s sensitivity to penicillin (see your local Healthpathway for details)

Monitor the patient and consider changing antibiotics only when necessary:

• Be aware that the natural history of cellulitis shows increasing redness and swelling within the first 48 hours.
• If the patient is improving overall at 48 to 72 hours after initiation of oral therapy, do not start intravenous therapy solely due the persistence of redness or swelling.
• Consider intravenous (IV) antibiotics with probenecid if the patient has moderate cellulitis and you have concerns about adherence or absorption. (This may need approval in your district by an infectious diseases specialist, or to be prescribed in the emergency department.)

5.  Removal of funding restrictions for zoledronic acid

Pharmac is removing all Special Authority funding restrictions from zoledronic acid from 1 March, 2023, e.g. there will no longer be a requirement for bone mineral density scanning. The bisphosphonate zoledronic acid is indicated for people with osteoporosis and Paget disease, as well as some cancer-related indications. It is given as an intravenous infusion over 15 minutes and can be administered by health professionals as part of the community-based infusion service.

A reminder there are pre-screening and monitoring requirements associated with zoledronic acid infusion and these are summarised on your local HealthPathways under the headings:   Zoledronic Acid Infusion and Zoledronic Infusion Checklist 

6.  UTI in ACF

 The Health Quality and Safety Commission have developed this guide to support aged residential care multidisciplinary teams in implementing strategies to:

• improve symptom recognition and communication in the diagnosis of urinary tract infections (UTI) including use of a decision support tool to ensure clinical criteria for treatment are met.  Dipstick urinalysis is recommended only to rule out UTI. 
• reduce the rate of urinary antibiotic prescriptions for residents whose symptoms do not meet clinical criteria for UTI
• improve systems for review of antibiotic treatment following results of laboratory testing: urine microscopy, sensitivity and culture.

The guide has been written for aged residential care teams, but it’s also relevant to general practice.

7.  Legionellosis season

• The Waikato December Public Health Bulletin notes that  an increase in the rate of legionellosis is expected at this time of year due to increased exposure to compost and potting mix as part of gardening activities.
• Legionella bacteria are ubiquitous in New Zealand environments, with L. pneumophilia being mostly associated with warm-water systems and L. longbeachae with compost/potting mix.
• Nationally, there were 34 cases in the 3 weeks to 29 November 2022. This is 1.89 times higher than the same period in 2021. In Waikato we had 4 cases notified in November, up from 1 case in October.
• Symptoms are less helpful than risk factors in assessing risk for Legionella, but may include:
  • dry coughing.
  • high fever, chills.
  • shortness of breath, chest pains.
  • headaches, excessive sweating, nausea, vomiting.
  • abdominal pain.
  • diarrhoea, which is more common than with other forms of community-acquired pneumonia.
• Send sputum for PCR and culture noting risk factors on request form.  Urine antigen test is positive only for Legionella pneumophila serogroup 1, so not helpful after exposure to potting mix.  Treatment for possible or suspected Legionellosis is addition of roxithromycin orally 300 mg once daily for 10 to 14 days to standard CAP treatment.

8.  Cyber Incident Response planning hui

 Te Whatu Ora – Health New Zealand is hosting a cyber incident and response hui for general practices on 25 January 2023, 12-1pm.  The workshop will cover:

• the importance of incident response planning
• possible scenarios
• incident response checklist
• support and resources available

 Please email: Nancy.Taneja@health.govt.nz if you would like to attend