Month: May 2024

The New Zealand General Practice Podcast

opotikigp family medicine, general practice, Healthcare , ,

Clinical Snippets May 2024

Clinical Snippets May 2024

1.  ACC – Integrated Care Pathways Musculoskeletal (ICPMSK)

(i)  ACC has launched the Integrated Care Pathways Musculoskeletal (ICPMSK) described as an innovative way of supporting people with injuries that require multiple rehabilitation services, designed for kiritaki/clients needing more integrated, specialised and coordinated treatment. Services may include physical rehabilitation, assistance with return to work, specialist opinion and navigation through the ACC and health system via a team of health providers called the ICPMSK interdisciplinary team.

(ii)  Referral into the programme require the following criteria:

  • Accepted cover for a non-permanent musculoskeletal injury to their lower back, shoulder and/ or knee.
  • Intend to reside in Aotearoa New Zealand for the duration of the programme.
  • The injury happened within the last 12 months at time of referral
  • [Exceptions:  If the time between the date of the accident on a claim and the date of the referral to ICPMSK is greater than 12 months, entry to ICPMSK will only be appropriate for kiritaki with these suspected or confirmed diagnoses:
  • ligament rupture with conservative management
  • post-traumatic osteoarthritis (for example, ACL rupture ≥ 15 years ago)
  • dislocation of shoulder
  • previous surgery with internal fixation where removal of metalware is being applied for.
  • The injury carries a high chance of needing surgery.
  • The injury must be of a level of complexity that is likely to require specialist oversight and interdisciplinary treatment to achieve a return to work or return to independence. For example, in the shoulder this might be a full-thickness tear of the rotator cuff, or an AC joint dislocation. In the knee it could be a rupture of the ACL. In the lower back it could be a lumbar disc prolapse that causes pain in the leg.

(iii)  To refer (with patient knowledge and consent):

  • Contact the ICPMSK supplier in your region. A list of suppliers can be found on the ACC website.  Ease of referral varies but e-referrals are possible with many.  Request ICPMSK pre-screen and provide the relevant claim number. 
  • A member of the supplier’s ICPMSK team contacts the kiritaki to discuss the injury and their recovery so far. This pre-screen will help establish if they’re likely to meet the service entry criteria.  Kiritaki that pass the pre-screen will go through further assessment (such as a physical exam, x-ray/CT, and/or medical specialist review) to determine suitability for the programme. 

2.  Amoxicillin dosing in acute otitis media

(i)  A recent article in the European Journal of Pediatrics reviewed in Issue 27 of NZ Child Health Research Review  compared the  efficacy and tolerance of amoxicillin administered twice and three times daily in children with acute otitis media.  The clinical course of acute otitis media was favourable in 92% of children who received amoxicillin twice daily and in 95% of those who received amoxicillin three times daily (not significant).

(ii)  Overall, 31% of those who were prescribed amoxicillin three times daily reported difficulties with the dosing schedule, and 9.6% found it difficult to take the specified volume of medication, compared with 5.8% and 25% of those who were prescribed the twice-daily regimen, respectively.

(iii)  The reviewer’s comment: I’m sure this finding applies to many drugs used in childhood where the evidence for three times daily administration is based on scant evidence. Linking dosages to when the child brushes their teeth morning and night may not only assist with successful treatment with oral medications but may possibly also benefit oral hygiene!

3.  Microplastics, nanoplastics and CVD risk

(i)  A study published in the NEJM in March reported on a prospective, multicenter, observational study involving patients who were undergoing carotid endarterectomy for asymptomatic carotid artery disease. The excised carotid plaque specimens were analyzed for the presence of MNPs.  The primary end point was a composite of myocardial infarction, stroke, or death from any cause among patients who had evidence of MNPs in plaque as compared with patients with plaque that showed no evidence of MNPs over approximately three years of follow-up. 

(ii)  58% of patients had polyethylene had MNPs detected in carotid plaque and 12% also had polyvinyl chloride MNPs detected.  Electron microscopy revealed visible, jagged-edged foreign particles among plaque macrophages and scattered in the external debris. Patients in whom MNPs were detected within the atheroma were at higher risk for a primary end-point event than those in whom these substances were not detected with a hazard ratio of 4.53. 

Stop drinking bottled water!

4.  COC + NSAID

(i)  A large Danish study reviewed in Issue 219 of Respiratory Research Review evaluated the risk of VTE while receiving hormonal contraception and NSAIDs in 2 million women aged 15–49 years, living in Denmark from 1996 to 2017. All women were free of known arterial or venous thrombotic conditions and did not have cancer or thrombophilia, and investigators excluded periods during which the women might have been put at higher VTE risk from other causes, including pregnancy and related events, surgeries requiring hospitalization, and the use of other drugs that carry a risk of thrombosis. Over 21 million person-years of follow-up, 8710 VTE events occurred. 

(ii)  With the use of NSAIDs, the risk of VTE was seven times higher than in non-users, among women who were not on hormonal contraception (HC).  Compared with non-NSAID users, the risk of VTE in women taking an NSAID was 11 times higher in women on high-risk HC[1], eight times higher in those on medium-risk HC and 4.5 time higher in those on low/no risk HC.   The corresponding numbers of extra venous thromboembolic events per 100 000 women over the first week of NSAID treatment compared with non-use of NSAIDs were 4 (3 to 5) in women not using hormonal contraception, 23 (19 to 27) in women using high risk hormonal contraception, 11 (7 to 15) in those using medium risk hormonal contraception, and 3 (0 to 5) in users of low/no risk hormonal contraception.

(iii)  The authors concluded: NSAID use was positively associated with the development of VTE in women of reproductive age. The number of extra VTEs with NSAID use compared with non-use was significantly larger with concomitant use of high/medium risk hormonal contraception compared with concomitant use of low/no risk hormonal contraception. Women needing both hormonal contraception and regular use of NSAIDs should be advised accordingly.  The authors point out that the absolute risk of VTE remains low despite the increase in risk over the first week of NSAID use.

5.  MANA

(i)  Issue 95 of the Best Practice Bulletin refers to the New Zealand Dementia Foundation release of Māori Assessment of Neuropsychological Abilities (MANA), a suite of diagnostic tools for evaluating mate wareware (dementia) in Māori.  MANA is intended to facilitate comprehensive assessment that is sensitive to Māori cultural needs, and is thought to be the first dementia assessment in the world incorporating a wairua (spiritual) evaluation. It is encouraged that these resources are considered when assessing dementia in Māori, and they may be particularly useful for clinicians wanting to increase their cultural competency skills and knowledge.

(ii)  The MANA tool has four key components:

  • A history-taking tool that guides you through taking a comprehensive history when seeing a person and their whānau for an assessment of possible dementia mate wareware.
  • A wairua and well-being tool. This component covers areas such as wairua (spirit), role, and identity that were identified as important in the preparatory research.
  • A cognitive tool, that is scored, with lower scores suggestive of dementia mate wareware.
  • A whānau or family tool that assesses symptoms and signs from a whānau, friend, or care-giver perspective. This component is also scored.

(iii)  The MANA suite may take up to an hour to work through, in much the same way as the whole of the general Cognitive Impairment Community Health Pathway may take an hour to work through. Similarly, splitting the MANA process into sections and involving more than one clinician may be essential, especially in the primary care setting.

(iv)  The website includes training videos, tips on the hui process and a manual in addition to links to each of the tools.  For general information on diagnosing dementia, including special considerations for Māori, see: “Recognising and managing early dementia” bpacnz, 2020.

6.  Apathy in dementia

(i)  A recent Tools for Practice from the Canadian College of Family looked at evidence for efficacy of medications for apathy in dementia.  Specifically, in patients with dementia, how safe and effective are stimulants, antidepressants, and antipsychotics for treating apathy?  The bottom line was that methylphenidate (10mg BD immediate release) may improve apathy scores by a small but potentially clinically meaningful amount compared to placebo (example: 5 points more on a 72-point scale) at ~12 weeks. Methylphenidate does not impact cognition in randomized, controlled trials (RCTs). Antipsychotics and antidepressants do not improve apathy compared to placebo

(ii)  Additional referenced context is provided:

  • No improvement in apathy with cholinesterase inhibitors alone versus placebo, but 60-100% of RCT methylphenidate patients used cholinesterase inhibitors.
  • Methylphenidate associated with weight loss, behavioural changes, insomnia, and cardiovascular harms.
  • Depression and apathy often overlap and can be difficult to distinguish in practice.
  • Non-pharmacologic options include sensory stimulation (example music therapy) and pet therapy based on low-quality evidence of benefit.

7.  RSV vaccine for adults

(i)  GSK has registered their adult RSV vaccine Arexvy in New Zealand from 1 May 2024. A funding application for Arexvy has also been submitted to Pharmac for their assessment.  The Medsafe data sheet notes Arexvy is indicated for active immunisation for the prevention of lower respiratory tract disease (LRTD) caused by respiratory syncytial virus RSV-A and RSV-B subtypes in adults 60 years of age and older.  

(ii)  Further information regarding the vaccine is available on the IMAC website.  This notes Arexvy is a recombinant protein vaccine that causes the immune system to produce RSV antibodies. It includes an adjuvant that enhances the immune response to the vaccination.    A single dose of Arexvy is highly effective at preventing serious respiratory illness from RSV for at least two seasons (around 80% effective overall, 94% effective against severe RSV illness), including in those aged over 70 and those with at least one underlying health condition.  Getting a second dose a year later offered little additional benefit compared to just one dose for two seasons and research is ongoing regarding optimal revaccination timing.

(iii)  Those adults aged 60 years and older who are at higher risk of severe RSV disease include:

  • people with chronic medical conditions including: respiratory, cardiovascular, neurological, haematological conditions, diabetes, or liver or kidney disorders
  • people with moderate or severe immune compromise
  • people who are frail
  • people aged over 80 years*
  • people living in nursing homes or other long-term care facilities
  • older people of Maori and Pacific ethnicity, especially if living in areas of high deprivation

*The risk of severe RSV among adults increases with age, with the highest rates of hospitalisation among those aged 75 years and older. Although age may be considered in determining an older adult patient’s risk for severe RSV-associated disease, there is no specific age threshold at which RSV vaccination is universally recommended within the age group of adults ages 60 years and older.

(iv) The vaccine press release (picked up by several newspapers at the start of the month) concluded: The Arexvy vaccine will be available for private purchase from GP clinics from 1 May 2024. The most common side effects are injection site pain, fatigue, muscle pain, headache, and joint pain.  The vaccine is currently unsubsidised. I have been unable to confirm a NZ price for the vaccine but in the US the list price is $US280 ($NZ470)

(v)  An unrelated aside:  Astra Zeneca announced yesterday that it is withdrawing its Covid vaccine, Vaxzevria, from the European market and likely globally citing reduced demand with sales not generating a profit since mid-2023.  IMAC notes Vaxzevria has not been available in NZ since September 2022 when exiting supplies expired.      Novavax’s Nuvaxovid remains as the non-mRNA option for those not wanting or not being able to have a Pfizer COVID-19 vaccine.  However, Pharmac have advised changes to the availability of Nuvaxovid from 1 May 2024. The current supply of this vaccine has expired.  The latest Novavax XBB vaccine application is currently being considered by Medsafe and the assessment is in its final stages.  This means there will be no Novavax XBB vaccine available from 1 May until the new vaccine is approved. Supply of the Pfizer XBB.1.5 COVID-19 vaccine (branded as Comirnaty) is unaffected, and continues to be available in New Zealand.

8.  Cycling to work

(i)  Issue 232 of GP Research Review reported on a paper ‘ Does cycle commuting reduce the risk of mental ill-health?’.   The paper reported on data from almost 400,00 individuals in Scotland, detailing their mode of transport to work according to the 2011 population census, and their prescriptions for mental health as per national records.  In Glasgow and Edinburgh, 1.85% and 4.8% of commuters cycled to work, respectively. A lower proportion of cyclists received a prescription for mental health than non-cyclists (9% vs. 14%), and cyclists were estimated to receive 15% fewer prescriptions for antidepressants or anxiolytics over the following 5 years.

(ii)  The reviewer noted there are many potential variables that are not addressed or acknowledged in the research such as is there a specific advantage in cycling as exercise, social or socioeconomic differences between the two groups and age loading.   In the meantime cycle commuting may be beneficial for your mental health provided you wear a helmet and don’t fall off!  

[1] High-risk HC includes tablets containing 50 µg ethinyl oestradiol, or the progestins desogestrel, gestodene, drospirenone, or the anti-androgen cyproterone. Medium-risk HC comprises all other combined oral contraceptives and depot medroxyprogesterone injections. No- or low-risk HC includes progestin-only oral contraceptives and implants and the LNG-IUDs.

The New Zealand General Practice Podcast

opotikigp family medicine, general practice, Healthcare , ,

Clinical Snippets April 2024

Shownotes :

Clinical Snippets April 2024

1.  Adrenaline auto-injectors – think twice

  • Hosted content (Viatris – manufacturer of Epi-Pen) in the March edition of NZ Doctor noted a report by the Commission on Human Medicines’ Adrenaline Auto-injector Expert Working Group that highlights the latest safety advice including the recommendations of prescribing two AAIs, and patients should carry these at all times.
  • For children attending daycare or school, this approach ensures that one Adrenaline Auto-Injector remains with the child at all times, whether at home or outside, while the second one is stored at the daycare or school for additional coverage.
  • Similarly, for older children or adults weighing 50 kg or more, having two Adrenaline Auto-Injectors enables individuals to carry both with them at all times. This becomes crucial in situations where more than one dose of AAI may be required, offering an added layer of preparedness. This could include reasons such as ambulance delays, a biphasic reaction (3-20% of patients) or incorrect administration technique.
  • EpiPen is fully funded for patients meeting the Pharmac eligibility criteria, including:
    • A patient who has had a previous anaphylactic reaction which required ED visit or hospital admission; OR
    • A patient who has had a significant anaphylaxis risk as determined by a relevant practitioner.

There is a maximum of 2 devices per prescription with additional prescriptions limited to replacement of up to two devices prior to expiry, or replacement of used device(s) for treatment of anaphylaxis.

2.  Scam Alert

The latest Medical Council newsletter reports actions taken by them on learning that the personal and professional details of several NZ practitioners have been utilised on a counterfeit telehealth platform, known as “prescripson.com.”   The Council recommends:

  • We urge all registered doctors to remain vigilant and to monitor any unsolicited or suspicious activities related to your professional credentials. Regularly review your online presence and the use of your professional details on websites outside of your control.
  • Should you encounter any unauthorised use of your details or receive questionable inquiries that seem related to this scam, please report them immediately to the authorities and the Medical Council for further action.

3.  Goodfellow Gem

  • The latest Goodfellow Gem reviews a meta-analysis of the effect of NSAIDs on post-fracture bone healing.    In this analysis, six RCTs (609 patients) were included. The risk of non-union was higher in the patients who were given NSAIDs after the fracture, with an OR of 3.47. 
  • However, once the studies were categorized into the duration of treatment with NSAIDs, those who received NSAIDs for a short period (<2 weeks) did not show any significant risk of non-union compared to those who received NSAIDs for a long period (>4 weeks).
  • Indomethacin was associated with a significantly higher non-union rate and OR ranging from 1.66 to 9.03 compared with other NSAIDs that did not show a significant non-union risk. This is not the best evidence, but perhaps we should avoid indomethacin. 

4.  On Road Safety Test

  • A NZ Herald article last month reported comments from NZ cognitive neuroscientist Dr Kerry Spackman criticising use of the SIMARD-MD test and other general cognitive screening tools in determining whether patients undergoing senior driving assessment medicals were safe to drive.  He cited a 2021 Canadian study which concluded the SIMARD-MD should not be used with either healthy drivers or those with cognitive impairment for making decisions about driving.
  • An on-road safety assessment (ORST) usually carried out by a driving instructor may be considered when mild cognitive impairment is suspected or reassurance is required regarding the patient’s driving habits. The Waka Kotahi website contains information regarding the ORST including written advice for candidates.  Selected AA and VTNZ branches offer the service.  AA also offer senior driving coaching sessions for 65-74 yo ($80 member, $65 non-member) and for 74+ yo (members only – free). 
  • The ORST is carried out in the patient’s vehicle and is in three parts:
    • Basic driving skills
    • Basic driving skills and hazard detection
    • More complex driving situations and hazard detection
  • The AA website notes the patient may fail the ORST because of a few simple mistakes or small lapses of concentration. The average pass rate is about 56%. If the patient’s licence is still current, they can continue driving until it expires. If they wish to re-sit the test, they can book another appointment with the testing officer. They may re-book your first test once at no extra charge, but subsequent attempts will incur an additional test fee.
  • Note the ORST is a limited test assessing the patient’s driving habits. Health Pathways advises a medical practitioner cannot use a driving instructor’s report to make a decision on someone’s fitness to drive. Instead, if an instructor has been used, this report can be forwarded to Waka Kotahi NZ Transport Agency (Waka Kotahi), along with the medical report from the medical practitioner, for Waka Kotahi to make a decision.  The ORST is not the same as a medical OT driving assessment which may be undertaken when the health professional is unsure whether the patient is medically fit to drive.  This is a comprehensive off-road and on-road assessment undertaken by an OT and driving instructor that includes checking of vision, range of movement, strength, sensation, coordination, judgement, memory, directional orientation, movement and decision-making times, cognition and comprehension and knowledge of road rules and signs in addition to practical driving skills and safety.  Private assessments cost up to $1000 and are not available in all areas.  TWO may fund assessments in some areas (see Health Pathways). 
  • Detailed advice on medical aspects of fitness to drive are contained in the Waka Kotahi health practitioner’s guide.  The Goodfellow Unit has published a ‘how-to guide’ on driving assessment for patients with dementia using a case example.  The Health Pathways section on Fitness to Drive is useful and includes a section on alternative transport and assistance options for patients deemed no longer safe to drive.  

5.  Medication Communications

(i)  Medsafe – Eczema with CCBs:  As of 18 March 2024, CARM has received six reports of eczema where the suspect medicine was a CCB.  In one case the diagnosis of CCB-associated eczema was made several years after initiation of the drug.  Of these reports, five were associated with felodipine and one with diltiazem.  Medsafe is encouraging reporting of new-onset eczema with calcium channel blockers to further determine whether there is cause for concern. 

(ii)  Medsafe – Undeclared topical steroids:  Do not use NaturaCoco Moisturising Cream or Dok Apo Moisturiser Soothing Cream.  These topical cream products have been found to contain fluocinonide, a potent corticosteroid, which is not listed in the product ingredients.  If a patient not currently using steroid creams presents with symptoms consistent with use potent steroids, then consider use of the above products.

(iii)   Novo-Nordisk has given advance notice to Pharmac that supply of three of its insulin products – PenMix 30, PenMix 50 and Mixtard 30, will be discontinued from 30 September 2024.  It is recommended patients using these products be transitioned to suitable alternatives.   Expect further advice from Pharmac in the near future. 

(iv)  Pharmac – a request for proposal for supply of oestradiol gel (subsidized) for the NZ market was released by Pharmac earlier this month, partly in response to ongoing supply issues with transdermal oestrogen patches.   Suppliers mist apply by 13 May 2024 and the bids will then be evaluated by Pharmac and its clinical advisers.

6.  Chasing results

Te Whatu Ora has published a document outlining four high level principles aimed at ensuring patient safety and equitable health outcomes by clarifying areas of responsibility and reducing ambiguity, in particular when there are transfers between secondary and primary care.

  • Principle 1: The clinician who orders an investigation (the requestor) is responsible, either personally or delegated, through defined team processes for review and actioning of the results regardless of subsequent transfer of care, unless explicitly agreed to and documented otherwise.
  • Principle 2: Where information is shared to add value to care and continuity, copying results to other clinicians or service providers is appropriate. But clear, separate communication is required if the recipient is expected to act on the result.
  • Principle 3: Any clinician copied into a significantly abnormal result needs to ensure appropriate action has been taken.
  • Principle 4: The requirements for regular monitoring and follow-up must be agreed between the referring and receiving clinicians.

The document notes: Copying of results is not a transfer of care and results should not be routinely copied to any other clinician at the time of request. This ensures that ongoing responsibility lies unambiguously with the requester. If handover of responsibility is requested, this needs to be clearly communicated in writing and with closed loop communications – ie, by phone call.

7.  Cellulitis study

  • Issue 231 of GP Research Review reported a recently published retrospective study from Dunedin comparing compare the safety and efficacy of outpatient parenteral antimicrobial therapy versus oral antimicrobial therapy in the treatment of cellulitis associated with the clinical pathway change from  IV cefazolin + probenecid, to oral flucloxacillin + probenecid.
  • When comparing outcomes before and after the change, there were no significant

differences in the rates of clinical treatment failure (15.4% vs. 14.3%, respectively; p=NS), treatment changes due to intolerance (3.2% vs. 5.7%; p=NS) or inpatient admission within 28 days (12.2% vs. 12.9%; p=NS). The pathway change was also associated with substantial cost savings, with a significant reduction in scheduled ED reattendances (43.1% vs. 2.9% of cellulitis patients; OR 0.04; p<0.01), mainly due to the decreased need for intravenous support.

  • Health Pathways gives comprehensive management advice including recommended antibiotic regimes for patients with history of mild and severe penicillin reactions or suspected MRSA.  Importance of screening for sepsis is emphasised with additional practical advice such as when wound swabs and blood tests including cultures might be considered (not routine) and:
  • Treat Māori and Pacific patients early – Māori and Pacific patients have high rates of hospitalisation due to sepsis and cellulitis. Start effective treatment early and arrange a review acceptable to the patient to monitor progress.
  • 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.
  • Always reassess moderate cellulitis at 48 hours and monitor fever. This is the most important indicator of response to antibiotics.

8.  Mirena for contraception

  • In January this year regulatory approval was received in the UK to extend the use of Mirena, for contraception only, to eight years from the previously recommended five years.  In the USA the FDA approved the device for eight years for contraception in August 2022.  The NZF and Medsafe data sheet in NZ currently retain the previous recommendation of five years so use for contraception beyond this time, while supported by evidence of efficacy, would require informing the patient such use in NZ is ‘off label’.  
  • Note there has been no change to approval or recommendations for use of Mirena for the management of heavy menstrual bleeding, or for endometrial protection as part of hormone replacement therapy which remain, in New Zealand, as five-year duration of use for each. 

9.  Did you know that…

  • The Australasian Menopause Society provides information on management of patients with endometriosis after menopause. They note that OCPs which contain oestrogen and progestin are often effective in controlling endometriosis in premenopausal women and it is prevention of ovulation by oophorectomy or medically, as in OCP use, or naturally by menopause, that has the major impact on the treatment of endometriosis.
  • Although the evidence remains sparse there have been case reports of endometriosis recurrence or malignant transformation of extrauterine endometriotic deposits in women with a history of extensive endometriosis treated with unopposed oestrogen therapy following menopause. Current recommendations favour continuous combined oestrogen-progestogen preparations instead of unopposed oestrogens for women with a history of substantial endometriosis even after hysterectomy, especially if there has been extensive disease.