Clinical Snippets May 2026

https://open.spotify.com/episode/36kWoqOhzJqdOdVy1lvsp0?si=oFfT4qOmS_SJJoS1E_u1Cw

Clinical Snippets May 2026

1.  Youth issues

(i)  Choking: A recent NZ Doctor article noted that strangulation during sex (often euphemistically labelled “choking”) is on the rise, especially among young people. The widespread access to pornography and influence of social media depicting “vanilla” sex as somehow shameful or boring is influencing sexual practice. There are new “norms” and some people think strangulation during sex is to be expected.  There is reference to a recent study of Australians aged 18–35 found 57% had been strangled during sex (61% of women, 43% of men, 79% of trans or gender-diverse people). Participants most commonly reported becoming aware of “sexual choking” during ages 16–18. Pornography was the most common source by which those reported first hearing about it (35%). There was a general perception that strangulation during sex can be safe and expected behaviour, and the authors highlighted this is contrary to the numerous and potentially significant harms that can result from strangulation.  The issue of consent is discussed in some detail and it is noted the concept of “consent” is a moot point when being strangled – how can you have informed consent and continue to consent when the practice reduces oxygen to your brain and your cognitive capacity?  The study concluded that results indicate the need for developing strong sexual health education around consent, harms, and normative expectations around sexual strangulation.  When talking about safe sexual practices with youth the issue of sexual choking should probably be included together with pregnancy and STI prevention.  

(ii)  Sexual violence disparities: A recently published study on sexual violence and unwanted sexual experiences among adolescents in Aotearoa New Zealand using Youth 2000 data and reviewed in issue 120  Maori Health Review found significant disparities between various ethnic and minority groups.  Māori adolescents experience a greater burden of sexual violence than the general adolescent population. The overall prevalence of sexual violence among adolescents was 12.4% in 2019, an increase from 9.5% in 2012. Prevalence was higher in girls (19%), Māori (15.3%), and those in socioeconomically deprived schools (15.3%) and neighbourhoods (13.4%). However, even higher rates of sexual violence occurred in transgender adolescents (31.9%), those involved with statutory child protection (26.7%), those with long-term conditions (23.4%), and sexual minorities (22.1%). The reviewer comments include: This study showing the extent of sexual violence among rangatahi Māori is deeply concerning because (1) this type of violence destroys rangatahi flourishing and (2) it reflects the fact that we aren’t adequately protecting Māori young people. Addressing this requires prevention and support approaches that are Māori-led – grounded in kaupapa Māori values and tackling broader determinants.

(iii)  Looksmaxxing:  A Medscape article titled ‘The Extremely Risky Trend That Should Be on Family Doctors’ Radar’ discussed the looksmaxing social media trend aimed mainly at teen and young adult males with influencers promoting a narrow and idealized version of masculinity centred on the belief that real men must have specific physical traits like a square jawline, tall stature, muscular build, perfect hair, and clear skin.  The article notes a growing number of men are taking cosmetic procedures into their own hands, injecting themselves with neuromodulators, fillers, fat dissolving products, and peptides, and some even taking mallets to their faces to reshape their bone structure. Followers are encouraged to use techniques like mewing and bone-smashing (repeatedly hitting the face with a blunt object) to reshape their face. Mewing, where the tongue is repeatedly pressed to the roof of the mouth, was developed by US orthodontist John Mew and is a looksmaxxing practice aimed at achieving a more defined jawline. He encouraged up to 8 hours of mewing daily and lost his license in 2017 due to unproven claims. The American Association of Orthodontists (AAO) advised against the practice in 2024, warning it carries risks for loosened teeth, misaligned bite, and speech impediments, all of which may require “complicated treatment” to resolve. Looksmaxxing is felt likely to be a risk factor for the development of an eating disorder or muscle dysmorphia.  The article recommends physicians become familiar with Looksmaxxing, pay closer attention to self-esteem and self-image among young men and boys, and provide body positivity resources (Link to some NZ resources here) . Validating that people are treated differently based on their appearance — a form of bias known as “looksism” — can also be a starting point for discussions about looksmaxxing, and it is important to push back or provide counterfactuals against looksmaxxing’s “really limited notions of what it means to be a man” and “derogatory opinions” of both women and other men.

2. Insulin update

(i)  A reminder that there are ongoing changes to availability of some insulin preparations.   Eli Lilly is stopping supply of some insulin products in 2026. This only affects the 10 mL vial presentation of the following products (the penfill versions remain available) with supplies ending at end of June 2026 for most:

• Humalog
• Humulin NPH
• Humulin 30/70
• Humulin R

Novo Nordisk has added two products to the discontinuation list (supplies end at end of 2026):

• Actrapid Penfill 3mL
• Protaphane Penfill 3mL

Details on insulin discontinuation and supply dates is available on the Pharmac website.

(ii)  There is an excellent resource on use of Ryzodeg, including case studies, on the Goodfellow Unit site, with further information on use of pre-mixed and co-formulated insulins available on the NZSSD website (also a great algorithm for initiating and adjusting insulin in patients with type 2 diabetes).    

(iii)  Patient information on insulin is available on Healthify and Starship Hospital has a link to a Ryzodeg patient leaflet with a more formidable consumer information sheet available from Medsafe. 

3.  Assessment and management of Abnormal Uterine Bleeding

Health New Zealand | Te Whatu Ora have shared the new national Assessment and management of Abnormal Uterine Bleeding (AUB) guideline which has been endorsed by the RNZCGP. It provides clear evidence-based best practice on the management of AUB in non-pregnant women of reproductive age.  Regional Health Pathways are being aligned with the guidelines and will be kept updated so worth consulting these in the first instance although the guideline document contains more detail on various aspects of management.   Health Pathways has additional sections on post-coital bleeding and post-menopausal bleeding,    Health Pathways in conjunction with Te Whatu Ora have made available an accompanying hour long webinar titled Abnormal Uterine Bleeding (AUB): What general practice needs to know. 

4.  MHT and all-cause mortality

A Danish registry-based cohort study recently published in BMJ aimed to assess whether menopausal hormone therapy increases the risk of all-cause mortality.  Almost 900,000 women born between 1950 and 1977 were involved in the study with follow-up from age 45 years ending on 31 July 2023 (median follow-up time 14.3 years).   Exclusion criteria included history (at time of entry) of thrombophilia, liver disease, arterial thrombosis or venous thrombosis, breast cancer, endometrial cancer, ovarian cancer, previous use of menopausal hormone therapy, or previous bilateral oophorectomy. Just under 12% of women received a prescription for MHT during the study period.  The principal findings were summarised as:

• There was no epidemiological evidence of excess mortality following menopausal hormone therapy use.
• Women who had undergone bilateral oophorectomy between age 45 and 54 years, were associated with a significant survival benefit when using menopausal hormone therapy, corresponding to a 27-34% decrease in mortality hazard.
• Stratified analyses found the lowest mortality among women predominantly using transdermal menopausal hormone therapy formulations, oestrogen monotherapy, cyclic progestogen regimens, and among women initiating menopausal hormone therapy aged 52 years or older, although these findings should be interpreted with caution and await scrutiny in future studies.
• No unambiguous changes in cause-specific mortality were found between groups.

5.  That’s interesting

(i)  Dry eye and vitamin D:  In a study recently published in the American Journal of Ophthalmology researchers conducted a retrospective cohort study involving about 12 million adults to evaluate whether adults with a deficiency of vitamin D were at an increased risk of developing dry eye disease.  During a median follow-up period of around 3.5 years there was a new diagnosis of dry eye disease in 3.3% of adults with a deficiency of vitamin D compared with 2.7% of those without the deficiency corresponding to a 28.6% higher risk of developing dry eye disease in those with the vitamin deficiency.   The authors concluded that in patients with dry eye disease, “identifying and correcting low vitamin D levels may be a reasonable adjunct to standard…therapies, while recognizing that supplementation should be guided by general medical indications rather than used as a stand-alone treatment” for the condition. 

(ii)  Topical lignocaine for IUD placement:  A College of Family Physicians of Canada ‘Tools for Practice’ addressed the question: Does topical lidocaine decrease pain during tenaculum placement and intra-uterine device (IUD) insertion? The ‘botom line’ was that topical lidocaine-prilocaine 2.5% cream (EMLA – 2mL applied with cotton swab 5 minutes before procedure) reduces pain with tenaculum placement and copper/levonorgesterel IUD insertion by about 2-3 points more than placebo on a 10-point scale (minimum clinically important difference for pain is 1.3-2). Lidocaine 10% spray reduces the proportion of women experiencing moderate/severe pain to 6% versus 41% on placebo, but ~55% experience vaginal irritation.  Topical lidocaine 2% is likely ineffective. 

(iii)  Jess’s Rule:  Jess’s Rule is a NHS England initiative launched in September 2025 that mandates a “three strikes and rethink” approach for GPs. The rule is named after 27-year-old Jessica Brady, who died of cancer in 2020 after over 20 GP consultations over six months with no clear diagnosis.  The stated purpose of the initiative is to prevent avoidable deaths by ensuring persistent, unexplained symptoms are not dismissed, particularly in young or, minority ethnic patients who may face diagnostic delays. Patients are encouraged to mention “Jess’s Rule” if they have seen a doctor three times for the same issue without improvement. The core approach is the three Rs: Reflect, Review, Rethink.

• Reflect: Think back on previous consultations, particularly if they were remote, and invite the patient for a face-to-face, physical exam.
• Review: Discuss the case with peers and check for “red flags,” disregarding assumptions based on young age.
• Rethink: If appropriate, refer onwards for further tests or for specialist input.

6.  Paediatric asthma

A recent Research Review educational series article on treating small airways dysfunction with extrafine inhaled corticosteroids in children with asthma included the following take home messages:

• The small airways are a major source of airway limitation in many children with asthma, across all levels of disease severity
• The use of extrafine ICS (inhaled corticosteroid – MMAD ≤2 μm) improves medicine deposition in the peripheral airways compared to larger-particle ICS, which may result in better lung function, reduced exacerbations and better asthma control in children with small airways involvement
• Extrafine BDP (beclomethasone diropionate) (Qvar®) is the only fully funded extrafine ICS available as a single product inhaler in New Zealand and low dose therapy (100 mcg/day) is recommended by local and international guidelines for maintenance treatment in children with asthma from age 5 years
• Extrafine BDP has a higher potency than budesonide and other formulations of BDP in New Zealand and is taken at half the dose, resulting in less systemic exposure and potentially fewer adverse effects (comparative tables available in the original article and Medsafe data sheet together with advice to take care to educate whānau when a change in inhaler translates to different practice.)
• Stepping up to extrafine BDP from a larger-particle inhaler appears to be as effective as adding on a LABA
• Extrafine BDP is most likely to benefit paediatric asthma patients with:
  • An increased exacerbation risk
  • Nocturnal symptoms
  • Increased bronchial hyperresponsiveness
  • Exercise-induced asthma
  • Reduced QoL.

7.  Post-vaccination observation time

• BPAC Bulletin 142 notes the standard post-vaccination wait time now 15 minutes for all publicly funded vaccines in New Zealand.  This change applies to all age groups and all vaccines, whether administered alone or at the same time as other vaccines.
• A shortened wait time of five minutes can also be considered in people who meet all of the following criteria:

• No known history of severe allergic reactions
• Has been assessed for immediate post-vaccination adverse reactions (after five minutes)
• Knows when and how to seek post-vaccination advice
• An adolescent or adult will be with them for the first 15 minutes post-vaccination
• Agree not to drive, skate, scoot, ride a bike or operate heavy machinery until 15 minutes post-vaccination
• Can contact emergency services if required
• Vaccinators may consider advising post-vaccination observation wait times longer than 15 minutes, in some clinical situations, e.g. history of allergy, syncope. IMAC has produced a flow chart for vaccinators.