Clinical Snippets October 2026

Clinical Snippets October 2026

1.  AUB Pathway

• The Health Pathways section on abnormal uterine bleeding has been recently updated with some significant changes including indications for and timing of endometrial sampling as part of the investigation process, and new analysis on the role of endometrial thickness in determining management.  There is a webinar available with panel discussion of practical application of the pathway.  

• The key take-home messages for assessing and managing AUB include:
  • Proactively ask about periods and bleeding impact in a whānau-centred, culturally appropriate way.
  • Treat the bleeding and iron deficiency as a core part of AUB care.
  • Use risk-based assessment for endometrial cancer; do not rely on ultrasound findings.
  • Be aware that endometrial sampling may be indicated despite ‘normal’ endometrial thickness on USS.

• Rates of endometrial cancer incidence are increasing, particularly among younger women, with Māori and Pacific Peoples experiencing a disproportionate burden of disease. The updated guideline reflects an equity-focused redesign of care, supporting earlier recognition, timely investigation, and appropriate management of AUB in primary care to reduce reliance on delayed secondary care assessment.

• A key change is the move from ultrasound‑led decision‑making to a risk‑based approach. Ultrasound and endometrial sampling are now separately indicated investigations, with key decisions guided by clinical risk factors rather than endometrial thickness. Endometrial sampling may be appropriate even when ultrasound findings are reported as normal if risk factors for endometrial hyperplasia or cancer are present. Risk factors include excess oestrogen exposure (such as obesity, PCOS, or chronic anovulation), diabetes, increasing age, relevant family history, and iron‑deficiency anaemia. For Māori and Pacific Peoples, investigation to exclude endometrial cancer or hyperplasia should be considered early, including at or soon after first presentation with AUB. Age informs decision-making, but age alone does not determine the need for endometrial sampling.

• Management should begin at the initial consultation alongside appropriate investigation, and may include medical management of bleeding, active treatment of iron deficiency, discussion of longer-term options (including LNG-IUS where appropriate), and planned follow-up or referral. Treating symptoms does not replace further investigation when clinically indicated.

• Clinicians should refer to their local HealthPathways site and PHO for current information on access, referral criteria, and training opportunities for LNG-IUS insertion and endometrial sampling.

2. Prescriber Update

Medsafe September Prescriber Update included the following practical points:

(i) Rosuvastatin dosing: 

• The usual starting dose of rosuvastatin for hypercholesterolemia is 5-10 mg regardless of prior history of statin use. If necessary, the dose can be increased after 4 weeks of treatment. The usual maximum dose is 20 mg per day.
• As with all statins, rosuvastatin can cause skeletal muscle toxicity, and the risk of rhabdomyolysis increases with higher rosuvastatin doses. Be aware of other risk factors for skeletal muscle toxicity with rosuvastatin and recommended dose modifications. Risk factors include Asian ethnicity, severe renal or hepatic impairment, some medications (ticagrelor, ciclosporin, some protease inhibitors)
• Advise patients to promptly report unexplained muscle pain, tenderness or weakness, particularly if accompanied by malaise or fever.
• Only use the 40 mg dose in patients who have not responded to the 20 mg dose, ie, who still have severe hypercholesterolaemia and are at high cardiovascular risk. The 40 mg dose is contraindicated in some patients. 
• Note that from 1 October 2026 Pharmac has removed the SA criteria for rosuvastatin although previous self-funding patients with repeats owing on a prescription written prior to 1 October 2026 will need a new prescription before they can access the funding for rosuvastatin.

(ii) Prednisone-induced thyrotoxic periodic paralysis

• In patients with hyperthyroidism, sudden intracellular shifts of potassium can cause thyrotoxic periodic paralysis (TPP). Attacks usually occur a few hours after ingesting a high carbohydrate meal or strenuous exercise.
• Prednisone can induce hypokalaemia. Therefore, suspect TPP in hyperthyroid patients treated with prednisone who present with signs or symptoms of muscle weakness.

(iii) Ocular adverse effects of stimulant medicines for ADHD

• Ocular adverse effects, including increased intraocular pressure (IOP), glaucoma, and dry eye, have been reported with use of stimulant medicines for attention deficit hyperactivity disorder (ADHD).
• Patients with a history of increased IOP or glaucoma, or who are at risk for acute angle-closure glaucoma require careful assessment before starting treatment and ongoing monitoring during treatment.
• Advise patients to promptly report visual disturbances or other changes in vision.

(iv) Alpha-gal syndrome: An emerging cause of hypersensitivity reactions to medicines

• Alpha-gal syndrome (AGS) is a tick-associated IgE-mediated allergy to alpha-galactose that may cause hypersensitivity reactions to some biological medicines including monoclonal antibodies (some of the ‘imabs’).
• Alpha-gal is a carbohydrate found in the tissues of most non-primate mammals, and in the gut and saliva of ticks. Sensitisation occurs following bites from certain tick species, although the tick species associated with AGS varies geographically
• Consider AGS in patients with unexplained hypersensitivity reactions, particularly if they have a history of tick bites or a history of delayed allergic reactions following consumption of mammalian products eg. beef, pork, lamb, gelatin or milk
• Clinical manifestations of AGS range from urticaria, angioedema and gastrointestinal symptoms, to severe anaphylaxis and unlike most food allergies, reactions associated with AGS are typically delayed, occurring 2 to 6 hours after exposure.

3. Arms Act 2026

• From 23 September 2026 the Arms Act 2026 came into effect with day-to-day responsibility for the firearms regulatory system shifting from Te Tari Pureke (Firearms Safety Authority) to Firearms Safety and Education New Zealand (FSE).  This means you will be interacting with the new regulator, but in all other respects very little is changing for health practitioners.  As previously, you must consider notifying FSE as soon as practicable if you have reason to believe:
  • your patient is a firearms licence holder (or you have reason to believe they are a licence holder); and
  • you consider the patient’s health condition may impact their safety or the safety of the public, if they continue to use or possess firearms.

• You need to provide the grounds on which your opinion is based and whether you believe the licence holder poses an immediate or imminent danger of self-harm or harm to others. Any decisions, and the reasons for them, should be carefully documented in the patient’s clinical record, in case they need to be referred to later. As long as they act in good faith, health practitioners are not liable to criminal, civil, or disciplinary proceedings by disclosing personal information while performing any of the notifications under the Act. Instructions on how to perform the notification and a link to the updated Health Practitioner Reporting form are available on the FSE website. 

• Note it is FSE’s responsibility to notify the applicant’s health practitioner when a firearms licence has been issued or when a licence holder notifies FSE that they have changed their health practitioner. However, do not assume your patient is not a firearms licence holder, just because you have not received a notification from Firearms Safety and Education New Zealand.  The licence holder may choose to nominate someone other than their registered GP as their health practitioner when applying for a firearms licence. A patient might also change health practitioner without notifying FSE.

• FSE suggests you include firearms licence holder information in the patient’s social history on the Patient Management System (PMS), which can be transferred as part of the medical record.  You will receive notification from Firearms Safety and Education New Zealand when a patient is issued with a new licence, or their licence is renewed (licenses can last for up to 10 years); or an existing licence holder nominates you as their health practitioner. If you have received a notification from FSE regarding a person who is not your patient, please let them know by completing the Health Practitioner Reporting form.

4. Quick bites

(i) PCV13 and flu vaccine coadministration reminder

A reminder from IMAC that parents and caregivers should be informed of the small risk of febrile convulsions in concomitant delivery of PCV13 and influenza vaccines in children aged 6 months to under 5 years.  If the child has a history of febrile convulsions, separation of two days between vaccines is recommended.

(ii)  Immunisation Handbook Update

Version 3 of the 2026 Immunisation Handbook has been published.  Updates include:

• Pre-vaccination screening guidance: Changed definition of unwell with fever (in relation to pre-vaccination screening) to be 38.5°C or over (from 38°C) – this is to reduce the number of children turned away for vaccination, and to align with Australia and the UK.
•  Polio: Updated catch-up guidance to accept any fractional inactivated polio vaccine (fIPV) doses administered overseas as equivalent to IPV doses.
• Hepatitis B: Section added about infants who are close contacts with hepatitis B-infected household members, and extended recommendation for serology testing of those infants given a birth dose of HepB.  Details of serology testing and managing results are in the Handbook.

(iii) New guide: Primary care providers supporting sensitive claims

ACC has created a new quick guide to help primary care providers support kiritaki who have experienced sexual abuse or assault. It outlines who can lodge a sensitive claim, key claiming requirements, what information to include on the ACC45, and the support available through the ACC Sensitive Claims Service.

(iv) Sepsis resource

Sepsis Trust NZ has released new patient information adult and paediatric ‘signs of sepsis’ cards for use in patients with infections or at risk of sepsis being managed in the community.  The cards have been endorsed by RNZCGP and RNZCUC. Cards can be ordered from Sepsis Trust.  A recently recorded webinar Unmasking Paediatric Sepsis is available on the Health Hub website.  The webinar provides an update on paediatric sepsis assessment and management, including the recently introduced paediatric sepsis pathway for use across primary and secondary care. There is a review of key signs and symptoms, red flags for deterioration, initial management priorities, and when escalation of care is required.

(v)  Private bowel screening

The Bowel Cancer NZ website includes a section on private bowel screening options for those not eligible for the national screening programme.  There are links to two FIT kit providers Allevia and True Proactive .  Cost is around $150 and website information refers to a positive result not necessarily entitling the patient to follow-up in the public system.  There is also a link to IGENZ which provides a stool DNA test that identifies specific epigenetic methylation markers associated with colorectal cancer.  The test claims 88% sensitivity, (12% false negative rate) and 92% specificity (8% false positive rate).  It has a sensitivity of 46% for detecting advanced adenoma and exhibits better sensitivity for detecting both colorectal cancer and advanced adenoma when compared with FIT testing. Cost is $265 and kits can be ordered from the IGENZ website and CareHQ. 

(vi)  Ivermectin cream for RPPP

A recent Research Review dermatology educational series publication on topical treatment of rosacea noted that first-line treatment options for the rosacea phenotype of papules and pustules (RPPP) include topical ivermectin 1% cream (Soolantra) recently approved by Medsafe, metronidazole 0.75% cream, and azelaic acid 20% cream. Ivermectin 1% cream demonstrates greater efficacy than metronidazole 0.75% cream in treating RPPP, especially in severe cases and is associated with longer remission periods after treatment cessation compared with metronidazole 0.75% cream. Ivermectin 1% cream is applied once daily, a regimen often preferred by patients over twice daily topical treatments.  Multiple studies have shown that ivermectin 1% cream is safe and effective for the long-term management of RPPP, with evidence supporting use for at least one year.  Cost for a 30g tube (prescription required) seems to be around $70 – 90. 

5.  Leisure

A recent Medscape article listed ’10 books doctors should read at least once’ and the justification for the choice.  The first five a represented below with the remaining five to wait until November Snippets.  

1. When Breath Becomes Air — Paul Kalanithi, 2016

A young neurosurgeon discovers he has an incurable cancer and switches sides in the doctor-patient relationship: from caregiver to patient. Perhaps the most important book of recent years on the theme of a doctor’s professional identity.

Why read it: It teaches what it means to care when a cure is not possible.

2. The Man Who Mistook His Wife for a Hat — Oliver Sacks, 1985

Every patient is a person first and foremost, even before being a medical case.

Why read it: Medicine without humanity becomes nothing more than classification. For many, it will serve as a reminder of the reasons behind their choice of this profession.

3. Being Mortal: Medicine and What Matters in the End — Atul Gawande, 2016

One of the most important works on the relationship between modern medicine and its limits.

Why read it: The success of medicine isn’t always about prolonging life but about helping a person live according to their own values.

4. Do No Harm: Stories of Life, Death, and Brain Surgery — Henry Marsh, 2014

A neurosurgeon reflects on the mistakes, uncertainties, and difficult decisions that shape his work, offering a powerful lesson in humility.

Why read it: A doctor is not someone who never makes mistakes but someone who recognizes the weight of their own choices.

5. The Death of Ivan Ilyich — Leo Tolstoy, 1886

In this short novel by the great Russian writer, published in 1886, the description of the progression of illness becomes a tool for exploring the fear of death and the human need to find meaning in existence.

Why read it: Many doctors consider it more instructive than numerous textbooks.

July 2026 Clinical Snippets

https://open.spotify.com/episode/0VTBsCutwu8wiYGLEP2m0N?si=B9EpzJ49RaKqHTOZqquJEQ

Clinical Snippets July 2026

1.  Prescriber Update

The latest issue of Prescriber Update includes the following useful updates: 

(i) Undesirable effects of opioids

Opioid data sheets are being updated to include the following potential adverse effects of opioid therapy, particularly long-term high dose treatment:

• Suppression of the hypothalamic-pituitary- adrenal (HPA) axis occasionally causing reversible adrenal insufficiency requiring monitoring and glucocorticoid replacement therapy. Symptoms include fatigue, dizziness, nausea, vomiting and low blood pressure.  Opioids can also cause hyperprolactinaemia in males and females.
• Suppression of the hypothalamic-pituitary-gonadal (HPG) axis leading to low testosterone and oestrogen levels. Clinical symptoms such as reduced libido (both sexes), erectile dysfunction and menstrual irregularities can then occur.
• Sphincter of Oddi spasm which can cause increased biliary pressure, increasing the risk of biliary tract symptoms and pancreatitis.  Administer opioids with caution and with appropriate monitoring in patients with pancreatitis and diseases of the biliary tract.
• Oesophageal dysfunction which manifests as oesophageal symptoms (most commonly dysphagia but also heartburn, regurgitation and non-cardiac chest pain) along with abnormal oesophageal motility following long-term opioid use.
• A 2022 BPAC article covers opioid prescribing in primary care and has some editable resources including a pain management plan and example opioid contract.

(ii) Insulin autoimmune syndrome

• Insulin autoimmune syndrome (IAS) is characterised by recurrent hypoglycaemic episodes, increased serum insulin and the presence of insulin autoantibodies. It usually occurs without exogenous insulin treatment.
• Medicines are a primary trigger of IAS in about half of cases. Medicines and active metabolites that contain a sulfhydryl group (-SH) or thiol group (R-SH) have been associated with IAS. Examples include carbimazole, clopidogrel and captopril.
• Other triggers include viral infections (eg, measles, mumps, rubella, varicella zoster) and haematological conditions (eg, multiple myeloma).
• IAS is a self-limiting condition that typically resolves within a few months. Management may include stopping the causative medicine and supportive treatment, such as dietary modifications (eg, small frequent meals with low carbohydrate content) to reduce the risk of hypoglycaemia.

2. Latest coffee update

Issue 270 of GP Research Review reviewed a study published recently in JAMA exploring whether coffee and tea intake were associated with long-term cognitive function and dementia risk.  This was a prospective cohort study following 131,821 participants across the Nurses’ Health Study and the Health Professionals Follow-up Study who did not have dementia, Parkinson’s disease or cancer at baseline. Data on diet were collected via questionnaires every 2–4 years. Across up to 43 years of follow-up (median 36.8 years), those in the highest quartile of caffeinated coffee consumption had a significantly lower risk of dementia compared to those in the lowest quintile, after adjustments for confounders (141 vs. 330 cases per 100,000 person-years; HR 0.82) as well as a lower rate of subjective cognitive decline (7.8% vs. 9.5%). In the Nurses’ Health Study, those in the highest quartile of caffeinated coffee consumption had higher objective cognitive performance scores. The associations were similar for higher intakes of tea, although decaffeinated coffee consumption was not associated with improved cognitive performance or reduced dementia risk. Benefits were non-linear and most evident at about 2–3 cups of coffee or 1–2 cups of tea daily.  So another reason to keep supporting your local coffee roaster!  Reference: JAMA. 2026;335(11):961–74

3.  Gout -treating to target

A study recently published in JAMA Intern Med. looked at the impact of treat-to-target urate-lowering treatment and cardiovascular outcomes in patients with gout.  This was a primary care cohort study (UK) of more than 109,000 new urate-lowering treatment users with up to five years follow-up.  Achieving a serum urate target below 0.36 mmol/L with therapy was associated with a modest but meaningful cardiovascular benefit with patients who reached the target within 12 months having higher event‐free survival and a lower risk of MACE (major adverse cardiac event) with improved 5-year event-free survival and fewer gout flares. Benefits were most pronounced for patients at high/very high cardiovascular risk, and for those who achieved a serum urate level <0.3 mmol/L.  BPAC published an excellent comprehensive article on all aspects of gout management last year that is well worth a review. 

4. MSD update

MSD update: Telehealth consultations and expiry dates for Work and Income certificates

• The Ministry of Social Development has recently seen examples where a Work and Income client has booked an appointment with a telehealth provider to have an interim Work Capacity Medical Certificate (WCMC) completed until they can be seen by their own GP/practice. This process often incurs an additional cost for the patient.

• Work and Income can provide discretionary benefit extensions for clients if they have a good and sufficient reason for being unable to provide a medical certificate prior to their benefit expiry date. An example of this is where the earliest possible GP appointment is after their current WCMC expires. The extension can be for up to four weeks.

• In the scenario noted above, the client can contact their own GP practice and ask for written confirmation indicating the date and time of their next booked appointment – this can be in the form of a printout from reception. Work and Income can then put an extension in place until the patient is seen, negating the need for the client to seek an interim certificate from another provider.

5. Testosterone for women

The CFPC Tools for Practice #408 examined evidence around the question Can testosterone improve sexual function in pre or post-menopausal women?  The bottom line was in post-menopausal women with hypoactive sexual desire disorder (mostly on estrogen therapy), testosterone improves the number of satisfying sexual events by ~1 more per month over placebo at 12-52 weeks. Absence of benefit in premenopausal women may be due to small study sizes. Versus placebo, testosterone increases risk of acne (7.2% versus 5%) and hirsutism (12% versus 8%).  Current guidance was summarised as:

• May consider off-label testosterone for hypoactive sexual desire disorder after addressing other causes.
• Testosterone gel 1%: One-half pump daily to posterior calf.
• Levels not recommended for diagnosis. If treatment initiated, total testosterone levels at baseline, 3-6 weeks and every 6 months (target ≤2.8nmol/L).
• Onset: 1-3 months. Discontinue if no benefit at 6 months.

6.  Deprescribing PPIs

A recent Research Review Educational Series examines in some detail the rationale for and process involved in stepping down and stopping proton pump inhibitors.  The review outlines best practices for PPI stewardship, including when and how to deprescribe PPIs. It highlights two deprescribing strategies and explains how alginate/antacid combinations can reduce breakthrough symptoms.  Practice points include:

• PPI therapy should be reviewed routinely to confirm ongoing clinical necessity
• In the absence of a long-term indication, a trial of PPI de-prescribing is recommended
• Most patients with a long-term indication for PPI therapy who have twice daily dosing should be considered for a step down to once daily dosing
• Patients with long-term indications (eg Barret’s oesophagus) should not be considered for PPI de-prescribing
• Patients who undergo PPI de-prescribing should be advised that they may experience transient upper GI symptoms due to rebound acid hypersecretion
• Consider dose taper or abruptly stopping PPI therapy when de-prescribing
• Decision to de-prescribe a PPI should be based solely on the lack of indication for continued PPI therapy, rather than concern for PPI-associated adverse events

BPAC has some resources to aid PPI deprescribing; a PPI Audit tool and an earlier article on de-prescribing PPIs in older people.

7.  Ozempic mouth 

A Medscape article published last month summarised information about Ozempic mouth and how to treat it.  Ozempic mouth symptoms (related to use of GLP-1 inhibitors – possibly more common with semaglutide) include dry mouth (most common symptom), bad “sulfur” breath and a metallic/bitter taste in the mouth, tooth sensitivity and increased risk of tooth decay and gum disease.  Symptoms are driven by delayed gastric emptying, reflux, vomiting in up to 24% of GLP-1 inhibitor users, and decreased saliva production.  Delayed gastric emptying may drive sulfur burps via bacterial overgrowth/fermentation.  Good oral hygiene is important with twice-daily brushing for 2 minutes each time and flossing at least once a day recommended as well as regular dental review.  Additional symptom control measures include:

(i) Dry Mouth

• Advise patients to drink plenty of water or herbal tea without sugar.
• Stimulate saliva production with sugar-free gum or pastilles containing xylitol, a sugar alcohol shown to prevent tooth decay. The act of chewing gum itself increases saliva production.
• Recommend over-the-counter oral moisturizing rinses, sprays, gels, or lozenges.
• In severe cases, consider prescribing pilocarpine to boost saliva production.

(ii) Changes in Taste Perception

• Suggest smaller, more frequent meals to better tolerate the effects.
• Consider dietitian counselling to maintain a balanced diet.
• Monitor the patient closely because altered taste perception can lead quickly to nutritional deficiencies.

(iii) Reflux and Vomiting

• Encourage patients to replenish fluids consistently and eat smaller, more frequent meals.
• Suggest sugar-free antacids.
• Help patients identify trigger foods or behaviours to avoid — they might include certain acidic or fatty foods or smoking.
• Advise against brushing teeth right after vomiting when tooth enamel is softened and vulnerable to mineral loss. Instead, have them swish with water immediately and wait at least 30 minutes to brush.
• Recommend using toothpaste formulated for sensitive teeth.
• Consider modifying the medication dose to reduce vomiting.

(iv) Sulfur Burps and Halitosis

• Advise the use of a fluoride-containing antibacterial toothpaste, preferably with zinc, to help neutralize sulfur compounds and kill odor-causing bacteria.
• Recommend tongue scraping and flossing at least once a day.
• Recommend a fluoride-containing mouth rinse.

8. Study of the month

A recent Medscape Impact Factor commentary reviewed an Australian study published in JAMA Network Open titled Regular Flatulence Patterns Among Community-Dwelling Individuals in Australia.  Flatulence patterns in 6416 individuals aged older than 14 years broadly representing the Australian population were recorded using a purpose-designed mobile phone application (Chart Your Fart).  Consenting participants were instructed to enter each passage as close as possible to its discharge over at least 2 weekdays and 1 weekend day. Time of event could be retrospectively edited. The app was designed to make recording simple and discreet. The primary outcome considered was total flatus per day (fls/d) with 360192 outputs recorded. 

Key findings included:

• Mean self-reported flatus frequency: ~5/day
• Men reported more flatus than women; reporting bias possible.
• Peak flatus frequency occurred in ages 26–45; lowest in 14–25 years.
• Flatus rate ↑ through day, peaking pre-bedtime; lowest early morning.

Authors note limitations of this study include failing to quantify emissions made while asleep due to reliance on self-report. Devices inserted into the anus to capture intestinal gas provide rigorous observation of flatulence production, but production is unlikely to be perfectly correlated with output, given conscious control over release and associated sociocultural standards. Furthermore, perception of excess relies on patient self-report. Nonetheless, self-report may also partially explain the observed gender differences. Greater efficiency in expulsion could also confound frequency data, with large variation in individual volume previously observed (33-125 mL/flatus).

Clinical Snippets – March 2026

https://open.spotify.com/episode/0UG8gzNIsEMYMBqg7unimr?si=08fPJi4CQR-SrQP559gahg

Clinical Snippets March 2026

1.  UTI in children

BPAC have published an update on managing urinary tract infection in children.  For rapid reference there is a B-Quick summary available that includes a useful dipstick interpretation algorithm.  Some relevant points include:

(i) Symptoms

• UTI symptoms in young children may be non-specific, e.g. fever, irritability, poor feeding, vomiting
• Older children may report urinary symptoms, e.g. frequent or painful urination, changes to urine colour or smell, abdominal or back pain
• Suprapubic or flank tenderness, palpable bladder or stool in the bowel, abdominal distension, dehydration and/or fever may be present on physical examination

(ii) Red flags for paediatric advice or referral

• Seek paediatric advice for children with a suspected upper UTI, i.e. with UTI symptoms accompanied by fever ≥ 38°C and/or loin or flank pain/tenderness
• Acute paediatric referral is indicated for children:
  • Aged under three months
  • With symptoms or signs of significant systemic illness or sepsis
  • With complicating factors, e.g. an abdominal or bladder mass, impaired renal function, anatomic urinary tract abnormalities, previous renal surgery/implants

(iii) Urinalysis

• Urinalysis is indicated for all children with a suspected UTI. Mid-stream or clean catch urine samples are preferred.  The full article and Starship guidelines describe various methods to facilitate sample collection including the Quick wee method, bladder percussion and the Perez reflex
• Urine dipstick testing can support the diagnosis. However, urine microscopy, culture and sensitivity analysis is required to confirm a UTI and determine microbial sensitivity.
• In children aged over three months, a UTI is unlikely with a negative dipstick test result for both leukocyte esterase and nitrite; consider alternative diagnoses
• In children aged three months to three years, a positive dipstick test result for either leukocyte esterase or nitrite is sufficient to initiate empiric antibiotic treatment and send the sample for microscopy, culture and sensitivity analysis

(iv) Treatment

• Initiate oral empiric antibiotic treatment while awaiting laboratory urinalysis results.  Review antibiotic choice once results are available. If symptoms are not improving and the pathogen is resistant to the empiric choice, select an alternative.  Seek paediatric advice if symptoms do not respond to appropriate antibiotic treatment within 48 hours
• Order of preference for empiric treatment (three-day course standard, up to seven days may be considered in children with more severe symptoms but no red flags for secondary care referral) is cefalexin then nitrofurantoin (can be compounded into a suspension) then if bacteria are known to be sensitive amoxiclav then co-trimoxazole. 

(v) Follow-up:  Request a renal ultrasound (ideally to be performed six weeks after presentation) for:

• Children aged < 12 months with their first UTI
• Children of any age with an atypical UTI who have not previously been investigated with a renal ultrasound 
  • Poor response to antibiotics after 48 hours
  • Poor urine flow/suspected urinary obstruction
  • Abdominal or bladder mass
  • Raised creatinine
  • Hypertension
  • Infection with a non-E. coli organism
• Children of any age with recurrent UTI   (≥ 2 culture-proven UTIs within one year, or ≥ 3 if the symptoms were only mild) who have not previously been investigated with a renal ultrasound

2. Prescriber Update

Some updates from the March Prescriber Update include:

(i)  Gynaecomastia

• Has been reported in association with a wide range of medicines (27 listed as a representation) including omeprazole, digoxin, spironolactone, amlodipine, most statins, isotretinoin, methotrexate, antipsychotics, sertraline, fluoxitene, methyphenidate.  Atomoxetine is currently on the reporting list.
• Onset can be delayed – gynaecomastia can develop weeks to years after starting treatment or adjusting the dose. Dose reduction or discontinuation of the suspect medicine may lead to improvement, particularly when gynaecomastia is identified early. Persistence beyond 12 months may be less likely to resolve without intervention.
• Consider a medicine-related cause in male patients presenting with breast enlargement or other breast tissue changes.

(ii) Fournier gangrene

• Fournier gangrene (necrotising fasciitis) is a rapidly progressive infection affecting the soft tissue and fascia of the perineal, perianal or genital areas.
• Fournier gangrene has been known to occur in patients treated with empagliflozin for type 2 diabetes mellitus and is now known to occur with the use of empagliflozin in patients who do not have type 2 diabetes mellitus (eg when used in heart failure).

(iii) Zoledronic acid in the elderly

• Elderly patients receiving zoledronic acid infusions are at higher risk of adverse reactions and may experience more severe adverse reactions or find them more disabling than younger people.  In particular, acute phase reactions are noted as a cause of concern including fever, joint pain and swelling, myalgia, influenza-like illness and gastrointestinal symptoms (abdominal pain, vomiting and diarrhoea). These usually occur within the first three days after zoledronic administration. Ocular inflammation, such as uveitis, can rarely occur and requires prompt ophthalmologist review.  Administering paracetamol shortly after the zoledronic acid infusion may reduce symptoms (some clinicians recommend a dose 60 mins prior to the infusion and regular administration for up to three days post-infusion).

• Consider the following prior to the zoledronic infusion:

• Inform the patient that acute phase reactions are common and usually resolve in a few days. However, patients should seek medical attention if symptoms are serious or prolonged. 
  • Ensure the patient is adequately hydrated and measure their serum creatinine. Maintain adequate hydration following the infusion.
  • Treat pre-existing hypocalcaemia with adequate intake of calcium and vitamin D.

(iv)  GLP-1 receptor agonists

GLP-1 receptor agonists can cause altered skin sensations.

• Semaglutide (Wegovy) is associated with dysaesthesia, paraesthesia, hyperaesthesia, burning sensation, allodynia and sensitive skin.
• Tirzepatide (Mounjaro) is associated with dysaesthesia.
• Consider GLP-1 receptor agonists as a possible cause in patients presenting with altered skin sensations.

NB Healthcare professionals and consumers are encouraged to report any suspected acute persistent visual loss associated with use of GLP-1 receptor agonists per Medsafe monitoring communication in January 2026.   Cases of retinal vein occlusion and non-arteritic anterior ischaemic optic neuropathy (NAION) have been described in patients taking GLP-1 receptor agonists although the significance of this association is yet to be determined. 

3.  In other news…

(i)  Coffee:  The DECAF randomised clinical trial is a study of 200 patients with persistent AF and baseline coffee intake of 7 cups per week in which patients were randomly assigned in a 1:1 ratio to either regular caffeinated coffee consumption or complete abstinence from coffee and caffeine for 6 months following successful cardioversion.  The consumption group was encouraged to drink at least one cup daily, while the abstinence group avoided all caffeinated and decaffeinated coffee and other caffeine products.  In the primary analysis, AF or flutter recurrence occurred in 47% of the coffee group versus 64% of the abstinence group, with a 17% absolute difference.

(ii)  Paracetamol:  Two recent analyses of reviews and metanalyses regarding prenatal paracetamol exposure and child neurodevelopment, one published in the BMJ and another in The Lancet, have both concluded that current evidence does not indicate a clinically important increase in the likelihood of autism spectrum disorder, ADHD, or intellectual disability in children of pregnant individuals who use paracetamol as directed.  This is in contrast to the Trump administration proclamation in September last year.  The BMJ authors note Any apparent effect observed after in utero exposure to paracetamol on autism and ADHD in childhood might be driven by familial genetic and environmental factors and unmeasured confounders. 

(iii)  Morphine:  Issue 239 of Respiratory Research Review included comment on the Morphine for chronic breathlessness (MABEL) trial undertaken in the UK with results published in The Lancet late last year.  Adults with chronic breathlessness due to cardiorespiratory conditions were randomised to receive oral long-acting morphine 5–10mg twice daily with a laxative (evaluable n=73) or placebo (evaluable n=67) for 56 days.  At 28 days, 88% in the active arm and 99% in the placebo arm had regime adherence of >90%.  However, there was no significant difference between morphine versus placebo for the primary outcome of worst breathlessness at day 28 or at other time points.  There was improved cough at day 56 favouring morphine.  There were more adverse events in the morphine arm than in the placebo arm.  The authors concluded we did not show a benefit of morphine for our primary outcome of breathlessness. However, secondary outcome findings taken together (some evidence of benefit [eg, cough, physical activity], some evidence of no difference [eg, morphine-related neurocognitive or respiratory harms], and newer insights into morphine-related harms [eg, morphine withdrawal, persistence of constipation despite resolution of nausea and vomiting]) alongside acceptable tolerability indicate that further research is needed to fully understand the role of morphine in people living with chronic breathlessness. 

4.  Equity focus

(i)  Issue 118 of Maori Health Research Review examined a recently published observational study on CVD risk assessment by ethnicity in Aotearoa New Zealand.  People aged 25-74 years living in New Zealand on 31 March 2018 who were eligible for CVD risk assessment (n = 1,476,747) were analysed. Between 1 April 2018 and 31 March 2023, 67.1% of men and 65.5% of women had CVD risk assessments undertaken. After adjustment for socioeconomic deprivation and residential district, the odds of CVD risk assessment when compared with Europeans was lower in Māori men with diabetes (aOR 0.77) and without diabetes (aOR 0.73), and in Maori women with diabetes (0.93) and without diabetes (0.89).  The odds of CVD risk assessment was also lower in Pacific men (aOR 0.86 [95% CI 0.78-0.94] with diabetes (aOR 0.86) and without diabetes (aOR 0.72) and Pacific women without diabetes (aOR 0.95) compared with Europeans. The reviewer notes With CVD being a leading cause of avoidable premature death for Māori, this study has importantly quantified an often-invisible step in the CVD prevention continuum. Targeted strategies that redress equity in the wider determinants, in system design and in clinical practice, rather than simply increase screening overall, are needed.

(ii)  Goodfellow Gem #253 summarised a recent NZMJ study looking at cancers potentially attributable to excess body weight in Aotearoa New Zealand from 2019 to 2023.  The authors express concern that excess body weight (EBW) contributes to many cancers in New Zealand and compounds health inequities, with higher proportions of EBW-attributable cancers within Māori and Pacific populations.  Pacific peoples had the highest population attributable fraction (11.8%), and this was highest among Pacific females (16.1%). Māori also had a higher PAF (6.9%) than European/other (4.5%). The cancers most commonly attributable to EBW were colorectal cancer, followed by uterine cancer and breast cancer among postmenopausal females.  The authors conclude A pro-equity, anti-stigmatising approach to prevention, early detection and treatment of EBW is important. Ultimately, sustained reductions in EBW-attributable cancers will depend on preventing EBW.

5.  Recent releases

(i) The Medical Council of New Zealand has recently published Guidance on using artificial intelligence in patient care.  It is important to review the statement in its entirety but some clauses include:

• AI is not a substitute for your clinical judgement, and you remain responsible for all your clinical decisions and actions. AI can make mistakes or reflect bias and may produce inaccurate or fabricated information. Therefore, as far as is reasonably practicable, you should check the accuracy of any AI output and confirm it is appropriate for the individual patient before using it for patient care or including it in patient records.

• Patients should know when AI is being used in their care. For low-risk AI, this can be explained in a simple statement that describes how AI is used in their care and how their data is protected. For high-risk AI that influences clinical decisions, you must explicitly inform the patient.

• There are some specific situations where you need to obtain informed consent for the use of AI, including when:
  • using an AI tool to record the consultation, such as a transcription tool (scribe)
  • the patient’s personal details are shared outside of the primary medical record or used for AI training in a way that could identify them
  • the AI technology plays a significant role in diagnosis, treatment or delivery of care.

In these situations, let the patient know how their care will be affected if they decide against the use of AI. Always document in the patient’s records whether informed consent was obtained.

(ii)  GP2GP:  Some recent reporting in NZ Doctor highlighted potential good news on the horizon for those concerned with clinical notes transfer between practices. 

• PMS providers Medtech and Valentia Technologies say testing and rollout of an upgraded GP2GP patient file-transfer system is underway.
• Medtech expects the upgrade to be available to its customers by the end of June, while Valentia says its rollout to Indici users could be completed by May.

(iii) Meningococcal disease:  The reporting earlier this month of two cases of meningococcal disease in tertiary students in Dunedin has led to a reminder from IMAC that now is a good time to check meningococcal immunisation status for school and university students.   

• The vaccinations Bexsero (B strain) and the quadrivalent MenQuadfi (A,C,W and Y strains) are recommended and funded for those aged 13-25 years inclusive who are entering within the next three months, or are in their first year of living in boarding school hostels, tertiary education halls of residence, military barracks, Youth Justice residences or prisons.  Funding covers individuals who turn 13 years of age while living in boarding school hostels.

• IMAC notes that the MeNZB vaccine used in NZ from 2004 to 2011 targeted one type of meningococcal group B disease. Those who received MeNZB are no longer expected to have protection against this type of group B disease.  IMAC provides an FAQ resource on meningococcal vaccines including information on co-administration and duration of effectiveness. 

(iv)  Season 2 of The Pitt was released in NZ in January (Neon) and a Medscape emergency medicine article has several doctors rating the accuracy of the clinical presentations or procedures dominating each episode.  These include:

• A hilar flip during an emergency clamshell thoracotomy to stop a catastrophic lung haemorrhage (realistic)
• Hypokalaemic periodic paralysis masquerading as traumatic paraplegia (zebra)
• Intrarectal manipulation for a coccygeal fracture (without anaesthetic!)
• Management of medication related priapism (OK except for the gentle massage and no 3-way stopcock (for phenylephrine injection and aspiration)