Clinical Snippets October 2024

Dr Dave Maplesden and Dr Jo Scott-Jones – video version available at https://myhealthhub.co.nz/the-new-zealand-general-practice-podcast/ and on the Pinnacle Practice website.

Clinical Snippets October 2024

1.  No thanks doc

I have recently looked at a complaint where the consumer had declined follow-up of an elevated PSA level over several years although did get occasional tests done which confirmed progressive elevation of the PSA.  He was eventually diagnosed with metastatic prostate cancer and a complaint was made that he had not been adequately informed of the risks of not proceeding earlier with further investigations. 

MPS have published some general advice on this situation in the latest issue of Casebook noting the consumer has a right to refuse treatment even if the clinician feels this is unwise.  Advice includes:

• There should be clear written documentation that the consumer has been offered treatment but has declined it.  This should include that the possible consequences of declining the treatment have been explained to the patient, including the worst possible outcome.  Giving the consumer written information about the recommended treatment is always helpful and you should document in the notes what written material has been provided.

• Available alternative treatments should be discussed including pros and cons of these and the discussion documented.  Try and arrange a follow-up appointment to allow the consumer time to reconsider their choice.  If possible, it is helpful for a relative or support person to be with the consumer at follow-up, both to support the consumer and also so whanau is aware of the choices being offered to the consumer.

• There is no legal requirement for the patient to sign a document saying they have declined treatment and good contemporaneous notes detailing the discussion undertaken is appropriate.    It should be made clear to the patient that if they were to change their mind in the future and wish to undertake treatment, whether that may be possible and what pathway the patient would follow to achieve this.

• If there is any concern that the patient may not have the decision-making capacity to consent or decline treatment, a formal competence assessment is advisable. 

2.  Salty navels, warts and gels

(i)  Goodfellow Gem #224  recommends that neonatal umbilical granulomas are treated with cooking salt.  Due to a propensity to infection potentially leading to omphalitis and necrotizing fasciitis, an umbilical granuloma should be treated. Silver nitrate is often advocated as the first-line treatment for umbilical granulomas. However, along with its antiseptic effect, it is caustic and could damage healthy tissue adjacent to the umbilicus. A systematic review demonstrated that salt treatment was effective in most of 10 studies with no adverse effects.  The NHS provide a treatment pamphlet outlining the regime and Children’s Health Queensland also provide a printable resource that could be adapted for local practice use. 

(ii)  Duct tape has been used to treat warts in children for many years with several studies attesting to its efficacy and tolerability and in these constrained economic times the fact it is an inexpensive treatment option is important.  Instructions are to cut a piece of duct tape close to the size of the wart, place it on the wart and leave in place for six days.  Then remove the tape, soak the wart in warm water, pare off any soft skin, and leave overnight.  Replace the tape the next morning and follow the process for up to two months or until the wart is gone, whichever comes first.    A printable instruction sheet for patients is available on the Healthinfo website. 

(iii)  Pharmac has confirmed that from 1 November 2024, Estrogel (oestradiol gel) will be funded without restriction alongside other funded presentations of oestradiol.  The Australasian Menopause Society produces a guide to MHT progestogen and oestrogen doses comparing strength of the various products. 

3.  Coffee and pre-diabetes

Issue 242 of GP Research Review looked at a cohort study on habitual coffee drinking and the chance of prediabetes remission.  A total of 334 patients with pre-diabetes (mean age 49.4 years; 51.5% male) were followed over a period of 9 years. Overall, 39.8% of all patients returned to normal glycaemia, while 39.8% progressed to type 2 diabetes. The likelihood of achieving normal glycaemia was substantially higher among patients who reported habitual coffee consumption (OR 2.26; 95% CI 1.03-4.97), although there was no association with total daily caffeine intake.  Previous studies have suggested a protective association between habitual coffee intake and risk of developing type 2 diabetes in women with a history of gestational diabetes and in prevalence of metabolic syndrome in men and women. 

4.  Breast Resource

• BreastNet NZ is a knowledge base for clinicians, including GPs, practice and breast nurses, SMOs and allied health providers.  It promotes adherence to best-practice care through equipping primary care professionals with accurate, up-to-date information about breast cancer. By providing trusted information to medical professionals, BreastNet hopes to support the development of a skilled breast cancer workforce.

• The site has a searchable database on all things breast and breast cancer related including descriptions of investigations and breast cancer treatments and support for cancer patients.  There are currently two clinical tools available – a breast cancer risk calculator and Screen 70+ tool to help a patient to decide whether or not to continue screening beyond age 70 years.

• For example – comment on breast density:  Cancer cells and dense breast tissue appear white on mammograms. Dense breasts can make it harder to interpret mammogram results, and can ‘mask’ cancer cells. However, the risk of the masking effect has reduced since BreastScreen Aotearoa, the national breast screening programme, became fully digital.  Breast density is not currently measured through BreastScreen Aotearoa (BSA). Women must have mammograms through the private system if they wish to know their density grade. Those with high breast density could consider having yearly mammograms at their own cost. These patients may also be offered ultrasound, digital breast tomosynthesis or MRI (for high-risk patients) for more accurate imaging.

5.  Diabetes resources

(i)  Novo Nordisk is discontinuing its supply of Penmix30, Penmix50 and Mixtard30 to the NZ market from September 30th 2024.  If you have patients that still require changing from these products there is a 1-page advisory document available to download on the NZSSD Noticeboard.  This advises on alternative products and their dose equivalents with respect to the discontinued products.   The importance of monitoring and titrating accordingly after any dose or product change is emphasised. 

(ii)  From 1 October 2024 some patients will become eligible for subsidised continuous glucose monitors and insulin pumps.  Pharmac has provided a list of resources for clinicians and patients to assist with new prescribing of or transition on to the subsidies products and you can subscribe to the resource to be kept updated on any developments.  Goodfellow Unit have published a half-hour podcast on the devices with links to additional training resources.  Starship Hospital has also produced a resource which compares features of the subsidised CGM and pump devices. 

(iii)    A meta-analysis on efficacy and safety of the ultra-long-acting basal insulin analogue icodec administered one weekly in type 2 diabetics concluded Once-weekly insulin icodec showed a better HbA1c reduction with a higher proportion of patients achieving HbA1c targets in comparison with once-daily basal insulin analogues. They were no major safety concerns with respect to hypoglycaemia or adverse events.

6.  Safety netting

BPAC’s best practice bulletin Issue 105  reviewed a UK study on provision of safety netting advice in after-hours primary care.  The article published in the British Journal of General Practice found safety-netting advice was provided in more than three-quarters of consultations, however, patients were given generic advice in approximately half of those consultations and only one-fifth were advised of a specific timeframe after which to seek medical attention (if their symptoms did not improve or deteriorated). Clinicians were also more likely to provide safety-netting advice in-person, when prescribing or if an infection was suspected. Surprisingly, situations where safety-netting advice was less commonly given included mental health and telephone consultations. As primary care continues to evolve in the face of current challenges, safety-netting advice remains a critical tool in preventing serious patient harms, but clinicians must keep their tools sharp. BPAC provided a list of ‘Clinical Sharpeners: Safety-netting advice’:

• Provide specific rather than generic advice where possible (enabling patients to take more responsibility for their health)
• Give timeframes for when to seek further medical attention
• Use written advice (if available), especially with more complex information, e.g. multiple symptoms
• Document any advice given in the patient’s notes, e.g. symptoms, timeframes

7.   Nitrofurantoin

The NZ Formulary September 2024 update includes a practice highlight on nitrofurantoin with safety reminders for prescribing, dispensing, and monitoring.  Comments and recommendations include:

• Nitrofurantoin is commonly used for the treatment of urinary-tract infection (UTI) and may also be used in some cases for prophylaxis of recurrent UTI. Duration of treatment for prophylactic doses may be up to 6 months, and in some instances longer if treatment is reviewed and the benefits outweigh the risk.

• Always check you are prescribing and dispensing the correct product and dose—immediate-release and modified-release preparations are available and funded:  Standard dosing of modified-release capsules is twice daily for a urinary-tract infection, while the immediate-release tablets are typically prescribed four times daily.

• Prescribers should ensure the correct brand is noted on the prescription so that it is clear whether they intend to prescribe the modified-release or immediate-release preparation, and pharmacists should query any non-standard dosing to ensure it is intentional.

• Serious pulmonary reactions such as pulmonary fibrosis (may be irreversible) and interstitial pneumonitis can occur with short-term or long-term use:  Keep an eye out for signs and symptoms of pulmonary toxicity in your patients on nitrofurantoin.  Ensure your patient is aware of what to watch for, including new or worsening symptoms of cough or shortness of breath, and that they must report these.  Monitor lung function in patients on long-term nitrofurantoin.  Stop treatment at the first sign of pulmonary toxicity.

• Creatinine clearance of less than 60 mL/minute is listed as a contraindication to prescribing of nitrofurantoin with specialist advice recommended if prescribing is required.  NZF also includes the comment that concomitant urinary alkalinisers (e.g. Ural^®) are no longer routinely recommended in the acute treatment of urinary tract infections as they raise urinary pH which may decrease the effectiveness of nitrofurantoin.

8.  Methylphenidate supply issues

Pharmac is regularly updating their information regarding methylphenidate supplies.  The latest update (23 September) includes detailed clinical advice regarding management options for affected patients including dose equivalence charts and pharmacokinetics summaries of the products concerned.  General advice includes: 

Do not start any new patients on a methylphenidate extended-release formulation unless absolutely necessary. Instead consider alternative shorter duration methylphenidate formulations, i.e. immediate release tablets, or one of the 8-hour formulations Ritalin LA or Rubifen SR (note the release profiles of these two formulations are different).

For patients currently treated with a methylphenidate extended-release formulation, make an individual case by case decision. You may wish to consider the following:

• can the patient/parent/carer liaise with their usual pharmacy to establish whether they are expecting deliveries of their required strength of methylphenidate?
• is the patient’s prescribed strength anticipated to have an upcoming shortage?
• is a treatment break an option?
• is an alternative formulation of methylphenidate an appropriate interim measure?
• is an alternative formulation appropriate to switch to over a longer period?
• does the patient have an appropriate Special Authority approval.

Note that while the SA approval criteria apply to methylphenidate rather than a specific formulation of the drug, a different SA form/number is required for Concerta and Ritalin LA (SA 2305) with the SA 1964 form required for other preparations.  Pharmac notes that GPs and nurse practitioners can legally apply for an alternative Special Authority for a methylphenidate presentation if needed, provided that all other relevant eligibility criteria are met.  This relates to the legal situation only. From a clinical perspective, GPs and nurse practitioners may still need specialist advice to change presentations of methylphenidate.

9.  MPOX

The Community Health Pathway on Mpox has been updated since the recent outbreak with advice as follows.  Clinicians are asked to:

• Be alert for cases linked to the Queenstown Winter Pride festival.
• Prioritise assessment and testing of people with symptoms compatible with mpox who attended Winter Pride or related events, or had sexual contact with event attendees.
• Notify Public Health urgently of suspected and confirmed cases. Public Health will contact these people to provide advice and support.

Note:

• Isolation is not routinely required; covering lesions is the mainstay of preventing transmission. Public Health will advise cases of any additional restrictions required to prevent transmission.
• Mpox vaccination is recommended for mpox contacts as post-exposure prophylaxis, ideally within 4 days of exposure to a case, although it can be given up to 14 days after exposure. A list of established Mpox clinics is available on the Pathway.
• Mpox consultations and vaccinations at sexual health clinics are free.

The Pathway includes more detailed information on assessment and diagnosis including criteria for testing and appropriate use of PPE when assessing and testing suspected cases. 

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.

Clinical Snippets March 2024

Dr Dave Maplesden educates Dr Jo about….

CLINICAL SNIPPETS – MARCH 2024 

1.  Prescribing 

Health Pathways has released a new section on practical prescribing aimed mainly at new prescribers but some helpful reminders for veteran prescribers.  Covers most general aspects of prescribing including legal requirements.  Some practical information includes: 

• If you prescribe intermittent PRN medicines e.g., two tablets QID PRN, without ordering a specific amount then the pharmacy will dispense the maximum allowable amount i.e., 720 tablets for three months. If you continue to print this medicine automatically on your repeat prescriptions the patient is liable to receive excessive amounts. This has safety implications, especially if it is a medicine of potential abuse such as codeine-containing medicines. 

• When a patient tells a prescriber they have different numbers of each of their medications, write “Please vary quantities for patient stock management.” Pharmacists can then dispense the required quantities to bring medications into line. 

• Patients not eligible for pharmaceutical subsidies but covered by ACC  for an injury may be eligible to claim back the cost of usually subsidised prescriptions related to that injury using an ACC249 form (which the pathway suggest the prescriber gives to the patient) 

• Pharmacists check that a medicine or a dose of medicine is correct by comparing the new prescription with the patient’s medicine history.  To avoid the pharmacist needing to check with you that a change in the prescription is deliberate, please underline and annotate any change from the previous prescription. Annotation of changes is important. Pharmacists’ systems are not linked and if a patient does not return to the same pharmacy, the pharmacist may be unaware of a change in prescription for that patient. 

• Advice on medications that can be compounded into liquid form by the pharmacy is available on the Pharmaceutical Society website. 

2.  Concussion   

• BPACs Best Practice Bulletin: Issue 92 includes updated Sport Concussion Guidelines from ACC including a six-stage graduated return to education/work & sport protocol.  It is worth familiarising yourself with the protocol to ensure patients are given a consistent message regarding return to sport.  The protocol notes day 14 is the earliest time at which return to normal work/study and sports specific training should be considered, and day 21 is the earliest at which return to competitive sport should be considered.  

• There is reference to the recent ACC statement on post-concussion syndrome:  ACC considers that post-concussion syndrome is an unhelpful and out-dated clinical construct. Our view is that there are risks inherent in continuing to diagnose clients with this condition, not least that disabling symptoms will be misattributed to this condition rather than to potentially reversible medical, psychological, or psychiatric factors that remain undiagnosed and untreated. Consequently, ACC no longer accepts ‘post-concussion syndrome’ as a covered injury. Where clients/patients have persisting symptoms that clinicians consider are caused by concussion, the appropriate covered injury would be ‘concussion’. Symptoms that persist beyond three months are most appropriately described as ‘persisting concussion symptoms.’ 

• I’ll put in my regular plug for use of the Brain Injury Screening Tool (BIST-2) (not just for sports related concussion) which is validated for patients aged over 8 years and is designed to be completed in about six minutes.  It gives objective baseline and progress measures covering physical, vestibular-ocular and cognitive symptoms of concussion.   

• There is an excellent 2022 BPAC article on diagnosing and managing concussion in primary care.    

3.  Two defibrillators? 

• The February edition of NZ Doctor describes a new emergency procedure for cardiac arrest known as double sequential external defibrillation (DSED) which has been adopted here, the second country after Canada to do so.  The article notes that early defibrillation can dramatically improve the likelihood of surviving a cardiac arrest but around 20% of patients whose cardiac arrest is caused by VF or pulseless VT don’t respond to the standard defibrillation approach.  The use of DSED has been shown to double the survival rate of such patients.  

• DSED provides rapid sequential shocks to the heart using two defibrillators. The pads are attached in two different locations: one on the front and side of the chest, the other on the front and back. A single operator activates the defibrillators in sequence, with one hand moving from the first to the second. New Zealand ambulance data from 2020 to 2023 identified about 1,390 people who could potentially benefit from novel defibrillation methods. This group has a current survival rate of only 14%.   

• Relevant paramedic guidelines are to be updated reflecting the new approach including that if ventricular fibrillation or pulseless ventricular tachycardia persist after two shocks with standard defibrillation, the DSED method should be administered. Two defibrillators need to be available, and staff must be trained in the new approach.   

4.  Equitable prescribing 

• Issue 230 of GP Research Review reviews a recently published study on inequities in pre-pregnancy folic acid use in Central and South Auckland. The study notes that rates of neural tube defects are markedly higher among Māori (4.58/10,000 live births), and Pacific peoples (4.09/10,000 live births) as compared with non-Māori, non-Pacific peoples (2.81/10,000 live births).  

• Only 46% of the 400 women surveyed as part of the study reported using pre-pregnancy folic acid supplementation. Rates were lower among women who did not intend to become pregnant (21%) or were “pregnancy-ambivalent” (27%) than in those who intended their pregnancy (58%). Women who identified as European, Middle Eastern, Latin American or African were around five times more likely to use supplementation than Māori.  Supplementation was also more likely among those managed by a private obstetrician versus a midwife and in women aged over 30 years. 

• The study concluded Low rates of pre-pregnancy folic acid supplementation exist in Auckland with significant ethnic disparity. Mandatory fortification of non-organic wheat is important, but supplementation is still recommended to maximally reduce risk. 

5.  Medication supply issues and brand changes 

• Morphine oral liquid (RA-Morph) 1 mg per ml and 10 mg per ml strengths are out of stock, and remaining supply of RA-Morph 2 mg per ml and 5 mg per ml will expire at the end of March.  Re-supply RA-Morph 1 mg per ml is expected by June-2024. Other strengths of RA-Morph are expected later in 2024.  This leaves two unapproved but funded (s29) brands of 2mg per ml strength available – Wockhart and Oramorph.  Further detail and prescribing advice is available on He Ako Hiringa website.   
• Omeprazole 20 and 40mg capsules – monthly dispensing from 1 March 2024 until stocks arrive (expected April 2024) 

• Oestradiol valerate 1mg tabs (Progynova) – monthly dispensing from 1 March 2024 until stocks arrive (expected June 2024).  2mg tabs not affected. 
• Mesalazine 800mg tabs (Asacol) – shortage expected until July 2024.  Two x 400mg tabs suitable alternative 
• Olsalazine 250 and 500mg tabs (Dipentum) – both unavailable with 500mg expected available from April 2024.  Consider change to alternative medication eg mesalazine 
• The funded bisoprolol brand is changing from 1 April 2024 when bisoprolol-Mylan and Viatris will no longer be funded.   A patient information leaflet about the brand change is available on the Pharmac website.  
• From 1 March 2024, Pharmac has removed the requirement for annual renewal of SA numbers for patients taking sacubitril with valsartan (Entresto), for heart failure.  
• Modafinil – contra-indications (contraindicated in pregnancy), contraception and conception, pre-treatment screening, and patient advice has been updated in NZF.  This includes pretreatment screening with BP, ECG and excluding pregnancy, and Effective contraception is recommended during treatment and for 2 months after stopping treatment. Effectiveness of hormonal contraception (including contraceptive pills, implants, injectables and hormone releasing intrauterine devices) may be reduced.  The UK FSRH gives current guidance on contraceptive options in patients taking enzyme inducers.    

6.  Frank’s sign 

Issue 111 of Cardiology Research Review reports a Spanish study looking at Frank’s sign (Sanders T Frank – 1973) and cardiovascular risk.  Frank’s sign is a diagonal earlobe crease.   The estimated cardiovascular mortality risk was significantly higher in individuals who presented diagonal earlobe crease. The number of individuals with moderate, high, or very high cardiovascular risk increased significantly as the presence of the crease increased (23.8% had no crease, 35.6% had unilateral creases, and 58% had bilateral creases). The mean cardiovascular risk estimated was significantly higher for individuals with longest and deepest diagonal earlobe crease, and with accessory creases.  The conclusion:  The diagonal earlobe crease is independently associated with higher cardiovascular risk scores, especially when the crease is complete, bilateral, deep, and has accessory creases.  

7.  The limping adolescent 

• Beware the child with unexplained limp or knee pain.  I’ve recently reviewed a case of missed diagnosis of SUFE in a slim 11yo female which had disastrous consequences for her – stable mild slip converting to a severe acute slip. 

• Health Pathways has a section devoted to SUFE partly because of the potentially severe consequences of missed or late diagnosis.  This includes the practice point:  All children complaining of knee pain need exclusion of hip pathology. If there is no evidence of knee pathology on examination, arrange hip X-ray with AP pelvis and frog lateral view.  However, if you suspect an acute SUFE on the basis of history and examination, refer immediately for orthopaedic assessment rather than imaging.   

• As a quick refresher, SUFE usually occurs in the 8-15 year age group, more common in males and a more than half of sufferers are overweight or obese.   The most common presentation is a chronic slip with gradual movement of the epiphysis and the patient may present with vague chronic or intermittent aching pain in hip, groin, thigh or medial knee. 15% of patients only have thigh or knee pain. Pain worsens with physical activity and there is usually no preceding trauma. It may be bilateral (18-50%).  An acute slip presents after a sudden event with inability to weight bear and appearance of a hip fracture.  You can get an acute slip on background of a chronic slip (sudden exacerbation of symptoms in a setting of more consistent low-grade symptoms, may be episodic). 

• A chronic slip may present with persistent or episodic limp. Foot on the affected side may be out-turned. Loss of internal rotation at hip.  Leg length shortening may be present.  When the hip is flexed passively to 90º, the thigh will abduct and roll into external rotation. Examine the knee to rule out local process at the knee to account for knee pain.  With an acute slip there is a marked limp and Trendelenburg gait and often an inability to weight bear.  There may be an external rotational deformity of the hip and shortening of the affected leg. 

• The annual incidence of SUFE in the 0–16-year age group is around 5/100,000 meaning around 40-50 cases in NZ annually so you may never see one.  An Australian study suggests there is delayed diagnosis (weeks to years) in around 60% of cases of chronic stable slip, and most patients (76%) present initially to their GP.      

Clinical Snippets November 2023

1. Non-subsidised medications for beneficiaries

A recent issue of GP Voice described how patients can apply for non-subsidised pharmaceuticals to be included in Disability Allowance

The cost of an ongoing non-subsidised pharmaceutical can be included as an expense for Disability Allowance if you, as the client’s medical practitioner, verify that the pharmaceutical item is essential and there are no suitable subsidised or partly subsidised alternatives.

Examples of non-subsidised pharmaceuticals include melatonin, empagliflozin, dulaglutide, liraglutide, medicinal cannabis products and others, but to be considered it must be confirmed that any subsidised or partly subsidised alternatives are not suitable for your patient.

The application requires a Disability Allowance medical certificate and a letter from you confirming:

• the reasons for prescribing the non-subsidised pharmaceutical
• that there is not a suitable subsidised or partly subsidised alternative
• that the medication is essential and directly related to the client’s disability
• if PHARMAC funding has been applied for and declined, the reasons for this decision
• if there is no suitable subsidised or partly subsidised alternative, and if PHARMAC funding has not been applied for, the reasons why funding has not been sought.

For further information, please contact cathy.stephenson006@msd.govt.nz

2.  RNZCGP statement on medical cannabis prescribing

(i)  ARNZCGP statement on medicinal cannabis prescribing has been recently released. Pertinent points include:  The College…

• neither recommends nor encourages the use of medicinal cannabis products; however, it recognises that as specialists, GPs may offer to prescribe medicinal cannabis products. The sole medicolegal responsibility for prescribing rests with the prescriber.
• has assessed the evidence about the safety and effectiveness of medicinal cannabis products that have not been approved as medicines by Medsafe and has found it to be limited and inconclusive.
• asserts that medicinal cannabis products should only be considered when all first-line, conventional, evidence-based treatment options have been exhausted.
• supports specialist GPs who, based on their clinical assessment, decline to prescribe or to issue a repeat prescription in response to patient requests for medicinal cannabis products that have not been approved as medicines by Medsafe.
• reminds specialist GPs that if they have concerns about the prescribing or record keeping of a prescriber, they should talk to them directly in the first instance. If their concerns remain, they should consider notifying the Medical Council of New Zealand or the Health and Disability Commissioner.

(ii)  BPAC provided a comprehensive article on prescribing of medicinal cannabis last year.  The Ministry of Health constantly updates its medicinal cannabis product website with medicinal cannabis products that have met the minimum quality standard under the Misuse of Drugs (Medicinal Cannabis) Regulations 2019.  However, it is important to note the products that are listed as having been verified as meeting the minimum quality standard are unapproved medicines – there has been no assessment of their safety or efficacy. Being listed does not guarantee that the products is currently available in New Zealand.  Medsafe has published advice on use of unapproved medicines or approved medicines for unapproved conditions and this advice is contained in the NZMC statement on good prescribing practice which also notes:  Medicines or treatment must not be prescribed for your own convenience or simply because patients demand them. 

(iii)  On a related note, Medsafe has reclassified the medicinal cannabis product, cannabidiol (CBD), from a prescription-only medicine to a restricted (pharmacist-only) medicine, aligning the NZ approach with Australia, which made a similar change in December 2020.  While no CBD products are currently approved in New Zealand, this change means that from mid-October 2023, any low-dose CBD product which becomes approved in the future can be supplied by registered pharmacists to patients over 18 years.  The supply is restricted to medicines with dosing instructions for 150 mg or less CBD per day and containing not more than 4.5 grams, when sold in the manufacturer’s original pack. 

3.  IFNAR1 deficiency

Having recently reviewed a case of adverse reaction to MMR vaccination related to IFNAR1 deficiency, I came across a statement from Te Whatu Ora released in 2020 but last updated in June this year, which includes the following information:

• IFNAR1 deficiency is an extremely rare immune disorder that results in the individual’s immune system not responding to certain viruses. The disorder requires genetic testing to be diagnosed and cannot be prevented. IFNAR1 deficiency was only discovered in 2019.

• This genetic condition increases the risk of serious illness and death to the individual when they are exposed to certain viruses, including measles and COVID-19.

• IFNAR1 deficiency also increases risk of severe reaction from some vaccines containing weakened live virus such as MMR, yellow fever, and possibly varicella vaccines. Other childhood vaccines and COVID-19 vaccines can be safely given to someone who has IFNAR1 deficiency.

• The study identifying the mutation suggests that some Pacific groups (people with Samoan, Tongan and Niuean heritage) could be at more risk of having the deficiency than the general population. Initial estimates are that the number of children with two Samoan parents who may be affected is 1 in every 6,450 births. Although equivalent data in Tongan and Niuean populations is lacking, cases have occurred where parents are Tongan or Niuean. This may roughly equate to one child per year born in Aotearoa New Zealand, but much more work is needed. For comparison, cystic fibrosis affects about 1 in every 3,500 births.

• Health care providers may wish to inform aiga or whanau of children with Samoan, Tongan and Niuean heritage of the newly discovered risk as part of obtaining informed consent for the first dose of MMR at 12 months. It is important to also provide information about the risks associated with deciding not to vaccinate against measles, mumps and rubella. We know the risks of not vaccinating, are far greater than the risks of vaccinating. If an older sibling or relative had a severe illness following MMR this should be discussed with immunisation experts.

4.  Emergency contraceptive pill

Issue 224 of GP Research Review  reviewed an interesting Lancet article on combining piroxicam 40mg with standard levonorgestrel EC  (LNG-EC) dose of 1.5mg concluded the combination of levonorgestrel plus piroxicam prevented 94.7% of expected pregnancies versus 63.4% with levonorgestrel plus placebo. There were no differences in advancement or delay of the next period, nor in the adverse event profile.   A response to the article by the UK FSRH notes that LNG-EC acts to delay ovulation until sperm from unprotected sex that has already taken place are no longer viable, thus preventing fertilisation. There are not significant post-ovulatory contraceptive effects, therefore LNG-EC can be effective only if taken early enough in the menstrual cycle to delay ovulation.  The rationale for the trial of piroxicam was that as prostaglandins support ovulation, fertilisation, tubal function and implantation, COX inhibitors (which inhibit prostaglandin production) could act synergistically with LNG-EC to affect ovulation, and could also have post-ovulatory contraceptive effects.  The study did not compare effectiveness of use prior to ovulation with use after ovulation as it had intended, because too few individuals agreed to have blood tests. And no comparison was made between individuals with higher and lower BMI and weights.  FSRH concluded that while in certain settings, LNG-EC/piroxicam could offer an alternative to use of LNG-EC alone, their current guidance regarding emergency contraception remains unchanged.

Current Health Pathways guidance includes:

• Offer Cu‑IUD unless contraindicated.  Cu‑IUD is the first choice EC unless contraindicated because it is the most effective method of EC.

• LNG-EC is effective when taken as soon as possible after coitus, preferably within 12 hours, but within 72 hours. Pregnancy rate after taking oral LNG‑EC within 72 hours of unprotected sexual intercourse (UPSI) is approximately 2.2%.
• Efficacy has been demonstrated for up to 96 hours (unapproved indication).
• Efficacy diminishes with time.
• There is no evidence that oral emergency contraception is effective if taken after ovulation or more than 96 hours after UPSI.

The FSRH guideline on emergency contraception includes a useful one-page algorithm to aid in choosing EC taking into account factors such as time since UPSI, previous UPSI in the same cycle, and proximity of UPSI to ovulation.  Note there is an additional oral EC preparation available in the UK  (Ulipristal) which is a little more efficacious than levonorgestrel although again only if used prior to ovulation. 

5.  Urinary retention – what not to take

• I have reviewed a complaint recently relating to development of acute urinary retention in a man with pre-existing LUTS suggestive of bladder outflow issues (poor stream and frequency) who was prescribed oxybutynin for urinary frequency.  He was not provided with any information regarding the risk of urinary retention and had Googled the drug and noted contraindications included significant bladder outflow obstruction.

• Had he been provided with a NZF patient information leaflet, this refers to potential side effect of trouble peeing – inform your doctor  and also to remind your doctor before taking the drug if you have known prostate problems.

• The list of drugs that may cause retention is quite lengthy and includes some anticholinergic agents, SSRIs, calcium channel blockers, opioids, first generation antihistamines, TCAs, some NSAIDs, and many antipsychotics including quetiapine.  It is certainly worth considering your older male patient’s LUTS if you are considering prescribing any of these. 

6.  Advantages of retirement

NZ Research Review Issue 225 includes review of a study that examined the associations of retirement with cardiovascular risk factors and disease. Overall, 106,927 individuals aged 50–70 years were included in the analysis. During a mean follow-up of 6.7 years, there was a 2.2 percentage-point decrease in the risk of heart disease and a 3.0 percentage point decrease in physical inactivity among retirees compared with workers. In people with high educational levels, retirement was associated with decreased risks of stroke, obesity and physical inactivity. In people who retired from non-physical labour, retirement was associated with reduced risks of heart disease, obesity and physical inactivity. However, those who retired from physical labour were at increased risk for obesity.

7.  Resource – HQSC updated frailty care guides

• HQSC has released updated frailty care guides. The guides are focused on the aged residential care environment; however, they may be helpful in other health care settings serving older people living with frailty. They are designed for use by health care professionals, and they support and do not replace clinical judgement. 

• One guide quite applicable to frail patients inside and outside the  aged care facility environment is that relating to de-prescribing and includes a tool and associated algorithm which aid in identifying medications which are most often suitable for de-prescribing and when stopping or continuing a drug might be indicated.     

• On the horizon is the Polyscan tool developed in NZ, a primary care information technology tool, to triage older adults with polypharmacy who are prescribed potentially inappropriate medicines.  The initial study of the tool involving review of medical records of 300 older patients identified nine individuals (3%) with polypharmacy and indicators of potentially inappropriate medicine. Five unique indicators were detected. PolyScan achieved 100% sensitivity, specificity, and positive and negative predictive values.

Snippets of useful clinical information for New Zealand General Practice

https://podcasters.spotify.com/pod/show/opotikigp/episodes/Clinical-Snippets-September-2023-e2a4m9j/a-aaeded9

Clinical Snippets September 2023 

https://podcasters.spotify.com/pod/show/opotikigp/embed/episodes/Clinical-Snippets-September-2023-e2a4m9j/a-aaeded9

Shownotes

1.  Assessing capacity 

KEY PRACTICE POINTS 

• A person is presumed to have the capacity to make a decision unless there are good reasons 

to doubt this presumption (EOLC Act is an exception). 

• In general, capacity is assessed with respect to a specific decision at a specific time. 
• Assessment is of a person’s ability to make a decision, not the decision they make. A person is entitled in law to make unwise or imprudent decisions, provided they have the capacity to make the decision. 
• Supported decision-making involves doing everything possible to maximise the opportunity for a person to make a decision for themselves 
• Capacity assessment procedures need to consider tikanga Māori and cultural diversity. 

Legal Test for Capacity 

A person lacks capacity if they are unable to: 

• understand the nature and purpose of a particular decision and appreciate its significance for 

them; 

• retain relevant, essential information for the time required to make the decision; 

• use or weigh the relevant information as part of the reasoning process of making the decision and to consider the consequences of the possible options, (and the option of not making the decision); or 
• communicate their decision, either verbally, in writing, or by some other means. 

Useful resources: 

• A Toolkit for Assessing Capacity (Douglass, Young & McMillan) 
• Your local Community Health Pathway (section: Mental Capacity) 

• Goodfellow Unit online course:  Assessing decision-making capacity: the clinical basics and  Decision-making capacity: the legal aspects and the webinar Assessment for Mental Capacity 
• Forms required  for activating EPOA for Property (Form 4) and Personal Care & Welfare (Form 5) 

2.  HPV screening update 

From 12 September, 2023, HPV testing will become the primary cervical screening test in New Zealand.  The National Cervical Screening programme has released a second information pack  that contains information on training and responsibility changes for clinical and administration staff involved in the HPV primary screening process. 

Key points from the pack include: 

• From 12 September, 2023, only primary care clinicians who are accredited to perform cervical screening will be able to offer HPV testing (including offering self-testing); this includes nurses and nurse practitioners who have completed NZQA training in cervical screening as well as doctors and midwives 
• Requirements to allow those not currently accredited to perform cervical screening to offer HPV testing are being developed by the National Screening Unit 
• A summary of required training for specific roles is included.  The Clinical Modules: Cervical Screening using HPV Testing for Clinical – Cervical Sample-Takers, GPs, and Midwives is made up of four e-Learning modules and is available on LearnOnline (Cervical Screening Using Human Papillomavirus (HPV) Testing Programme).  The modules are: 

• MODULE 1 | Introduction to Cervical Screening using HPV testing (60 minutes) 

• MODULE 2 | Navigating the Cervical Screening pathways – practising using the pathways with various cases (30 minutes) 
• MODULE 3 | Cervical Screening in Aotearoa New Zealand – History and Context (30 minutes) 
• MODULE 4 | Talking about Cervical Screening and HPV (60 minutes) 

• Be prepared for a potential increase in uptake of cervical screening due to funding for some groups and the ability to self-test 
• Additional resources include the updated 2023 Clinical Practice Guidelines for Cervical Screening in Aotearoa New Zealand and Goodfellow Unit webinars 

3.  Changes to opioid prescribing 

At the end of July 2023, the Ministry of Health acknowledged the importance of Cabinet making the decision to reduce the maximum limit for opioid prescriptions from 3 months to 1 month. This new limit will apply to both Class B and Class C opioids.  This will bring the prescribing limit for Class C opioids – such as codeine and dihydrocodeine – in line with Class B opioids. Additional regulation changes will result in the re-classification of tramadol as a Class C2 controlled drug from 1 October 2023 although it is exempt from the requirement to be stored in a controlled drug safe.  This means once the relevant legislative changes are enacted (later this year) both codeine and tramadol will have one month prescribing restrictions.  However, methadone will be available as a three-month prescription when being used as part of an OST programme.   

4.  Ferrinject and hypophosphataemia 

A September 2021 NZ Doctor article reviewed hypophosphataemia associated with iron infusion therapy.  Key points included: 

• Iron infusion with ferric carboxymaltose (Ferrinject) is associated with a higher incidence of hypophosphataemia than other formulations.    
• Testing of serum calcium and phosphate levels before iron infusions should only be done for high-risk people such as those with a BMI <18kg/m2 , if the person has chronic diarrhoea or malnutrition, or if the person is to receive a second iron infusion within six months.  HealthPathways recommends seeking general medicine advice if pre-infusion phosphate is less than 0.8 mmol/L (ref range >16y 0.7-1.5), as treatment with calcitriol may be recommended. 
• Testing after an iron infusion is usually based on clinical symptoms.  The mean time to the nadir of hypophosphataemia is usually between one and six weeks. While most recover within three months, there are reports of prolonged recovery time up to two years,although this would require further investigation into cause. Clinical symptoms of hypophosphataemia include tiredness, weakness and muscle pain. 
• Treatment and monitoring of hypophosphataemia depends on severity.  Check calcium, magnesium and renal function. 

• Mild hypophosphataemia – 0.6 to 0.8mmol/L. 

• Phosphate replacement is not usually needed unless symptoms are present. 
• Increase phosphate-containing foods – chicken, seafood, dairy (milk, cheese, yoghurt), nuts and seeds, whole grains. 

• Moderate hypophosphataemia – 0.3 to 0.6mmol/L. 

• Phosphate 16mmol per tablet (Phosphate Phebra), up to one to two tablets three times daily.  Reduce dose if estimated glomerular filtration rate is less than 60ml/min/1.73m² or not tolerated at higher doses (diarrhoea, gastric irritation) 
• Do not give with calcium or antacids (reduces absorption). 
• Each phosphate tablet contains 20mmol sodium and 3mmol potassium; take care in people with heart failure. 

• Severe hypophosphataemia – less than 0.3mmol/L. Refer for intravenous therapy. 

• Monitoring depends on the severity of the hypophosphatasaemia. For severe hypophosphataemia, phosphate concentrations are checked every 24 to 72 hours, but mild hypophosphataemia could be monitored in one to two weeks. If hypophosphataemia is prolonged, check parathyroid hormone and vitamin D levels. 

5.  CAP in children 

Issue 7 of GP Practice Review commented on a recent systematic review and meta-analysis that compared shorter (≤5 days) versus longer treatment with antibiotics for children diagnosed with CAP.  The authors reported no significant differences between short and longer courses of antibiotics in the following areas; 

• clinical cure 

• treatment failure 
• relapse mortality risk 
• need to change antibiotic 
• need for hospitalisation 
• severe adverse events 

The reviewer concluded:  This study provides further evidence that there is no benefit to be gained from longer courses of antibiotic treatment for many infections that are managed in the community. In the case of paediatric community-acquired pneumonia, shorter treatments durations ≤5 days should be recommended with caregivers provided with education about the rationale, which may be counter to information they have previously received.  Current HealthPathways and BPAC guidance refers to a 5-7 day course of amoxicillin with a longer course for alternative antibiotics (7 days for erythromycin and 7-10 days for roxithromycin).   

6.  MHT Algorithm 

A recent article in the British Journal of General Practice gives a succinct summary of key considerations for primary care physicians when prescribing menopause hormone therapy including a helpful algorithm.  The four key considerations are listed as:  

1. Is HRT appropriate (including contraindications) 

2. What preparation and regimen are required 

3. What is the most appropriate route and dose to start on 

4. Is testosterone or vaginal oestrogen required in addition 

Drug names listed are different to NZ and not all formulations discussed are available here but the algorithm is a useful one-page reminder of issues to consider.  Last month Pharmac announced a procurement opportunity that may result in a wider range of transdermal oestrogen products becoming available including a topical gel.  With respect to testosterone therapy in menopause, Goodfellow Unit have a useful resource on this topic including reference to use of a commercially manufactured (not compounded) topical testosterone gel (Androfeme) which can be prescribed off-label under s29 of the Medicines Act at a cost of $153 for 100 days treatment at standard dose.    

7.  The goldilocks approach to measuring blood pressure 

Issue 81 of Best Practice Bulletin comments on the importance of having a variety of blood pressure cuff sizes available at your fingertips.  Most health professionals know that incorrectly sized cuffs can lead to inaccurate blood pressure measurements and the potential for misdiagnosis. A recent randomized crossover trial published in JAMA Internal Medicine reported on blood pressure measurements using an automated measuring device on 195 community-dwelling adults with a wide range of mid-arm circumferences.   Use of a regular BP cuff resulted in a 3.6 mm Hg lower systolic BP reading among individuals requiring a small BP cuff.  In contrast, among individuals requiring a large or extra-large BP cuff, use of a regular BP cuff resulted in 4.8 mm Hg and 19.5 mm Hg higher systolic BP readings, respectively.  Many home-monitoring devices come with a standard size cuff which may not be appropriate for the patient.  The AMA have produced a pamphlet to guide correct cuff-size selection based on mid upper arm circumference.   

8.  Breathe VQ 

 Issue 212 of Respiratory Research Review refers to a recent study validating a short six-item tool – Breathe VQ or the Breathing Vigilance Questionnaire – to assess ‘breathing vigilance’, an important component of dysfunctional breathing.  The reviewer notes that dysfunctional breathing is common in clinical practice. It cannot be fully explained by organic disease and isn’t specific to any specific respiratory disorder with overlap with many conditions including anxiety, asthma, and post-COVID Syndrome (long COVID).   The Nijmegen questionnaire is often used to assess dysfunctional breathing (although has some limitations in applicability) and the Breathe VQ adds another dimension to assessment.    

HealthPathways section on Dyspnoea gives further advice on assessment of patients with persistent breathlessness following recovery from Covid-19 infection and who do not have known respiratory disease.  There is recommendation to consider completing consider completing a 1MSTS test and mMRC score with recommendations for further management (respiratory specialist review, respiratory physiotherapist or respiratory physiologist) depending on results.    

The Goodfellow Unit has a 20 minute podcast on Dysfunctional Breathing Disorders (2021) with a presentation by a physiotherapist on Understanding Breathing Pattern Disorders scheduled for 17 October 2023.