Watch the August clinical update from Jo Scott-Jones joined by Dave Maplesden, Pinnacle GP liaison in this 39 minute video. (Written version below.)
Clinical snippets are available as a podcast too! Search on your favourite podcast platform for The New Zealand General Practice Podcast to listen, or click here to listen on Anchor.
A recent Tools for Practice from the College of Family Physicians of Canada looked at the question: Do antibiotics change clinical outcomes for patients with acute uncomplicated diverticulitis? The bottom line based on current evidence is that for non-septic immunocompetent patients with acute uncomplicated diverticulitis, antibiotics do not alter early complication or recurrence rates.
This approach is emphasised in a 2023 BPAC article on diverticular disease which contains detailed diagnostic and management advice including the following practice points:
As an example there was reference in a recent GPs for GPs Facebook post to changes in recommendations for first line drug therapy for patients with persistent restless legs syndrome (RLS). The BMJ Best Practice site takes a practical approach through diagnosis and what tests to order to treatment algorithms with recommendations changing depending on severity of RLS (intermittent, chronic, refractory) and pregnancy status. For non-pregnant patients with chronic RLS gabapentinoids (e.g., pregabalin, gabapentin) are the first-line pharmacological option with dopamine agonists now regarded as second line.
WINZ have produced a downloadable one-page summary of main and supplementary financial benefits available to eligible patients which may be of assistance when advising patients in need.
A UK-based cohort study recently published in the BMJ and reviewed in Issue 13 of GP Practice Review found that, the GLP-1 receptor agonist-SGLT-2 inhibitor combination was associated with a lower risk of major adverse cardiovascular events and serious renal events compared with either drug class alone. The reviewer noted the study provides evidence that after initiating lifestyle change and pharmacotherapy with metformin and either a SGLT-2 inhibitor or a GLP-1 receptor agonist, stepping up to triple therapy by adding either a SGLT-2 inhibitor or a GLP-1 receptor agonist is an effective method of intensifying treatment to reduce cardiovascular risk and potentially improve renal outcomes. However, in New Zealand this would require patients to self- fund at least one of these medicines with Pharmac special authority criteria as they currently stand.
Related to this - Pharmac’s procurement process for continuous glucose monitoring (CGM) devices, insulin pumps and insulin pump consumables is progressing but it appears funding for these products will be limited to those with type 1 diabetes. The Aotearoa Diabetes Collective has created a useful guide with templates for letters to support WINZ Disability Allowance applications for CGM and empagliflozin (for those already prescribed a GLP1 receptor agonist) for people living with type 2 diabetes.
Health New Zealand Te Whatu Ora have provided an update on two COVID-19 technology products that are being decommissioned from 1 August 2024.
A Recent issue of NZ Doctor contained an excellent article on management of perinatal depression. Important practice points included:
The article reviews use of all classes of antidepressants and current evidence base for risks versus benefits. There are links to a variety of support and self-help resources including:
The article also includes links to two sites that provide consumer-oriented information on risks and benefits of various drugs that may be used in pregnancy:
The following information sheets are especially designed to support primary care consultations, and can be downloaded and printed, or the link sent to patients via text or email.
Funding for HPV screening and follow-up priority groups has been extended until 30th June, 2025. Details of the process are available on Te Whatu Ora's website and includes two algorithms aimed at simplifying determination of eligibility for funding.
Preliminary studies have shown a significant decrease in severity of obstructive sleep apnea (OSA) with the use of a combination of atomoxetine and oxybutynin, with patients having moderate pharyngeal collapsibility during sleep (a higher proportion of hypopneas to apnea and mild degree of oxygen desaturation) more likely to respond. A 2022 study evaluated the efficacy and safety of atomoxetine 80 mg and oxybutynin 5 mg in the treatment of OSA confirming findings of previous studies. The most common adverse events (insomnia (12%) and nausea) were consistent with the expected profile of the individual drugs. A 2024 study adding acetazolamide to the combination found no increase in efficacy with this addition.
I have recently reviewed the case of an older child assessed in primary care after running in to a barrier pipe (waist level) with subsequent abdominal pain. There were no findings of an acute abdomen and the child was discharged after responding to simple analgaesia but collapsed and died at home about 36hrs later. Post-mortem findings revealed a jejeunal rupture.
Children are more vulnerable to blunt abdominal injury than adults because they have relatively compact torsos with smaller anterior-posterior diameters, which provide a smaller area over which the force of injury can be dissipated; larger viscera, especially liver and spleen, which extend below the costal margin; and less overlying fat, and weaker abdominal musculature to cushion intra-abdominal structures. Uptodate notes that repeated, serial examinations are necessary in children with abdominal trauma because serious intra-abdominal injury (IAI) may not be apparent upon the initial examination. Abdominal tenderness may be especially difficult to determine in young children who are frightened and cannot clearly communicate and in older children who are uncooperative or neurologically impaired. The message is to have a high index of suspicion for possible IAI in children presenting with blunt force abdominal trauma.
Coincidentally, Issue 28 of Child Health Research Review reviewed the recently published Pediatric Emergency Care Applied Research Network (PECARN) prediction rules to reduce inappropriate use of computed tomography (CT) in children with abdominal or head trauma. The rules were validated with a high degree of accuracy: the intra-abdominal injury rule had a sensitivity of 100.0% and a negative predictive value (NPV) of 100.0% but has not been validated for use in primary care and given presence of abdominal pain is a ‘not very low risk’ criterion I’m not sure how practical it would be.
Saladino R et Conti K. Pediatric blunt abdominal trauma: Initial evaluation and stabilization. Uptodate. Accessed 1 August 2024.
Otorohanga Medical has experienced a steady rise in the number of patients accessing their patient portal since beginning their push in September 2018.
Read moreThere's a lot going on in the data and digital space and many issues nurses are facing can be solved with digital solutions. Health Informatics New Zealand (HiNZ) would love to see more nurses present at Digital Health Week this year (2-5 December). Scholarships to attend close midnight, Friday 19 July.
Read moreThe clinical diabetes specialist in primary care provides clinical mentorship and advice to the practice team in supporting patients with diabetes.
View detailsA guide for clinical management of type 2 diabetes, to support nurses at all levels to develop their knowledge and clinical reasoning in diabetes care.