Watch the October clinical update from Jo Scott-Jones joined by Dave Maplesden, Pinnacle GP liaison in this 35 minute video. (Written version below.)
Clinical snippets are now 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.
(i) Acute sinusitis is usually viral and does not need antibiotics
There is agreement that most acute sinusitis is caused by viral infections causing pressure in the facial sinuses…Duration of more than five days or symptoms getting worse may warrant antibiotics. The safest ones for initial treatment are the narrow spectrum ones such as Amoxil or Doxycycline.
(ii) Augmentin only has two first line indications
There are only two indications for this medication and these are diabetic foot ulcers and human or animal bites. Thus the 700,000 prescriptions annually in New Zealand are unlikely to be for these conditions…There are usually better alternatives such as flucloxacillin for skin infections. Augmentin has been used for taste in children but there are safer alternatives such as cephalexin which is very consumable.
(iii) UTI nitrofurantoin (Macrobid) twice daily now the first line antibiotic for cystitis
There is now a new first line option for cystitis (due to increasing resistance to Trimethoprim) …You need to put the trade name Macrobid into the prescribing line to get the correct product otherwise you may under dose the patient. 100 mg BD for five days is probably long enough but the duration has not been well studied. Remember nitrofurantoin is contraindicated in patients with eGFR < 60 mL/min/1.73m2
(iv) Stop using topical antibiotics
This is to preserve them for eradicating nasal carriage. Due to the widespread use of topical Bactroban and Foban the prevalence of resistance has increased markedly. If a topical medicine is needed hydrogen peroxide or povidone-iodine can be tried first. If that fails, then an oral antibiotic is preferred to a topical one.
(v) Pimafucort is overkill (and the cream form is becoming unavailable)
There are 180,000 prescriptions for this medication annually…if the lesion gets better, you don’t know what component worked. Fungal infections are rarer than eczema in primary care and can be confirmed with a skin scraping. So, a more precise prescribing is to try one thing and if that does not work try another.
(vi) Colds and secondary bacterial infection are a myth
Secondary bacterial infection is a myth and the production of coloured sputum later in the course of an illness is usually oxygenated mucous and not an infection. A true bacterial infection would be pneumonia and that is clinically fairly obvious and certainly needs antibiotics.
A single question, The Emoqol 100, has been developed to enable clinicians to get a quick assessment of their patients' mood. The question narrative goes like this: "How is your emotional quality of life now, with 100 being perfect and zero being worst imaginable?". It has a sensitivity of 47% and specificity of 93%. What that means is if their score is 50 or less, the person is very likely to have a PHQ-9 score of ≥ 10, which indicates a low mood.
Some highlights from the recent document provided by Waikato DHB (v2, 24 December 2021) include:
For GPs, try to ascertain who the LMC is and liaise if possible. For LMCs, try to ascertain who the GP is and liaise if possible.
All pregnant wāhine with COVID-19 are at increased risk of both pregnancy complications and COVID-19 complications and hence all require a referral to obstetric department. This should be done by LMC (or GP if no LMC). If urgent and/or >39/40, a phone call is advised.
All pregnant wāhine with COVID-19 have a significantly increased clotting risk and require at least 14 days of Clexane (NB this is slightly different to the information currently on Midlands Community HealthPathways – as at 20/1/22).
The Ministry of Health, Medsafe and other agencies have re-iterated their advice around communicating risk to people receiving COVID-19 vaccines.
Myocarditis is a rare adverse effect of the Pfizer COVID-19 vaccination – about 30 cases per million in NZ
The risk of myocarditis is substantially greater in people with COVID-19 infection
Myocarditis is treatable if identified, and early detection improves outcomes
Most cases of myocarditis following Pfizer COVID-19 vaccination are mild and resolve within a short time with standard treatment and rest
Anyone receiving a COVID-19 vaccination and their caregiver (if relevant) should be told about common expected adverse effects and rare adverse effects and when and how to seek medical advice if they develop any unexpected or concerning symptoms
Specifically discuss the following symptoms to be alert for: chest pain, tightness or discomfort, shortness of breath, abnormal heartbeat (e.g. fluttering, rapid), light-headedness or dizziness
Caregivers should actively question children/adults about any symptoms and observe them for decreased activity
A recent BPAC article looks at post-treatment follow-up and surveillance of people treated for melanoma. The following key points are noted:
A recent well referenced Tools for Practice summary noted, based on 2 open-label trials, higher risk outpatients (≥1 comorbidity) with suspected or confirmed COVID-19 infection may benefit from inhaled budesonide 800ug BID for 14 days. Compared to usual care, budesonide shortened the time to recovery (12 versus 15 days), increased the proportion of patients recovering by day 14 (32% versus 22%) and reduced need for health services (54% versus 59%). COVID-19 evidence is evolving and further research will help clarify/confirm benefits/harms.
The Te Tumu Waiora integrated mental health and wellbeing service has been up and running in general practices in Taupō and Tūrangi since July 2019. The response from practices and the community has been overwhelmingly positive.
Read moreWith the Women's Refuge Shielded Site, victims of domestic violence access a shielded portal through which they can contact Women's Refuge and find out how to make a plan to safely get out of a dangerous situation.
Read moreThis programme provides funding for Aclasta infusions for eligible patients. The infusion is to be provided in the community by the patient’s general practice.
View detailsDr Jo Scott-Jones and Dr Dave Maplesden discuss assessing capacity (in activating enduring power of attorney), HPV screening, changes to opioid prescribing and more.