Published: 18th October, 2024
Contents
New from bpacnz: Smoking cessation: supporting patients to break the cycle
Smoking rates have progressively declined in New Zealand over the past decade since tighter restrictions and targets have been introduced; in the most recent NZ Health Survey, 7% of adults reported daily smoking. However, smoking remains more prevalent among certain groups, including Māori and people living in the most deprived communities. It is essential we maintain our focus on achieving a smokefree society, as it is the leading cause of preventable death, and there is no “safe level” of use. Long-term smoking cessation can reverse many smoking-associated adverse health outcomes and provides immediate quality of life benefits.
Primary healthcare professionals have an important role in supporting smoking cessation by prompting quit attempts and encouraging patients to use the various forms of cessation support available. This can be facilitated by using the ABC pathway:
- Ask about the smoking status of every patient and document this information in their clinical record
- Briefly advise every person who smokes to stop, regardless of their desire or motivation to quit
- Cessation support should be discussed and strongly encouraged for every person who smokes. Healthcare professionals should offer to help patients access cessation support services, i.e. refer them to Quitline (or local stop smoking services). Briefly explain the smoking cessation options; best results are achieved through a combination of behavioural support and pharmacological treatment.
Nicotine replacement therapy (NRT) is the first-line pharmacological option for people who want to quit smoking. Combination NRT (e.g. patches plus gum or lozenges) is the most effective approach and is most suitable for patients with higher levels of nicotine dependence. Single form NRT may be sufficient in patients with a lower level of dependence. Other smoking cessation medicines include bupropion, nortriptyline and varenicline (currently unavailable).
Read the full article here. A B-QuiCK summary is also available here.
Smoking cessation audit. To help clinicians support smoking cessation in primary care, we have prepared an audit that assesses use of the ABC pathway. It identifies whether: (1) smoking status is routinely documented, and (2) if those identified as smokers have been provided with brief advice to quit and offered cessation support.
Click here to view the audit
Pertussis Public Health Alert
The National Public Health Service and Health New Zealand, Te Whatu Ora, are asking healthcare professionals to remain vigilant for pertussis (whooping cough) and encouraging eligible people to get vaccinated, following a significant increase in reported pertussis case numbers across New Zealand. According to data from ESR, there have been 189 cases of pertussis (confirmed, probable and suspected) in September; in comparison, 75 cases were reported in August. The total number of cases so far in 2024 is now 620 (data up to 11th October), far surpassing the total number of cases reported for the whole of 2023 (141). Concern about the growing number of cases has previously been reported in Bulletins 100 and 103.
Pertussis PCR testing is recommended for all people presenting with characteristic symptoms. All suspected cases of pertussis must be notified to the local Medical Officer of Health. Do not wait for laboratory confirmation before isolating, treating and notifying.
Read more about pertussis vaccination
Vaccination (with diphtheria, tetanus and pertussis vaccine, Boostrix) is recommended and funded for certain groups, including pregnant women during every pregnancy and as a booster dose for children aged 11 years. Click here for full eligibility criteria. Pertussis vaccination is also recommended, but not funded, for some groups, including close contacts of young infants and general practice staff; read more here.
This is a timely reminder to opportunistically check whether patients (particularly children) have completed their course of pertussis vaccination and offer immunisation where appropriate.
Further information about pertussis, including a factsheet for healthcare professionals is available from IMAC, here.
Medicine supply news: dexamfetamine, oxycodone
The following news relating to medicine supply, of particular interest to primary care, has recently been announced. These items are selected based on their relevance to primary care and where issues for patients are anticipated, e.g. no alternative medicine available or changing to the alternative presents issues. Information about medicine supply is available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.
Dexamfetamine supply issue
There is a supply issue affecting stock of dexamfetamine 5 mg tablets, indicated for narcolepsy in adults and refractory ADHD in children, due to a delay in the supplier obtaining an export license. Stock may still be available in some pharmacies, but the supplier and some wholesalers are out of stock. No specific timeframe has been given for the supply issue, but it is expected to resolve once the license has been issued.
Pharmac is considering a proposal to fund lisdexamfetamine, a prodrug of dexamfetamine, from 1st December for patients with ADHD who meet Special Authority criteria (as reported in Bulletin 108; consultation has now closed).
Oxycodone oral liquid out of stock
A temporary supply issue is affecting stock of oxycodone oral liquid (Lucis, Section 29), due to a shipment delay. Stock has now arrived and is expected to be in pharmacies in the next one to two weeks. Prescribers are reminded that morphine is recommended first-line if an opioid is indicated; oxycodone is usually reserved only for patients who cannot tolerate morphine.
If oxycodone liquid is not available, Pharmac advise that Amneal oxycodone immediate-release tablets can be prescribed as an alternative with instructions to disperse in water; one tablet can be dispersed in 6 – 7 mL of water and consumed immediately.
Medicine reclassifications: naproxen, paracetamol liquid
Naproxen and paracetamol oral liquid have been reclassified as of 1st October, 2024 (as reported in Bulletin 86):
- Some medicines containing naproxen are now pharmacist-only and can be supplied with a higher recommended daily dose (> 750 mg/day) than pharmacy-only products (≤ 750 mg/day). Click here for further information.
- Paracetamol liquid in packs containing ≤ 10 g are now classified as pharmacy-only and packs containing > 10 – 50 g have been reclassified as pharmacist-only. Click here for further information. N.B. A 200 mL bottle of 250 mg/5 mL strength contains 10 g of paracetamol.
A Pharmacist-only medicine (also referred to as a restricted medicine) may be sold without a prescription, but the sale must be made by a registered pharmacist in a pharmacy and details of the sale recorded.
A Pharmacy-only medicine may only be sold in a pharmacy or a shop in an isolated area licensed to sell that particular medicine, and can be sold by any salesperson.
Update: lack of evidence that calcium channel blockers are associated with new-onset eczema
In April, Medsafe asked prescribers to report any cases of new-onset eczema with calcium channel blocker use, e.g. amlodipine, diltiazem: this was covered in Bulletin 97. The reporting period has now ended, and the Centre for Adverse Reactions Monitoring (CARM) has received two reports of patients with an eczematous dermatitis/rash with amlodipine and felodipine (between 8th April and 8th October). There is currently insufficient information to determine the association between calcium channel blockers and new-onset eczema. Urticaria, rash, pruritus and erythema are listed as adverse effects in calcium channel blocker data sheets. On balance, Medsafe advises that the benefit/risk for calcium channel blockers remains positive, and that further investigation will occur if additional information becomes available.
Revised Medical Council statement on treating yourself and those close to you
The Medical Council of New Zealand has published a revised statement on “Treating yourself and those close to you”, following a consultation process earlier this year (as reported in Bulletin 97). Key updates include changes to the allowance for intermittent management of minor ailments, accommodating the challenges faced by doctors in certain communities, e.g. rural, remote, under-served, and responding to emergency situations.
Read the full statement here.
Proposal to extend prescribing duration to 12 months
The Ministry of Health, Manatū Hauora, has recently requested feedback from stakeholders on a proposal to extend the prescribing duration from three months to 12 months. The short consultation period has now closed.
Proposed amendments to the Medicines Regulations 1984 would increase the period of supply limit from three months to 12 months (one initial dispensing and three repeat dispensings); determining the appropriate duration would remain the responsibility of the prescriber. There would be no change to the current dispensing limit (i.e. this would remain at three months), or to the prescribing restrictions that apply to controlled drugs. Additional Pharmaceutical Schedule restrictions for funded medicines would also remain, e.g. monthly dispensing limit for certain medicines.
We will report any updates or outcomes from this proposal as they become available.
Rural Health National Clinical Network seeking members
The Rural Health National Clinical Network is seeking expressions of interest from healthcare professionals to become a member of a new Health New Zealand, Te Whatu Ora, group designed to improve rural health services for people in New Zealand. Members will ideally be healthcare professionals with experience or expertise in improving equity for people who live rurally, involvement in community or professional groups and experience advocating for priority groups, including Māori and Pacific peoples.
Expressions of interest can be made here, and close on Sunday, 20th October, 2024.
Information about all National Clinical Networks is available here.
October is Health Literacy Month
Many adults in New Zealand have low health literacy and this can have wide ranging implications for their wellbeing and the provision of health services. Health literacy is defined as the capacity to obtain, process and understand basic health information and services in order to make informed and appropriate health decisions. Social factors including older age, limited education or language proficiency and socioeconomic deprivation are often associated with lower levels of health literacy, which contributes significantly to health disparities.
Health Literacy Month is an opportunity to consider how you communicate health information to patients. Effectively communicating health information in a way that confirms and builds on people’s knowledge and understanding, in a context that is relevant to them, is key. Improving health literacy is about more than enhancing the readability of information. It is about developing the skills and knowledge of individuals, whānau and communities so that they can evaluate, synthesise and act on the information they receive, to improve their health outcomes.
For further reading on how healthcare professionals can develop people’s health literacy knowledge and skills, see: https://bpac.org.nz/bpj/2012/august/upfront.aspx
Resources on health literacy are also available from Health Quality & Safety Commission, Healthify and Health Literacy NZ.
Pilot programme enables Plunket nurses to give childhood vaccinations
Health New Zealand, Te Whatu Ora, has announced a new pilot programme that allows Plunket nurses in some areas of New Zealand to administer childhood vaccinations, with the overall aim being to increase access and uptake. The pilot will trial offering vaccinations during Well Child visits, at immunisation clinics and community events, and there is the possibility to offer in-home vaccination. The programme is intended to support general practice in vaccinating families who face barriers to access, and is an opportunity to encourage people who are not yet enrolled at a general practice, to enrol. Plunket nurses in Whangārei are expected to begin offering childhood immunisations before the end of 2024, and the pilot will be extended to Kaikohe, Hamilton, Taumarunui and Whanganui by March, 2025.
International Lead Poisoning Prevention Week: 20th – 26th October
International Lead Poisoning Prevention Week, an initiative from the World Health Organization (WHO) highlighting the negative health impacts of lead exposure, is coming up on the 20th – 26th of October. The theme for this year is “Bright futures begin lead free”. The removal of lead from petrol and restricting the use of lead paint has reduced lead exposure in many countries, however, more can be done to raise awareness of the dangers of lead exposure and to prevent it occurring, especially in children. Paint on older homes and buildings, cots, toys, some painted items manufactured overseas, rainwater tanks with runoff from lead roofs or piping, and contaminated soil are examples of environmental sources of lead in New Zealand.
Notifiable blood lead levels in New Zealand
In New Zealand, the notifiable blood lead level was reduced from 0.48 micromol/L to 0.24 micromol/L in April, 2021. This was in response to findings from the Dunedin Multidisciplinary Health & Development Study that suggest long-term neurological and behavioural health effects may occur at lower blood lead levels than previously thought. The new level also aligns with reference values from the Centers for Disease Control and Prevention (CDC) in the United States and the Australian National Health and Medical Research Council.
Electronic reporting is available for lead exposures in your practice management system via the Hazardous Substances Disease and Injury Reporting Tool (HSDIRT), developed by BPAC Clinical Solutions, in association with Environmental Health Intelligence New Zealand, and sponsored by the Ministry of Health, Manatū Hauora.
For further information on lead exposure and reporting notifiable lead levels in New Zealand, see: https://bpac.org.nz/2021/lead.aspx
The Medical Factorium: The science behind “man flu”
Every now and then, patients ask “why?” and the answer alludes us. In this occasional bulletin segment, we attempt to answer some of those curious questions.
The question: One half of the population often claims to get hit a little harder by seasonal viruses than the other. So, is there any legitimacy to the diagnosis of “man flu”? The answer may be unpopular with at least half of you...
Read more
“Man flu” is a social term defined in the Oxford dictionary as “a cold or similar minor ailment as experienced by a man who is regarded as exaggerating the severity of the symptoms”. Numerous theories about “man flu” have emerged over time, including:
A 2022 analysis of a randomised controlled trial involving patients with rhinosinusitis did not find data to support “man flu”. Symptoms objectively measured by a clinician did not differ at baseline between males and females, but were slightly reduced in females compared to males at day five and eight. Females reported a higher subjective symptom burden at baseline but a faster recovery from acute rhinosinusitis than males. Subsequent analysis showed that sex differences in time to improvement were only significant for “emotional” symptoms (e.g. sadness, reduced concentration and productivity) and females did not recover more quickly in terms of nasal, otological or sleep symptoms.
So, what can we conclude from this? “Flu” doesn’t care whether the host is male or female – it infects equally and impartially, but females may be better equipped to recover from it, or perhaps just slightly less inclined to keep complaining (despite possibly complaining more to start with!). These conclusions of course, are general only and do not take into account individual circumstances that can make some people suffer worse than others. The authors also suggest that bias in how males and females are clinically assessed may also influence this argument, but that is a Factorium for another day.
In summary, there may be no such thing as “man flu” but if you are feeling particularly poorly, and happen to be a man, don’t be hesitant to report those symptoms as the benefit of identifying something serious early is far greater than the risk of a little light teasing.
View previous Medical Factorium items here.
Do you have a clinical oddity that you would like us to investigate, or better yet, can you share a fascinating medical fact with our readers? Email: editor@bpac.org.nz
Paper of the Week: Encourage regular hearing checks in middle-aged adults
Hearing loss significantly impacts the way people communicate with the world around them. Older adults are most commonly affected, and it is likely that the total number of people living with some degree of hearing loss will increase with an ageing population. Hearing loss has also been identified as a modifiable risk factor for dementia, reinforcing the significance of early identification and intervention to limit hearing impairment. However, previous studies investigating this association have relied on self-reported evaluations of hearing and/or testing that assess a singular aspect of cognitive impairment. Evidence surrounding any protective effects of hearing aids on cognitive impairment is also controversial.
A study published in JAMA Network Open analysed the effects of hearing loss and the use of hearing aids on cognitive impairment in middle-aged adults. Mild and disabling hearing loss were associated with more substantial global cognitive impairment, compared with normal hearing. The use of hearing aids was not shown to reduce the odds of cognitive impairment, compared with disabling hearing loss in most cases. The exception was participants with depression in whom hearing aid use was found to be protective. The main results of this study support the link between hearing loss and cognitive impairment and emphasise the importance of regularly enquiring about hearing loss in middle-aged patients. If hearing loss is identified, monitoring cognitive function should be included as part of regular patient review alongside interventions to limit further loss of hearing function. Lifestyle changes to prevent cognitive decline (e.g. increasing mental stimulation, reducing alcohol consumption) could also be recommended, if appropriate.
Were you aware of the link between dementia and hearing loss? Do you opportunistically ask about hearing function in middle-aged patients? Do you think it would be beneficial to monitor cognitive function in patients with confirmed hearing loss?
Read more
- This cross-sectional cohort study included more than 60,000 adults aged 45 – 69 years (mean age 57.4 years). Participant audiometric data and cognitive evaluation was undertaken at 21 health centres across France.
- At the beginning of the study, standard audiometry testing was conducted to determine a baseline hearing function for most participants
- Of the total study population, 49% had normal hearing (classified as pure-tone average [PTA] of < 20 dB hearing level for the better ear), 38% experienced mild hearing loss (20 – 34.99 dB hearing level) and 10% experienced disabling hearing loss (≥ 35 dB hearing level). The other 3% were regular hearing aid users who did not undergo baseline testing.
- Neuropsychologists administered five cognitive tests to evaluate multiple aspects of the participants cognition, e.g. attention, psychomotor speed, reasoning, episodic verbal memory, shifting abilities, executive function, global cognitive functioning and language abilities
- Male sex, older age, co-morbidities, higher personal and social deprivation, higher body mass index, lower education level and more frequent workplace exposure to noise were risk factors for worse hearing function
- More participants with mild (27%) and disabling hearing loss (37%) had global cognition scores suggesting impairment (i.e. test score ≤ 25% of the total study population’s score), compared to participants with normal hearing (16%)
- Both mild hearing loss (odds ratio [OR] = 1.1, 95% confidence interval [CI] = 1.1 – 1.2) and disabling hearing loss (OR = 1.2, CI = 1.2 – 1.3) were associated with increased global cognitive impairment
- Among participants who use hearing aids and those with disabling hearing loss who do not use hearing aids, the odds of cognitive impairment were not statistically different (OR = 0.94, CI = 0.8 – 1.1) in most cases. Therefore, the use of hearing aids should be based on potential improvements in quality of life and reduced social isolation, rather than protection of cognitive function.
- Notably, hearing aid use in participants with depression was linked with a reduction in the odds of cognitive impairment (OR = 0.6, CI = 0.4 – 0.9). The authors suggest the effect of reducing social isolation was responsible, however, it is unclear why this effect was not also observed in other participants who used hearing aids.
- While both cognitive impairment and hearing loss have a role in social isolation, the link between the two is not fully understood. Proposed theories include that cognitive impairment results from reduced auditory stimulation and processing, or a potential analogous effect of age-related neuronal degradation on centres involved in cognition and auditory perception. Hearing loss has also been established as a risk factor for neurodegeneration including hippocampus and entorhinal cortex decline and temporal lobe volume loss.
- Study limitations include the cross-sectional design, the high rate of excluded participants due to missing data and the lack of available information on the patterns of hearing aid use, e.g. uni- or bilateral hearing aid use, total duration of use, average daily use, whether cognitive impairment was present before the participant began using hearing aids
- No reference was made to adapting cognitive function assessment for participants with hearing impairment as this may have influenced test scores
Grenier B, Berr C, Goldberg M, et al. Hearing Loss, hearing aids, and cognition. JAMA Netw Open 2024;7:e2436723. doi:10.1001/jamanetworkopen.2024.36723.
For further information on assessing hearing loss and the diagnosis and management of tinnitus in primary care, see: https://bpac.org.nz/2023/tinnitus.aspx
This Bulletin is supported by the South Link Education Trust
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