The standards include information on what should be covered as part of the comprehensive assessment, treatment and management plan, pharmacological and non-pharmacological treatments, monitoring requirements and reviewing treatment response. The framework states that vocationally registered general practitioners and nurse practitioners “who have developed further clinical expertise in ADHD” are appropriate healthcare professionals to assess and diagnose ADHD in adults. This includes training in diagnostic assessment of ADHD and experience conducting clinical interviews and administering and interpreting clinical assessment tools related to ADHD. However, no information is given on how this training will be provided for clinicians who do not already have this expertise, or on how the comprehensive assessment process can be accommodated and funded within primary care.

The framework has been developed in collaboration with clinicians who have experience in ADHD assessment and treatment, as well as people with lived experience of ADHD.

Supply issues affecting salbutamol with ipratropium bromide inhalers (Duolin HFA) remain ongoing. Prescribing a salbutamol inhaler (SalAir) and ipratropium bromide inhaler (Atrovent) may be a suitable alternative, however, two new prescriptions will be required. Pharmac has temporarily removed the co-payment on ipratropium bromide inhalers meaning that patients who require both inhalers will only pay one dispensing fee (for SalAir).

The FreeStyle Libre 2 Plus continuous glucose monitor (CGM) has been funded since May, 2025, for patients with type 1 or type 3c diabetes (as reported in Bulletin 121). This device is an upgraded version of the FreeStyle Libre 2 model, and can be worn for an additional day (15 instead of 14), and is considered more accurate. Stock of the FreeStyle Libre 2 will no longer be supplied from 1^st November, 2025. Pharmacies can submit claims up until 1^st May, 2026, when the product will be delisted from the Pharmaceutical Schedule.

Patients prescribed the FreeStyle Libre 2 can begin to be switched to the new device now, to avoid a rush on devices in November. When a patient next presents for their CGM renewal, specify on the prescription “FreeStyle Libre 2 Plus”, so that this brand can be dispensed. Special Authority criteria remain the same (a new application is not required).

Pharmac has advised that framycetin sulphate 0.5% ear/eye drops (Soframycin; partly funded), used in the treatment of otitis externa when a steroid is not required, are out of stock due to higher than anticipated demand. Re-supply is expected in August. Funded alternatives are available (click here for details), however, a new prescription will be required.

There is a lack of evidence regarding the utility of DRE as a routine screening test for prostate cancer. A DRE only assesses the back wall of the prostate gland; abnormalities elsewhere in the gland cannot be manually detected. DREs may also represent a barrier for males discussing prostate concerns with their clinician or in some cases, attending primary care in the first place; in a survey of over 2,000 males in the UK, 60% reported concerns about having a rectal examination. These concerns were sufficient to prevent 37% of these males discussing prostate issues with their general practitioner. There was also variation in the levels of cultural stigma around DRE between different ethnic groups, which must be balanced against the increased risk of diagnosis and death from prostate cancer in these groups. In New Zealand, people of Māori and Pacific ethnicity are more likely to be diagnosed with and die from prostate cancer than non-Māori, non-Pacific peoples.

The authors of the BJGP article recommend that healthcare professionals ask themselves “will DRE change my clinical decision making?” when deciding whether or not to perform a DRE. The authors emphasise the importance of considering DRE if clinical suspicion persists following a negative PSA test result, particularly in patients with risk factors, e.g. family history of prostate cancer. Under these circumstances, DRE may be useful in detecting a proportion of the 2% of prostate cancers that do not produce PSA and may therefore otherwise remain undetected; an estimated 20% of prostate cancers that do not produce PSA are detected through an abnormal DRE result. DRE also has value in detecting benign prostatic conditions, such as prostatitis, in patients who are symptomatic, e.g. those with pelvic or genitourinary pain and lower urinary tract symptoms.

This advice does not align with the New Zealand Prostate Cancer Management and Referral Guidance (2015), which recommends both PSA testing and DRE for males aged over 50 years, or over 40 years with a family history of prostate cancer, who present with prostate concerns. However, the guidance does acknowledge that some males may be averse to DRE, in particular those of Māori and Pacific ethnicity for whom there may be an additional cultural barrier, and that this should not represent a barrier to prostate cancer screening. A pragmatic approach may be to perform PSA testing prior to DRE. In the event of an abnormal initial PSA result, a repeat test should be performed 6 – 12 weeks later; referral is usually warranted following two abnormal PSA results even in the absence of a DRE result, e.g. if DRE is declined. Individuals with normal PSA results should be informed about the value of DRE for detecting prostate cancer that does not produce PSA, particularly those with risk factors, e.g. family history of prostate cancer. Check local HealthPathways for region-specific guidance.

Crying is defined as the shedding of tears in response to an emotional state.¹ Tears can be classified as: basal (lubrication), reflex (debris removal) and emotional.^{1, 2} Before the lacrimal gland was identified as the origin of tears in 1662, there were numerous theories for where tears came from. For example, emotions were heated in the heart, which then generated water vapour; this vapour would then rise to the head, and condense in the eyes, which resulted in tears.

Emotional tears occur in response to positive (e.g. kindness) or negative events (e.g. injury, pain, grief).² The exact mechanism of emotional tear production and reasons for crying are not fully understood.² The process of crying is believed to involve multiple components, including muscle activity, vocalisation, tear production and emotional experience.³ In response to stimuli, a signalling pathway is activated (mostly parasympathetically mediated) which results in the secretion of tear fluid by the lacrimal gland. Multiple aspects of the nervous system, areas of the brain and neurotransmitters are understood to be involved; further research is needed to determine the specific neural circuits involved in crying.³

Charles Darwin once stated that emotional tears were “purposeless”.¹ Since then, multiple theories on why people cry have been proposed, with most involving communicative functions.² Crying is thought to act as a distress signal to elicit social support.^{1, 3} Crying can also activate empathy and affection from others, further facilitating social connections.^{1, 3} The act of crying may release endorphins or oxytocin, and may affect mood in a positive or negative way.^{4, 5}

When a patient cries during a consultation, it can sometimes be difficult to know how best to respond. A suggested approach is to allow the patient time to express their emotions for a few moments (ensure tissues are within reach), take note of your own body language and reaction, and be empathetic, sensitive and validate the patient’s feelings and situation. In many cultures and demographics, crying is viewed as a sign of weakness. It’s important to reassure all patients that it’s okay to cry and be vulnerable; after all, crying is simply a normal biological response.

References

1. Sidebotham C. Viewpoint: Why do we cry? Are tears ‘purposeless’? Br J Gen Pract 2020;70:179–179. doi:10.3399/bjgp20x709049.
2. Sznycer D, Gračanin A, Lieberman D. Emotional tears: What they are and how they work. Evolution and Human Behavior 2025;46:106652. doi:10.1016/j.evolhumbehav.2025.106652.
3. Bylsma LM, Gračanin A, Vingerhoets AJJM. The neurobiology of human crying. Clin Auton Res 2019;29:63–73. doi:10.1007/s10286-018-0526-y.
4. Gračanin A, Vingerhoets AJJM, Kardum I, et al. Why crying does and sometimes does not seem to alleviate mood: a quasi-experimental study. Motiv Emot 2015;39:953–60. doi:10.1007/s11031-015-9507-9
5. Bylsma LM, Gračanin A, Vingerhoets AJJM. A clinical practice review of crying research. Psychotherapy 2021;58:133–49. doi:10.1037/pst0000342.

• This was a population-based cohort study, based on health records of people hospitalised between March, 2015, and August, 2022, in England, UK
• The exposed cohort included approximately 1,100,000 children and young people aged 0 – 17 years who first tested positive for SARS-CoV-2 infection between May, 2020, and August, 2022
• Four unexposed cohorts were included for comparison. These comprised of children and young people admitted to hospital either electively or due to trauma during the pandemic (May, 2020 – August, 2022) or the years beforehand (January, 2018 – December, 2019); they did not have a record of SARS-CoV-2 infection during the study period (those with chronic medical conditions were excluded)
• Type 1 diabetes diagnosis incidence was recorded at three timepoints: acute (0 – 27 days after the index date), post-acute (28 – 209 days) and late (210 days or later). N.B. The index date was the date the child or young person tested positive for SARS-CoV-2 infection (exposed) or the day of first admission (unexposed).
• The primary outcome of this study was diagnosis of type 1 diabetes during the post-acute period
• A diagnosis of type 1 diabetes was recorded in 2,637 children and young people across all cohorts (a further 324 had a diabetes diagnosis recorded but no type specified and 395 were diagnosed with type 2 diabetes)
• During the post-acute period, 475 of the 1,100,000 children and young people exposed to SARS-CoV-2 developed type 1 diabetes. This translated to an incidence rate per 100,000 person-years of 90.5 (95% confidence interval [CI] = 82.7 – 99.0). In comparison, the incidence rate in the trauma cohort (not exposed to SARS-CoV-2) was 37.6 per 100,000 person-years (95% CI = 25.2 – 56.2) and 29.8 (95% CI = 21.2 – 41.9) in the elective cohort (not exposed to SARS-CoV-2).
• The incidence rates in the historic cohorts were 22.4 per 100,000 person-years (95% CI = 13.8 – 36.6) and 37.7 per 100,000 person-years (95% CI = 29.5 – 48.0) for the trauma and elective hospital admissions, respectively
• The risk of being diagnosed with type 1 diabetes in the post-acute period following SARS-CoV-2 infection was significantly higher, compared to those in the unexposed trauma cohort (hazard ratio [HR] = 2.4, 95% CI = 1.58 – 3.64), unexposed elective cohort (HR = 2.9, 95% CI = 2.00 – 4.13), historic trauma cohort (HR = 4.2, 95% CI = 2.56 – 7.04) and historic elective cohort (HR = 2.4, 95% CI = 1.81 – 3.10)
• A stronger association was observed during the period when the SARS-CoV-2 Delta variant was the predominant circulating variant (HR = 2.6, 95% CI = 1.24 – 5.65), however, this analysis was based on smaller case numbers and the hazard ratios have wide confidence intervals
• The authors concluded that exposure to SARS-CoV-2 was associated with a significantly increased risk of being diagnosed with type 1 diabetes, although the absolute risk of this was still low
• Further investigation needs to be conducted on the mechanisms underlying the association (i.e. whether there is something specific about how SARS-CoV-2 may unmask type 1 diabetes or whether other viruses act in the same way) and whether vaccination status affects results
• Study limitations include:
• Inaccuracies and coding mistakes in patient health records and misclassification in the National Diabetes Audit which may influence these results, e.g. type was not recorded in 9% of diabetes diagnoses, prescription or laboratory testing data was not available to confirm the accuracy of the diagnosis
• Variation in health-seeking behaviours during the SARS-CoV-2 pandemic. Some people could have avoided testing or seeking medical attention and therefore were not captured or were recorded in the wrong cohort (e.g. some of the unexposed cohort did have SARS-CoV-2, but did not test).