Published: 29 September, 2023
Contents
New from bpacnz: Prostatitis: diagnosis and management in primary care
Prostatitis can be categorised into four distinct conditions: acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and asymptomatic inflammatory prostatitis. Primary care clinicians are likely to be most familiar with treating acute bacterial prostatitis, in which prompt treatment and appropriate antibiotic choice are crucial to avoid severe complications. Chronic prostatic conditions are actually more common, but likely under-diagnosed. Treatment interventions vary depending on the symptom(s) most concerning to the patient and should be used in combination, with the overall goal of improving the patient’s quality of life.
B-QuiCK summaries for acute and chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) are available.
A new prostatitis topic has also been added to the bpacnz Primary Care Antibiotic Guide.
Last days of life care: seeking feedback
In the last bulletin, we announced the publication of our comprehensive new resource aiming to educate and support primary healthcare professionals in delivering community-based care during a patient’s last days of life. This was developed with the support of Te Aho o Te Kahu, Cancer Control Agency, and contextualises information from the Ministry of Health, Manatū Hauora, “Te Ara Whakapiri: Principles and guidance for the last days of life” resources specifically for general practice.
Hopefully by now many of you will have had the opportunity to browse the content. In the next phase of this project, we are going to examine some of the issues more closely and ask our panel of experts to provide their insights. We would really like to hear from our readers about what you would like us to explore in more detail or any personal experience you would like to share.
Perhaps the morphine dosing information wasn’t clear enough; or you want to know more about combined management when you are dealing with multiple symptoms; or maybe you just want to know what to expect if it’s your first time “in charge” when someone dies, or how different cultures and spiritual beliefs can be incorporated and acknowledged during this time.
Send us your questions and feedback; your responses will be anonymised if published, and your details will not be shared with the panel. Email: editor@bpac.org.nz
bpacnz HPV testing guide for general practice
As reported in Bulletin 83, HPV testing is now the primary cervical screening test in New Zealand, replacing the previous cytology-based test. There is a large amount of information about the new programme now available, so we have produced a summary to help practices come up to speed with these changes. This brief guide provides an overview of the HPV Primary Screening programme, participant eligibility, how to conduct the test, including what sample to take, facts and tips about HPV testing and information on managing samples and results.
There is now an information hub for HPV Primary Screening on the Te Whatu Ora, Health New Zealand, website.
Cryptosporidium outbreak in Queenstown
The number of confirmed cases of cryptosporidiosis associated with the cryptosporidium outbreak in Queenstown is increasing rapidly. Te Whatu Ora, Health New Zealand, is advising healthcare professionals throughout New Zealand to be alert for symptoms and signs of gastroenteritis in patients who are residents in the area or who have recently travelled to Queenstown or Frankton, i.e. on or after 18th August. A faecal sample should be collected if the person is currently symptomatic or has experienced symptoms in the last two weeks (indicate in the clinical details on the laboratory form that it is suspected to be part of the outbreak). Te Whatu Ora is providing funding for arranging the faecal specimen and public health notification (see local HealthPathways or latest Te Whatu Ora communication).
All suspected cases of cryptosporidium must be notified to the local Medical Officer of Health through ERMS. Do not wait for laboratory confirmation before notifying.
Cryptosporidium infections are usually self-limiting and treatment is generally symptomatic and supportive, e.g. oral hydration. Discussion with an infectious diseases physician is recommended for people with suspected cryptosporidiosis who are immunocompromised.
A cryptosporidium fact sheet for patients from Te Whatu Ora can be found here
Measles cases in Auckland
Two cases of measles have been confirmed in New Zealand. The cases are not related; however, both involve overseas travel. Exposure events are listed here.
Healthcare professionals should be alert for symptoms and signs of measles in patients, particularly those who are not vaccinated or are immunocompromised, and have a history of recent overseas travel.
Consider the possibility of measles in a patient with the following:
- Generalised maculopapular rash, that starts on the head and neck and spreads down and out and fades
- Fever > 38℃ (usually begins around two days before the rash appears)
- Cough, coryza, conjunctivitis or Koplik spots
All suspected cases of measles must be notified to the local Medical Officer of Health. Do not wait for laboratory confirmation before notifying.
Information about measles from the Immunisation Advisory Centre is available here.
Is your patient population up to date with MMR vaccinations?
This is another timely reminder to opportunistically check whether patients have received both doses of the MMR vaccine and to offer vaccination where appropriate. Some children may have missed out on their scheduled MMR vaccine during the last three years, due to the COVID-19 pandemic and lockdowns.
Also ensure that patients with upcoming international travel are fully vaccinated with MMR.
MMR vaccination is funded for all children in New Zealand and anyone born after 1968 who has not received two doses. N.B. MMR vaccination is contraindicated during pregnancy.
For further information on MMR, see: https://bpac.org.nz/2021/mmr.aspx
Methylphenidate supply issue
There is a supply issue affecting methylphenidate extended-release tablets (Teva) and stock is expected to run out. As reported in Bulletin 83, this supply issue previously only affected the 18 mg, 27 mg and 36 mg formulations, however, stock of the 54 mg tablets is now low as well. A resupply date is not known at this stage.
People who are prescribed methylphenidate extended-release tablets (Teva) can switch to either Concerta or Rubifen SR brands. From 1st October, 2023 the Special Authority criteria for Concerta will be updated meaning that people with an existing Special Authority approval for methylphenidate (Teva) will automatically be eligible to receive methylphenidate (Concerta) with a new Special Authority. Pharmac are funding a single consultation with a primary care clinician for people who need to discuss any concerns, e.g. changing dose. A brand switch fee will also be available for pharmacists. See the medicine notice for details.
N.B. Caution is recommended when switching patients to a different brand of modified release methylphenidate due to variations in biphasic release profiles caused by slight differences in formulation.
Medsafe Alert: Pholcodine-containing medicines to be withdrawn next year
Medsafe has announced that pholcodine-containing medicines (over-the-counter cough suppressants) will no longer be available from 12th January, 2024. The decision to withdraw the consent to supply these medicines was made following a review of pholcodine-containing medicines by Medsafe (as reported in Bulletin 73) and based on advice from the Medicines Adverse Reactions Committee. Overseas regulators (e.g. in Australia and Europe) have already withdrawn these medicines due to a small increase in the risk of anaphylaxis for people who receive neuromuscular blocking agents during surgery, who have previously used pholcodine.
Pholcodine-containing medicines are not being recalled and will be available to purchase up until 11th January, 2024. Advise patients to report any use of a pholcodine-containing product to their surgeon or anaesthetist before undergoing general anaesthesia.
Watch this space for an upcoming bpacnz article about over-the-counter cough preparations
Frailty care guidance released
Te Tāhū Hauora, Health Quality & Safety Commission, has released the 2023 edition of the Frailty care guides, Ngā aratohu maimoa hauwarea. These resources are aimed at clinicians who work in aged residential care but may be useful for healthcare professionals providing support in other situations as well, e.g. home-based care. In addition to clinical and legal/ethical guidance, cultural considerations are included to increase awareness and assist healthcare professionals in delivering culturally appropriate care for kaumātua.
For further information on caring for patients in their last days of life, click here
Protected & Proud: new website for contraception information
Protected & Proud is a new website launched on World Contraception Day (Tuesday 26th September) that provides accessible and convenient sexual and reproductive health and contraception information for patients. The initiative began in 2019 and was developed by health professionals, Kaupapa Māori providers and consumers from Hauora a Toi Bay of Plenty. This website gives primary care providers another resource to direct patients to if they are seeking further information on different contraception options. A directory of contraception service providers is also available on the website, e.g. long acting reversible contraception services, subsidised contraception services.
bpacnz contraception resources for healthcare professionals are available here
Guidelines for endometrial hyperplasia and cancer
New guidelines have been published on the management of patients with endometrial hyperplasia and early endometrial cancer. These guidelines, developed by the New Zealand Gynaecological Cancer Group, provide guidance for clinicians on the detection of endometrial hyperplasia and cancer and focus on non-surgical and fertility-preserving management options.
bpacnz has published a gynaecological cancer series of articles, supported by Te Aho o Te Kahu, Cancer Control Agency, covering the early detection and referral of patients with suspected gynaecological cancer and follow-up in primary care after curative-intent treatment. For further information, click here.
More people with disabilities now eligible for COVID-19 antivirals
Pharmac has extended criteria for people with disabilities and those with severe health conditions who will be able to access funded COVID-19 antiviral treatments, from 1st October, 2023. These updated access criteria apply to nirmatrelvir with ritonavir (Paxlovid), remdesivir (Veklury) and molnupiravir (Lagevrio – separate access criteria) and will include people who:
- Receive Disability Support Services
- Require direct family, whānau or external disability care
- Have severe frailty and/or vulnerability due to one or more severe health conditions, e.g. severe neurological, cardiovascular, renal and respiratory conditions
For the full access criteria for COVID-19 antiviral treatments, click here
Podcast of the Week: Cyber security for your practice
A recent episode of The Good GP, an Australian podcast series, discusses common cyber security risks that general practice staff, and particularly practice administrators and owners, should be aware of such as phishing emails and password compromises. All practices face cyber security risks on a daily basis, but there are certain steps that can be taken to minimise this risk, e.g. enabling two factor identification, using an email filtering service, ensuring antivirus software is up to date.
Listen to the full podcast here (~11 minutes)
Paper of the Week: Risky business – alcohol consumption following cancer diagnosis
Alcohol consumption is ingrained in New Zealand society despite an association with numerous negative health effects, including increased risk of some cancers. Indeed, what some New Zealanders think of as “normal” drinking often meets the definition of binge drinking. Following a cancer diagnosis, a person’s attitude to alcohol may change; some may see the diagnosis as a wake-up call to make healthier life choices and reduce their alcohol consumption (or stop completely), while others choose to continue to consume or increase their alcohol consumption to help them cope with the situation.
A study published in JAMA Network Open investigated the alcohol consumption of people who have been diagnosed with cancer. Although rates of alcohol use were lower than the general population, the findings suggest that most people who have been diagnosed with cancer regularly consume alcohol and for many, their pattern of alcohol consumption meets the threshold for risky drinking. It is understandable that following a cancer diagnosis, decisions about cancer treatment are usually the focus of patient management, however, the mental and social impacts of cancer cannot be understated and a “whole person” approach to care is required for the best overall outcomes. Discussions around mental health and wellbeing, e.g. alcohol intake, risk-taking behaviours, should always be included as part of active treatment and long-term follow-up in people with cancer.
Is alcohol consumption a topic that you regularly discuss with people who have been diagnosed with cancer/undergoing cancer treatment or those whose cancer is in remission?
Read more
- This cross-sectional study analysed data from the United States National Institutes of Health All of Us Research Program. A total of 15,199 participants (63% female) were identified with a reported cancer diagnosis between May 2018 and January 2022 who had sufficient data available to quantify alcohol consumption (according to a baseline survey)
- Information on sex, ethnicity, smoking status and recent cancer treatment history was also analysed
- Alcohol-related cancers in this study included breast, colon and rectum, and head and neck cancers (N.B. Liver cancer was not included in the original survey used to obtain data and therefore not encompassed in this analysis)
- Participants were allocated to three groups; current drinkers (one alcohol-containing drink in the last year), former drinkers (no alcohol-containing drinks in the last year but had at least one alcohol-containing drink in their life) and never drinkers (no alcohol-containing drinks in their life). Of those who were current drinkers, risky drinking behaviours was further categorised to:
- Exceeding moderate drinking - consuming more than two alcohol-containing drinks during a typical drinking session
- Binge drinking - consuming more than six alcohol-containing drinks during one drinking session
- Hazardous drinking - an AUDIT-C score of three or greater for females and four or greater for males
- Current drinkers accounted for 78% of the study cohort (77% of females and 79% of males). Of the participants who had received cancer treatment within one year of the baseline survey, 76% were classified as current drinkers.
- People who had received a diagnosis of an alcohol-related cancer were more likely to be current drinkers (OR = 1.16; 95% CI, 1.06 – 1.27)
- Of participants who were current drinkers, males were more likely to exceed moderate drinking (18%) and engage in binge drinking (28%) compared with females (11% and 21%, respectively). However, overall rates of hazardous drinking defined by AUDIT-C score in males and females were similar.
- A participant’s drinking was more likely to be considered risky or binge drinking if they were aged under 18 years when they received a cancer diagnosis
- However, the prevalence of risky drinking behaviour in participants with a reported cancer diagnosis was lower than the general population
- Rates of exceeding moderate drinking in people without a previous cancer diagnosis were higher for both males and females (26% and 18%). Higher rates of binge drinking were also reported in the general population (41% for males and 33% for females).
- The authors acknowledged that the definitions of exceeding moderate drinking and binge drinking used in this study may not match widely accepted guidelines, suggesting their results may actually underestimate the problem
- Given that alcohol consumption has been associated with an increased risk of cancer recurrence, secondary primary tumours and mortality in people who have been diagnosed with cancer, as well as complications relating to alcohol consumption during active cancer treatment, it is likely this group of people would benefit from more robust discussions regarding their drinking during treatment and recovery follow-up
- This study may give some insight into the coping strategies that people use following a cancer diagnosis and highlights why mental health and wellbeing assessment, e.g. alcohol intake evaluation, should form part of regular management and long-term cancer follow-up
Shi M, Luo C, Oduyale OK, et al. Alcohol consumption among adults with a cancer diagnosis in the all of us research program. JAMA Netw Open 2023;6:e2328328. doi:10.1001/jamanetworkopen.2023.28328
For further information on assessing and managing alcohol misuse in primary care, see: https://bpac.org.nz/2018/alcohol.aspx
This Bulletin is supported by the South Link Education Trust
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