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Published: 17th May, 2024


Round up of recent bpacnz publications – reviewing your ABCs

Atrial fibrillation

Atrial fibrillation (AF) is the most common form of sustained cardiac arrhythmia in adults, but people with AF are often asymptomatic. Detection in primary care usually relies on opportunistic assessment in patients aged ≥ 65 years, or sooner in those with other risk factors, e.g. Māori or Pacific peoples, previous TIA, hypertension. Early action is essential as AF significantly increases the risk of stroke. Unless the onset of AF occurred within the past 12 hours, referral for electrical cardioversion is not appropriate in haemodynamically stable patients without prior anticoagulation due to the risk of thromboembolic complications. In most cases, treatment using direct oral anticoagulants (DOACs) and rate control medicines, alongside relevant lifestyle changes, is sufficient in primary care.

The full article can be accessed here. A B-QuiCK summary is also available here.

Watch this space for more bpacnz updates on cardiovascular topics in the coming months. Next up is a revision of our article on prescribing beta blockers for cardiovascular conditions.

Burden of anticholinergic medicines in older people

Medicines with anticholinergic activity are widely prescribed in primary care and commonly associated with adverse effects. Anticholinergic burden refers to the cumulative effect of taking anticholinergic medicines, further increasing the risk of developing adverse effects. Older people, particularly those who are frail and with multiple morbidities, are most susceptible to the cumulative effects of anticholinergic medicines, leading to adverse effects such as cognitive impairment and falls. Prescribers should be aware of which medicines are most likely to increase anticholinergic burden, and how to recognise and manage this if it occurs.

The full article can be accessed here. A B-QuiCK summary is also available here.

Watch this space for an upcoming bpacnz clinical audit on identifying inappropriate anticholinergic medicine prescribing.

COVID-19: new paediatric vaccines + upsurge in case numbers

Since March, 2024, a new COVID-19 vaccine (XBB.1.5) has been available in New Zealand for people aged 12 years and over; a single dose is sufficient for a primary course. Eligible adults and children who have not yet received a primary COVID-19 vaccination, or are not up to date with additional (booster) doses, should be encouraged to do so. It is reported that paediatric Comirnaty XBB.1.5 vaccines (10 microgram for children aged 5 – 11 years and 3 microgram for children aged six months to < 5 years) will be available from 30th May, 2024. A webinar about these vaccines is being held by IMAC on Tuesday 21st May at 5.30 pm. Click here to register. Further information about these vaccines is expected to be released soon.

The latest data from ESR (week ending 12th May, 2024) show a recent upsurge in reported COVID-19 case numbers throughout New Zealand, and a decline in wastewater detections after they reached a significant peak in the week prior. Hospitalisation rates due to COVID-19 are also reportedly increasing.

Click here to read the latest information about COVID-19 and influenza vaccines for 2024

Antibiotic prescribing report incoming: Are your “Mybpac” details up to date?

As subscribers to Best Practice Bulletin, many of you may also have a “Mybpac” account. This allows full access to all the features on our website, including the ability to make comments on articles, earn certificates for completing CME quizzes, receive email alerts when new resources in your chosen topics are published, personalise the content you see, store favourite articles and manage electronic mailing list details. Another important benefit specifically for primary care prescribers is that it allows you to access personalised data when we release prescribing reports, and compare your choices against national averages, comparator prescribers and your practice colleagues; click here for an example.

If you already have a Mybpac account, log-in to check that your details are up to date: click on “Amend account details” and ensure your occupation is selected to show you are a primary care prescriber (if applicable) and that your practice details are correct.

If you don’t have a Mybpac account, sign-up for free now.

New antibiotic report coming soon

Previous investigations have shown that national antibiotic use steadily declined in the years leading up to the “COVID-19” era, and the bpacnz 2020 Annual report demonstrated a significant drop in antibiotic use in the initial stages of the pandemic response. A new bpacnz report will assess whether this trend has continued, or whether antibiotic use has returned to “pre-COVID” levels.

What do you predict has happened and how will your prescribing compare?

If you are a primary care prescriber, it’s not too late to sign-up to Mybpac to ensure you get this report.

Promethazine now contraindicated in children aged under six years

Medsafe has released an Alert Communication stating that all promethazine products are now contraindicated in children aged under six years due to an increased risk of central nervous system and psychiatric adverse effects; previously they were contraindicated in children aged under two years for all indications and in children aged under six years for cough and cold. The following products are affected:

  • Allersoothe elixir and tablets (funded)
  • Phenergan elixir and tablets (not funded)
  • AdiraMedica Promethazine tablets (not funded)

World Smokefree May: backing patients to stop

May is World Smokefree Month, culminating on World Smokefree Day (also known as World No Tobacco Day) on the 31st May, 2024. This year’s theme is: “We’re Backing You”. People who smoke are being encouraged to trial any of the free support programmes and funded smoking cessation products that are available to help them quit. Health New Zealand, Te Whatu Ora, are promoting the national Quitline service (0800 778 778 or text 4006) and a range of free community support services such as pop-up events and community outreach activities.

The international theme for World Smokefree Day on 31st May is: “Protecting children from tobacco industry interference”. This theme has been chosen to highlight the rising use of e-cigarettes in young people and the tactics of the tobacco industry; approximately 37 million teenagers (aged 13 – 15 years) worldwide use tobacco products. The goal in New Zealand is to have fewer than 5% of the population still smoking by 2025. As reported in Bulletin 90, the most recent figures from the New Zealand Health Survey show that 6.8% of adults continue to be daily smokers in 2022/23, down from 8.6% in the previous year.

For further information on smoking cessation, see:

Cow’s milk should only be given after age one year

In October, 2023, the World Health Organization (WHO) introduced a new guideline for complementary feeding of infants and young children aged 6 – 23 months. In this guide, the WHO recommended that: “for infants 6 – 11 months of age who are fed milks other than breast milk, either milk formula or animal milk can be fed”. However, the Ministry of Health, Manatū Hauora, has responded to this in a recent news article and reiterated that in New Zealand, the current recommendation (2021) that cow’s milk as a drink* for infants only be introduced after age one year still stands.

*Cow's milk products, e.g. yoghurt and cheese, can be introduced after age six months. Small amounts of cow's milk may be used to alter the consistency of solids in this age group, if required; however, breast milk or infant formula is preferred.

Medicine supply news: oxycodone liquid, cilazapril, oestradiol

The following news relating to medicine supply, of particular interest to primary care, has recently been announced. Medicine supply information is also available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.

New fetal alcohol spectrum disorder guidelines

Health New Zealand, Te Whatu Ora, has published new guidelines on fetal alcohol spectrum disorder (FASD). It is estimated that up to 3,000 children are born with FASD per year in New Zealand. The diagnosis of FASD is complex and ideally requires a multidisciplinary team of clinicians; this may also include psychologists, speech-language therapists, occupational therapists, physiotherapists and social workers. While a specialist is usually required to diagnose FASD, primary care clinicians may be an entry point for referral for formal diagnosis, and they provide ongoing care and support for patients already diagnosed with FASD.

Read the full guideline here

World Family Doctor Day

World Family Doctor Day is coming up on Sunday (19th May). The theme for this year is “Healthy Planet, Healthy People”. This day is an opportunity to appreciate the role of general practitioners and primary care teams and acknowledge their contribution to improving patient health. In addition, the aim this year is to raise awareness of the impact that climate change has on different aspects of health, e.g. environmental changes contribute to a rise in both communicable and non-communicable diseases. The World Organization of Family Doctors (WONCA) note that health outcomes can be improved, and carbon emissions lowered, if there is a focus on the early detection of disease and promotion of lifestyle changes, as this reduces the need for more energy intensive treatment procedures later on.

To support this year’s theme, the Royal New Zealand College of General Practitioners has released an update to their 2016 position statement on “Climate change, health and general practice in Aotearoa New Zealand and the Pacific”.

In Bulletin 48, we marked World Earth Day and published 10 recommendations for action for general practices to address factors driving climate change and advocate for the health of patients and the planet. These recommendations may be worth revisiting for this year’s World Family Doctor Day theme.

International Nurses Day

International Nurses Day was held on 12th May. The theme for this year was “Our Nurses. Our Future. The economic power of care.”, which aimed to “reshape perceptions, demonstrating how strategic investment in nursing can bring considerable economic and societal benefits”. This day is an opportunity to acknowledge and recognise the work that nurses do in the community to deliver healthcare and improve patient outcomes. The Nursing Council of New Zealand released a statement about the day, here, with profiles of nurses working in various roles within the sector, including in primary care.

Podcast of the Week: Managing patients with anxiety in primary care

The Curbsiders is a United States-based internal medicine podcast series. The clinical setting and available treatments may not always be relevant to a New Zealand audience, but episodes are presented in an informative and enjoyable way. In a recent episode, the team discusses the management of anxiety from a primary care perspective. Primary care clinicians are well placed to intervene before anxiety causes significant disruption to a patient’s life. Cognitive behavioural therapy is the most effective form of psychotherapy for anxiety, and patients can be directed to access this via free online courses if referring to professional services is not feasible due to cost or wait times.

"Medications can not remove thoughts from our mind. They may allow us to feel less on edge, help us sleep, or to feel better to tolerate certain thoughts, but these thoughts will still be there. Psychotherapy can help change negative thoughts and patterns." – Dr Jessi Gold

Listen to the full podcast here (~1.5 hours; skip ahead to 7 minutes for the main content)

Paper of the Week: "Don’t be silly... You’re far too young to be worried about cancer"

Conventional medical training tells us that cancer is a disease associated with ageing. However, rates of some cancer diagnoses in people aged under 50 years are increasing, e.g. colorectal cancer. Local guidelines and referral programmes often set an age threshold to ensure resources are used for investigating and treating patient groups with the highest prevalence of cancers. This can result in younger people undergoing multiple evaluations in primary care before being referred for cancer investigation. This is concerning given that there is evidence in New Zealand that patients aged under 50 years with colorectal cancer are often diagnosed at an advanced stage. Age threshold criteria in referral and screening programmes may be necessary to maintain adequate healthcare resources, but they do have potential to worsen cancer outcomes for some patients.

A qualitative study published in the British Journal of General Practice examines the clinical decisions made by general practitioners in England for younger patients with symptoms suggestive of cancer who do not meet age-specific criteria for targeted investigations. Personal experience, patient's behaviour and views, level of clinical suspicion and ability to circumvent referral systems influenced general practitioner decision-making for these patients. Clinical judgement is the key skill when evaluating patients with red flag symptoms who do not meet age-specified criteria for referral. While the findings of this study are specific to the healthcare setting in the United Kingdom, similar challenges exist in primary care in New Zealand and many of the conclusions are applicable.

Have you been involved in a cancer diagnosis in a younger patient? How many times did the patient present in primary care before cancer investigations were commenced and what barriers did they face during this process? Are there any specific red flag symptoms or signs that immediately raise your suspicion for cancer in a younger patient?

di Martino E, Honey S, Bradley SH, et al. Understanding GPs’ referral decisions for younger patients with symptoms of cancer: a qualitative interview study. Br J Gen Pract 2023;:BJGP.2023.0304. doi:10.3399/BJGP.2023.0304

This Bulletin is supported by the South Link Education Trust

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