Published: 26 May, 2023
New article: Gynaecological cancer - follow-up and surveillance
To conclude our gynaecological cancer series, we have published an article on the role of primary care in the follow-up and surveillance of patients who have undergone curative-intent treatment. A B-QuiCK summary is available here, and a gynaecological cancer themed peer group discussion and quiz are also now available.
Follow-up and surveillance of patients who have undergone curative-intent treatment for gynaecological cancer is an opportunity to identify recurrence as early as possible, and therefore optimise outcomes. Most cases of recurrence occur within two to three years post-treatment and patients are generally symptomatic; patients must be encouraged to seek advice if symptoms occur between scheduled follow-up appointments.
The article follows on from the early detection and referral series of articles on cervical, ovarian, endometrial, vulval and vaginal cancers. View the complete gynaecological cancer series here.
Thank you to Te Aho o Te Kahu - Cancer Control Agency for supporting this series of articles.
New guidelines available on heart failure with a preserved ejection fraction
Heart failure is a complex clinical syndrome that can be divided into two types according to the driving mechanism: heart failure with a reduced ejection fraction (HFrEF) and heart failure with a preserved ejection fraction (HFpEF).
While the distinction between the two depends on echocardiography findings, treatment in primary care often proceeds immediately under the assumption that patients have HFrEF, for which there is significantly more evidence. If echocardiography later reveals the patient has HFpEF, management can subsequently be refined.
The American College of Cardiology (ACC) has now released guidelines on the identification and management of patients with HFpEF, providing more evidence for treating this condition. Although optimal management still requires cardiology guidance, primary care clinicians have an important role in the identification of HFpEF and initiation of treatment. We have added a new section in our article on addressing heart failure in primary care: “Initiating and escalating treatment for heart failure” to cover the key findings from these guidelines. To view the updated section, click here.
Bowel screening clinical practice guidelines published
Te Whatu Ora, Health New Zealand, has published Clinical Practice Guidelines for Bowel Screening in New Zealand. Bowel screening using faecal immunohistochemistry (the FIT test) is currently recommended every two years for people aged 60 – 74 years. The eligibility age is in the process of being lowered across all regions for Māori and Pacific peoples to age 50 years (as reported in Bulletin 74 ).
The guidelines have a section on recommendations for primary care, including primary health care providers responsibilities, expected timelines for notifying a patient with a positive FIT and referral for colonoscopy and National Bowel Screening Programme eligibility and exclusion criteria.
All recommendations can be read here.
National female pelvic mesh service established
A New Zealand Female Pelvic Mesh Service (FPMS) has been established by Te Whatu Ora, Health New Zealand for females experiencing complications after pelvic mesh surgery.
Patients are eligible if they had pelvic mesh inserted for either pelvic organ prolapse, stress urinary incontinence or rectal prolapse* and developed symptoms secondary to this. Patients are also eligible if they have experienced complications after a non-mesh sling was inserted for stress urinary incontinence. The service does not currently cover other surgeries where mesh was inserted and does not include males.
General practitioners and specialists can refer eligible patients to this service, which is based in Auckland and Christchurch. Some appointments or assessments may not require attendance at a physical location; telehealth consults will be available as appropriate. Travel assistance is available for the patient and a support person if they are required to attend in person. Patients may be referred to the service via usual referral processes (i.e. ERMS, HealthLink). Check local HealthPathways for further information, including what to include in a referral.
* If pelvic mesh for pelvic organ prolapse or stress urinary incontinence was also inserted
Medicines Adverse Reactions Committee (MARC) vacancies
Medsafe is currently seeking general practitioners to join the Medicines Adverse Reactions Committee (MARC). MARC is an independent expert advisory group that provides recommendations to the Minister of Health regarding adverse effects of medicines to promote their safe use in New Zealand. MARC meets four times per year and the committee appointment is for a three-year term (with the option of a second three-year term).
Medsafe is advertising vacancies for two general practitioners with at least five years’ of clinical experience. Ideally, one clinician who works in an urban setting and the other from a rural setting.
Further information on required applicant experience and qualifications, as well as how to submit an application can be found here. Applications close 5 June, 2023.
For further information on the role of MARC, see: www.medsafe.govt.nz/committees/marc.asp
Updated COVID-19 booster eligibility
Te Whatu Ora, Health New Zealand and Manatū Hauora, Ministry of Health have expanded the eligibility for an additional COVID-19 booster to also include people aged 12 to 15 years who have a health condition that puts them at higher risk of severe illness from COVID-19. This booster dose must be prescribed.
Read more about additional COVID-19 boosters
The following groups are now eligible for an additional COVID-19 booster regardless of the number of boosters previously received:
- People aged 30 years and over
- People aged 16 years and over who are pregnant
- People aged 16 to 29 years who are at higher risk of severe illness from COVID-19 (no prescription required). N.B. People aged 16 to 29 years who are not at higher risk of severe illness are only eligible for a single booster following their primary vaccination course.
- People aged 12 to 15 years who are at higher risk of severe illness from COVID-19 (only eligible with a prescription). N.B. People aged under 16 years who are not at higher risk of severe illness are not eligible for a COVID-19 booster.
COVID-19 boosters are “especially recommended” for:
- All people aged over 65 years
- Māori and Pacific people aged 50 years and over
- People who are pregnant and at higher risk of severe illness from COVID-19 due to a health condition
- People with serious mental health conditions
- People with a disability and significant or complex health needs
- People aged 12 to 15 years who are at higher risk of severe illness from COVID-19 (only eligible with a prescription)
People can receive an additional booster if they have completed their primary course and it has been at least six months since their previous dose or positive COVID-19 test. However, clinicians or vaccinators can use their discretion with regard to the spacing of booster doses following informed consent from the recipient; there should be a minimum of five months between the primary course and first booster, four months between booster doses and a minimum of three months after infection with COVID-19.
Check in with your patients who meet eligibility criteria to ensure that they are aware an additional booster dose is available. The influenza vaccine can also be given concomitantly.
For further information on booster eligibility, click here
Reminder: Check immunisation status of adults
Childhood immunisation remains a focus in primary care as we come in to winter. However, clinicians should opportunistically check that adult patients are also up to date with their immunisations as part of routine appointments.
A list of available vaccinations for adults, including for special circumstances, e.g. overseas travel, can be found here on the recently launched consumer-facing immunisation website “Immunise”.
A new tool has been launched to allow people to check their eligibility for the measles, mumps and rubella (MMR) vaccine. This can be found here
Medical Council seeking feedback on telehealth
The Medical Council of New Zealand is currently reviewing its official statement on telehealth and has issued a consultation seeking feedback from general practitioners on proposed changes. The statement was last updated in October, 2020, to respond to the challenges with providing care and prescribing medicines during the COVID-19 pandemic.
Ideally, the new statement will acknowledge the role of telehealth as a method to overcome challenges currently faced in primary care while preserving public safety. A new section has also been included on the use of telehealth to ensure continuity of care.
The consultation closes on 12 June, 2023. You can submit your response here
Proposal to fund candesartan with hydrochlorothiazide
Pharmac is seeking feedback on a proposal to fund combination candesartan with hydrochlorothiazide tablets for patients with hypertension from 1 July, 2023. This medicine would be funded without restriction and is a suitable fixed-dose alternative medicine to quinapril with hydrochlorothiazide (Accuretic) which was recalled last year and delisted in May, 2023 (see Bulletin 53 and 61).
Submissions are due by 4 pm on Thursday, 1 June, 2023.
For further information on the management of hypertension in primary care, see: bpac.org.nz/2023/hypertension.aspx
Medicine supply issues
The following issues relating to medicine supply, of particular interest to primary care, have recently been announced. This information is also available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here
Aripiprazole 5 mg tablets
The manufacturer of aripiprazole 5 mg tablets (Sandoz) has advised that these will be out of stock in July and August, 2023. Other tablet strengths will be unaffected. An alternative brand of aripiprazole 5 mg tablets (Ascend Aripiprazole) will be funded from 1 June, 2023, and supplied under Section 29.
Clinicians should notify patients who are prescribed aripiprazole about the upcoming brand change and discuss any concerns.
Paracetamol 250 mg/5 mL oral liquid
There is shortage of paracetamol 250 mg/5 mL oral liquid due to increased demand. Suppliers are allocating stock to ensure equitable access. Supply of the paracetamol 120 mg/5 mL oral liquid is unaffected.
Reminder: ensure appropriate quantities of paracetamol are being prescribed as demand is expected to remain high over winter. Prescribing and dispensing limits remain in place (as first reported in Bulletin 51).
Paper of the Week: Detecting rheumatic heart disease in primary care
Acute rheumatic fever and rheumatic heart disease can develop from an untreated Group A Streptococcus infection. In New Zealand, previous studies (here, here and here) have shown these conditions are most prevalent among Māori and Pacific children (particularly those living in low socioeconomic areas in the Northern and Central North Island), while they rarely occur in NZ European children. However, the prevalence among adults in high incidence communities has been uncertain.
A New Zealand-based study, published in 2023, has now found that 2% of young Pacific adults (aged 16 – 40 years) in urban South Auckland have definite rheumatic heart disease. This prevalence is comparable to that seen in middle to low-income African countries. These findings suggest that education and prevention strategies for acute rheumatic fever/rheumatic heart disease are still of utmost importance and should be targeted to young adults as well as children.
The study also provides evidence of the benefit of portable echocardiography screening in detecting cases of rheumatic heart disease. As such, there may be a future role for primary care-based echocardiographic screening in high-risk people to enable earlier detection of rheumatic heart disease, convenient follow-up and continuity of care.
Discuss with your peers: do you see a role for portable echocardiography screening in your practice? Or is this just not feasible in terms of cost, training and resource constraints?
- A total of 465 people aged between 16 – 40 years (median age 28 years) who were enrolled in a Pacific-led primary care clinic in Otara, South Auckland participated in the study. Almost all (99%) identified as Pasifika.
- Eight participants (1.7%) self-reported a history of acute rheumatic fever/rheumatic heart disease; two were receiving regular IM benzathine penicillin and two had a history of heart valve surgery for rheumatic heart disease
- Family history of acute rheumatic fever/rheumatic heart disease was reported by 56 participants (12%) and a first-degree relative with acute rheumatic fever/rheumatic heart disease was reported by 31 participants (7%)
- Echocardiograms were conducted using a portable machine between December 2014 and March 2016. Echocardiograms were reviewed by one of the study authors, and a panel of cardiologists (blinded to patient details and medical history) reviewed any abnormal results.
- Results that showed evidence of rheumatic heart disease were categorised as either definite or borderline based on World Heart Federation diagnostic criteria
- Of the eight participants who self-reported a history of acute rheumatic fever/rheumatic heart disease, four had definite rheumatic heart disease on echocardiography, one had borderline rheumatic heart disease and three participants had normal echocardiograms
- If the results from the echocardiogram were abnormal, participants were invited to attend follow-up with a doctor involved in the study, and then referred to their primary care clinician or a cardiologist, as appropriate
- Eight participants with rheumatic heart disease (including two who were clinically diagnosed before the study) and 11 with non-rheumatic cardiac abnormalities were referred to cardiology clinics. Secondary prophylaxis with IM benzathine penicillin was initiated in four participants.
- The overall prevalence of rheumatic heart disease (definite and borderline) in young Pacific adults was found to be 56 per 1,000 population (95% confidence interval: 36 – 78 per 1,000 population).
- Ten participants were found to have definite rheumatic heart disease (six newly detected cases and four clinically diagnosed cases confirmed) with a prevalence of 22 per 1,000 population (95% confidence interval: 9 – 36 per 1,000 population)
- Borderline rheumatic heart disease (aged < 20 years) was found in 16 participants with a prevalence of 34 per 1,000 population (95% confidence interval: 19 – 52 per 1,000 population)
- Non-rheumatic cardiac abnormalities were found in 29 participants with a prevalence of 62 per 1,000 population (95% confidence interval: 33 – 73 per 1,000 population)
- Of the total number of participants who underwent an echocardiograph, 5.6% had features of rheumatic heart disease and 2.2% met World Heart Federation criteria for definite rheumatic heart disease. This suggests approximately one in 50 young Pacific adults living in South Auckland may have rheumatic heart disease.
- International studies that use the World Heart Federation diagnostic criteria are limited. In Uganda, the prevalence of definite rheumatic heart disease among people aged 21 – 30 years is reported as 20 per 1,000, and 15 per 1,000 in those aged 31 – 40 years, and the severity of disease is lower than found in South Auckland.
- Four participants with a prior history of clinically diagnosed rheumatic heart disease had normal follow-up echocardiograms. The authors suggested that these results highlight that the course of rheumatic heart disease may vary over time and either progress, remain stable or improve.
- The study also found that for every case of rheumatic heart disease diagnosed clinically, portable echocardiography detected an additional case
- Having the ability to detect rheumatic heart disease in primary care may identify cases earlier and improve outcomes for people who cannot access secondary care
- This also allows for convenient follow-up and continuity of care by the patient’s regular general practitioner
Webb R, Culliford-Semmens N, ChanMow A, et al. High burden of rheumatic heart disease confirmed by echocardiography among Pacific adults living in New Zealand. Open Heart 2023;10:e002253. doi:10.1136/openhrt-2023-002253
For further information on the prevention of rheumatic fever and management of sore throat, see: https://assets.heartfoundation.org.nz/documents/shop/heart-healthcare/non-stock-resources/gas-sore-throat-rheumatic-fever-guideline.pdf
This Bulletin is supported by the South Link Education Trust
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