The New Zealand General Practice Podcast

April 2022

Listen Here https://anchor.fm/opotikigp/episodes/Clinical-Snippets-April-2022-e1kdp4b

Clinical Snippets April 2022

1.  Eating disorders

Some useful resources for parents while they wait include (Goodfellow Gem):

• F.E.A.S.T info for parents
• EDANZ 
• Eating disorders. Mental Health Foundation
• Eating disorders. Health Navigator NZ
• Centre for Clinical Interventions   https://www.cci.health.wa.gov.au/  

For clinicians: Regional clinical pathways.   Also links to multiple resources for patients and whanau together with advice on management and monitoring. 

Private options include:

New Zealand Eating Disorders Clinic (NZEDC)

2.  BPAC update on weight loss

BPAC has recently released an update on weight loss: the options and the evidence.   Some key practice points include:

• The overriding principle of weight loss is that energy intake needs to be less than energy expenditure; there is no consistent evidence that any one calorie-restricted diet is better than another at achieving weight loss
• At least 2.5 hours of moderate intensity physical activity per week should be included in all weight loss interventions
• Contrary to popular belief, rapid weight loss is not associated with an increased risk of weight regain compared to gradual weight loss
• Pharmacological interventions may be considered only after dietary, exercise and behavioural approaches have been initiated and evaluated for people who are obese or as an adjunct to diet and lifestyle interventions, after the potential harms and benefits of treatment have been reviewed

There are two new pharmacological interventions approved in New Zealand (but not funded) for weight management:

Liraglutide (a GLP 1 receptor agonist – Saxenda) – daily SC injection, cost about $500 per month

Naltrexone + bupropion (Contrave) – tablet uptitrated over 3 weeks, cost about $220 per month

Cost comparison:  phentermine Duromine (30mg caps) $100/month;  orlistat (Xenical)  $180/month

Indication:  BMI ≥30 or 27-30 if at least one weight-related co-morbidity

Recent Tools for Practice question:  Is naltrexone/bupropion (Contrave^®) effective for weight loss?

Bottom line:  Over 28-56 weeks, at best, ~50% of patients taking naltrexone/bupropion achieved a >5% loss in body weight, compared to ~20% in control. Naltrexone/bupropion adverse events (examples nausea, constipation) lead to withdrawal in 23% of patients versus 12% on placebo.

3.  Depo-Provera dose interval update

In the April 2022 NZF update a change to dosing recommendation for Depo-Provera is noted as: 

• Individuals should be advised to return every 13 weeks for a repeat injection of intramuscular DMPA (outside the product licence for intramuscular DMPA). Health practitioners should be aware that this is an evidence-based recommendation and signals a change in practice in New Zealand. This recommendation may differ from the Manufacturer data sheet.

• Good practice points:  An injection of DMPA can be administered up to 7 days late (up to 14 weeks after the last injection) without the need for additional contraceptive precautions (outside the product licence for intramuscular DMPA). If necessary, an early repeat injection of DMPA can be administered from 10 weeks. 

4.  Supply issues with smoking cessation treatments

All patients who smoke should be encouraged to stop and provided with cessation support, including both behavioural and pharmacological treatment. Currently, the options for pharmacological support are limited due to supply constraints.

•  Varenicline has been unavailable for almost 12 months due to a manufacturing safety issue, and bupropion supply is now being managed in New Zealand due to increased global demand and manufacturing constraints.
• This leaves nicotine replacement therapy (patches, gum or lozenges) as the remaining funded pharmacological option; note that this is usually the first-line recommended treatment for smoking cessation. Nortriptyline (funded) may also be an option for some patients. Read more about smoking cessation treatments here.
• Vaping is not an approved smoking cessation method, but health care professionals can provide information to help smokers make an informed choice: read more here.

5.  Chronic pain guideline for primary care 

A recent Goodfellow Gem looked at the work of a Canadian panel that filtered 74,000 papers to get a summary for chronic pain management of osteoarthritis, low back pain, and neuropathic pain.  The findings are summarised in a table that might be useful for discussion with patients.

Some findings of note include:

• Placebo is fairly effective 29% to 40%.
• Physical activity is essential for OA and back pain.
• For OA (NZ available drugs) – steroid injections, oral and topical NSAIDs are effective.
• Glucosamine and chondroitin are of uncertain benefit as the publicly funded trials found no benefit while the industry-sponsored ones did show benefit.
• For low back pain – spinal manipulation, oral NSAIDs, and TCAs.
• The authors felt cannabinoids and opiates showed that harms exceeded benefits.

6.  The dangers of psychosis induced violence

Findings of a recent Coronial inquest into the deaths of five people who were killed in 2015 and 2016 by patients who were in a florid psychotic state have been summarised in GP Pulse with learnings for GPs documented as:

• When you are concerned about a patient and refer them, be ASSERTIVE. Say what you think and if it is a phone call, identify exactly who you are talking to. 
• Insist on talking to a consultant psychiatrist if you have concerns.  
• If you have an expectation about the type of care required, you need to state it clearly. You should also state that if your recommendation is not to be acted upon, then you should be contacted (leave your contact number) and you may wish to speak to a more senior member of the mental health team.
  • These cases are monumentally complicated, and a peer-to-peer discussion is the safest form of communication. You may well be the person who has the greatest insight into the case.
• Once you have made a referral, document it carefully.
  • If something goes wrong, you may find that other health professionals have a very different interpretation of what you said/documented.
• Keep clinical antennae up with patients who are guarded in their communication. Despite being psychotic, some patients can be wary of health professionals who may insist on treatments that they find intolerable.
• When family members or indeed other members of the public report abnormal behaviour you need to talk to and listen to them. This is not breaking patient confidentiality and may be critical to everyone’s welfare. You need to interview these people often without the patient present.
• We have a duty of care to our patients and their families and better outcomes for both should be paramount in our thinking.

The New Zealand General Practice Podcast

Clinical Snippets May 2022

May 2022

Listen Here : https://anchor.fm/opotikigp/episodes/Clinical-Snippets-May-2022-e1kdn7i

Clinical Snippets – May 2022

1.  ACC Treatment Injury

• Refusal to provide or delays in lodging a Treatment Injury claim with ACC is not an uncommon source of patient complaints.  However, on average a third of Treatment Injury claims are declined each year

• ACC has a provider resource (to which a patient could also be referred) clarifying the process

• The principles of a claim are:
  • An injury has occurred that has resulted in physical harm or damage to the patient
  • The injury has been caused by the treatment (probability rather than possibility considered)
  • The injury is not a necessary part or an ordinary consequence of treatment, having regard to the clinical knowledge at the time of treatment and the underlying health condition of the patient

• A precipitating event can include when treatment has not been given by mistake or has been given unreasonably late

• Lack of evidence of physical injury caused by treatment is the most common reason for a claim to be declined

• If review of an ACC Treatment Injury claim results in concern there is a risk to the public, the details may be forwarded to HDC

2.  Concussion

BPAC has recently published a comprehensive overview of concussion management for primary healthcare professionals – audiovisual and written resources including a summary sheet.  Key practice points include:

• Recognising concussion in primary care can be challenging as symptoms and signs are often subtle, non-specific, and can progress over time.  Initial loss of consciousness only occurs in one in ten people with concussion
• The Brain Injury Screening Tool (BIST) is a standardised and validated assessment tool to evaluate patients with suspected concussion; this is specifically tailored for use in time-limited clinical consultations (takes 5-6 minutes to complete)
• Initial management of patients with concussion involves physical and mental rest for 24 – 48 hours; in most cases patients should then progressively re-engage in normal activities after this rest period, assuming the degree of engagement does not significantly worsen symptoms – excessive rest can prolong recovery.
• Patients who have sustained a sports-related concussion should be immediately removed from play, and not return until they have been medically cleared after completing a graduated return-to-play protocol
• Patients can be reassured that most people who experience a concussion will fully recover within two to four weeks. However, recovery is strongly influenced by the timeliness of clinical review and follow-up, effective education delivered at an appropriate level of health literacy (and whether the advice given is culturally appropriate/relevant), as well as other patient-specific factors, e.g. initial symptom burden, ‘yellow flags’
• On-line educational resources are available from ACC for adult patients (English and Te Reo Maori) and for carers of an affected child
• Post-concussion syndrome is no longer a recognised as a diagnosis in DSM-5. ICD-11 or by ACC.  The preferred term is ‘persistent concussion symptoms’ (beyond three months). 

The article covers all aspects of assessment, education, recovery and rehabilitation,  complications, return to work and sport advice etc. 

3.  Calcium for hypertension?

A recent PEARL published in NZ Doctor referenced a Cochrane review noting several studies have shown an inverse association between calcium intake and blood pressure, and small reductions in blood pressure have been shown to produce rapid reductions in cardiovascular disease risk even in individuals with normal blood pressure. A 2 mmHg lower systolic blood pressure is predicted to produce about 10% lower stroke mortality and about 7% lower mortality from ischaemic heart disease.

An increase in calcium intake slightly reduced both systolic and diastolic blood pressure in normotensive people. The effect was confirmed in multiple prespecified subgroups, including a possible dose–response effect (1500mg per day being more efficacious than 1000mg), reinforcing the efficacy of the intervention. The effects were observed after only 3.5 months of intervention and were more pronounced in younger patients.

Most of the studies used calcium supplements and there is some suggestion that the effect might be lost over time in populations with adequate calcium intake.

Conversely, a 2021 meta-analysis in the journal Nutrients reported that dietary calcium intake of 700–1000 mg per day or supplementary calcium intake of 1000 mg per day increased the risk of CVD by about 15% in healthy postmenopausal women.

4.  Dog bites

Starship Hospital has updated its guidance on management of dog bite injuries which are increasing in frequency.  Practice points include:

• In serious incidents police or animal management may require photos or DNA collection from the wound prior to washout or closure. Encourage patients to take their own photos of injuries to keep for future reference.

• Consider imaging (Xray/CT) in even seemingly simple dog-bite injuries. Significant force (>1000N) can be involved, with deep penetration or crush injuries not initially obvious.
• Examination and copious irrigation should be done if the dermis has been penetrated or if the wound is in the proximity of joints
• Primary wound closure is recommended if early presentation (<4-6hours) AND absence of non-viable/heavily damaged tissue/contamination.  Delayed wound closure or healing by secondary intention is recommended for all other wounds.
• There is evidence that prophylactic antibiotics are associated with a statistically significant reduction in infection in dog-bites to hands.  There is conflicting evidence for other wounds. Antibiotics are also indicated for any infected wound, or as prophylaxis for puncture wounds, bite-injuries to hands, feet, face or genitalia, immunocompromised patients, those requiring surgery or who have an underlying structural injury, or if presenting >8 hours after the bite. 
• Amoxicillin/clavulanic acid is the antibiotic of choice with alternative for penicillin allergic patients being metronidazole plus co-trimoxazole (≥1 month – 11 years) or metronidazole plus doxycycline ( ≥ 12 years)
• It is strongly recommended that health professionals notify all dog-bite and serious non-bite dog-related injuries to the Animal Management Service of the council where the dog bite occurred, and do not require patient consent. Dogs pose a serious health risk to vulnerable people, including children, who are more likely to receive serious bites to the head/face/neck, and the potential for significant psychological harm in any age group
•   Any serious risk to a child or the public also needs to be referred to Social Work, Oranga Tamariki and/or Police. Animal Management Officers have limitations on what they can do in situations where a dog has bitten a family member, and may require further input from these services to ensure safety measures are put in place.
• Offer psychological support to all victims, and to whānau who have witnessed an attack. ACC can provide support with counselling or therapy sessions. 
• The Starship website has a printable information sheet for carers of affected children which includes reference to notification to Animal Control Officers, and a Council Notification form (currently Auckland specific – Hamilton details are Ph 07 8386632, email: animalweb@hcc.govt.nz  ) 

5.  Avocados

• A recent BPAC update references a recent paper published in the Journal of the American Heart Association that has found higher avocado intake is associated with a significantly lower risk of cardiovascular disease (CVD) and coronary heart disease.

• In a study of almost 70,000 women and over 40,000 men who did not have a history of cancer, coronary heart disease or stroke at baseline, followed up for thirty years, it was found that those who had two or more servings of avocado per week had a 16% lower risk of CVD and 21% lower risk of coronary heart disease. There was no significant association with a lower risk of stroke.

• The authors concluded that CVD risk could be lowered by 16 – 22% by replacing half a serving per day of high fat content foods such as margarine, butter, egg, yoghurt, cheese or processed meat with the equivalent amount of avocado.