Clinical Zoom meeting snippets - February 2023

• A NZ retrospective study published recently sought to estimate the proportion of women with a first episode of gestational diabetes who received post-partum type 2 diabetes screening in accordance with local guidance.   
• The study showed only 40% of women were screened within 3 months post-partum and that only improved to 61% after 12 months. Additional findings included that Māori women and those with higher deprivation were less likely to be screened, and there was extreme variation by postcode (15.3–67.5% screened by 12 months).   
• HealthPathways notes the Increased risk of patients with gestational diabetes developing type 2 diabetes following the pregnancy:  
  • the cumulative risk has been estimated to be as high as 50% within 5 years postpartum, depending on ethnicity and time from index pregnancy
  • there is good evidence that the risk of developing type 2 diabetes can be reduced by either lifestyle or pharmacological interventions (e.g. metformin) in the non-pregnant population. 

• Post-partum screening advice for women who developed gestational diabetes is to check HbA1c at 3 months and annually thereafter 

The end of year BPAC bulletin commented on some criticism the agency had received that some referral criteria and advice documented in various articles aren’t realistic, there is no way that patient will be seen...”.   

The comments noted BPAC is presenting what should happen, based on clinical trial data and consensus guidelines to improve patient outcomes. If we don’t refer based on the presumption that the referral will be declined due to resource constraints, the health system cannot measure unmet need. Te Whatu Ora in the October, 2022 “Planned Care Taskforce – Reset and Restore Plan” acknowledges that there is “no current effective measure of unmet need” and there is also no ability to measure the “not to refer” decisions that are based on a presumption that the outcome of the referral will be a denial of access. “Decline rates” are the simplest measure of unmet need, until other tools are developed to assess this. 

A recent Pharmac decision means that EpiPen and EpiPen Jr will be funded from 1 February, 2023, for people who have previously experienced anaphylaxis or who are at high risk. 

• Funding restrictions include a maximum of two devices per prescription, and replacement of up to two devices prior to expiry or after a device is used.
• Special Authority eligibility criteria include previous anaphylactic reaction which has resulted in presentation to an emergency department, or assessed by a relevant practitioner (including general practitioners, nurse practitioners and pharmacist prescribers) as being at significant risk of anaphylaxis; renewals of approval are not required.
• Patients being prescribed an Epipen can register on the supplier's website (Mylan EpiClub ) to order a free training pack and practice pen. There are also videos on how to use the pen and other resources. 

Access to the meningococcal B vaccine, Bexsero, will be widened from 1 March, 2023, to include all children aged up to 12 months, 1-5 year olds, and people aged 13 to 25 years in their first year of a specified close-living situation. 

• Pharmac eligibility criteria for the 13-to-25-year age group are either: 
  • two doses for individuals who are entering within the next three months, or in their first year of living in boarding school hostels, tertiary education halls of residence, military barracks, or prisons; or 
  • two doses for individuals who are currently living in boarding school hostels, tertiary education halls of residence, military barracks, or prisons, from 1 March 2023 to 28 February 2024.   

• Existing eligibility criteria for patients over one year of age are:   
  • up to two doses and a booster every five years for patients pre- and post-splenectomy and for patients with functional or anatomic asplenia, HIV, complement deficiency (acquired or inherited), or pre- or post-solid organ transplant; or 
  • up to two doses for close contacts of meningococcal cases of any group; or 
  • up to two doses for person who has previously had meningococcal disease of any group; or 
  • up to two doses for bone marrow transplant patients; or 
  • up to two doses for person pre- and post-immunosuppression (Immunosuppression due to corticosteroid or other immunosuppressive therapy must be for a period of greater than 28 days). 

(i)  A recent Te Whatu Ora Waikato newsletter commented on the significant volume of requests being received for non-specific soft tissue mass USS.  There is reference to national imaging guidelines which include standard indications for community imaging referral as: 

• Soft tissue mass with red flags; however, specialist assessment is preferred, so only request imaging if there is likely to be a delay before the patient is seen 
• suspicion of a foreign body where not covered by ACC. 

(ii)  Red flags include a soft tissue mass with any of the following characteristics:  

• growing 
• >5 cm in size 
• deep to deep fascia (limited mobility, less mobile with muscle flexion) 
• painful (most malignant lumps are painless; pain suggests nerve or bone involvement) 
• recurring after a previous excision. 

(iii)  Additional guidance is: 

• Apply caution in the use of ultrasound, as its ability to characterise solid mass lesions is limited and incorrect diagnosis can lead to significant treatment delays. 
• Consider requesting a plain X-ray as well. 
• If a sarcoma is suspected, reserve biopsy for an orthopaedic or sarcoma specialist. 

(iv)  A localised HealthPathway for Soft Tissue Lumps and Sarcoma has been recently published.  The pathway reiterates the limitations of ultrasound in determining whether or not a mass is likely to be malignant although it can determine  if a mass is present, superficial or deep to fascia, and solid or cystic.      

(v)  If a lump is not being investigated or referred: 

• advise the patient to report any changes promptly. 
• reassess at 3 months if any concern. 
• consider discussing with a general practitioner colleague for a second opinion. 

• Ramadan 2023 is expected to run from the evening of Wednesday 22 March to the evening of Thursday 20 April.  The Research Review series has published an excellent guide on diabetes management during Ramadan.  

• Many Muslims with diabetes have a strong desire to participate in the Ramadan fast, even though they may be exempted due to their underlying condition.  Be proactive about asking Muslim patients about their intention to fast as they may not volunteer this information. A pre-Ramadan assessment is essential for patients with diabetes who wish to fast.  

• Individualised risk stratification forms the basis for shared-decision making and recommendations regarding lifestyle, blood glucose monitoring and dose adjustments for glucose-lowering therapies. Patients at low risk should be able to fast safely, while those at moderate risk may be able to fast safely with appropriate education and monitoring. Patients at high risk should be discouraged from fasting.  

• Reassure patients who are at high risk that there are alternatives ways of obtaining spiritual rewards if they do not fast; consider engaging with a local Iman if the patient is uncertain about any of the medical recommendations provided.  

• Education about the risks associated with fasting and the provision of individualised strategies to preventing adverse outcomes are essential for the safety of patients with diabetes. Avoiding dehydration by drinking adequate quantities between Iftar and Suhoor is important.  

• SMBG is important for all patients with diabetes who are fasting and doing so does not break the fast. Patients at low risk should SMBG at least once during the day and following Iftar, as well as whenever they feel unwell or have symptoms of hypoglycaemia or hyperglycaemia. Patients at higher risk should test more frequently.  

• All patients with diabetes should break the fast if at any stage: 
  • Blood glucose <3.9 mmol/L 
  • Blood glucose >16.6 mmol/L 
  • Symptoms of hypoglycaemia or acute illness develop.  

• Information about dosing and/or timing adjustments should be provided to all patients taking glucose-lowering therapies, especially those using insulin.  It is recommended that patients be on a stable treatment regimen before beginning the Ramadan fast.  

• A post-Ramadan follow-up is recommended to review what went well for the patient and to discuss challenges to make any future fasts safer and more rewarding. 

A recent Tools for Practice summary looked at the question:  In elderly, does asymptomatic bacteriuria (ASB) cause altered mental state and will treating ASB improve clinical outcomes? 

The context:  Ordering urine culture is associated with antibiotic use.  ASB is common in elderly: 5-20% in community age>80 (females>males) and institutionalization (25-50% women/15-40% men). 

ASB guidelines recommend:  

• avoiding ASB treatment in elderly without clear infection signs/symptoms   
• assessment for other causes; careful observation; attention to contributing factors like dehydration. 

BOTTOM LINE: Due to important evidence limitations, it is not confirmed that ASB, or even Urinary Tract Infection (UTI), is clearly associated with altered mental state. Treating ASB does not improve clinical outcomes (including altered mental state) but may increase adverse events from 1% to 7%. In elderly patients with ASB and altered mental state, antibiotics should be avoided without clear signs/symptoms of infection, and alternative reasons for altered mental state should be considered.