Clinical Zoom meeting snippets - March 2024

Health Pathways has released a new section on practical prescribing aimed mainly at new prescribers but some helpful reminders for veteran prescribers. Covers most general aspects of prescribing including legal requirements. Some practical information includes the following. 

• If you prescribe intermittent PRN medicines e.g., two tablets QID PRN, without ordering a specific amount then the pharmacy will dispense the maximum allowable amount i.e., 720 tablets for three months. If you continue to print this medicine automatically on your repeat prescriptions the patient is liable to receive excessive amounts. This has safety implications, especially if it is a medicine of potential abuse such as codeine-containing medicines.  

• When a patient tells a prescriber they have different numbers of each of their medications, write "Please vary quantities for patient stock management." Pharmacists can then dispense the required quantities to bring medications into line.  

• Patients not eligible for pharmaceutical subsidies but covered by ACC  for an injury may be eligible to claim back the cost of usually subsidised prescriptions related to that injury using an ACC249 form (which the pathway suggest the prescriber gives to the patient). 

• Pharmacists check that a medicine or a dose of medicine is correct by comparing the new prescription with the patient's medicine history.  To avoid the pharmacist needing to check with you that a change in the prescription is deliberate, please underline and annotate any change from the previous prescription. Annotation of changes is important. Pharmacists' systems are not linked and if a patient does not return to the same pharmacy, the pharmacist may be unaware of a change in prescription for that patient.  

• Advice on medications that can be compounded into liquid form by the pharmacy is available on the Pharmaceutical Society website. 

• BPACs Best Practice Bulletin: Issue 92 includes updated Sport Concussion Guidelines from ACC including a six-stage graduated return to education/work & sport protocol. It is worth familiarising yourself with the protocol to ensure patients are given a consistent message regarding return to sport. The protocol notes day 14 is the earliest time at which return to normal work/study and sports specific training should be considered, and day 21 is the earliest at which return to competitive sport should be considered.   

• There is reference to the recent ACC statement on post-concussion syndrome: ACC considers that post-concussion syndrome is an unhelpful and out-dated clinical construct. Our view is that there are risks inherent in continuing to diagnose clients with this condition, not least that disabling symptoms will be misattributed to this condition rather than to potentially reversible medical, psychological, or psychiatric factors that remain undiagnosed and untreated. Consequently, ACC no longer accepts ‘post-concussion syndrome’ as a covered injury. Where clients/patients have persisting symptoms that clinicians consider are caused by concussion, the appropriate covered injury would be ‘concussion’. Symptoms that persist beyond three months are most appropriately described as ‘persisting concussion symptoms.’  

• I’ll put in my regular plug for use of the Brain Injury Screening Tool (BIST-2) (not just for sports related concussion) which is validated for patients aged over 8 years and is designed to be completed in about six minutes. It gives objective baseline and progress measures covering physical, vestibular-ocular and cognitive symptoms of concussion.    

• There is an excellent 2022 BPAC article on diagnosing and managing concussion in primary care.    

• The February edition of NZ Doctor describes a new emergency procedure for cardiac arrest known as double sequential external defibrillation (DSED) which has been adopted here, the second country after Canada to do so. The article notes that early defibrillation can dramatically improve the likelihood of surviving a cardiac arrest but around 20% of patients whose cardiac arrest is caused by VF or pulseless VT don’t respond to the standard defibrillation approach.  The use of DSED has been shown to double the survival rate of such patients.   

• DSED provides rapid sequential shocks to the heart using two defibrillators. The pads are attached in two different locations: one on the front and side of the chest, the other on the front and back. A single operator activates the defibrillators in sequence, with one hand moving from the first to the second. Aotearoa New Zealand ambulance data from 2020 to 2023 identified about 1,390 people who could potentially benefit from novel defibrillation methods. This group has a current survival rate of only 14 per cent.    

• Relevant paramedic guidelines are to be updated reflecting the new approach including that if ventricular fibrillation or pulseless ventricular tachycardia persist after two shocks with standard defibrillation, the DSED method should be administered. Two defibrillators need to be available, and staff must be trained in the new approach.   

• Issue 230 of GP Research Review reviews a recently published study on inequities in pre-pregnancy folic acid use in Central and South Auckland. The study notes that rates of neural tube defects are markedly higher among Māori (4.58/10,000 live births), and Pacific peoples (4.09/10,000 live births) as compared with non-Māori, non-Pacific peoples (2.81/10,000 live births).   

• Only 46 per cent of the 400 women surveyed as part of the study reported using pre-pregnancy folic acid supplementation. Rates were lower among those who did not intend to become pregnant (21%) or were “pregnancy-ambivalent” (27%) than in those who intended their pregnancy (58%). Women who identified as European, Middle Eastern, Latin American or African were around five times more likely to use supplementation than Māori. Supplementation was also more likely among those managed by a private obstetrician versus a midwife and in women aged over 30 years.   

• The study concluded low rates of pre-pregnancy folic acid supplementation exist in Auckland with significant ethnic disparity. Mandatory fortification of non-organic wheat is important, but supplementation is still recommended to maximally reduce risk. 

• Morphine oral liquid (RA-Morph) 1 mg per ml and 10 mg per ml strengths are out of stock, and remaining supply of RA-Morph 2 mg per ml and 5 mg per ml will expire at the end of March. Re-supply RA-Morph 1 mg per ml is expected by June-2024. Other strengths of RA-Morph are expected later in 2024.  This leaves two unapproved but funded (s29) brands of 2mg per ml strength available – Wockhart and Oramorph.  Further detail and prescribing advice is available on He Ako Hiringa website.  
• Omeprazole 20 and 40mg capsules – monthly dispensing from 1 March 2024 until stocks arrive (expected April 2024).
• Oestradiol valerate 1mg tabs (Progynova) - monthly dispensing from 1 March 2024 until stocks arrive (expected June 2024).  2mg tabs not affected. 
• Mesalazine 800mg tabs (Asacol) – shortage expected until July 2024.  Two x 400mg tabs suitable alternative.
• Olsalazine 250 and 500mg tabs (Dipentum) – both unavailable with 500mg expected available from April 2024.  Consider change to alternative medication eg mesalazine. 
• The funded bisoprolol brand is changing from 1 April 2024 when bisoprolol-Mylan and Viatris will no longer be funded. A patient information leaflet about the brand change is available on the Pharmac website.  
• From 1 March 2024, Pharmac has removed the requirement for annual renewal of SA numbers for patients taking sacubitril with valsartan (Entresto), for heart failure.  
• Modafinil - contra-indications (contraindicated in pregnancy), contraception and conception, pre-treatment screening, and patient advice has been updated in NZF.  This includes pretreatment screening with BP, ECG and excluding pregnancy, and Effective contraception is recommended during treatment and for 2 months after stopping treatment. Effectiveness of hormonal contraception (including contraceptive pills, implants, injectables and hormone releasing intrauterine devices) may be reduced. The UK FSRH gives current guidance on contraceptive options in patients taking enzyme inducers.    

Issue 111 of Cardiology Research Review reports a Spanish study looking at Frank’s sign (Sanders T Frank – 1973) and cardiovascular risk. Frank’s sign is a diagonal earlobe crease. The estimated cardiovascular mortality risk was significantly higher in individuals who presented diagonal earlobe crease. The number of individuals with moderate, high, or very high cardiovascular risk increased significantly as the presence of the crease increased (23.8% had no crease, 35.6% had unilateral creases, and 58% had bilateral creases). The mean cardiovascular risk estimated was significantly higher for individuals with longest and deepest diagonal earlobe crease, and with accessory creases. The conclusion: The diagonal earlobe crease is independently associated with higher cardiovascular risk scores, especially when the crease is complete, bilateral, deep, and has accessory creases.  

• Beware the child with unexplained limp or knee pain. I’ve recently reviewed a case of missed diagnosis of SUFE in a slim 11yo female which had disastrous consequences for her – stable mild slip converting to a severe acute slip.  

• Health Pathways has a section devoted to SUFE partly because of the potentially severe consequences of missed or late diagnosis. This includes the practice point: All children complaining of knee pain need exclusion of hip pathology. If there is no evidence of knee pathology on examination, arrange hip X-ray with AP pelvis and frog lateral view.  However, if you suspect an acute SUFE on the basis of history and examination, refer immediately for orthopaedic assessment rather than imaging.    

• As a quick refresher, SUFE usually occurs in the 8-15 year age group, more common in males and a more than half of sufferers are overweight or obese. The most common presentation is a chronic slip with gradual movement of the epiphysis and the patient may present with vague chronic or intermittent aching pain in hip, groin, thigh or medial knee. 15% of patients only have thigh or knee pain. Pain worsens with physical activity and there is usually no preceding trauma. It may be bilateral (18-50%). An acute slip presents after a sudden event with inability to weight bear and appearance of a hip fracture. You can get an acute slip on background of a chronic slip (sudden exacerbation of symptoms in a setting of more consistent low-grade symptoms, may be episodic).  

• A chronic slip may present with persistent or episodic limp. Foot on the affected side may be out-turned. Loss of internal rotation at hip. Leg length shortening may be present. When the hip is flexed passively to 90º, the thigh will abduct and roll into external rotation. Examine the knee to rule out local process at the knee to account for knee pain.  With an acute slip there is a marked limp and Trendelenburg gait and often an inability to weight bear. There may be an external rotational deformity of the hip and shortening of the affected leg.  

• The annual incidence of SUFE in the 0–16-year age group is around 5/100,000 meaning around 40-50 cases in NZ annually so you may never see one. An Australian study suggests there is delayed diagnosis (weeks to years) in around 60% of cases of chronic stable slip, and most patients (76%) present initially to their GP.