Clinical Zoom meeting snippets - September 2023

KEY PRACTICE POINTS

• A person is presumed to have the capacity to make a decision unless there are good reasons to doubt this presumption (EOLC Act is an exception).
• In general, capacity is assessed with respect to a specific decision at a specific time.
• Assessment is of a person’s ability to make a decision, not the decision they make. A person is entitled in law to make unwise or imprudent decisions, provided they have the capacity to make the decision.
• Supported decision-making involves doing everything possible to maximise the opportunity for a person to make a decision for themselves.
• Capacity assessment procedures need to consider tikanga Māori and cultural diversity.

Legal test for capacity

A person lacks capacity if they are unable to:

• understand the nature and purpose of a particular decision and appreciate its significance for them;
• retain relevant, essential information for the time required to make the decision;
• use or weigh the relevant information as part of the reasoning process of making the decision and to consider the consequences of the possible options, (and the option of not making the decision); or
• communicate their decision, either verbally, in writing, or by some other means.

Useful resources

• A Toolkit for Assessing Capacity (Douglass, Young & McMillan)
• Your local Community Health Pathway (section: Mental Capacity)
• Goodfellow Unit online course: Assessing decision-making capacity: the clinical basics and  Decision-making capacity: the legal aspects and the webinar Assessment for Mental Capacity
• Forms required for activating EPOA for Property (Form 4) and Personal Care & Welfare (Form 5)

From 12 September, 2023, HPV testing will become the primary cervical screening test in New Zealand.  The National Cervical Screening programme has released a second information pack  that contains information on training and responsibility changes for clinical and administration staff involved in the HPV primary screening process.

Key points from the pack include:

• From 12 September, 2023, only primary care clinicians who are accredited to perform cervical screening will be able to offer HPV testing (including offering self-testing); this includes nurses and nurse practitioners who have completed NZQA training in cervical screening as well as doctors and midwives
• Requirements to allow those not currently accredited to perform cervical screening to offer HPV testing are being developed by the National Screening Unit

• A summary of required training for specific roles is included. The Clinical Modules: Cervical Screening using HPV Testing for Clinical – Cervical Sample-Takers, GPs, and Midwives is made up of four e-Learning modules and is available on LearnOnline (Cervical Screening Using Human Papillomavirus (HPV) Testing Programme).  The modules are:

• MODULE 1 | Introduction to Cervical Screening using HPV testing (60 minutes)
• MODULE 2 | Navigating the Cervical Screening pathways - practising using the pathways with various cases (30 minutes)
• MODULE 3 | Cervical Screening in Aotearoa New Zealand – History and Context (30 minutes)
• MODULE 4 | Talking about Cervical Screening and HPV (60 minutes)

• Be prepared for a potential increase in uptake of cervical screening due to funding for some groups and the ability to self-test.
• Additional resources include the updated 2023 Clinical Practice Guidelines for Cervical Screening in Aotearoa New Zealand and Goodfellow Unit webinars.

At the end of July 2023, the Ministry of Health acknowledged the importance of Cabinet making the decision to reduce the maximum limit for opioid prescriptions from 3 months to 1 month. This new limit will apply to both Class B and Class C opioids.  This will bring the prescribing limit for Class C opioids – such as codeine and dihydrocodeine – in line with Class B opioids. Additional regulation changes will result in the re-classification of tramadol as a Class C2 controlled drug from 1 October 2023 although it is exempt from the requirement to be stored in a controlled drug safe.  This means once the relevant legislative changes are enacted (later this year) both codeine and tramadol will have one month prescribing restrictions.  However, methadone will be available as a three-month prescription when being used as part of an OST programme. 

A September 2021 NZ Doctor article reviewed hypophosphataemia associated with iron infusion therapy.  Key points included:

• Iron infusion with ferric carboxymaltose (Ferrinject) is associated with a higher incidence of hypophosphataemia than other formulations. 
   
• Testing of serum calcium and phosphate levels before iron infusions should only be done for high-risk people such as those with a BMI <18kg/m2 , if the person has chronic diarrhoea or malnutrition, or if the person is to receive a second iron infusion within six months.  HealthPathways recommends seeking general medicine advice if pre-infusion phosphate is less than 0.8 mmol/L (ref range >16y 0.7-1.5), as treatment with calcitriol may be recommended.
  
  
• Testing after an iron infusion is usually based on clinical symptoms.  The mean time to the nadir of hypophosphataemia is usually between one and six weeks. While most recover within three months, there are reports of prolonged recovery time up to two years, although this would require further investigation into cause. Clinical symptoms of hypophosphataemia include tiredness, weakness and muscle pain.
  
  
• Treatment and monitoring of hypophosphataemia depends on severity.  Check calcium, magnesium and renal function.
  
  
• Mild hypophosphataemia – 0.6 to 0.8mmol/L.
  • Phosphate replacement is not usually needed unless symptoms are present.
  • Increase phosphate-containing foods – chicken, seafood, dairy (milk, cheese, yoghurt), nuts and seeds, whole grains.
    
    
• Moderate hypophosphataemia – 0.3 to 0.6mmol/L.
  • Phosphate 16mmol per tablet (Phosphate Phebra), up to one to two tablets three times daily. Reduce dose if estimated glomerular filtration rate is less than 60ml/min/1.73m² or not tolerated at higher doses (diarrhoea, gastric irritation).
  • Do not give with calcium or antacids (reduces absorption).
  • Each phosphate tablet contains 20mmol sodium and 3mmol potassium; take care in people with heart failure.
    
    
• Severe hypophosphataemia – less than 0.3mmol/L. Refer for intravenous therapy.
  
  
• Monitoring depends on the severity of the hypophosphatasaemia. For severe hypophosphataemia, phosphate concentrations are checked every 24 to 72 hours, but mild hypophosphataemia could be monitored in one to two weeks. If hypophosphataemia is prolonged, check parathyroid hormone and vitamin D levels.

Issue 7 of GP Practice Review commented on a recent systematic review and meta-analysis that compared shorter (≤5 days) versus longer treatment with antibiotics for children diagnosed with CAP.  The authors reported no significant differences between short and longer courses of antibiotics in the following areas;

• clinical cure
• treatment failure
• relapse mortality risk
• need to change antibiotic
• need for hospitalisation
• severe adverse events

The reviewer concluded:  This study provides further evidence that there is no benefit to be gained from longer courses of antibiotic treatment for many infections that are managed in the community. In the case of paediatric community-acquired pneumonia, shorter treatments durations ≤5 days should be recommended with caregivers provided with education about the rationale, which may be counter to information they have previously received.  Current HealthPathways and BPAC guidance refers to a 5-7 day course of amoxicillin with a longer course for alternative antibiotics (7 days for erythromycin and 7-10 days for roxithromycin). 

A recent article in the British Journal of General Practice gives a succinct summary of key considerations for primary care physicians when prescribing menopause hormone therapy including a helpful algorithm.  The four key considerations are listed as:

1. Is HRT appropriate (including contraindications).
2. What preparation and regimen are required.
3. What is the most appropriate route and dose to start on.
4. Is testosterone or vaginal oestrogen required in addition.

Drug names listed are different to NZ and not all formulations discussed are available here but the algorithm is a useful one-page reminder of issues to consider.  Last month Pharmac announced a procurement opportunity that may result in a wider range of transdermal oestrogen products becoming available including a topical gel.  With respect to testosterone therapy in menopause, Goodfellow Unit have a useful resource on this topic including reference to use of a commercially manufactured (not compounded) topical testosterone gel (Androfeme) which can be prescribed off-label under s29 of the Medicines Act at a cost of $153 for 100 days treatment at standard dose.  

Issue 81 of Best Practice Bulletin comments on the importance of having a variety of blood pressure cuff sizes available at your fingertips.  Most health professionals know that incorrectly sized cuffs can lead to inaccurate blood pressure measurements and the potential for misdiagnosis. A recent randomized crossover trial published in JAMA Internal Medicine reported on blood pressure measurements using an automated measuring device on 195 community-dwelling adults with a wide range of mid-arm circumferences.   Use of a regular BP cuff resulted in a 3.6 mm Hg lower systolic BP reading among individuals requiring a small BP cuff.  In contrast, among individuals requiring a large or extra-large BP cuff, use of a regular BP cuff resulted in 4.8 mm Hg and 19.5 mm Hg higher systolic BP readings, respectively.  Many home-monitoring devices come with a standard size cuff which may not be appropriate for the patient.  The AMA have produced a pamphlet to guide correct cuff-size selection based on mid upper arm circumference. 

 Issue 212 of Respiratory Research Review refers to a recent study validating a short six-item tool – Breathe VQ or the Breathing Vigilance Questionnaire - to assess ‘breathing vigilance’, an important component of dysfunctional breathing.  The reviewer notes that dysfunctional breathing is common in clinical practice. It cannot be fully explained by organic disease and isn’t specific to any specific respiratory disorder with overlap with many conditions including anxiety, asthma, and post-COVID Syndrome (long COVID).   The Nijmegen questionnaire is often used to assess dysfunctional breathing (although has some limitations in applicability) and the Breathe VQ adds another dimension to assessment.   

HealthPathways section on Dyspnoea gives further advice on assessment of patients with persistent breathlessness following recovery from Covid-19 infection and who do not have known respiratory disease.  There is recommendation to consider completing consider completing a 1MSTS test and mMRC score with recommendations for further management (respiratory specialist review, respiratory physiotherapist or respiratory physiologist) depending on results.  

The Goodfellow Unit has a 20 minute podcast on Dysfunctional Breathing Disorders (2021) with a presentation by a physiotherapist on Understanding Breathing Pattern Disorders scheduled for 17 October 2023.