Clinical Matters Newsletter November 2022 30 Nov 2022
Welcome to the November Edition of Clinical Matters!
In this issue...
New Obstetric and Urology Specialists starting at Virtuoso Clinic at Tauranga
Dr Kylie Gilmore
Dr Kylie Gilmore is a General Physician and Obstetric Physician at Tauranga Hospital and is starting private work at Virtuoso. As an Obstetric Physician, Dr Gilmore specialises in caring for women with medical problems which may complicate pregnancy. Dr Gilmore welcomes referrals related to medical conditions during pregnancy, pre-pregnancy counselling and general internal medicine.
Dr Gilmore attending Medical School at the University of Auckland and completed specialist training in General Medicine in 2017. She completed advanced training in Obstetric Medicine at Auckland City Hospital and was awarded to SOMANZ Certificate in Obstetric Medicine in 2017. She is an Honorary Lecturer at the University of Auckland.
Outside of work, Dr Gilmore has a busy family life with her husband and two young boys.
Please send your private referrals to Kylie:
- Post to Virtuoso, Level 1, 850 Cameron Road, Tauranga
- Fax (07) 579 0468
- EDI uro22bop
- Email: reception@urobop.co.nz
- Phone: 07 579 0466
Dr Cinthia Minatel Riguetto
Dr Cinthia Minatel Riguetto works as a consultant Endocrinologist at Waikato Regional Diabetes Service at Waikato Hospital and is starting private work at Virtuoso in November 2022. Dr Riguetto welcomes referrals related to all types of diabetes and technology (insulin pumps and continuous glucose monitors), thyroid diseases and other general endocrine disorders.
Dr Riguetto was born in Brazil and completed her endocrinology training at the University of Campinas - São Paulo - Brazil in 2016. She finished her master's degree in Graves' disease and Graves' orbitopathy in 2018 and is about to complete her PhD in the same field. Dr Riguetto also completed her vocational assessment with the Medical Council in New Zealand in April 2022 and was invited to become a Fellow of the Royal College of Physicians right after that.
Outside of work, Dr Riguetto spends time with her family and loves to explore the stunning countryside of New Zealand.
Please send your private referrals to Cinthia:
- Post to Virtuoso, Level 1, 850 Cameron Road, Tauranga
- Fax (07) 579 0468
- EDI uro22bop
- Email: reception@urobop.co.nz
- Phone: 07 579 0466
Mr Wikus Vermeulen
Mr Wikus Vermeulen is a Consultant Urologist commencing private practice with Mark Fraundorfer and Peter Gilling at Urology BOP located at Virtuoso, Cameron Road, Tauranga.
Wikus' pre- and post-graduate training was in Bloemfontein, South Africa. He completed advanced urological training in Belgian, France and Johannesburg and was in private practice in South Africa for 11 years before moving to New Zealand in February 2021. He has spent the last 18 months in the public sector at Tauranga Hospital.
Wikus received further advanced endourology training in BPH from Professor Peter Gilling. His main role was clinical lead for prostate and bladder cancer and his interests are in urological oncology. He is robotically trained and accredited and enjoys all endourology procedures including BPH and renal stone disease.
He is vocationally registered as Urologist at MCNZ and HPCSA, a member of RACS, ACS, EUA, SIU and a council member of the South African Colleges of Medicine (Urological College).
Wikus is married with three school aged children and enjoys hiking and gold and is a keen skier. My wife, Ilne, is a personal stylist and his youngest daughter (7y) shares her love and interest in fashion. Wikus and Ilne also have a teenage son (14y) and daughter (16y) who love music and the arts.
- Post to Virtuoso, Level 1, 850 Cameron Road, Tauranga
- Fax (07) 579 0468
- EDI uro22bop
- Email: reception@urobop.co.nz
- Phone: 07 579 0466
Opioid Prescribing
There has been a rising incidence of oxycodone prescribing in NZ for many years 1, 2. Patients have often been initiated on medication in hospital and this has been continued in Primary Care. Through advice from the Pain Team in Tauranga, the Anaesthetic Department at Whakatāne would like you to be aware they are changing the way the hospital prescribes opiates. Following the WHO analgesic ladder for acute pain, strong opiate medication is advised at step 3 for acute pain or first line in severe cancer related pain 3. Patients have often been prescribed Oxycodone first line at step 3. The NZ formulary 4 and the guidance for Whakatāne hospital via the Tauranga pain team is that morphine sulphate (Sevredol) or liquid morphine hydrochloride (RA-Morph) is first line for immediate release morphine. Oxycodone will be reserved for second line use if morphine is not tolerated or contraindicated. The issues with Oxycodone are the changes in bioavailability and dosing compared with oral morphine and also the increased potential for opioid addiction.
- Oxycodone use still increasing - BPJ Issue 36 (bpac.org.nz
- Oxycodone prescribing: New Zealand solutions to a global problem - bpacnz, September 2016
- Analgesia in Adults with Acute Pain - Community HealthPathways Te Manawa Taki | Midland Region
- Pain - New Zealand Formulary (nzf.org.nz)
Urology Service Update on Referral Guidelines
Venturo Urology is contracted to provide elective urological services to Te Whatu Ora, previously BOP and Lakes DHBs. Acute services are also managed by Venturo but under a different arrangement. From a referrers' point of view, we are one regional service. We have four consultant Urologists and three (four in 2023) registrars in our team.
We thought it useful to update you on referral guidelines for some common urological conditions.
- Haematuria
Clinically significant microscopic haematuria is defined as >20mill RBC/L without UTI on two MSU samples collected at least 7 days apart. Macroscopic haematuria associated with a UTI or urinary catheterisation does not require formal investigation unless there are ongoing concerns.Haematuria should be investigated initially with a urinary tract USS which can be requested from Te Whatu Ora BOP and Lakes at time of presentation. We use CX Bladder Triage sparingly and usually for remote patients.
- Raised screening PSA
We follow MOH guidance which states a normal PSA to be <4.0 for men aged 70 and younger, <10.0 in men aged 71-75 and <20.0 in men aged over 75. We don't investigate on the basis of single slightly raised PSA unless red flags are present (acute neurological symptoms, renal failure, bone pain or macroscopic haematuria without UTI). Increased PSA levels can be transient, which is why men should always have a repeat PSA test after 6-12 weeks to confirm the result. An abnormal DRE is another indicator for referral. We usually request a screening multi-parametric MRI Prostate as an initial investigation. (Please let us know if your patient is claustrophobic, has hip join replacement/s, has a pacemaker or any history of metallic foreign bodies in his eyes) - Unfunded conditions
Venturo has never been funded to investigate/treat/carry out the following:
- Social, cultural or religious circumcision
- Impotence/erectile dysfunction
- Vasectomy
- High litigation of varicocele for infertility
We also decline benign scrotal lesions unless they are significantly interfering with the ability to work or function. - High Suspicion of Cancer (HSC)
This label is commonly misused, examples include:
- Haematuria with a normal USS
- A slight to moderately raised screening PSA
- Scrotal swellings with not USS. Almost invariably a testicular cancer will be palpable and not masked by hydrocoele. Use the radiology scrotol ultrasound eReferral form for a new adult hydrocoele. - Stress urinary incontinence
Ventuoro urologists are currently not accredited to carry out mid urethral prolene mesh slings (or fascial slings) since all surgical mesh was banned for female pelvic reconstruction in late 2017. We carry out urodynamics for our uro-gynaecology colleagues but cannot accept referrals for stress urinary incontinence at the current time. We anticipate this may change when the MOH finally get their act together around re-accreditation in 2023. - LUTS
Men with lower urinary tract symptoms (LUTS) should not be referred unless an adequate trial of pharmalogical treatment has been trialed (alpha blockers, then finasteride). Currently, because of the very long wait times for laser proctectomy in Te Whatu Ora BOP, patients with LUTS who are not in acute or chronic retention are temporarily being declined. For this we apologise but it is an issue beyond our control. - Small renal stones
Asymptomatic renal stones of 7mm and less are not considered clinically significant and do not meet the threshold for treatment. - Ureteric stones
Ureteric stones <7mm will usually pass over a 6-8-week period should be managed with analgesia and doxazosin 2mg nocte unless septic or experiencing uncontrolled pain. If no resolution after six weeks, refer. - ACC
Patients with ACC covered conditions are not treated in the public system (other than as acutes) and should be referred privately. - Private care
Many patients either have medical insurance or have more than adequate means to access private treatment but only express this after months of waiting in the public system. It is always an ethical dilemma for urologists working in the public system to discuss private options for obvious reasons and it would be much simpler if this was discussed at the time you refer. - Private transfers of care
Seeing a urologist in private will not result in "queue jumping" (other than in clearly agreed HSC/FCT/acute situations). Patients referred into the system by private urologists including those who work for Venturo, will be triaged in the same manner and same priority as if referred by a GP. - Declines
Whenever we decline a referral, we remain open to further information that may alter our initial opinion which can only be made on the basis of information supplied. This is in the context of extremely constrained access to theatre and beds in Tauranga hospital. In Lakes, the lack of resident medical staff, HDU and ICU back up in Southern Cross Hospital excludes high risk elective cases. - Contact
We have an on-call urology registrar 0800-2200hrs seven days a week available to give advice and there is always a consultant on call.
CLINICAL UPDATE: STI Collection Kit Change Reminder
The new STI swab and urine collection kits/tubes have been available since September and many requestors have already transitioned to them.
We would like to remind you to use up your existing stock, but you MUST transition to the new STI kits/tubes by Friday 18th of November. Any of the old black cap STI tubes received from Monday 21st of November will result in a recollect request as the old Viper XTR instruments will be turned off and these tubes are not compatible with the new BC COR instrument.
Please click here to read the full update from Pathlab
IV Iron Infusion or Bolus Injections in General Practice
Key purpose/Benefit
For the correction of Iron Deficiency in Anaemia in Patients who are eligible for the publicly funded programme, where it is clinically appropriate to be delivered in a community setting
*Please note, this only applies to WBOPPHO practices*
Please click here to view the full Iron Infusion or Bolus Injections Guide
IV Iron Infusions - Referral Process
Process
- Referrals for iron infusions should be sent via BPAC referral to General Medicine - stating 'Iron Infusion' in the reason for referral.
- Do not address to 'Day Stay or Medical Day Stay' as there are no dedicated Day Stay staff.
- Ensure appropriate investigations have been completed and the information below is included in your referral. This is required by the non-clinical admin team for entry into the booking system.
Please click here to view the full IV Iron Infusions Referral Process Document
Message from Planned Care Team: Action being Taken to Remediate Delays in Transcription
We would like to acknowledge the delays that are occurring currently in the transcription service. The situation is being closely monitored.
The current strategies in place to address the backlog include:
- Team working overtime.
- Casual staff engaged to provide support.
- Increased outsourcing volumes.
A software update to the Winscribe dictation/transcription platform due in early 2023 will significantly improve workflow and increase turnaround time.
Please contact the GP Liaison team via baynav@bopdhb.govt.nz with any queries.
Rheumatology Thresholds
We will continue to accept Grade 1 referrals only until March 2023 at which point a further review will occur with a plan to lower the threshold.
Midland HealthPathways Update
New pathways for GPs on HealthPathways
There are no new HealthPathways this month.
And remember there is up-to-date information on all matters Covid-19 for primary care on Health Pathways, including national as well as local information.
HealthPathways is a collection of management guidelines specifically tailored to primary care. Our GP Liaison team is in the process of 'localising' these pathways to the Bay of Plenty, i.e., making them relevant to GPs and other primary care providers specifically in the Bay of Plenty. You'll find valuable pointers on history, examination, treatment and of course when and how to refer patients on to other services. These pathways will, over time, be replacing the Bay Navigator pathways.