PMR is an inflammatory rheumatological condition that causes a specific pattern of joint pain and morning stiffness; it almost never occurs in people aged under 50 years. Treatment requires long-term oral corticosteroids which can be associated with significant adverse effects, so diagnostic certainty is important. Other conditions that can mimic PMR should be first ruled out, and the patient should be assessed for giant cell arteritis, as this has a strong association with PMR and is a diagnosis not to miss. This article also includes audio commentary from rheumatologist, Professor Simon Stebbings.

A B-QuiCK summary is available here, and a PMR themed peer group discussion and quiz are also available on this topic.

Preventing SARS-CoV-2 infection and managing the acute phase of illness has been the central focus of our healthcare system since the beginning of the COVID-19 pandemic. While most patients are expected to recover from COVID-19 within two to four weeks, some continue to experience symptoms 12 weeks or more post infection; this is defined as long COVID.

Given the diverse clinical picture associated with long COVID, it is not a “natural fit” for any one medical specialty, and primary care is often tasked with leading the management of affected patients. To help support clinicians, we have recently published a new long COVID resource, including advice to guide a progressive and tailored diagnostic work-up, and management tips to address the diverse range of possible symptoms.

The appropriate use of serum tumour marker testing is complex and patient harm can occur when testing is requested but not clinically indicated. This overview article covers the most frequently used tumour markers, and when they should, and should not, be requested. The main role for a tumour marker test is in the management of a patient with a known malignancy. However, there are some tumour markers that are useful in the detection of specific cancers, e.g. CA 125 in ovarian cancer.

We have made some small changes to the format of bpac^nz clinical audits. The Royal New Zealand College of General Practitioners (RNZCGP) has updated its Te Whanake CPD programme and clinical audits are no longer compulsory. However, they are an important tool to help improve clinical practice and patient outcomes in primary care. An audit does not require RNZCGP approval before use, but it is encouraged that the proposed audit topic is discussed with your practice colleagues or peer group before commencing, to ensure relevance, and after to reflect on the results. While audits have been designed with general practitioners in mind, they are applicable to all primary care clinicians, and we encourage use by anyone for whom the topic is relevant.

Recently updated audits:

• Reviewing patients using opioid medicines long-term for non-cancer pain
• Improving safety for patients taking an ACE inhibitor/ARB + diuretic
• Managing winter illnesses without antibiotics
• Lowering serum urate levels in patients with gout

• When you are doing a driving medical for an older person you should always consider if there is a need for a Mini-ACE - conversely, if you do a Mini-ACE, you should always consider the implications for driving. N.B. there is no specific Mini-ACE result that will give you a definitive answer about driving ability - Dr Mathew Croucher
• If you have patients with insomnia who cannot divorce themselves from their screens in the evening, recommend the use of blue light blocking glasses to decrease the effect of blue light on melatonin production – Professor Richard Porter
• The “fake news” relating to statin intolerance is resulting in statins not being as widely or effectively used as they should. There is good evidence that many people experience adverse effects from being on a pill, not from being on a statin – Professor Gerry Wilkins
• “Quick starting” of any contraceptive method (i.e. initiation at any time in the cycle) should be the norm as it reduces the risk of an unwanted pregnancy and there is increasing evidence that none of the contraceptive hormones result in fetal harm - Dr Orna McGinn and nurse practitioner Emma MacFarlane
• Extended use of oral contraceptive pills (“running packs together”) can be done for as long as the patient chooses. If there is breakthrough bleeding suggest either just “riding it out” or having a four-day break only - Dr Orna McGinn and nurse practitioner Emma MacFarlane
• Assess every child’s vision to find those at risk of visual loss (e.g. from cataract or retinoblastoma) or who have strabismus (free screening is available in many regions if strabismus is suspected). Always check three things in children; corneal light reflex, red reflex and pupil response so that “no child goes blind” – Dr Antony Bedggood
• Pay attention to missing eye lashes (madarosis). They are very likely to be a sign of an eyelid malignancy – Dr Rebecca Stack (for Dr Jo-Anne Pon)

BP targets continue to be debated in the literature; the 2023 ESH guidelines recommend a lower diastolic threshold than in the 2018 version, now suggesting that a target of < 140/80 mmHg is suitable for most patients (rather than < 140/90 mmHg). The justification for this was based on randomised controlled trials which showed the incremental reduction in CVD outcomes and mortality observed with lower diastolic targets. If antihypertensive treatment is well-tolerated, the systolic BP target can be further reduced to < 130 mmHg in most patients aged < 80 years (ideal range 120–129/70–79 mmHg). Intensive blood pressure management (i.e. targeting BP < 120/70 mmHg) continues to be recommended against, mainly because any small protective effect demonstrated in clinical trials is outweighed by the increased risk of harm and discontinuation in the general population.

As discussed in a recent Medscape commentary featuring cardiologist Dr Christopher Labos, it is not so much the precise target that matters, but rather our approach to ensuring all patients receive adequate treatment. He notes that “perhaps the most insightful thing that can be said about the blood pressure guideline controversy is that it's not all that controversial ... arguing about 140/90 mmHg or 130/80 mmHg is less important than acknowledging that we should be aggressive in screening for and treating hypertension”. For some patients in primary care this may just involve lifestyle changes, whereas others may also require antihypertensives to make a meaningful change, particularly those at higher CVD risk. Individualisation of targets should always be considered, with less assertive objectives sometimes being appropriate based on patient-specific factors, e.g. frailty, dementia, limited life expectancy.

In this study, investigators used a regular size cuff regardless of an individual’s mid-upper arm circumference and investigated BP measurements using an automated device. These results were compared against automated measurements using an appropriately sized cuff (i.e. their “true blood pressure”). It was shown that systolic BP measurements were 3.6 mmHg lower among patients that would otherwise have required a small cuff. In contrast, among participants that would otherwise have required a large or extra-large cuff, use of a regular sized cuff resulted in 4.8 mmHg and 19.5 mmHg higher systolic blood pressure measurements, respectively. All differences were statistically significant, and mis-cuffing effects were consistent regardless of the BP magnitude or obesity status.

Cuff sizing depends on the equipment brand available and associated specifications, but as a rule the bladder (inflatable portion) should encircle 80% of the patient’s arm. Study authors recommend the following approximate sizing principles:

Ideally, clinics should stock all cuff sizes and follow manufacturer instructions regarding correct fit, e.g. Welch Allyn 10 small adult (20 – 26 cm), Welch Allyn 11 adult (25 – 34 cm), Welch Allyn 12 large adult (32 – 43 cm), Welch Allyn 13 thigh (40 – 55 cm).

Eleven general practitioners took part in the interviews. Most participants were female (n = 9), over half had received specialist postgraduate dementia education but only one had previously been involved in dementia research. The duration of experience in primary care was evenly split with approximately half having less than five years’ experience, and the other half at least 20 years’ experience.

Three themes were identified from the interview responses:

• The general practitioner role; preventative vs reactive health care
  • When asked about the role they play in preventing dementia, none of the participants said they proactively screened for this
  • Management of chronic conditions, e.g. diabetes and cardiovascular disease, focuses on secondary prevention and limiting further morbidity such as stroke, heart attack or cancer. Dementia education was not commonly included in these discussions.
  • When dementia was discussed, conversations were often initiated by the patient due to concerns regarding family history
  • Participants felt that reducing dementia risk should involve all of primary care, e.g. nurse prescribers, practice nurses and pharmacists
• Communication barriers when discussing dementia risk
  • Time – conversations around dementia are often lengthy and complex, and may not be possible for primary care clinicians who are already time limited
  • Knowledge – understanding of dementia risk factors varied; cardiovascular risk factors associated with dementia were easily identified, however, only one respondent listed air pollution as a dementia risk factor, and no one mentioned a history of traumatic brain injury
  • Stigma – assumed anxiety or fear regarding dementia may prevent primary care led discussions about risk factors
• Strategies to enable dementia risk communication
  • Participants suggested incorporating dementia risk assessment into regular patient follow up for chronic conditions
  • Providing patient-focused health promotion material(s) could help raise awareness of risk factors for dementia
  • Using the term “brain health” may avoid the negative connotations and resulting communication barriers associated with the term “dementia”

Study authors concluded that an increased awareness of risk factors for dementia and subtle changes in how we think and talk about dementia may provide opportunities for primary care clinicians to reduce the burden of future neurodegenerative disease.