more_vertWhat does it mean to be a doctor? Is it still medicine we practise when a machine knows better than us our patient’s diagnosis, treatment, or fate? Would the hand we hold at the bedside still be reassured by our words and care? It remains hard to predict when artificial intelligence (AI) will become so powerful that it outreasons human beings. Some see that day arriving soon, and extreme predictions see whole disciplines like radiology or dermatology disappearing, replaced by AI.1 The truth is much less clear.
Preference: Dermatology
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MBS review changes to phototherapy items
BY DR ANDREW MILLER
From November 1, the MBS review has brought a change to the ultraviolet phototherapy items, consolidating them into one item 14050 with imposed conditions.
It has become clear that there has been both an implementation and a communication failure regarding these changes and all GPs claiming these items since November 1 have had rebates refused. As a result of an intervention from the Australasian College of Dermatologists (ACD), the Department has agreed to reconsider these claims, where the necessary documentation regarding Dermatologist supervision is present, and allow them to be resubmitted. The ACD also requested a moratorium of three months on compliance implementation to allow affected GPs to make the necessary arrangements. This has been refused by the Department, however the AMA will continue to argue this case.
Poor communication has led to affected GPs being unaware of the impending changes. This is a time of frenetic activity in the MBS Review, with numerous cascading recommendations flooding stakeholders, in this instance GP organisations, and clearly overwhelming their capability to appropriately inform their constituencies.
In the instance of the changes to phototherapy items, there is an obvious need for receipting practices to be changed but this needs to be supported by a reasonable lead-in period. The Dermatology, Allergy and Immunology (DAICC)MBS Review working group recommended a grace period which the Department has chosen not to apply, which the ACD supported because of concerns particularly for patients in rural or remote areas, or in areas of Dermatology workforce shortage where appropriate support from a Dermatologist may be difficult to arrange, in the time made available before the changes were put in place.
In the meantime, information on the change is below:
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14050 UVA or UVB phototherapy administered in a whole body cabinet or hand and foot cabinet including associated consultations other than the initial consultation, if treatment is initiated and supervised by a specialist in the specialty of dermatology Applicable not more than 150 times in a 12 month period TN 1.14 A component for any necessary subsequent consultation has been included in the Schedule fee for this item. However, the initial consultation preceding commencement of a course of therapy would attract benefits. Phototherapy should only be used when: · Topical therapy has failed or is inappropriate. · The severity of the condition as assessed by specialist opinion (including symptoms, extent of involvement and quality of life impairment) warrants its use. Narrow band UVB should be the preferred option for phototherapy unless there is documented evidence of superior efficacy of UVA phototherapy for the condition being treated. Phototherapy treatment for psoriasis and palmoplantar pustulosis should consider the National Institute of Health and Care Excellence’s Guidelines at https://pathways.nice.org.uk/pathways/psoriasis Involvement by a specialist in the specialty of dermatology at a minimum should include a letter stating the diagnosis, need for phototherapy, estimated time of treatment and review date. |
New precision UV sensors helpful, but shouldn’t replace good sun protection
Wearable UV sensors are increasingly marketed to help people tailor their sun exposure to their Vitamin D needs, but there are warnings they could cause more harm than good.
An array of personalised UV meters are now available as wristbands, patches and clothing clips linked to smartphone apps, alerting users when they have received enough UV radiation for their body to produce sufficient Vitamin D, but not so much as to increase their skin cancer risk.
New sensor measures sunburn-causing rays
Last month RMIT University researchers headed by Professor Vipul Bansal announced a breakthrough in UV sensor precision, having developed an invisible ink that directly measures UVA, UVB (which causes sunburn) and UVC, and changes colour at different UV saturations.
Professor Bansal told doctorportal: “Previous sensors have been unable to distinguish between the different types of rays, and had to rely on estimates based on total UV, which means they suffered from significant accuracy problems.”
For instance, one randomised controlled trial of 91 people found those who were given old-generation UV sensors experienced more frequent sunburns than those not given sensors at all (OR:1.60). The authors concluded either sensor inaccuracies or user behaviours could be to blame.
Professor Bansal said his team’s new generation of precision sensors would be available by 2020 at a cost of around $1 a day in forms such as stickers and wristbands.
“Personally, I’m vitamin D deficient so I’m always worried about how much time I should spend in the sun,” he told doctorportal. “I was passionate about this work because people like me need some sort of tool to give them an idea what’s enough sun exposure, and what’s too much.”
Currently, the Cancer Council Australia recommends that if the UV index is 3 or above – as calculated by the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) – people should wear full sun protection including sunscreen, sleeved clothing and a hat.
However, Professor Bansal said dark-skinned people had difficulty relying on the UV index, as it was a “blunt tool” that failed to take into account variations in UV-absorption rates according to skin tones.
The RMIT sensors have been developed in six different colours to be matched to individuals’ particular skin tones.
Users urged not to completely rely on sensors
Adjunct Associate Professor Craig Sinclair, Head of Prevention at the Cancer Council Australia, told doctorportal accurate UV sensors could be valuable education tools by revealing how quickly UV causes harm to the skin. However, he urged users not to rely on sensors to determine whether or not to apply sun protection.
“In the summer months, especially in the middle of the day, you really need to put sun protection on before you head outside because sunburn can happen so quickly,” he said.
He added: “There is no evidence to suggest that regular use of sunscreen has any impact on Vitamin D levels, especially given the intensity of UV in most of Australia, and the ability of the body to convert that to Vitamin D.”
Associate Professor Sinclair said it was risky for people to self-assess their skin type when deciding on sun protection measures.
“Having dark skin might be the equivalent of SPF 3 or 4 or 5. There’s definitely some protective benefit from dark skin but it doesn’t overcome the primary message – come the summer months, everyone needs sun protection.”
He added: “We don’t want these UV sensors to potentially cause more harm than good if they delay the time people use sun protection.”
Professor Bansal told doctorportal he strongly supported the Cancer Council’s sun safety messages. He suggested that people who used wearable sensors follow sun safety guidelines as per usual, and apply sunscreen to the device.
“The sensor will change more slowly if the wearer applies sunscreen to it, and will indicate when they have had enough exposure,” he said.
The Cancer Council recommends the SunSmart phone app, which advises Australians when to use sun protection.
GPs to retain access to MBS item 30202
Following representations from the AMA, it has now been confirmed by the Department of Health that GPs will not be precluded from accessing MBS item 30202.
In response to questions from the AMA, the DoH has stated that the MBS Taskforce response to the recommendations of the Dermatology, Allergy and Immunology Clinical Committee had been misreported in the Taskforce’s finding on the website. The reported change to MBS item 30202 would have seen GPs, the predominant users, excluded from claiming the cryotherapy item for removing malignant neoplasms.
The Clinical Committee recommended that the descriptor for MBS item 30202 be amended to replace “specialist” with “Australian Medical Council (AMC) recognised dermatologist”. It was also recommended that the Department of Health should monitor high-volume users to ensure that providers were requesting the appropriate pathology tests to confirm malignancy. At no point was it recommended that GPs be excluded from claiming the item.
However, the material that was released was inconsistent with this and suggested that the MBS Taskforce had recommended to Government that the descriptor be amended to restrict the use of this item to AMC recognised dermatologists and plastic surgeons to support appropriate use of the item and improve patient safety.
The DoH has now acknowledged the concerns raised by the AMA about the potential impact of the change and has confirmed an error was made during the publication of the taskforce’s findings. This will be corrected and amendments to the item descriptors will ensure GPs retain access to this item.
Many GPs, particularly those in rural areas, will be relieved that appropriate patient treatment will not have to be delayed for an unnecessary specialist referral.
MICHELLE GRYBAITIS
[Clinical Picture] Xanthoma disseminatum
A 20-year-old man presented to the dermatology department of our hospital in November, 2012, with a 5-year history of multiple brownish-yellow xanthoma-like papules and nodules affecting the face, flexures of the trunk, and limbs, with no systemic symptoms. The lesions had initially appeared as discrete or grouped papules, which then coalesced into plaques and nodules, especially in the axillae, over a period of 2 years. They were painless and asymptomatic, and the patient sought medical help only for cosmetic resions, particularly regarding the lesions on his face.
[Department of Error] Department of Error
Williams HC, Wojnarowska F, Kirtschig G, et al, on behalf of the UK Dermatology Clinical Trials Network BLISTER Study Group. Doxycycline versus prednisolone as an initial treatment strategy for bullous pemphigoid: a pragmatic, non-inferiority, randomised controlled trial. Lancet 2017; 389: 1630–38—In this Article (published online first on March 6, 2017), in the UK Dermatology Clinical Trials Network BLISTER Study Group list of names, C DeGiovanni was incorrectly listed as C Barnard. This correction has been made to the online version as of Oct 26, 2017.
[Clinical Picture] Generalised cowpox virus infection
A 24-year-old man presented to our dermatology clinic with three haemorrhagic partially ulcerated nodules located in the right groin, surrounded by inflammation and oedema, which had evolved over the course of 1 week (figure), and fatigue. He had identical isolated skin lesions on the right shoulder, left knee, and left ankle. On examination he was febrile (temperature 38·5°C) and had tender generalised lymphadenopathy. He had no signs or personal history of atopy (atopic dermatitis, hay fever, asthma), although family history was positive for a sister with dermatitis.
[Clinical Picture] Generalised nodules in pemphigoid nodularis
An 82-year-old woman presented to the department of dermatology at our hospital in February, 2016, with a 6-month history of widespread pruritic nodules on her neck, trunk, arms, and legs (figure), which were easily eroded by scratching. She had been diagnosed with prurigo nodularis in a local clinic and treated with triamcinolone acetonide acetate ointment and oral antihistamines without improvement. We took a biopsy sample from one of the lesions on her back. Haematoxylin and eosin staining showed hyperkeratosis, epidermal hyperplasia, acanthosis, papillomatosis, subepidermal blisters, and the infiltration of lymphocytes and eosinophils in the upper dermis (appendix).
[Clinical Picture] Non-healing ulcerative paronychia
A 32-year-old man with a 14-year history of ulcerative colitis presented to our dermatology clinic in December, 2014, with a 2-month history of a mildly tender, purulent paronychial lesion of his right big toe.
[Clinical Picture] Scleromyxoedema
A 76-year-old woman with a history of type 2 diabetes, chronic obstructive pulmonary disease, myocardial infarction, and successfully treated rectal carcinoma presented to the dermatology outpatient clinic in January, 2016, with a 2-year history of prominent skin changes. On examination we saw asymptomatic symmetrical skin-coloured flat papules of 2–3 mm diameter arranged in a linear pattern on the extensor surface of all fingers and the back of both ear helices (figure), and in the nasolabial folds (appendix).