Vitamin B3 and Skin Cancer – a bit more prevention.

A recent study has suggested that vitamin B3 otherwise known as nicotinamide may be able to reduce pre-cancerous skin lesions like actinic keratosis and non-melanoma skin cancers, such as basal and squamous cell cancers.

The Australian Oral Nicotinamide to Reduce Actinic Cancer (ONTRAC) study was run over 12 months and published in the NEJM in 2015. The study gave people who had a high risk of skin cancer 500mg of nicotinamide twice a day. The authors found that nicotinamide reduced non-melanoma skin cancer by a quarter with comparable efficacy against both basal cell and squamous cell cancers. If you want to learn about how nicotinamide may do this have a read of these review articles. Role of Nicotinamide in DNA Damage, Mutagenesis, and DNA Repair and Nicotinamide for skin cancer chemoprevention.

 

Aktinic keratosis or solar keratosis

Squamous cell cancer

Basal cell cancer

Lentigo maligna or malignant melanoma

As with all medical advances, there are some caveats.

The trial subjects were considered at high risk defined as those having had 2 or more non-melanoma skin removed in the last 5 years. In reality that would probably be most of my over 50 year patient here in North Queensland.

The benefit of nicotinamide disappeared once the medication was stopped after 12 months.

Nicotinamide was found to be safe for the duration of this study, although some people did complain of nausea. A smaller dose of 500mg once a day may help those and has been shown to have some benefit albeit less.

The nicotinamide used in this study was donated by Blackmores. Just remember that you need NICOTINAMIDE, not nicotinic acid or niacin, as at that dose you’ll end with facial flushing, headache and hypotension with the latter.

Importantly, taking nicotinamide doesn’t replace the need for protecting yourself from the sun by avoiding being out in the heat of the day, wearing long sleeves and pants, wearing a hat and using sunscreen. The study noted that even for these high risk people who have had skin cancer removed, only 50% used sunscreen. Here’s my hint, to help you remember to use sunscreen.

The study didn’t look at incidence of melanomas, apparently that is next on the authors agenda.

If you recognise any of the spots shown above on your face in the mirror go and see your GP.

May I indulge a short but very sad anecdote from a few year ago. Everyone including the butcher and baker told this bloke to get that ugly spot on his cheek looked at. Instead he put on a band aid and ignored everyone including his wife. Finally, when the spot turned into an even uglier, smelly, ulcer he saw a doctor. Alas it was far too late to save him the squamous cell cancer despite surgery and radiotherapy.


References

http://www.nejm.org/doi/full/10.1056/NEJMoa1506197#t=article

https://www.cancercouncil.com.au/blog/the-role-of-vitamin-b3-in-reducing-non-melanoma-skin-cancer/

https://www.skincancer.org/publications/the-melanoma-letter/spring-2016-vol-34-no-1/nicotinamide

https://www.hindawi.com/journals/jna/2010/157591/

http://onlinelibrary.wiley.com/doi/10.1111/ajd.12631/full

Pictures are from a great skin website from New Zealand called Dermnet

 

 

 

 

 

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Trying to understand Medicare #2

What does Medicare Cover?

Rule one – You have to have a valid Medicare card

Rule two – Not everything is covered

Rule Three – GP and Specialists have some different rules. I might leave that for a different blog.  This one if just about GPs.

Rule Four – You have to be alive. You can claim a rebate if I visited and determined you dead, but then that’s when the rebates end!

Rule Five – When you talk with your GP, it is not always safe you assume there is a Medicare rebate for this visit.

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Enough of the rules….

It may be easier to list what Medicare doesn’t cover. And the list is longer than you may think. I have used the most up to date Medicare Benefits Schedule Book Category 8 as the basis of this information.

Firstly, unless there are really special occasions (like a case conference) you need to have a face-to face consultation to access a Medicare rebate.

Telephone consultations, Facebook posts and Skype or FaceTime chats do not have a rebate.

There is no rebate for repeat prescriptions when the patient doesn’t consult with their GP. Many prescriptions used to treat chronic illness last 6 months. If you have a chronic health problem a six month check up may be sensible. After all you service your car regularly.

Non-therapeutic cosmetic surgery doesn’t attract a rebate. So, that annoying mole on your nose, unless it looks like a skin cancer doesn’t earn a rebate when it is removed. Likewise,  Botox for wrinkles doesn’t have a rebate.

Euthanasia and any service directly related to the procedure doesn’t have a rebate.  This one surprised me given that until Victoria’s law is enacted, euthanasia is not legal. This was also listed in the 2014 version of the Medicare Book, so maybe it was written in that brief time euthanasia was legal in the NT.  However, for counselling about euthanasia will attract a rebate.

Medicare rebates are not payable for a compensable injury or illness for which the patient’s insurer or compensation agency has accepted liability. However, whilst the process is pending, a rebate is available. Medicare then seeks reimbursement from the insurer.

Medicare benefits are not available for a medical examination for the purposes of life insurance, superannuation, a provident account scheme, or admission to membership of a friendly society. This also applies to Likewise pre-employment and workplace medicals, and health screening (although there are some exceptions).

Medicare lists a number of specific treatment that it doesn’t rebate for. I’ll list these, although many are things that a GP is unlikely to do. Other’s are areas of controversy in the world of evidence based medicine. Specifically these are

  • chelation therapy other than for the treatment of heavy-metal poisoning
  • the injection of human chorionic gonadotrophin in the management of obesity
  • the use of hyperbaric oxygen therapy in the treatment of multiple sclerosis
  • the removal of tattoos
  • the transplantation of a thoracic or abdominal organ, other than a kidney, or of a part of an organ of that kind
  • the removal from a cadaver of kidneys for transplantation
  • the administration of microwave (UHF radio wave) cancer therapy, including the intravenous injection of drugs used in the therapy
  • cannulation and/or catheterisation of surgical sites associated with pain pumps for post-operative pain management
  • filling or re-filling of drug reservoirs of ambulatory pain pumps for post-operative pain management
  • injection of blood or a blood product that is autologous.
  • endoluminal gastroplication, for the treatment of gastro-oesophageal reflux disease
  • gamma knife surgery
  • intradiscal electro thermal arthroplasty
  • intravascular ultrasound (except where used in conjunction with intravascular brachytherapy)
  • intra-articular viscosupplementation, for the treatment of osteoarthritis of the knee
  • low intensity ultrasound treatment, for the acceleration of bone fracture healing, using a bone growth stimulator
  • lung volume reduction surgery, for advanced emphysema
  • photodynamic therapy, for skin and mucosal cancer
  • placement of artificial bowel sphincters, in the management of faecal incontinence
  • selective internal radiation therapy for any condition other than hepatic metastases that are secondary to colorectal cancer
  • specific mass measurement of bone alkaline phosphatase
  • transmyocardial laser revascularisation
  • vertebral axial decompression therapy, for chronic back pain
  • autologous chondrocyte implantation and matrix-induced autologous chondrocyte implantation
  • vertebroplasty

Although some screening programmes like breast cancer and cervical cancer screening are allowed a Medicare rebate, most health screening services are not covered. Medicare lists the following examples where there is no rebate available.

  • multiphasic health screening
  • testing of fitness to undergo physical training program, vocational activities or weight reduction programs
  • compulsory examinations and tests to obtain a flying, commercial driving or other licence
  • entrance to schools and other educational facilities
  • for the purposes of legal proceedings
  • compulsory examinations for admission to aged persons’ accommodation

Specifically, Medicare does recognise the following kinds of health screening

“A medical examination or test on a symptomless patient by that patient’s own medical practitioner in the course of normal medical practice, to ensure the patient receives any medical advice or treatment necessary to maintain their state of health. Benefits would be payable for the attendance and tests which are considered reasonably necessary
according to patients individual circumstances (such as age, physical condition, past personal and family history).”

Medicare then uses some examples which at the bread and butter of primary care in general practice.

  • cervical cancer screening under the National Cervical Screening Program
  • blood lipid estimation where a person has a family history of lipid disorder
  • pathology service requested by the National Heart Foundation of Australia, Risk Evaluation Service
  • age or health related medical examinations to obtain or renew a license to drive a private motor vehicle. Commercial license medical examination is not rebatable, although if you were unemployed my interpretation is it would be.
  • medical examination of, and/or blood collection from persons occupationally exposed to sexual transmission of disease
  • medical examination for a person as a prerequisite of that person becoming eligible to foster a child or children
  • medical examination being a requisite for Social Security benefits or allowances
  • medical or optometrical examination provided to a person who is an unemployed person as the request of a prospective employer

Finally,

Medicare rebates are not paid when a doctor treats his or her practice partner, spouse or children. Medicare also excludes the practice partner’s dependents too.

For a hard earned thirst….

Just finished a hard day at work?

Just put away the lawn mower?

Just been for a big run?

Just powered through a gym session?

Just getting ready to meet the rellies for Xmas bbq lunch?

Have a nice cold glass of water first, then you’ll not be holding onto an cold, empty beer bottle thinking

“Where did that go? I’d better have another!”

 

Remember for healthy Aussie men and women, drinking no more than two standard drinks on any one day reduces the lifetime risk of harm from alcohol-related disease or injury.

If you’d like to know about healthy drinking, have a look here

And for those with a nostalgia for times of old….. not that I have drunk a Vic for a long time!

Slop….

How do you start your morning? I think my idea of having the sunscreen next to the toothpaste reminds met to Slop up each day, because I always, well nearly always brush my teeth! Thankfully, I am yet to brush my teeth with Sunscreen…..

When I do a Skin Cancer Check, I will run through the Sunsmart message. You know slip slop slap. I see that  the Cancer Council has added a couple of extra hints in addition to the original Slip Slop and Slap. I have to confess that I have only realised today that Sid is a seagull. I think the yellow face threw me.

Slip on sun protective clothing that covers as much of your body as possible.

Slop on SPF 30 or higher broad-spectrum, water-resistant sunscreen, at least 20 minutes before sun exposure. Reapply every two hours when outdoors or more often if perspiring or swimming.

Slap on a broad-brimmed hat that shades your face, neck and ears.

Seek shade.

Slide on sunglasses.

I think we are doing a much better job of protecting our skin in these sunny latitudes. I remember my Dad at work laying bricks in the Perth summer sun with just a pair of shorts and boots. He added a hat a bit latter. Now more workers are choosing or are required to wear long pant and sleeves. Long sleeve fishing shirts are trendy. My kids remind me to cover up.

A few statistics from Australian Institute for Health and Welfare to encourage you protect yourself.

  • In 2016, an estimated 13,280 new cases of melanoma will be diagnosed in Australia, and 1,770 people will die from this disease.
  • The rate of melanoma is increasing; from 27 cases per 100,000 in 1982 to 49 per 100,000 in 2016.
  • Some good news is that for those under 40 the rate has dropped from a 13 cases per 100,000 in 2002 to an 9.4 per 100,000 in 2016.

But

  • Between 1982 and 2016, the mortality rate rose from 4.7 deaths per 100,000 to an 6.2 deaths per 100,000.

If you are too busy to see your GP for a skin check, have at a look at this guide melanoma, basal cell or squamous cell cancer. But really make the time to have a skin check.

PS Not endorsing Colgate, Oral B nor Galderma in their post – just the concept!

 

Helpful hint to make your GP consultation run smoother #2

What to wear to a Medical Consultation

I have never worn a white coat as a doctor, but in some countries this the is the expected “uniform”. Really, I mean white is not my colour, although back in 1985 there was a pair of white jeans. They didn’t last long as I seem to attract dirt. It would be even worse in a world of blood, pus, poo and urine!

The aptly titled TAILOR study (that is, targeting attire to improve likelihood
of rapport) was a review of published papers to find out if patient preferred their doctor to wear formal attire. The authors were American but they did review papers from a variety of countries. They concluded “the influence of physician attire on patient perceptions is complex and multifactorial.” And suggested that “patients harbour a number of beliefs regarding physician dress that are context and setting-specific.”

One of the Tailor study authors went onto a write a commentary for The Conversation. His final comment was “While scrubs are appropriate for operating or emergency rooms, we suggest changing into more formal attire to visit patients in the hospital or the clinic. Regardless of the occasion, flip-flops, showy jewelry or jeans simply don’t belong in the hospital, just as scrubs do not belong outside the hospital environment. Especially not in the grocery store.”

In another BMJ article a microbiologist berated junior doctors for not wearing ties.  And heaven forbid facial jewelry. This was frowned upon by the authors of this study. The majority of American patient surveyed gave such jewelry a big thumbs down; “negatively affects perceived competency and trustworthiness.” 

I will stick with comfortable shoes, pushed down socks, shorts and a casual shirt with absolutely no tie. And I may just see if the stud still goes through the hole in my ear.
Mark

Now moving onto patients!

Are there any rules?

Should there be any rules?

What are the expectations?

Doing a PubMed search revealed very little on the subject. Amongst lots of articles (1120 to be exact) they all focused on patient’s perceptions of what health care professional should wear and not visa versa . Maybe there is a PhD in that?

So, here is my thoughts on what will make the consultation run smoother based on experience and chatting with colleagues.

First may I state the obvious,  make sure you are wearing clothing.  Turning up to the consultation naked will have you transported to the nearest psychiatric unit for an assessment of your mental health.

Secondly, don’t feel obliged to wear a suit and tie or even smart casual. Dress comfortably as we may be chatting for a while. I don’t work in a 3 minute appointment clinic and I like to get to know my patients. But you remember all those studies mentioned above, well I am human and despite my intensive training, I will sometimes lapse into making a judgement about you if you turn up in smelly torn jeans, odd socks, and NSFW emblazoned t-shirts.

Now I am not suggesting that I make my patients wear gowns for an examination as is the case in other countries,

My suggestion would be wear what would you to visit your Gran?

Here are some other logical practical suggestions.

1. Consider having a shower on the day of the consultation.

2. Consider wearing underwear and if you do make sure they are also clean.

3. Consider leaving your muddy boots at the front door of the clinic, but have fresh socks available.

4. Consider loose clothing. This is especially important if you have knee or hip pain or have come in for pap (oops… cervical screening test).

5. If I have to listen to your chest, the stethoscope works best on the bare skin. If you have several layers of clothing, some will need to be removed.

6. If you have booked a skin check be prepared to remove shoes, socks and at least some other clothing. Not wanting to make anyone paranoid, but melanomas can develop on places which may not get a lot of sunshine.

7. And, although strictly not clothing, please bring in your glasses and hearing aids.

Have I missed anything??

Helpful hint to make your GP consultation run smoother #1

Do you think you may have a Urinary Tract Infection?

Symptoms of a urinary tract infection can include needing to pee a lot more than normal (frequency), stinging or burning when you do (dysuria), seeing spots of blood in your urine (haematuria), have belly or lower back pain and having a fever.

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If you arrive early or are waiting for your doctor, please ask to see the clinic nurse to get a clean-catch urine specimen.

It may sound like I am may be telling you to “suck eggs” but if a urine specimen is contaminated by skin cells it the laboratory may report the presence of bacteria there were never in your urine. This may lead to unnecessary use of antibiotics and all its attended problems and cost.

For women
Open the sterile jar and hold it in one hand. Sit on the toilet with your legs wide apart. Use the fingers of your other hand to hold your labia apart. The urine should not touch either your labia or your fingers. Start passing urine directly into the toilet. After a few seconds, catch your urine in the container. Once the container is half filled, screw the cap on tightly.

For men
Open the sterile jar and hold it in one hand. Retract your foreskin if you have one. Start by passing urine directly into the toilet. After a few seconds, catch your urine in the container. Once the container is half filled, screw the cap on tightly.

Kids who are toilet trained can also do this.

For kids who are not yet toilet trained you need patience or some special techniques to get a uncontaminated urine specimen. The Quick-Wee is a interesting and less invasive alternative. As is the bladder tap and back massage techniques. Failing that, suprapubic aspiration or a urinary catheter

 

Trying to understand Medicare #1

Referrals to Specialists

In Australia you don’t need a Referral to see a Specialist. So, say you wanted to see a Plastic Surgeon about a skin lesion, you can just find a Plastic Surgeon on the internet or ask a friend and make an appointment and off you go. But be prepared for a bill – sometimes a really big bill. This is because, you won’t be able to access a Medicare rebate for the Plastic Surgeon’s fees. To do so you need to first have a valid referral from your GP. But it is not as simple as just calling your GP and asking for a referral.

What is a Referral letter?

It is a legal requirement to have a valid referral to access Medicare for the care provided by the Specialist. In Medicare speak, the referrer must first “consider the need for the referral.”

A referral is a written, signed and dated request to a Specialist to assist with care of your medical problem. Often the Referral is to a specific Specialist, but this is not necessary. From DHS

“Referring practitioners don’t need to address a referral to a specific specialist or consultant physician. Patients should also be given the choice of where to present the referral, including where the referral is submitted electronically.”

This however can be an issue for referrals to public hospitals (that is a story for another time).

In the Referral letter, I usually would explain the problem, what I would like the specialist to do and provide a list of your medications, allergies, previous medical problems along with a copy of relevant investigations that may have been done. I find that this is best done face to face in a consultation to avoid miscommunication.

A specialist may run a triage system; a way of sifting through referrals to pick those that need more urgent care.

There is an expectation that a letter of reply will be forthcoming following your consultation with the Specialist.

How long does a Referral last?

A standard Referral is for 12 months of care. This starts when you first see the Specialist, not form the date the Referral was made. This makes sense as you are unlikely to see a Specialist on the same day as seeing the GP.

Referrals can be made for an indefinite period. but this is generally used for conditions that are unlikely to go away. For example, you could be referred to an Endocrinologist for help with managing diabetes indefinitely.

What is a Referral for?

A referral is for a single course of treatment of the specified problem. If a new problem arises then a new referral is needed. Therefore, if you see an Orthopedic Surgeon to manage your broken arm you will need a new referral to deal with your hip replacement.

The Specialist can bill more for a for a first visit, then less for subsequent. Unless a new problem arises, which requires a new referral, you shouldn’t be billed for a new visit after that.

Who does Referrals?

GP can refer to all Specialists.

Opticians can refer to Ophthalmologists. Midwives and Nurse Practitioners are also able to make Referrals under Medicare rules. Dentists can refer to Dental or Orofacial Maxillary Surgeons.

A Specialists can refer to another Specialist but these referrals only last 3 months. An example here could be a Paediatrician may refer to a Paediatric Neurologist to help with management of problematic epilepsy. For ongoing care by the second Specialist a GP’s referral may be needed.

Backdating Referrals

As a Referral is a legal document, Medicare does not permit backdating a Referral.

A Specialist can see a patient without a valid referral only in an emergency. Apparently, if your dog ate your referral, or another good excuse, there is a exemption available for you to claim your rebate if the Specialist notes that the “Referral is lost”. I am sure that Medicare would get suspicious if this happened a lot. Medicare do audit what GP’s and Specialists get up to make sure the rules are being followed. There are fines for not following the rules!

If you need a Referral make sure you see your GP before seeing the Specialist if you wish to get a Medicare rebate for the service. Asking your GP for a backdated Referral is like asking the Specialist to forward date your consultation so you can get a Referral. Both are not permitted under Medicare.

One final thought

Surprisingly, your may find that your GP may actually be able to fix the problem you want a Referral for and save the inconvenience of seeing a Specialist.

Medicare rule can be found here

Here is a summary from the AMA

For more details you may wish to read the Health Insurance Act 1973 and Health Insurance Registration 1975 but it isn’t easy reading with its subsections and subregulations, respects and accordances. Lots of Legal speak.

https://www.legislation.gov.au/Details/F2013C00002

http://www.austlii.edu.au/cgi-bin/viewdb/au/legis/cth/consol_act/hia1973164/