Teleleprosy

Ref.: Teleleprosy
From: Grace W., Sidney, Australia
Dear Salvatore I refer to:-
"Accuracy of store-and-forward diagnosis in leprosy"
Bianconcini Trinidade et al
Journal of telemedicine and telecare 2008; 14: 208-210
Grace



Dear Salvatore,

Thanks for your note and for inviting me to publish my comments on the above mentioned paper. So, you do not think I am just nuts and getting too old to be able to understand new concepts; I certainly find it hard to keep up sometimes!

I guess it may be good to spread my comments about it or some of them and I am sure there are many who are confused especially over the sensory impairment and the writers really do not give any indication of what they use to decide the diagnosis. I am interested to see what response we get? For or against [teleleprosy]?; I guess I am basically against in the format in which it is at present presented but “for” when realising that it could be a big help to isolated persons if there was a good protocol as to what should be examined and recorded and photographed to send for a second opinion.

I was intrigued to see the “Teleleprosy” paper come up in LML June 20th, 2008 by Bianconcini Trindade et al, from Sao Paulo, Brazil, as diagnosis and even surgery by television is getting so popular in medical fields. However, I must confess that it has left me “cold”; I just cannot follow the logic and unless a lot of explanation is given I cannot see that will be gained and fear that many patients will be missed because the primary examiners do not really look for leprosy.

A major request that I have for Dr Bianconcini Trindade and collaborators is to get from them more explanation of what they require for diagnosis and how they make a diagnosis? However, when I tried to study the article I got completely left behind. May be I am just too old and do not understand new terminology; but then I got a phone call from someone asking me what it meant and how to make sense from the statistics reported in table 1.

Yes, I can see the usefulness of being able to confirm leprosy by teleleprosy but not many details are supplied as to what is recorded to make a diagnosis. If telemedicine is to be utilised the various clinics need details of exactly what is to be recorded and forwarded and the clinicians must keep leprosy well to the front of their differential diagnosis list.

I think that in this teleleprosy medicine the diagnosis appears not to depend on monofilament type sensory testing as is too often recommended. Too many workers depend on monofilaments and state that if the patient can feel the filament they have no nerve damage and do not have leprosy.

The WHO Guide to “Eliminate leprosy.......” states that “A leprosy patient is someone who has a patch or skin patches with a definite loss of sensation: .......”. If this is so then all patients with leprosy have one or more anaesthetic patch. This is not true. Many patients with severe LL type leprosy do not have obvious skin patches. They just have vague infiltrated lesions without any real edges and certainly no detectable sensory changes for many years. In some of my Chinese patients the skin became grossly thickened after about 10-20 years and only then was there any evidence of altered sensory perception. According to the WHO description in this book these patients do not have leprosy! We are not told what are the signs that Telemedicine accept to make a diagnosis.

I have had a fight for years with the ”specialists” who love using monofilaments and saying that if they [the patients] can feel the monofilaments they are not at risk for traumatising themselves. Monofilaments test pressure, when it is the inability to feel pain or heat which is far more dangerous. WHO keep accenting the loss of sensation being needed in patches to diagnose leprosy. I have seen so many patients with typical ulnar claw hand and easily palpable nerves who have been rejected by WHO Leprosy consultants who say no skin lesions Not leprosy! Some have turned up a couple of year later covered with patches and multiple deformities!

But it was when I started to try and look at the statistics reported in the paper that I really got lost. Table 1. is stated to show the agreement between "in person" diagnosis and "telemedicine" diagnosis. But the first line of the table states telemedicine and beneath that phrase is written Leprosy, Not-leprosy Total. But no numbers are given? Under “In-person diagnosis” there are two lists of numbers stated to be Leprosy and non-leprosy? But are the numbers listed then relevant to the telemedicine three lines? As it appears to me there are no figures given for the telemedicine. What does it mean to list on the left ”Leprosy” and then under “In-person diagnosis” there is leprosy 43 and Non-leprosy 16 total is 59?

Please explain to a novice what this really means. Does it mean that telemedicine diagnosed the total of 59 of which 43 cases were actually leprosy and 16 were non-leprosy? The total of 59.

Sorry I have no answers or explanation to give to younger colleagues. It maybe they have the explanations! I would be interested to hear them. Sorry Salvatore, I just cannot get enthusiastic. I do not know if other ordinary clinicians have given you any reactions; but if someone can give an explanation I would be pleased to read it.

Thanks for the LML,

Grace