Tom Aitchison

CANCER, WARTS, AND SUNSHINE IN RENAL TRANSPLANT PATIENTS: A Case-control Study

94 renal transplant patients were examined for the presence of cutaneous malignancies, actinic keratoses, warts, and cutaneous fungal infection, and a history was taken of infection with herpes simplex and herpes zoster. Each patient had a control matched for age, sex, and sun exposure. Of the 17 patients with high exposure to sunshine (more than 3 months in a tropical or subtropical climate or more than 5 years in an outdoor occupation), 2 had squamous cell carcinoma and 7 actinic keratoses. These lesions did not occur in the other renal transplant patients or the control group. The immunosuppressive effect of ultraviolet radiation in the sunburn spectrum (290-320 nm) in man and animals may be related to the increased incidence of cutaneous malignancy, actinic keratoses, and warts. Transplant patients should be under regular surveillance for the early detection and treatment of premalignant cutaneous lesions, and they should receive advice on avoiding sun exposure.

PERSONAL RISK-FACTOR CHART FOR CUTANEOUS MELANOMA

Information from a case-control study of all patients with cutaneous malignant melanoma first diagnosed in Scotland in 1987 has been used to derive a personal risk-factor chart that can be used by both the medical profession and the general public. The relative risk of cutaneous melanoma is estimated from the four strongest risk factors identified by conditional logistic regression. These factors are total number of benign pigmented naevi above 2 mm diameter; freckling tendency; number of clinically atypical naevi (over 5 mm diameter and having an irregular edge, irregular pigmentation, or inflammation); and a history of severe sunburn at any time in life. Use of this risk-factor chart should enable preventive advice for and surveillance of those at greatest risk.

IS HOMOEOPATHY A PLACEBO RESPONSE? CONTROLLED TRIAL OF HOMOEOPATHIC POTENCY, WITH POLLEN IN HAYFEVER AS MODEL

The hypothesis that homoeopathic potencies are placebos was tested in a randomised, double-blind, placebo-controlled trial. The study model chosen compared the effects of a homoeopathic preparation of mixed grass pollens with placebo in 144 patients with active hayfever. The homoeopathically treated patients showed a significant reduction in patient and doctor assessed symptom scores. The significance of this response was increased when results were corrected for pollen count and the response was associated with a halving of the need for antihistamines. An initial aggravation of symptoms was noted more often in patients receiving the potency and was followed by an improvement in that group. No evidence emerged to support the idea that placebo action fully explains the clinical responses to homoeopathic drugs.

Randomised controlled trial of advice on an egg exclusion diet in young children with atopic eczema and sensitivity to eggs

Background: The role of exclusion diets in the management of atopic eczema in young children is uncertain. This randomised controlled trial evaluates the effect of excluding egg from the diet in young children with atopic eczema and sensitivity to eggs. Fifty‐five such children were randomised either to a 4‐week regimen, in which mothers were given general advice on care of eczema and additional specific advice from a dietician about an egg exclusion diet (diet group), or to a control group in which general advice only was given. Both groups continued conventional topical treatment. Disease activity was assessed by estimates of the surface area affected by eczema and by an arbitrary severity score. Possible egg sensitivity was identified by RAST before randomisation and after the trial by double‐blind placebo‐controlled egg challenge. Results: The mean reduction in surface area affected by eczema was significantly greater (p = 0.02) in the group receiving dietary advice (from 19.6% to 10.9% area affected) than in the control group (from 21.9% to 18.9%). A significant improvement also occurred in severity score (p=0.04): from 33.9 to 24.0 units for the diet group compared with a decrease from 36.7 to 33.5 in the control group. The study suggests that advice on the dietary exclusion of eggs is useful as part of the overall management of young children with atopic eczema and sensitivity to eggs.

Randomised controlled trial of homoeopathy versus placebo in perennial allergic rhinitis with overview of four trial series.

Abstract Objective: To test the hypothesis that homoeopathy is a placebo by examining its effect in patients with allergic rhinitis and so contest the evidence from three previous trials in this series. Design: Randomised, double blind, placebo controlled, parallel group, multicentre study. Setting: Four general practices and a hospital ear, nose, and throat outpatient department. Participants: 51 patients with perennial allergic rhinitis. Intervention: Random assignment to an oral 30c homoeopathic preparation of principal inhalant allergen or to placebo. Main outcome measures: Changes from baseline in nasal inspiratory peak flow and symptom visual analogue scale score over third and fourth weeks after randomisation. Results: Fifty patients completed the study. The homoeopathy group had a significant objective improvement in nasal airflow compared with the placebo group (mean difference 19.8 l/min, 95% confidence interval 10.4 to 29.1, P=0.0001). Both groups reported improvement in symptoms, with patients taking homoeopathy reporting more improvement in all but one of the centres, which had more patients with aggravations. On average no significant difference between the groups was seen on visual analogue scale scores. Initial aggravations of rhinitis symptoms were more common with homoeopathy than placebo (7 (30%) v 2 (7%), P=0.04). Addition of these results to those of three previous trials (n=253) showed a mean symptom reduction on visual analogue scores of 28% (10.9 mm) for homoeopathy compared with 3% (1.1 mm) for placebo (95% confidence interval 4.2 to 15.4, P=0.0007). Conclusion: The objective results reinforce earlier evidence that homoeopathic dilutions differ from placebo.

Assessment of a contact-plate sampling technique and subsequent quantitative bacterial studies in atopic dermatitis

The aerobic bacterial flora of 20 patients with atopic dermatitis and 19 control subjects was extensively sampled using the Williamson and Kligman scrub technique and a contact‐plate method (cysteine lactose electrolyte deficient media). Comparison of the two quantitative techniques showed that the contact plate is a reliable and convenient alternative to the scrub technique for the quantification of Staphylococcus aureus, micrococci and coagulase negative staphylococci. Quantification of bacterial flora using both techniques showed high rates of colonization by S. aureus on both involved and clinically normal skin of patients with atopic dermatitis. A linear increase in S. aureus counts with increasing severity of dermatitis was found. In contrast, diphtheroids showed a trend of decreasing isolation rates and counts as the severity of the dermatitis increased. Isolation rates and absolute counts for micrococci/coagulase negative cocci were unaffected by the severity of the dermatitis.

Walk in to work out: a randomised controlled trial of a self help intervention to promote active commuting

Study objective: To determine if a self help intervention, delivered via written interactive materials (the “Walk in to Work Out” pack), could increase active commuting behaviour (walking and cycling). Design: Randomised controlled trial. The intervention group received the “Walk in to Work Out” pack, which contained written interactive materials based on the transtheoretical model of behaviour change, local information about distances and routes, and safety information. The control group received the pack six months later. Focus groups were also conducted after six months. Setting: Three workplaces in the city of Glasgow, Scotland, UK. Participants: 295 employees who had been identified as thinking about, or doing some irregular, walking or cycling to work. Main results: The intervention group was almost twice as likely to increase walking to work as the control group at six months (odds ratio of 1.93, 95% confidence intervals 1.06 to 3.52). The intervention was not successful at increasing cycling. There were no distance travelled to work, gender, or age influences on the results. Twenty five per cent (95% confidence intervals 17% to 32%) of the intervention group, who received the pack at baseline, were regularly actively commuting at the 12 month follow up. Conclusion: The “Walk in to Work Out” pack was successful in increasing walking but not cycling. The environment for cycling must be improved before cycling will become a popular option.

Cutaneous malignant melanoma, Scotland, 1979-89

Abstract The Scottish Melanoma Group (SMG) was established in 1979 to assess mortality from and incidence, features, pathological data, and management of cutaneous malignant melanoma in Scotland. Incidence during the first five years and five-year survival have already been reported. We now have data about incidence and mortality over eleven years in relation to anatomical site and pathological types. From 1979 to 1989, 1354 male and 2459 female patients with primary cutaneous malignant melanomas were first diagnosed in Scottish residents. The incidence rate per 100 000 population per year has increased from 3·4 in 1979 to 7·1 in 1989 for men, and from 6·6 to 10·4 for women. The overall increase over eleven years is 82% (7·4% per year). The greatest rates of increase are seen in lesions of the superficial spreading histogenetic type, arising on the female leg and the male trunk. Following public education programmes started in 1985, the proportion of all melanomas less than 1·5 mm thick has shown a sustained and significant increase. Mortality data for 1661 patients for whom a minimum of five-year follow-up is available shows five-year survival of 71o6% overall (77·6% for women, 58·7% for men). The survival advantage for women persists when appropriate statistical adjustment is made for thickness, ulceration, and histogenetic type. These data are useful in designing public education programmes aimed at both primary and secondary prevention of melanoma and in auditing changes in trends that might result from such education.

A comparison of narrow band phototherapy (TL-01) and photochemotherapy (PUVA) in the management of polymorphic light eruption.

Twenty‐five patients suffering from severe polymorphic light eruption (PLE) were randomized to either photochemotherapy (PUVA) or narrow‐band phototherapy (TL‐Ol UVB) treatment in early spring; patients receiving UVB were given placebo tablets to achieve a matching therapy procedure. During the 4 months following treatment, patient exposure to solar UVB was monitored with polysulphone badges. PLE occurrence, severity, and restriction of outdoor activity were recorded, using weekly diary‐sheets. Analysis of covariance on this data, using the logarithm of UVB exposure as the explanatory variable, showed no significant differences between the treatments. TL–01 UVB is an effective alternative to PUVA in the management of PLE.

Measurement of fundal height as a screening test for fetal growth retardation

Summary. Fundal heights were measured on 761 women in the course of their routine antenatal care. This information was assessed, alone and in combination with other variables such as previous obstetric history and smoking, for its utility in predicting growth retardation. The results were disappointing. By most criteria used for classification, approximately half of the growth retarded babies were classified as such while half were missed. False positive rates were unacceptably high. It is concluded that fundal height measurement is of little use as a screening test for growth retardation.