2
7/21/2019 Diet http://slidepdf.com/reader/full/diet5695cf311a28ab9b028d00a3 1/2 bereavement. The voice may simply call the person s name. Normal people usually have no difficulty recognising the unreality of this experience. JOHN CUTTING Consultant Psychiatrist, Bethlem Royal Hospital, Beckenham, Kent BR3 3BX I Malitz S, Kanzler M Effects of drugs on perception in man. Res Publ Assoc Res Nerv Ment Dis 1976;48:35-53. 2 Margo A, Hemslev DR Slade PO. The effects of sarying auditory input on schizophrenic hallucinations. Br] Psvchiarv 1981;139:122-7. 3 Slade PO. The effects of svstematic desensitisation on auditory hallucinations. Behav Res Ther 1972;10:85-91. 4 Sedman G. A comparative study of pseudohallucinations, imagery and true hallucinations. Brj Psychiatrv 1966;122:9-17. 5 Alpert M Silvers KN Perceptual characteristics distinguishing auditory hallucinations in schizophrenia and acute alcoholic psychoses. AmJ Psvchiatry 1970;127:298-302. 6 Taylor P, Fleminger JJ. The lateralization of symptoms in schizophrenia. Br J M ed Psychol 1981;54:59-65. 7 Critchley EMR Denmark JC, Warren F, Wilson KA Hallucinatory experiences of prelingually profoundly deaf schizophrenics. BrJ Psychiatry 1981 ;l38:30-2. 8 Starker S, Jolin A. Imagery and hallucinations in schizophrenic patients. J Nerv Ment Dis 1982;170:448-51. 9 Schneider K. Clinicalpsychopathology. Ne w York: Grune and Stratton, 1959. 10 Birchwood M. Control of auditory hallucinations through occlusion of monoaural auditory input. Br J Psychiatry 1986;149:104-7. 11 Falloon IRH, Talbot RE. Persistent auditory hallucinations: coping mechanisms and implications for management. Psychol Med 1981;11:329-39. 12 Gross MM Halpert E, S ab ot L, Polizos P. Hearing disturbances and auditory hallucinations in the acute alcoholic psychoses: tinnitus, incidence and significance. J Nerv Ment Dis 1 3;137: 455-65. 13 Saravay SM, Pardes H. Auditory elementary hallucinations in alcoholic withdrawal psychosis. Arch Gen Psychiatry 1 7;16:652-8. 14 Penfield MC Perot P. The brain s record of auditory and visual experience. Brain 1963;86:595-696. Diet and dermatology Food explains some, but by no means all skin conditions  Could it be something I v e eaten doctor? is guaranteed to provoke a sigh from most doctors. Even so, although many dietary hypotheseshave now been discarded, diet does cause some skin diseases and may modify others. Too much or too little food may affect the skin. Some obese patients with insulin resistance and hyperinsulinaemia develop acanthosis nigricans and skin tags,23 which may be due to the binding of insulin to peptide growth factors.4 The same cellular defect may predispose to both obesity and acanthosis nigricans, but diet is probably at least partly responsible because the insulin resistance responds to fasting.5 To o much of a single food constituent may cause problems. Hypervitaminosis A causes diffuse alopecia and hypercarotenaemia discolours the palms and soles orange. This occurs usually in slimmers having low calorie diets who eat too many carrots and oranges.6 Chronic starvation deficiency of protein and calories causes a scaly rash, and the hair tends -to become. dry and sparse.7 Kwashiorkor produces a scaling of the skin, which often takes on the glazed appearance of adherent enamel flakes, and a characteristic reddish discoloration of black hair. The hair may also show the  flag sign, with alternating dark and light bands in individual hairs, which is due to intermittent protein deficiency. Measurement of hair growth has been suggested as useful for assessing nutritional state, particularly for proteins.8 Patients with anorexia nervosa develop dry skin, lanugolike body hair, thinning of the scalp hair, and brittle nails.9 The cutaneous manifestations of specific deficiencies of various vitamins and minerals provide classic examples of dietary dermatoses.  0 3 Food and drink may be either inherently toxic or toxic as a result of contaminants such as fungi or added chemicals. Alcohol is a cutaneous vasodilator, and the Chinese and Japanese are particularly susceptible to alcohol induced flushing. 4 Chillies and red peppers also produce flushitg and sweating by a pharmacological action. 5 Ergotism, characterised by severe Raynaud's phenomenon leading to digital. gangrene, is due to eating bread made from rye infected with a fungus. An example of a dermatosis caused by chemical contamination occurred in Turkey, when the ingestion of wheat treated with a fungicide, hexachloro- benzene, resulted in many cases of porphyria cutanea tarda.  6 Urticaria is commonly due to ingested food allergens, but the gluten enteropathy of dermatitis herpetiformis is a more subtle example. If gluten is avoided and the bowel recovers completely the skin disease may go into complete remission. Idiosyncratic susceptibility to dietary factors may be commoner than appreciated. Some cases may be due to interactions with systemic medication-for example, the severe alcohol induced flushing in some patients wh o take chlorpropamide 8l20 and the reaction to cheese or pickles in patients taking inhibitors of monoamine oxidase. Other reactions may be due to anatomical abnormalities such as the flushing that accompanies the postgastrectomy dumping syndrome. Some idiosyncratic reactions-for example, the urticaria and bronchospasm caused by bisulphites used to keep fruit and vegetables fresh-may be mediated by neural activity as the results of tests for allergy are negative.and the adverse reaction is blocked by atropine.2 The Chinese restaurant syndrome, in which similar symptoms occur after eating sodium glutamate, seems to be mediated by the transient release of compounds similar to acetylcholine.22  3 Clinical observations have led to many attempts to improve skin disease by changing the diet, though few have stood the test of time. Some improvements may be due to idiosyncratic reactions. Many patients think, for example, that chocolate makes their acne worse despite several studies showing that it does not affect its course.24  5 The value of exclusion diets for treating atopic eczema is also controversial26 27; though these are widely used, it seems that women's magazineshave more success with them than doctors. The use of fatty acid supplements to treat atopic eczema is another idea that was fashionable in the 1930s, died out in the 1950s, and has recently been exhumed in the light of increasing knowledge of fatty acid and eicosanoid meta- bolism.28 Patients with atopic eczema havelow concentrations of essential fatty acid metabolites in their plasma,29 and some plant and fish oils are particularly rich in these compounds and their precursors. Evening primrose oil and borage, for example, are rich in y-linolenic acid, which is depleted in atopic eczema. Several trials have shown that oral evening primrose oil in large doseshas beneficial effects in eczema,28-33 and meta-analysis of several controlled trials has shown that the clinical improvement correlates with the increase in plasma fatty acid metabolites after such treatment.34 Similar studies have shown modest benefit from dietary supplements with fish oil in psoriasis and eczema.28 The exact mechanism of these clinical changes is uncertain, but a better under- standing of the intermediary metabolism of essential fatty acid metabolites and trace metals such as zinc might pave the way 770 BMJ VOLUME 298 25 M RCH 1989

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Page 1: Diet

7/21/2019 Diet

http://slidepdf.com/reader/full/diet5695cf311a28ab9b028d00a3 1/2

b e r e a v e m e n t . T h e

v o i c e

may s i m p l y

c a l l t h e

p e r s o n s

n a m e .

N o r m a l

p e o p l e

u s u a l l y

h a v e

n o

d i f f i c u l t y

r e c o g n i s i n g t h e

u n r e a l i t y

o f

t h i s

e x p e r i e n c e .

JOHN

CUTTING

C o n s u l t a n t

P s y c h i a t r i s t , B e t h l e m

R o y a l

H o s p i t a l ,

B e c k e n h a m , K e n t

BR3

3BX

I

M a l i t z S , K a n z l e r

M E f f e c t s o f d r u g s

o n

p e r c e p t i o n

i n

m a n .

R e s

P u b l A s s o c R e s N e r v

M e n t

D i s

1 9 7 6 ; 4 8 : 3 5 - 5 3 .

2

M a r g o A ,

H e m s l e v

DR S l a d e P O .

T h e e f f e c t s

o f

s a r y i n g

a u d i t o r y

i n p u t

o n

s c h i z o p h r e n i c

h a l l u c i n a t i o n s . B r ]

P s v c h i a r v

1 9 8 1 ; 1 3 9 : 1 2 2 - 7 .

3

S l a d e

P O .

T h e e f f e c t s o f

s v s t e m a t i c

d e s e n s i t i s a t i o n

o n

a u d i t o r y

h a l l u c i n a t i o n s .

B e h a v R e s

T h e r

1 9 7 2 ; 1 0 : 8 5 - 9 1 .

4

S e d m a n

G .

A c o m p a r a t i v e

s t u d y o f

p s e u d o h a l l u c i n a t i o n s ,

i m a g e r y

a n d t r u e h a l l u c i n a t i o n s .

B r j

P s y c h i a t r v

1 9 6 6 ; 1 2 2 : 9 - 1 7 .

5 A l p e r t

M S i l v e r s KN

P e r c e p t u a l c h a r a c t e r i s t i c s

d i s t i n g u i s h i n g

a u d i t o r y h a l l u c i n a t i o n s

i n

s c h i z o p h r e n i a a n d

a c u t e

a l c o h o l i c

p s y c h o s e s .

Am J

P s v c h i a t r y 1 9 7 0 ; 1 2 7 : 2 9 8 - 3 0 2 .

6 T a y l o r P , F l e m i n g e r

J J .

T h e l a t e r a l i z a t i o n

o f s y m p t o m s

i n

s c h i z o p h r e n i a .

B r

J

Med P s y c h o l

1 9 8 1 ; 5 4 : 5 9 - 6 5 .

7

C r i t c h l e y EMR D e n m a r k J C ,

W a r r e n

F , W i l s o n KA

H a l l u c i n a t o r y e x p e r i e n c e s o f

p r e l i n g u a l l y

p r o f o u n d l y d e a f

s c h i z o p h r e n i c s .

B r J

P s y c h i a t r y 1 9 8 1

; l 3 8 : 3 0 - 2 .

8

S t a r k e r

S ,

J o l i n

A .

I m a g e r y

a n d

h a l l u c i n a t i o n s

i n

s c h i z o p h r e n i c

p a t i e n t s .

J

N e r v

M e n t

D i s

1 9 8 2 ; 1 7 0 : 4 4 8 - 5 1 .

9

S c h n e i d e r

K .

C l i n i c a l p s y c h o p a t h o l o g y . Ne w Y o r k :

G r u n e a n d

S t r a t t o n , 1 9 5 9 .

1 0

B i r c h w o o d

M . C o n t r o l o f

a u d i t o r y

h a l l u c i n a t i o n s

t h r o u g h

o c c l u s i o n o f m o n o a u r a l

a u d i t o r y i n p u t .

Br J

P s y c h i a t r y 1 9 8 6 ; 1 4 9 : 1 0 4 - 7 .

1 1

F a l l o o n

I R H , T a l b o t R E .

P e r s i s t e n t a u d i t o r y h a l l u c i n a t i o n s : c o p i n g m e c h a n i s m s

a n d

i m p l i c a t i o n s

f o r

m a n a g e m e n t .

P s y c h o l Med 1 9 8 1 ; 1 1 : 3 2 9 - 3 9 .

1 2 G r o s s M M

H a l p e r t E , S ab ot L , P o l i z o s P . H e a r i n g

d i s t u r b a n c e s

a n d

a u d i t o r y h a l l u c i n a t i o n s i n t h e

a c u t e a l c o h o l i c p s y c h o s e s :

t i n n i t u s ,

i n c i d e n c e a n d

s i g n i f i c a n c e .

J

N e r v

M e n t D i s

1 3 ; 1 3 7 :

4 5 5 - 6 5 .

1 3

S a r a v a y

S M ,

P a r d e s

H . A u d i t or y e l e m en t a r y

h a l l u c i n a t i o n s

i n

a l c o h o l i c w i t h d r a w a l p s y c h o s i s .

A r c h G e n P s y c h i a t r y 1 7 ; 1 6 : 6 5 2 - 8 .

1 4

P e n f i e l d M C

P e r o t

P .

T h e

b r a i n s

r e c o r d

o f

a u d i t o r y a n d v i s u a l

e x p e r i e n c e .

B r a i n

1 9 6 3 ; 8 6 : 5 9 5 - 6 9 6 .

D i e t

a n d

d e r m a t o l o g y

F o o d

e x p l a i n s

s o m e ,

b u t

b y

n o

m e a n s a l l

s k i n

c o n d i t i o n s

  C o u l d

i t b e

s o m e t h i n g I v e e a t e n

d o c t o r ? i s

g u a r a n t e e d

t o

p r o v o k e

a s i g h

f r o m

m o s t

d o c t o r s .

E v e n

s o , a l t h o u g h

m a n y

d i e t a r y

h y p o t h e s e s h a v e

now b e e n d i s c a r d e d ,

d i e t d o e s c a u s e

s o m e s k i n

d i s e a s e s a n d

may m o d i f y o t h e r s .

T o o much o r

t o o

l i t t l e

f o o d

may

a f f e c t

t h e

s k i n .

S o m e

o b e s e

p a t i e n t s

w i t h i n s u l i n

r e s i s t a n c e a n d

h y p e r i n s u l i n a e m i a

d e v e l o p

a c a n t h o s i s

n i g r i c a n s a n d

s k i n

t a g s , 2 3

w h i c h

may

b e

d u e

t o t h e

b i n d i n g

o f

i n s u l i n t o

p e p t i d e

g r o w t h f a c t o r s . 4

T h e

s a m e

c e l l u l a r

d e f e c t

may p r e d i s p o s e

t o b o t h

o b e s i t y

a n d

a c a n t h o s i s

n i g r i c a n s ,

b u t

d i e t

i s

p r o b a b l y

a t

l e a s t

p a r t l y

r e s p o n s i b l e

b e c a u s e t h e i n s u l i n

r e s i s t a n c e

r e s p o n d s

t o

f a s t i n g . 5 To o

much

o f

a s i n g l e f o o d

c o n s t i t u e n t

may

c a u s e

p r o b l e m s .

H y p e r v i t a m i n o s i s

A

c a u s e s

d i f f u s e

a l o p e c i a a n d

h y p e r c a r o t e n a e m i a d i s c o l o u r s

t h e p a l m s a n d

s o l e s o r a n g e .

T h i s

o c c u r s

u s u a l l y

i n

s l i m m e r s

h a v i n g l o w

c a l o r i e d i e t s

who

e a t t o o

many

c a r r o t s

a n d

o r a n g e s . 6

C h r o n i c

s t a r v a t i o n

d e f i c i e n c y

o f

p r o t e i n

a n d

c a l o r i e s

c a u s e s

a

s c a l y

r a s h ,

a n d

t h e h a i r

t e n d s

- t o

b e c o m e .

d r y

a n d

s p a r s e . 7

K w a s h i o r k o r

p r o d u c e s

a

s c a l i n g o f

t h e s k i n ,

w h i c h

o f t e n

t a k e s

o n

t h e

g l a z e d a p p e a r a n c e o f a d h e r e n t

e n a m e l

f l a k e s , a n d a

c h a r a c t e r i s t i c

r e d d i s h d i s c o l o r a t i o n o f

b l a c k

h a i r . T h e h a i r

m a y

a l s o

s h o w t h e

  f l a g

s i g n ,

w i t h

a l t e r n a t i n g

d a r k a n d

l i g h t

b a n d s

i n

i n d i v i d u a l

h a i r s ,

w h i c h

i s

d u e

t o i n t e r m i t t e n t

p r o t e i n

d e f i c i e n c y . M e a s u r e m e n t

o f h a i r

g r o w t h

h a s

b e e n

s u g g e s t e d

a s

u s e f u l f o r

a s s e s s i n g

n u t r i t i o n a l

s t a t e ,

p a r t i c u l a r l y

f o r

p r o t e i n s . 8

P a t i e n t s w i t h

a n o r e x i a

n e r v o s a

d e v e l o p

d r y s k i n ,

l a n u g o l i k e b o d y

h a i r ,

t h i n n i n g

o f

t h e s c a l p

h a i r ,

a n d

b r i t t l e

n a i l s . 9

T h e c u t a n e o u s

m a n i f e s t a t i o n s

o f

s p e c i f i c

d e f i c i e n c i e s

o f

v a r i o u s

v i t a m i n s

a n d

m i n e r a l s

p r o v i d e

c l a s s i c

e x a m p l e s

o f

d i e t a r y

d e r m a t o s e s .

  0 3

F o o d

a n d

d r i n k

m a y

b e

e i t h e r

i n h e r e n t l y

t o x i c

o r

t o x i c

a s

a

r e s u l t

o f

c o n t a m i n a n t s

s u c h

a s f u n g i o r a d d e d

c h e m i c a l s .

A l c o h o l

i s

a c u t a n e o u s

v a s o d i l a t o r ,

a n d

t h e

C h i n e s e

a n d

J a p a n e s e

a r e

p a r t i c u l a r l y

s u s c e p t i b l e t o

a l c o h o l i n d u c e d

f l u s h i n g . 4

C h i l l i e s

a n d

r e d

p e p p e r s a l s o

p r o d u c e

f l u s h i t g

a n d

s w e a t i n g b y

a

p h a r m a c o l o g i c a l a c t i o n .

5

E r g o t i s m ,

c h a r a c t e r i s e d b y

s e v e r e R a y n a u d ' s

p h e n o m e n o n

l e a d i n g

t o

d i g i t a l .

g a n g r e n e , i s d u e

t o e a t i n g

b r e a d

m a d e

f r o m

r y e

i n f e c t e d w i t h

a

f u n g u s . An e x a m p l e

o f

a d e r m a t o s i s

c a u s e d

b y c h e m i c a l

c o n t a m i n a t i o n

o c c u r r e d

i n T u r k e y ,

w h e n

t h e

i n g e s t i o n

o f

w h e a t

t r e a t e d w i t h a

f u n g i c i d e ,

h e x a c h l o r o -

b e n z e n e ,

r e s u l t e d

i n

m a n y

c a s e s

o f

p o r p h y r i a

c u t a n e a

t a r d a .

  6

U r t i c a r i a

i s

c o m m o n l y

d u e t o

i n g e s t e d f o o d

a l l e r g e n s ,

b u t

t h e

g l u t e n

e n t e r o p a t h y

o f

d e r m a t i t i s

h e r p e t i f o r m i s

i s a m o r e

s u b t l e

e x a m p l e .

I f

g l u t e n

i s

a v o i d e d

a n d

t h e b o w e l

r e c o v e r s

c o m p l e t e l y

t h e

s k i n d i s e a s e

m a y g o

i n t o

c o m p l e t e

r e m i s s i o n .

I d i o s y n c r a t i c s u s c e p t i b i l i t y

t o d i e t a r y f a c t o r s

may b e

c o m m o n e r

t h a n

a p p r e c i a t e d .

S o m e

c a s e s

may

b e

d u e

t o

i n t e r a c t i o n s

w i t h s y s t e m i c m e d i c a t i o n - f o r

e x a m p l e ,

t h e

s e v e r e

a l c o h o l

i n d u c e d

f l u s h i n g

i n s o m e

p a t i e n t s

wh o t a k e

c h l o r p r o p a m i d e 8 l 2 0

a n d

t h e

r e a c t i o n

t o c h e e s e

o r

p i c k l e s

i n

p a t i e n t s t a k i n g

i n h i b i t o r s

o f

m o n o a m i n e o x i d a s e .

O t h e r

r e a c t i o n s may b e

d u e t o

a n a t o m i c a l a b n o r m a l i t i e s

s u c h

a s

t h e

f l u s h i n g

t h a t

a c c o m p a n i e s

t h e

p o s t g a s t r e c t o m y d u m p i n g

s y n d r o m e .

S o m e

i d i o s y n c r a t i c

r e a c t i o n s - f o r

e x a m p l e ,

t h e

u r t i c a r i a

a n d

b r o n c h o s p a s m

c a u s e d

b y

b i s u l p h i t e s

u s e d t o

k e e p

f r u i t a n d v e g e t a b l e s

f r e s h - m a y

b e m e d i a t e d

b y n e u r a l

a c t i v i t y

a s

t h e r e s u l t s

o f

t e s t s f o r

a l l e r g y

a r e

n e g a t i v e . a n d t h e

a d v e r s e r e a c t i o n i s

b l o c k e d

b y

a t r o p i n e . 2 T h e C h i n e s e

r e s t a u r a n t

s y n d r o m e ,

i n

w h i c h

s i m i l a r

s y m p t o m s

o c c u r

a f t e r

e a t i n g

s o d i u m

g l u t a m a t e ,

s e e m s t o b e

m e d i a t e d

b y

t h e

t r a n s i e n t

r e l e a s e o f

c o m p o u n d s

s i m i l a r t o

a c e t y l c h o l i n e . 2 2

  3

C l i n i c a l o b s e r v a t i o n s

h a v e l e d t o

many a t t e m p t s

t o

i m p r o v e

s k i n

d i s e a s e

b y

c h a n g i n g

t h e

d i e t , t h o u g h

f e w h a v e s t o o d

t h e

t e s t

o f

t i m e . S o m e

i m p r o v e m e n t s may

b e d u e t o

i d i o s y n c r a t i c

r e a c t i o n s . Many

p a t i e n t s t h i n k , f o r

e x a m p l e , t h a t c h o c o l a t e

m a k e s t h e i r a c n e

w o r s e

d e s p i t e

s e v e r a l

s t u d i e s

s h o w i n g

t h a t

i t

d o e s n o t a f f e c t i t s

c o u r s e . 2 4   5 T h e

v a l u e o f

e x c l u s i o n d i e t s f o r

t r e a t i n g

a t o p i c

e c z e m a

i s a l s o

c o n t r o v e r s i a l 2 6 2 7 ; t h o u g h

t h e s e

a r e

w i d e l y u s e d ,

i t s e e m s t h a t

w o m e n ' s

m a g a z i n e s h a v e m o r e

s u c c e s s w i t h

t h e m t h a n d o c t o r s .

T h e

u s e o f f a t t y

a c i d

s u p p l e m e n t s t o

t r e a t a t o p i c e c z e m a

i s

a n o t h e r

i d e a t h a t

w a s

f a s h i o n a b l e

i n

t h e

1 9 3 0 s ,

d i e d o u t i n

t h e

1 9 5 0 s ,

a n d

h a s

r e c e n t l y

b e e n

e x h u m e d

i n

t h e

l i g h t o f

i n c r e a s i n g k n o w l e d g e

o f

f a t t y a c i d

a n d

e i c o s a n o i d

m e t a -

b o l i s m . 2 8

P a t i e n t s w i t h

a t o p i c

e c z e m a

h a v e l o w c o n c e n t r a t i o n s

o f

e s s e n t i a l

f a t t y

a c i d

m e t a b o l i t e s

i n t h e i r

p l a s m a , 2 9 a n d s o m e

p l a n t

a n d

f i s h o i l s a r e

p a r t i c u l a r l y r i c h i n

t h e s e

c o m p o u n d s

a n d t h e i r

p r e c u r s o r s . E v e n i n g p r i m r o s e

o i l

a n d

b o r a g e ,

f o r

e x a m p l e ,

a r e r i c h i n

y - l i n o l e n i c

a c i d ,

w h i c h i s d e p l e t e d i n

a t o p i c

e c z e m a . S e v e r a l t r i a l s

h a v e

s h o w n

t h a t

o r a l

e v e n i n g

p r i m r o s e

o i l

i n

l a r g e

d o s e s h a s

b e n e f i c i a l

e f f e c t s

i n

e c z e m a , 2 8 - 3 3

a n d

m e t a - a n a l y s i s

o f

s e v e r a l c o n t r o l l e d t r i a l s

h a s s h o w n t h a t

t h e c l i n i c a l i m p r o v e m e n t

c o r r e l a t e s

w i t h

t h e

i n c r e a s e

i n

p l a s m a

f a t t y a c i d m e t a b o l i t e s a f t e r

s u c h t r e a t m e n t . 3 4

S i m i l a r

s t u d i e s h a v e s h o w n m o d e s t

b e n e f i t f r o m

d i e t a r y

s u p p l e m e n t s

w i t h

f i s h

o i l

i n

p s o r i a s i s

a n d

e c z e m a . 2 8

T h e

e x a c t

m e c h a n i s m

o f

t h e s e c l i n i c a l

c h a n g e s

i s

u n c e r t a i n ,

b u t

a b e t t e r

u n d e r -

s t a n d i n g

o f

t h e

i n t e r m e d i a r y

m e t a b o l i s m

o f e s s e n t i a l

f a t t y

a c i d

m e t a b o l i t e s

a n d t r a c e

m e t a l s s u c h

a s z i n c

m i g h t p a v e

t h e

w a y

7 7 0

B M J

VOLUME

2 9 8 2 5

M RCH 1 9 8 9

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f o r

b e t t e r

s u p p r e s s i o n

o f

i n f l a m m a t i o n b y

d i e t a r y m o d u l a t i o n .

J

L BURTO N

R e a d e r a n d

C o n s u l t a n t D e r m a t o l o g i s t ,

B r i s t o l R o y a l I n f i r m a r y ,

B r i s t o l

B S 2  HW

I B u r t o n

J L .

D i e t a n d

d e r m a t o l o g y

i n

1 8 8 8 : t h e

i n f l u e n c e

o f

H

R a d c l i f f e

C r o c k e r .

B r j

D e r m a t o l

1 9 8 8 ; 1 1 9 : 4 7 1 - 8 .

2 K a h n C R , F l i e r

J S ,

B a r R S , e t

a l .

T h e

s y n d r o m e

o f

i n s u l i n

r e s i s t a n c e a n d a c a n t h o s i s n i g r i c a n s :

i n s u l i n

r e c e p t o r d i s o r d e r s

i n

m a n .

N

E n g I 7 J

Med

1 9 7 6 ; 2 9 4 : 7 3 9 - 4 5 .

3 F l i e r

J S .

M e t a b o l i c

i m p o r t a n c e

o f

a c a n t h o s i s

n i g r i c a n s .

A r c h

D e r m a t o l

1 9 8 5 ; 1 2 1 : 1 9 3 - 4 .

4

B l u n d e l l TL

B e d a r k i a n

S , H u m b e l R E .

T e r t i a r y

s t r u c t u r e s ,

r e c e p t o r b i n d i n g a n d

a n t i g e n i c i t y

o f

i n s t i l i n - l i k e

g r o w t h

f a c t o r s .

F e d e r a t i o n

P r o c e e d i n i g s

1 9 8 3 ; 4 2 : 2 5 9 2 - 7 .

5 P e t e r s E T , S t u a r t C A , P r i n c e

M j .

A c a n t h o s i s n i g r i c a n s

a n d

o b e s i t y :

a c q u i r e d a n d i n t r i n si c d e f e c t s

i n i n s u l i n a c t i o n .

M e t a b o l i s m

1 9 8 6 ; 3 5 : 8 0 7 - 1 3 .

6 B i l i m o r i a

S ,

K e c k e s

K , W i l l i a m s o n D , R o w e l l

NR H s p e r c a r o t e n a e m i a i n w e i g h t w a t c h e r s .

C l i n

E x p

D e r m a t o l 1 9 7 9 ; 4 : 3 3 1 - 4 .

7

M a c L a r e n

D S .

S k i n i n

p r o t e i n

e n e r g y

m a l n u t r i t i o n .

A r c h D e r ma t ol

1 9 8 7 ; 1 2 3 : 1 6 7 4 - 6 .

8 S i m s R T. T h e m e a s u r e m e n t

o f

h a i r

g r o w t h

a s

a n i nd ex o f

p r o t e i n

s y n t h e s i s

i n

m a l n u t r i t i o n .

B r J N u t r 1 9 6 8 ; 2 2 : 2 2 9 .

9

G u p t a

MA G u p t a A K , H a b e r m a n

HF

D e r m a t o l o g i c

s i g n s

i n a n o r e x i a n e r s o s a

a n d

b u l i m i a

n e r v o s a . A r c h D e r n at o l 1 9 8 7 ; 1 2 3 : 1 3 8 6 - 9 0 .

1 0 B a r t h e l e m y

H , C h o u v e t

B ,

C a m b a z a r d

F . S k i n

a n d

m u c o s a l

d e f i c i e n c i e s i n v i t a m i n

d e f i c i e n c y .

7

A m A c a d

D e r m a t o l

1 9 8 6 ; 1 5 : 1 2 6 3 - 7 4 .

1 1 R o e D .

N u t r i t i o n

a n d t h e

s k t n .

C o n t e m p o r a r y

s s u e s

i n

c l i n i c a l n u t r i t i o n . V o l 1 0 . Ne w

Y o r k :

L i s s ,

1 9 8 6 .

1 2 F r a k e r

B J ,

J a r d i e u

P , C o o k

J .

Z i n c

d e f i c i e n c y

a n d immune f u n c t i o n s .

A r c h D e r m a to l 1 9 8 7 ; 1 2 3 :

1 6 9 9 - 7 0 1 .

1 3

W e i s m a n n

K .

N u t r i t i o n

a n d t h e s k i n . I n :

Rook A , W i lk i n s o n

D S , E b l i n g J F G , C h a m p i o n RH

B u r t o n

J L ,

e d s . T e x t b o o k

o f

d e r m a t o l o g y .

4 t h e d . O x f o r d : B l a c k w e l l

S c i e n t i f i c P u b l i c a t i o n s ,

1 9 8 6 : 2 3 2 1 - 4 2 .

1 4 W o l f f

P H . E t h n i c d i f f e r e n c e s

i n a l c o h o l

s e n s i t i v i t y .

S c i e n c e 1 9 7 2 ; 1 7 5 : 4 4 9 - 5 0 .

1 5 W i l k i n

J K .

F l u s h i n g

r e a c t i o n s .

I n : C h a m p i o n

RH

e d .

R e c e n t a d v a n c e s

in

d e r m a t o l o g v .

V o l 6 .

E d i n b u r g h :

C h u r c h i l l

L i v i n g s t o n e , 1 9 8 3 : 1 5 8 - 8 7 .

1 6 C r i p p s

D J .

l P o r p h y r i a t u r c i c a , t w e n t y y e a r s a f t e r

h e x a c h l o r o b e n z e t t e

i n t o x i c a t i o n . A r c h

D e r m a w o l

1 9 8 0 ; 1 1 6 : 4 6 5 0

1 7 H a l l R P .

D i e t a r y

m a n a g e m e n t

o f

d e r m a t i t i s h e r p e t i f o r m i s .

A r c h

D e r r n a t o l

1 9 8 7 ; 1 2 3 : 1 3 7 8 - 8 0 .

1 8 B a r n e t t AH

P y k e

DA

C h l or p r o p a m i d e - a l co ho l i n d u c e d

f l u s h i n g

a n d l a r g e v e s s e l

d i s e a s e i n

n o n - i n s u l i n

d e p e n d e n t

d i a b e t e s

m e l l i t u s .

B r . V f e d j

1 9 8 0 ; 2 8 1 : 2 6 1 - 2 .

1 9

B a r n e t t

AH S p i l i o p o u l o s

A J ,

P y k e

DA B l o c k a d e

o f

c h l o r p r o p a m i d e - a l c o h o l f l u s h i n g

b y i n d o m e t h a c i n

s u g g e s t s

a n

a s s o c i a t i o n

b e t w e e n

p r o s t a g l a n d i n s a n d d i a b e t i c v a s c u l a r

c o m p l i c a t i o n s . L a n c e t 1 9 8 0 ; i i :

1 6 4 - 6 .

2 0 K o b b e r l i n g

J

W e b e r

M

F a c i a l f l us h

a f t e r c h l o r p r o p a m i d e - a l c o h o l

a n d

e n k e p h a l i n . L a n c e i

1 9 8 0 ; i : 5 3 8 - 9 .

2 1

S e t t i p a n e

G .

A d v e r s e

r e a c t i o n s

t o

s u l f i t e

i n

d r u g s

a n d

t o o d s .

I

- A m

A c a d D e r n m a t o l

1 9 8 4 ; 1 0 :

1 ) 7 7 - 8 0 .

2 2

G ha d i m i H , Kumar

S ,

A b a c i

F . S t u d i e s o n

m o n o s o d i u m

g l u t a m a t e

i n g e s t i o n ;

1 . B i o c h e m i c a l

e x p l a n a t i o n

o f

t h e

C h i n e s e

r e s t a u r a n t

s v n d r o m e .

B i l o c h e m

M I f e d M e t a b B i o l

1 9 7 1 ; 5 : 4 4 7 - 5 6 .

2 3 R e i f - L e h r e r L . P o s s i b l e s i g n i f i c a n c e

o f

a d v e r s e r e a c t i o n s

t o g l u t a m a t e i n h u m a n s . F e d e r a t i o n

P r o c e e d i n g s 1 9 7 6 ; 3 5 : 2 2 0 5 - 1

1 .

2 4 P le wi g G , K l i g m a n A L . A c n e

m o r p h o g e n e s i s

a n d t r e a t m e n t .

B e r l i n :

S p r i n g e r - V e r l a g , 1 9 7 5 : 2 7 0 - 1 .

2 5

F r i e s

J H . C h o c o l a t e - a

r e v i e w

o f

p u b l i s h e d

a l l e r g i c

a n d

o t h e r d e l e t e r i o u s

e f f e c t s , r ea l

a n d

p r e s u m e d . A n n A l l e r g v 1 9 7 8 ; 4 1 : 1 9 5 - 2 0 7 .

2 6

A t h e r a

n

D J .

R o l e o f

d i e t i n

t r e a t i n g a t o p i c

e c z e m a :

e l i m i n a t i o n

d i e t s c an b e

b e n e f i c i a l .

BrMedj

1 9 8 8 ; 2 9 7 :

1 4 5 8 - 6 0 .

2 7 A l l e n R . R o l e o f d i e t i n t r e a t i n g

a t o p i c

e c z e m a ; d i e t a r y m a n i p u l a t i o n ha s

n o v a l u e . B r

M e d ] J

1 9 8 8 ; 2 9 7 :

1 4 5 9 - 6 0 .

2 8

B u r t o n

J L . D i e t a r y

f a t t y

a c i d s a n d

i n f l a m m a t o r s

s k i n d i s e a s e .

L a n c e t

1 9 8 8 ; t : 2 7 - 3 1 .

2 9

Manku M S , H o r r o b i n D F , M o r s e NL W r i g h t S ,

B u r t o n

J L .

E s s e n t i a l f a t t y

a c i d s

i n

t h e

p l a s m a

p h o s p h o l i p i d s

o f

p a t i e n t s

w i t h

a t o p i c

e c z e m a .

B r ] D e r t n a t o l 1 9 8 4 ; 1 1 0 : 6 4 3 - 8 .

3 0

L o v e l l C R , B u r t on J L , I t o r r o b i n D F .

T r e a t m e n t

of

a t o p i c

e c z e m a w i t h e v en i ng p r im r os e

o i l .

L a n c e t

1 9 8 1 ; i : 2 7 8 .

3 1 W r i g h t

S ,

B u r t o n

J L .

O r a l

e v e ni n g p r i m ro s e s e e d o i l i m p r o v e s a t o p i c

e c z e m a .

L a n c e t

1 9 8 2 ; i i :

1 1 2 0 - 2 .

3 2 S c h a l i n - K a r r i l a

M

A I a t t i l a L , J a n s e n C T , U o t i l a

P .

E s e n i n g p r i m r o s e o i l

i n

t h e

t r e a t m e n t o f

a t o p i c

e c z e m a :

e f f e c t o n c l i n i c a l

s t a t u s , p l a s m a p h o s p h o l i p i d

f a t t y

a c i d s

a n d c i r c u l a t i n g

b l o o d

p r o s t a g l a n d i n s .

B r j

D e r m n a t o l

1 9 8 7 ; 1 1 7 :

1 1 - 9 .

3 3 S u g a l

T. C l i n i c a l e v a l u a t i o n o f

o r a l

e v e n i p g

p r i m r o s e

o i l

i n

a t o p i c p a t i e n t s .

S k i n

R e s e a r c h

1 9 8 7 ; 2 9 : 3 3 0 - 8 .

3 4 M or s e P F ,

H o r r o b i n

DF S t e w a r t C , e t a l .

M e t a - a n a l y s i s o f

p l a c e b o - c o n t r o l l e d s t u d i e s

o f t h e

e f f i c a c y o t

E p o g a m

i n t h e t r e a t m e n t

o f

a t o p i c

e c z e m a :

r e l a t i o n s h i p

b e t w e e n

p l a s m a

e s s e n t i a l

f a t t y

a c i d c h a n g e s

a n d

c l i n i c a l r e s p o n s e . B r ] D e r m a t o l ( i n p r e s s ) .

H e a l t h

n e e d s

o f

t h e

h o m e l e s s

H o m e s a r e

c h e a p e r t h a n

b e d

a n d

b r e a k f a s t

H a l f

a m i l l i o n

p o u n d s i s

s p e n t

e a c h w e e k

o n b e d a n d b r e a k f a s t

a c c o m m o d a t i o n

f o r

L o n d o n ' s

h o m e l e s s .

  M o s t o f t h e

f a m i l i e s

wh o

l i v e i n t h i s

d e p r e s s i n g ,

d r e a r y w a y h a v e

b e c o m e

h o m e l e s s

b e c a u s e t h e y c a n n o t a f f o r d

t o r e n t o r

b u y a n d

l o c a l

a u t h o r i t i e s

c a n n ot p r o v i d e a n y

a l t e r n a t i v e .

I n t h e p a s t

2 5 y e a r s t h e

n u m b e r

o f d w e l l i n g s

a v a i l a b l e

f o r r e n t i n B r i t a i n

h a s d r o p p e d

b y o n e

m i l l i o n .

Th e

n u m b e r

o f

h o u s e h o l d s i n

t e m p o r a r y

a c c o m m o d a t i o n

h a s d o u b l e d

s i n c e

1 9 8 1 a n d r e a c h e d 3 0 1 0 0

i n

E n g l a n d i n

D e c e m b e r 1 9 8 8 .

Among

t h e m a n y

p r o b l e m s

o f t h e h o m e l e s s

i s

g e t t i n g

m e d i c a l

c a r e

w h e n

t h e y

n e e d

i t a n d t h i s

i s s u e h a s now b e e n

e x a m i n e d

i n a

j o i n t

r e p o r t

b y

t h e H e a l t h

V i s i t o r s A s s o c i a t i o n

a n d

t h e

G e n e r a l

M e d i c a l

S e r v i c e s

C o m m i t t e e o f t h e BMA 2

P a r t

I I I

o f t h e H o u s i n g

A c t 1 9 8 5 r e q u i r e s

l o c a l a u t h o r i t i e s

i n

E n g l a n d

a n d W a l e s

t o h o u s e

h o m e l e s s

p e o p l e

w i t h s p e c i a l

n e e d s - c h i l d r e n , p r e g n a n t

w o m e n ,

t h e e l d e r l y , t h e d i s a b l e d ,

a n d

t h e m e n t a l l y

i l l . 3 Th e n u m b e r o f h o m e l e s s

f a m i l i e s

o f f e r e d

h e l p

b y

l o c a l

a u t h o r i t i e s

i n

E n g l a n d

h a s

m o r e

t h a n

d o u b l e d

s i n c e

1 9 7 9

a n d

r e a c h e d

1 1 6

0 6 0 l a s t

y e a r .

T h i s

d o e s

n o t

t a k e

i n t o a c c o u n t t h o s e who a p p l i e d

f o r

b u t w e r e r e f u s e d h e l p -

m o r e t h a n

4 0 0 0 0 0 h o u s e h o l d s

s i n c e

1 9 8 2 .

P e o p l e

l i v i n g i n

o v e r c r o w d e d

t e m p o r a r y

a c c o m m o d a t i o n

f a c e

many

h e a l t h r i s k s . 4

C h i l d r e n

c o m e

down

r e p e a t e d l y

w i t h

d i a r r h o e a l

i l l n e s s e s

a n d c h e s t i n f e c t i o n s ,

a n d h o m e l e s s

women

a r e

t w i c e a s l i k e l y

t o

h a v e

p r o b l e m s

a n d t h r e e

t i m e s a s l i k e l y t o

b e a d m i t t e d

t o

h o s p i t a l

d u r i n g

p r e g n a n c y

a s

o t h e r women

A c c i d e n t s

a n d f i r e s a r e s u b s t a n t i a l

h a z a r d s . D e p r e s s i o n

a n d

s t r e s s

a m o n g p a r e n t s

may

p r e d i s p o s e

t h e m

t o

a b u s e

t h e i r

c h i l d r e n . H e a l t h

v i s i t o r s

a r e c o n c e r n e d

a b o u t

t h e n u t r i t i o n o f

p e o p l e

i n

b e d

a n d b r e a k f a s t

a c c o m m o d a t i o n . 5 Many

f a m i l i e s

h a v e t o

v a c a t e t h e

p r e m i s e s

b e t w e e n 1 0 am

a n d 4

p m ,

a n d

w h e n

t h e y

a r e

a l l o w e d

b a c k

t h e y

h a v e

t o

s h a r e

i n a d e q u a t e

c o o k i n g

f a c i l i t i e s w i t h

many

o t h e r

f a m i l i e s .

M o t h e r s

a n d y o u n g c h i l d r e n

a r e a m o n g

t h e l a r g e s t

c o n -

s u m e r s

o f

p r i m a r y

h e a l t h

c a r e ,

a n d w h e n

t h e i r h e a l t h i s

e n d a n g e r e d

b y

t h e i r

l i v i n g

c o n d i t i o n s i t b e c o m e s e v e n

m o r e

i m p o r t a n t

t h a t t h e y h a v e e a s y

a c c e s s t o

h i g h q u a l i t y

h e a l t h

s e r v i c e s . S o m e g e n e r a l

p r a c t i t i o n e r s

a r e

r e l u c t a n t t o t a k e

h o m e l e s s

p e o p l e

o n

t o t h e i r

l i s t s . F a m i l i e s i n

t e m p o r a r y

a c c o m m o d a t i o n may

h o p e

t h a t

i t

w i l l

b e

f o r a s h o r t t i m e

a n d

may

f a i l t o r e g i s t e r

w i t h l o c a l g e n e r a l

p r a c t i t i o n e r s

o r d o s o

o n l y a s t e m p o r a r y

r e s i d e n t s ,

i n w h i c h c a s e t h e i r

n o t e s w i l l

n o t

b e

f o r w a r d e d t o

t h e i r new d o c t o r .

S u c h

f a m i l i e s

may t h e n

u s e

a c c i d e n t a n d

e m e r g e n c y

d e p a r t m e n t s

when t h e y n e e d m e d i c a l

h e l p , b u t t h i s

i s n o t t h e b e s t w a y t o

p r o v i d e

c o n t i n u i n g

c a r e

f o r

f a m i l i e s w i t h

y o u n g c h i l d r e n

a n d i s a w a s t e o f

t h o s e r e s o u r c e s .

T h e r e p o r t e m p h a s i s e s

t h e

n e e d f o r

m o r e

i n f o r m a t i o n

a b o u t

h o m e l e s s

f a m i l i e s

a n d h i g h l i g h t s t h e

p r o b l e m s f a c e d

b y

g e n e r a l

p r a c t i t i o n e r s

i n a r e a s w h e r e

t h e r e a r e many d w e l l i n g s

i n

m u l t i p l e

o c c u p a t i o n .

I t s u g g e s t s

t h a t

e a c h

d i s t r i c t h e a l t h

a u t h o r i t y

s h o u l d

h a v e

a l i a i s o n o f f i c e r

f o r h o m e l e s s

p e r s o n s

who

h a s r e s p o n s i b i l i t y

f o r i n f o r m i n g h e a l t h

v i s i t o r s a b o u t t h e

a r r i v a l

o f

a

n e w

f a m i l y , a r r a n g i n g

t r a n s f e r

o f

t h e

r e l e v a n t

n o t e s ,

a n d i n f o r m i n g t h e f a m i l y p r a c t i t i o n e r

c o m m i t t e e a b o u t

t h e

n u m b e r

o f

f a m i l i e s

i n

t e m p o r a r y

a c c o m m o d a t i o n .

A n o t h e r

p o s s i b i l i t y

i s

t h e

w i d e r

u s e

o f

c l i e n t

h e l d

r e c o r d s t o

r e d u c e

s o m e

o f t h e

p r o b l e m s c a u s e d

b y t h e

f r e q u e n t t r a n s f e r

o f n o t e s .

T h e

r e p o r t

c a l l s o n t h e g o v e r n m e n t

t o c o n s u l t

w i t h

t h e

BM

a b o u t

w a y s

o f r e m o v i n g

f i n a n c i a l a n d

o r g a n i s a t i o n a l

b a r r i e r s

t h a t

i n h i b i t h o m e l e s s

f a m i l i e s

f r o m

g a i n i n g

a c c e s s

t o

p r i m a r y

h e a l t h c a r e . I t s u g g e s t s

t h a t

g e n e r a l p r a c t i t i o n e r s

s h o u l d

r e c e i v e

a

r e g i s t r a t i o n

f e e

f o r

n e w

p a t i e n t s

a n d

t h a t

p a t i e n t s

a c c e p t e d

o n

t o

a l i s t a s

t e m p o r a r y

r e s i d e n t s

s h o u l d

c o u n t

t o w a r d s

t h e

l i s t s i z e . T h e

r e c o m m e n d a t i o n s

i n

t h e

r e p o r t

a r e

a n a t t e m p t

t o

i m p r o v e

t h e

p r o v i s i o n

o f

p r i m a r y

h e a l t h

c a r e t o

h o m e l e s s

f a m i l i e s ,

b u t

t h e

r e a l

a n s w e r

t o

t h e s e

p r o b l e m s

i s

t o p r o v i d e

p e r m a n e n t

h o m e s a t

a f f o r d a b l e

r e n t s .

S i n c e

1 9 8 0 t h e

g o v e r n m e n t

h a s

e n c o u r a g e d

c o u n c i l t e n a n t s

BM J

VOLUME

2 9 8 2 5 M A R C H 1 9 8 9

7 7 1