1407
Fall in deaths from respiratory disease SIR,-We, like many colleagues, have been examining routine data sources for the annual report of the Director of Public Health Medicine to plan the local strategies for health in Wales,! and assist in responding to the government’s consultative document The Health of the Nation.2 As part of this exercise, we have looked at mortality data for respiratory disease (ICD-9 460-519) among South Glamorgan residents and noted that there was a substantial fall in 1984. Routine data from the Office of Population Censuses and Surveys (OPCS), series VS3, recorded a total of 687 deaths from respiratory disease in 1983 and 411 deaths in 1984. This finding puzzled several respiratory and public health physicians who initially assumed that this reduction might be related to influenza activity. A closer look at the data revealed that most of the decrease seemed to be accounted for by a sudden drop in pneumonia deaths. The all-Wales data on respiratory death showed a similar drop. The total number of deaths from respiratory disease in 1983 was 5285; in 1984 this had fallen to 3408. Pneumonia deaths in Wales were recorded as 3307 in 1983 and 1411 in 1984. Further investigation showed that this sudden drop in respiratory disease mortality was in fact due to coding changes begun in 1984, which are explained in the introduction of OPCS series DH2 number 11.2 Essentially the changes entailed a more rigorous application of World Health Organisation rule 3 to death certificates. With this rule the coding includes the underlying cause of death from part II of the death certificate if, firstly, there is a major disease recorded in part II and, secondly, if the underlying cause of death recorded in part I is one of a list of terminal events that includes bronchopneumonia. The effect of this has been that the numbers of deaths ascribed to such terminal events has declined. We hope that this information will be of assistance to our colleagues. Temple of Peace Cathays Park,
and Health,
IAN HARVEY
Cardiff CF1 3NW, UK
Llandough Hospital,
IAN CAMPBELL
Cardiff
Temple of Peace and Health,
JANE WILKINSON
Cardiff
1 Welsh Health Planning Forum. Local strategies for health: a new approach to strategic planning. Cardiff: Welsh Office, 1989. 2. Secretary of State for Health. The health of the nation: a consultative document for health m England. London: HM Stationery Office, 1991 CM 1523. 3. Office of Population Censuses and Surveys. Mortality statistics: cause, 1984. London: HM Stationery Office, 1985: series DH2, no 11.
Retinoids to prevent skin
cancer
in organ
transplant recipients SIR,-It has been estimated that Australian
organ
transplant
20 6-fold increased risk of skin cancer.1 Furthermore, the normal predominance of basal cell over squamous cell carcinoma (SCC) is reversed. SCCs in transplant recipients appear to carry increased metastatic potential and are responsible for a 10-fold greater mortality from skin cancer.2 Recent studies have suggested that etretinate is effective in the treatment of solar keratoses, both in organ transplant recipients3 and in general4 Isotretinoin reduced skin cancer lesions in 5 patients with xeroderma pigmentosum by an average of 63%.’ 4 male renal transplant recipients who had large numbers of cutaneous SCCs (4-10 per year) have been treated for 8-13 months with the oral retinoid, etretinate (’Tigason’) at a dose of 50 mg per day. The number of SCCs during treatment with etretinate was compared with those in the 12 months immediately before and the 12 months after treatment. All patients experienced a considerable reduction during treatment (table). There were 23 SCCs in the 4 patients in the 12 months before treatment, 6 during treatment, and 34 in the 12 months after treatment. All patients had large numbers of solar keratoses. Photographs taken before treatment and 3-monthly during treatment confirmed the improvement,
recipients
have
a
SCC IN RENALTRANSPLANT RECIPIENTS BEFORE, DURING, AND AFTER TREATMENT WITH ETRETINATE
There were 6 basal cell carcinomas in the group in the year before treatment, 3 during treatment, and 14 in the year afterwards. All 4 patients were taking prednisolone, 3 were on azathioprine, and 2 were taking cyclosporin. There were no significant changes in immunosuppressive therapy during the study treatment.
period. Despite theoretical concerns about possible allograft rejection associated with the immunopotentiating effects of etretinateno patient in our study showed any deterioration in renal function, as indicated by monthly creatinine clearance, urea, and creatinine estimations. No increase in serum triglyceride or cholesterol above pretreatment levels was observed, and liver function remained unchanged. All patients experienced mild mucocutaneous sideeffects, and 1 patient had "sticky skin". In 1 patient thrombocytopenia developed after 8 months of therapy and etretinate was withdrawn.7 1 patient had 21 SCCs in 12 months after treatment. A similar early acceleration in tumour formation with cessation of therapy was observed in another of our patients and in 2 of 5 patients with xeroderma pigmentosum studied by Kraemer et al.sThe rapid onset and disappearance of a chemopreventive effect in our cases supports the observation that the retinoids act at a late stage in tumour development.s Further studies are needed to establish whether or not there is a rebound increase in skin cancer when retinoids are stopped. Our findings suggest that the formation of cutaneous SCCs in organ transplant recipients can be rapidly suppressed by etretinate. Dermatology and Renal Units and Department of Medicine Monash University, Alfred Hospital, Melbourne, Australia
J. W. KELLY J. SABTO F. W. GURR F. BRUCE
1. Hardie IR, Strong RW, Hartley LCJ, Woodruff PWH, Clunie GJA. Skin cancer in caucasian renal allograft recipients living in a subtropical climate. Surgery 1980; 87: 177-83. 2. Kinlen LJ, Sheil AGR, Peto J, Doll R. Collaborative United Kingdom-Australasian study of cancer m patients treated with immunosuppressive drugs. Br Med J 1979; ii: 1461-66. 3. Shuttleworth D, Marks R, Griffin PJA, Salaman JR. Treatment of cutaneous neoplasia with etretinate in renal transplant recipients. Q J Med 1988; 68: 717-24. 4. Moriarty M, Dunn J, Darragh A, Lambe R, Bnck I. Etretinate m the treatment of actinic keratosis. Lancet 1982; i: 364-65. 5.Kraemer KH, DiGiovanna JJ, Moshell AN, Tarone RE, Peck GL. Prevention of skin cancer in xeroderma pigmentosum with the use of isotretinoin. N Engl J Med 1988; 318: 1633-37. 6. McKerrow KJ, MacKie RM, Lesko MJ, Pearson C. The effect of oral retinoid therapy on the normal human immune system. Br JDermatol 1988; 119: 313-20. 7. Liang R. Thrombocytopenia associated with etretinate therapy. Acta Haematol 1988; 79: 112-13.
Paradoxical effect of octreotide in neoplastic inappropriate corticotropin secretion SIR,—The efficacy of octreotide (’Sandostatin’) in paraneoplastic Cushing’s syndrome has been documented in some tumours with ectopic corticotropin secretion.1,2 We report corticotropin, p-lipotropic pituitary hormone (&bgr;-LPH), and cortisol measurements in a patient treated with octreotide for paraneoplastic Cushing’s syndrome of pulmonary origin.
Fall in deaths from respiratory disease SIR,-We, like many colleagues, have been examining routine data sources for the annual report of the Director of Public Health Medicine to plan the local strategies for health in Wales,! and assist in responding to the government’s consultative document The Health of the Nation.2 As part of this exercise, we have looked at mortality data for respiratory disease (ICD-9 460-519) among South Glamorgan residents and noted that there was a substantial fall in 1984. Routine data from the Office of Population Censuses and Surveys (OPCS), series VS3, recorded a total of 687 deaths from respiratory disease in 1983 and 411 deaths in 1984. This finding puzzled several respiratory and public health physicians who initially assumed that this reduction might be related to influenza activity. A closer look at the data revealed that most of the decrease seemed to be accounted for by a sudden drop in pneumonia deaths. The all-Wales data on respiratory death showed a similar drop. The total number of deaths from respiratory disease in 1983 was 5285; in 1984 this had fallen to 3408. Pneumonia deaths in Wales were recorded as 3307 in 1983 and 1411 in 1984. Further investigation showed that this sudden drop in respiratory disease mortality was in fact due to coding changes begun in 1984, which are explained in the introduction of OPCS series DH2 number 11.2 Essentially the changes entailed a more rigorous application of World Health Organisation rule 3 to death certificates. With this rule the coding includes the underlying cause of death from part II of the death certificate if, firstly, there is a major disease recorded in part II and, secondly, if the underlying cause of death recorded in part I is one of a list of terminal events that includes bronchopneumonia. The effect of this has been that the numbers of deaths ascribed to such terminal events has declined. We hope that this information will be of assistance to our colleagues. Temple of Peace Cathays Park,
and Health,
IAN HARVEY
Cardiff CF1 3NW, UK
Llandough Hospital,
IAN CAMPBELL
Cardiff
Temple of Peace and Health,
JANE WILKINSON
Cardiff
1 Welsh Health Planning Forum. Local strategies for health: a new approach to strategic planning. Cardiff: Welsh Office, 1989. 2. Secretary of State for Health. The health of the nation: a consultative document for health m England. London: HM Stationery Office, 1991 CM 1523. 3. Office of Population Censuses and Surveys. Mortality statistics: cause, 1984. London: HM Stationery Office, 1985: series DH2, no 11.
Retinoids to prevent skin
cancer
in organ
transplant recipients SIR,-It has been estimated that Australian
organ
transplant
20 6-fold increased risk of skin cancer.1 Furthermore, the normal predominance of basal cell over squamous cell carcinoma (SCC) is reversed. SCCs in transplant recipients appear to carry increased metastatic potential and are responsible for a 10-fold greater mortality from skin cancer.2 Recent studies have suggested that etretinate is effective in the treatment of solar keratoses, both in organ transplant recipients3 and in general4 Isotretinoin reduced skin cancer lesions in 5 patients with xeroderma pigmentosum by an average of 63%.’ 4 male renal transplant recipients who had large numbers of cutaneous SCCs (4-10 per year) have been treated for 8-13 months with the oral retinoid, etretinate (’Tigason’) at a dose of 50 mg per day. The number of SCCs during treatment with etretinate was compared with those in the 12 months immediately before and the 12 months after treatment. All patients experienced a considerable reduction during treatment (table). There were 23 SCCs in the 4 patients in the 12 months before treatment, 6 during treatment, and 34 in the 12 months after treatment. All patients had large numbers of solar keratoses. Photographs taken before treatment and 3-monthly during treatment confirmed the improvement,
recipients
have
a
SCC IN RENALTRANSPLANT RECIPIENTS BEFORE, DURING, AND AFTER TREATMENT WITH ETRETINATE
There were 6 basal cell carcinomas in the group in the year before treatment, 3 during treatment, and 14 in the year afterwards. All 4 patients were taking prednisolone, 3 were on azathioprine, and 2 were taking cyclosporin. There were no significant changes in immunosuppressive therapy during the study treatment.
period. Despite theoretical concerns about possible allograft rejection associated with the immunopotentiating effects of etretinateno patient in our study showed any deterioration in renal function, as indicated by monthly creatinine clearance, urea, and creatinine estimations. No increase in serum triglyceride or cholesterol above pretreatment levels was observed, and liver function remained unchanged. All patients experienced mild mucocutaneous sideeffects, and 1 patient had "sticky skin". In 1 patient thrombocytopenia developed after 8 months of therapy and etretinate was withdrawn.7 1 patient had 21 SCCs in 12 months after treatment. A similar early acceleration in tumour formation with cessation of therapy was observed in another of our patients and in 2 of 5 patients with xeroderma pigmentosum studied by Kraemer et al.sThe rapid onset and disappearance of a chemopreventive effect in our cases supports the observation that the retinoids act at a late stage in tumour development.s Further studies are needed to establish whether or not there is a rebound increase in skin cancer when retinoids are stopped. Our findings suggest that the formation of cutaneous SCCs in organ transplant recipients can be rapidly suppressed by etretinate. Dermatology and Renal Units and Department of Medicine Monash University, Alfred Hospital, Melbourne, Australia
J. W. KELLY J. SABTO F. W. GURR F. BRUCE
1. Hardie IR, Strong RW, Hartley LCJ, Woodruff PWH, Clunie GJA. Skin cancer in caucasian renal allograft recipients living in a subtropical climate. Surgery 1980; 87: 177-83. 2. Kinlen LJ, Sheil AGR, Peto J, Doll R. Collaborative United Kingdom-Australasian study of cancer m patients treated with immunosuppressive drugs. Br Med J 1979; ii: 1461-66. 3. Shuttleworth D, Marks R, Griffin PJA, Salaman JR. Treatment of cutaneous neoplasia with etretinate in renal transplant recipients. Q J Med 1988; 68: 717-24. 4. Moriarty M, Dunn J, Darragh A, Lambe R, Bnck I. Etretinate m the treatment of actinic keratosis. Lancet 1982; i: 364-65. 5.Kraemer KH, DiGiovanna JJ, Moshell AN, Tarone RE, Peck GL. Prevention of skin cancer in xeroderma pigmentosum with the use of isotretinoin. N Engl J Med 1988; 318: 1633-37. 6. McKerrow KJ, MacKie RM, Lesko MJ, Pearson C. The effect of oral retinoid therapy on the normal human immune system. Br JDermatol 1988; 119: 313-20. 7. Liang R. Thrombocytopenia associated with etretinate therapy. Acta Haematol 1988; 79: 112-13.
Paradoxical effect of octreotide in neoplastic inappropriate corticotropin secretion SIR,—The efficacy of octreotide (’Sandostatin’) in paraneoplastic Cushing’s syndrome has been documented in some tumours with ectopic corticotropin secretion.1,2 We report corticotropin, p-lipotropic pituitary hormone (&bgr;-LPH), and cortisol measurements in a patient treated with octreotide for paraneoplastic Cushing’s syndrome of pulmonary origin.
