Chiaramente, ogni formato ha i propri vantaggi e svantaggi comprare amoxil senza ricetta per effettuare un acquisto, non è necessario fornire la prescrizione medica.

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Pilot study of the effect of individualised homeopathy on the pruritus associated with atopic dermatitis in dogs P. B. Hill, J. Hoare, P. Lau-Gillard, J. Rybnicek, R. T. Mathie Twenty dogs with confirmed atopic dermatitis
remedies, and reported reductions in the pruritus
were treated with homeopathy. In the first phase
score of 0, 0·2 and 0·8 following placebo treatment and
of this pilot study, all of the dogs were treated by a
4·3, 2·4 and 3·0, respectively, following the remedy.
veterinary homeopath with individualised remedies
prescribed on the basis of the dog's cutaneous signs

THE practice of homeopathy is currently under great scrutiny in both and constitutional characteristics. The response to
the medical and veterinary fields, and no other form of treatment treatment was assessed by scoring the severity of
appears able to polarise opinions to such an extent (Baker and oth-ers 2005, Hektoen 2005a). Conventional medical practice dictates that pruritus from 0 to 10 on a validated scale. The dogs
the principle on which homeopathy is based has no grounding in sci- were evaluated at monthly intervals for at least
ence, and any response to treatment is discounted as pure placebo effect. two months. In 15 cases, the owners reported no
However, trained medical and veterinary homeopaths maintain that their system, although not fully understood from a scientific point of improvement following homeopathic treatment.
view, yields genuine therapeutic results, often after conventional medi- In the other five cases, the owners believed that
cal treatment has failed.
the homeopathic treatment was associated with a
Two major problems prevent homeopathy from gaining widespread acceptance. The first, and most compelling, reason for disbelief is the substantial improvement, and reported reductions
nature of the remedies. To produce standard homeopathic medications, in pruritus scores ranging from 64 to 100 per cent.
the source material is diluted repeatedly, often to such an extent that These five dogs were selected for the second phase
no molecules of it are likely to remain in the final solvent. The second reason is that evidence from clinical trials to demonstrate the efficacy of the study, in which homeopathic remedies were
of homeopathic remedies is extremely limited, particularly in veterinary tested against placebos in a randomised and blinded
medicine, and often hampered by poor trial design. Most homeopathic trial. In one of these dogs, atopic dermatitis resolved
prescribing is based on 200 years of accumulated clinical experience, and reported outcomes can be greatly influenced by placebo and other completely and so this dog could not participate in
non-specific effects, random variation, observer bias, regression to the phase 2; another dog was euthanased because of
mean (where exacerbations or severe forms of a disease naturally revert status epilepticus before phase 2 could be started.
back to a more typical level) and spontaneous recovery. Such obstacles may appear insurmountable, leading some authors to conclude that the In the remaining three cases, the owners correctly
practice of veterinary homeopathy should cease (Baker and others 2005, distinguished between the placebo and homeopathic
Rijnberk and Ramey 2007).
However, both of the above problems are beginning to be addressed by the scientific community. Traditional chemical approaches state that the ultradilution of molecules in water beyond Avogadro's number will yield a final solution that is identical to the solvent. Although this seems Veterinary Record (2009) 164, 364-370
logical to most scientists, materials scientists regard it as a simplistic way P. B. Hill, BVSc, PhD, DVD,
J. Hoare, BVSc, VetMFHom,
to view the complex interactions between solutes and the three-dimen- sional structure of water. Different homeopathic remedies and different P. Lau-Gillard, DrMedVet, CertVD,
Faculty of Homeopathy, dilutions of the same remedy have been distinguished from each other R. T. Mathie, BSc, PhD,
using Raman and infrared spectroscopy, even though all should contain J. Rybnicek, MVDr, MRCVS,
British Homeopathic Association, nothing but water (Rao and others 2007). Such findings may relate to Division of Companion Animal Hahnemann House, 29 Park Street complex processes such as epitaxy (the transfer of information from the Studies, Department of Clinical West, Luton, Bedfordshire LU1 3BE Veterinary Science, University of surface of a solid substance to a liquid) and the formation of colloidal Bristol, Langford House, Langford, E-mail for correspondence: nanobubbles during succussion, the process in which homeopathic rem- North Somerset BS40 5DU edies are ‘pounded' with each successive dilution. Nanobubbles contain the VETERINARY RECORD March 21, 2009
gaseous inclusions of oxygen, nitrogen, carbon dioxide and possibly the TABLE 1: Age, breed and sex of the dogs included in the study
remedy source material (Rao and others 2007). Hence, although there is still no plausible mechanism for a ‘pharmacological' action of homeo- pathic remedies, a fixation on the fundamental problem of Avogadro's number may be inappropriate.
There is a lack of clinical evidence for the efficacy of homeopathic 2 years, 7 months Soft coated wheaten terrier remedies compared with conventional medicines. To date, compre- Labrador retriever hensive meta-analyses of placebo-controlled trials in human medicine Jack Russell terrier have, in general, suggested that homeopathy is superior to placebo, but 2 years, 5 months have not demonstrated specific conditions for which homeopathy is 5 years, 7 months West Highland white terrier clearly efficacious (Linde and others 1997, Ernst 2002). Reviews focus- 4 years, 7 months Labrador retriever ing on specific medical conditions have reported both positive (Taylor 6 years, 6 months German shepherd dog and others 2000) and negative (Ernst 1999) conclusions. In veterinary Jack Russell terrier medicine, there have been few studies to evaluate treatment-specific German shepherd dog effects of homeopathy, and most have addressed herd problems in farm 2 years, 8 months livestock (Hektoen 2005b, Mathie and others 2007). To date, control- English bull terrier led trials of homeopathy published in the veterinary literature have not Staffordshire bull terrier shown significant effects (Scott and others 2002, de Verdier and others 2 years, 7 months 2003, Hektoen and others 2004, Holmes and others 2005, Cracknell 3 years, 6 months Staffordshire bull terrier and Mills 2008), but beneficial responses have been reported elsewhere (Searcy and others 1995, Albrecht and Schütte 1999). One obstacle to the performance of clinical trials to investigate veterinary homeopathy F Female, FN Female neutered, M Male, MN Male neutered is the holistic approach taken by homeopathic practitioners, in which the whole patient is treated on the basis of the individual signs and con-stitutional characteristics, rather than just a specific disease. This makes pathic principles. In an attempt to address some of the complexities the monitoring of appropriate outcome parameters difficult. However, outlined above, a novel, two-stage study design was tested in order if veterinary or medical homeopathy is to gain acceptance by conven- to allow adherence to both homeopathic and allopathic principles. tional clinicians, it is essential that specific conditions are identified In phase 1, the aim was to identify dogs that showed an apparently that may be helped by this mode of therapy.
positive response to homeopathic remedies; in phase 2, the responding This study reports the use of homeopathic methods in the treat- dogs were put forward into a randomised, blinded, placebo-controlled ment of atopic dermatitis in dogs, a well characterised condition with phase to see whether that response could be linked to a homeopathic a specific clinical phenotype (Olivry and others 2001). This disease remedy. The results from this study were intended to be used to inform highlights some of the problems that can arise when clinical investiga- the design of a larger randomised controlled trial, including the poten- tions are performed to evaluate the use of homeopathy. For example, a tial for using placebos.
previous single-blinded, placebo-controlled study was conducted by an
eminent team of veterinary dermatologists to determine the efficacy of Materials and methods
a commercial homeopathic remedy in the treatment of canine atopic Dogs
dermatitis (Scott and others 2002). Although no beneficial effects were Twenty dogs were recruited to the study from the dogs referred to the
seen, the study design was widely criticised by homeopathic practition-
dermatology clinic at the University of Bristol School of Veterinary ers who wrote to the journal in which the study was reported, claiming Science. Details of the dogs' age, breed and sex are shown in Table 1. that the requirement for individualisation of remedies had been com- The median age at recruitment was two years and seven months.
pletely misunderstood and ignored by the authors (Drosdovech and
others 2002, Jouppi 2002, Kujala 2002, Taylor 2002, Van As 2002). Diagnostic inclusion criteria
In contrast, a study undertaken by veterinary homeopathic practition-
Dogs were diagnosed with non-seasonal atopic dermatitis if they had a ers reporting a moderate or major improvement in 56 per cent of dogs history and clinical signs consistent with published criteria (Willemse with atopic dermatitis (Mathie and others 2007) was non-controlled in 1986, Prélaud and others 1998, DeBoer and Hillier 2001, Griffin and nature, and can be criticised further because it did not use standardised DeBoer 2001). Pruritus due to ectoparasites, infectious agents or dietary methods of diagnosis, monitoring and assessment.
intolerances was ruled out or controlled before the dogs entered the The currently accepted standard for the conduct of clinical trials study. Ectoparasitic dermatoses were excluded by performing skin scrap- requires that three main parameters be fulfilled. Subjects should be ran- ings and hair pluckings and observing the response to treatments with domly assigned to treatment groups; the person conducting the assess- appropriate antiparasitic agents. Pruritus due to staphylococcal infection ment of the outcome measure should be blinded to the treatment being was excluded if typical lesions were not present, or was treated with given; and the treatment being tested should be compared with either appropriate antimicrobial therapy before the dogs entered the study. an established treatment, no treatment, or a placebo. Although the Malassezia species overgrowth was detected using stained acetate tape first two design features can easily be incorporated into trials of home- strips. Adverse reactions to food were ruled out as completely as possible, opathy, the third poses considerable problems. Placebo-controlled tri- depending on the owners' compliance; in any study of this kind, there is als are often considered poorly suited to the evaluation of homeopathy a possibility that some dogs with a concurrent dietary intolerance may (Weatherley-Jones and others 2004) because practitioners claim it is have remained in the study group.
not unusual to have to try two or three remedies before identifying one The dogs underwent intradermal allergy testing using a panel of 40 that is efficacious. Also, the optimal remedy may change with time as allergens (12 dogs) or had serum submitted for IgE serology (one dog), the patient's signs alter. The question asked by homeopathic practition- or had both tests performed (seven dogs). Positive skin test reactions ers is ‘What should be done at a second consultation if the patient has were identified subjectively using standard criteria (Hillier and DeBoer not responded, but it is not known whether the patient has received 2001). All the dogs entering the study had positive reactions to multiple the remedy or the placebo?' Comparing the first remedy that is selected allergens, confirming the diagnosis of atopic dermatitis.
with a placebo is therefore likely to underestimate the potential of the homeopathic approach.
The aim in this pilot study was to use conventional methods of Participation in the study was voluntary. All the owners of dogs diag- diagnostic investigation in cases of atopic dermatitis in dogs, and then nosed with atopic dermatitis were invited to take part, but only some to monitor the response to remedies prescribed according to homeo- agreed. The reasons for not taking part included the dog having severe March 21, 2009 the VETERINARY RECORD
disease, a desire to start conven-tional treatment, reluctance to TABLE 2: Rubrics (signs) used by the veterinary homeopath to select remedies*. The rubrics were identified
by questioning the owner and examining the dog. Local signs included clinical signs associated with the

consider homeopathy, inability skin or other organs. Constitutional signs included personality or character traits, or a history of the skin
to return for necessary rechecks or problem commencing shortly after vaccination. Where more than one remedy is listed, the subsequent
general uncertainty about clinical remedies were prescribed at follow-up consultations, not given concurrently
Constitutional signs Subsequent remedies Pruritic feet, anus, ears Pruritic ventrum, groin, axillae Arsenicum iodide 30C Concurrent conventional medica- tions were permitted during the study if the dog was on long-stand- Pruritic distal forelimbs and metatarsals ing medication for a non-dermato- logical condition, or was currently Multifocal alopecia receiving conventional medica- tion for its skin condition and sud- den withdrawal of that medication Right-sided otitis would not be in the animal's best Generalised pruritus Wet eczema on rump interests. This category included Hyperpigmentation of the ventrum Aversion to onions dogs that had residual, stable and persistent pruritus despite receiv- ing glucocorticoids, ciclosporin or allergen-specific immunotherapy. In the case of allergen-specific Worse when warm and damp immunotherapy, the dog must have been receiving the treatment Pruritus axillae and groin Arsenicum album 200C Sulphur 30C for at least nine months so that fur- Vomiting and bloody diarrhoea at night ther improvements were not to be Pruritus under tail, hindlimbs and chin expected. Vaccinations were not Sensitive to noise permitted during the study period.
To improve compliance with Pruritic perineum and chin the study, the owners were given a supply of prednisolone tablets in case there was a sudden worsening Pruritic face, axillae, groin Fear of thunder and noise of their dog's signs of pruritus. The Right-sided blue/black skin discoloration Dislikes cold and wet owners were told that they should Pruritic face, flanks, feet Arsenicum iodide 30C administer these tablets only on the advice of one of the derma- False pregnancies Likes warm not heat tologists, or if, in their opinion, the pruritus was worsening signifi- Very sensitive but does not console owner cantly at a time when a derma-tologist was not available.
the owners were asked a series of questions relating to the dog's skin prob- Withdrawal criteria during the study period included poor owner com- lem, general health and personality traits, and the dog's skin was exam- pliance, an unacceptable level of discomfort for the dog in the opinion ined. Based on the responses and clinical findings, the signs and features of the owner or veterinary surgeon, or the requirement for additional of the case (known as rubrics) were entered into a homeopathic software conventional treatments to be prescribed during the treatment period.
programme used to identify appropriate remedies (MacRepertory – the Complete 2005 Repertory; Kent Homeopathic Associates). Remedies that matched closely with the documented signs were scrutinised, and if a The severity of pruritus was used as the single outcome measure in single remedy did not emerge as the optimal candidate, a final choice was
this study. Pruritus was assessed by the dogs' owners using a validated determined by the homeopath based on clinical experience. The indi-
and published anchored visual analogue scale, which has severity, vidualised remedies were then prescribed and the owner was instructed
frequency and behavioural factors embedded within it (Hill and to administer them by crushing the tablets and tipping the powder into
others 2007). As this pilot study aimed only to determine the effect the dog's mouth so that it contacted the buccal mucosa.
of the remedies on the level of pruritus, concurrent assessment of
lesion scores with a CADESI (Canine Atopic Dermatitis Extent and Study protocol
Severity Index) scale (Olivry and others 2007) was not performed. In Open phase Owners of dogs participating in the study were requested to
order to justify consideration of a future, larger, randomised control-
attend the clinic on day 0 (the initial homeopathic consultation) and led trial, at least 25 per cent of the dogs were required to have shown 30 and 60 days later. After day 60, an owner could continue to bring a satisfactory reduction in their pruritus scores by the end of their the dog for further homeopathic consultations on a monthly basis if they period of investigation. For dogs with initially high pruritus scores (at wished to pursue this type of treatment for a longer period.
least 5·0), this degree of improvement was defined as a score reduction At each visit, the dog's pruritus score was recorded and the skin was of at least 50 per cent, whereas for dogs with initially lower scores (less examined. At each consultation after day 0, the owners were given the than 5·0), a decrease to a score less than 2·5 was required.
following options, depending on the response that had been observed: if the pruritus had completely resolved, the dog could be withdrawn from the study and monitored for future relapses; if the pruritus had not com- After agreeing to participate in the study, the owners attended a con- pletely resolved, but had decreased to a level that the owner considered sultation conducted by a veterinary homeopath (JH), with one of the a beneficial response, further remedies could be prescribed (either the dermatologists (PH, PL-G or JR) in attendance. During the consultation, same or modified); if the pruritus level had not decreased, the owner was the VETERINARY RECORD March 21, 2009
during the study would be used TABLE 2: Continued
for the final analysis. Changes in Constitutional signs Subsequent remedies the pruritus scores over time were analysed by Friedman's repeated Aggravated by milk, fats, rich food measures analysis of variance, with individual time points com- pared by Dunn's post hoc com- Delayed first oestrus Pruritic axillae, chest, groin, ears Desires fish, milk Aggravated by rubbing Sleeps with head low Clinical features at the time
Eats anything, including animal faeces Arsenicum iodide 30C of enrolment
The mean duration of pruritic skin disease before the dogs entered the trial was 26 months (range Pruritic feet, ventrum and axillae Dislikes rain and getting feet wet seven to 72 months). The pruritus Aggravated by rich food scores ranged from 3·5 to 8·0, with Loud flatus when excited Does not scratch when on owner's lapLoves children a median of 6·55. The number of Lies on back with feet in air allergens identified by skin testing and/or IgE serology ranged from Will scratch until skin raw Fears thunderstorms Arthritic swellings left elbow Desires chicken; oranges aggravate Rubrics and remedies
Pruritus, axillae and groin, worse in The rubrics and remedies for Likes cold bathing Staphisagria 200C each dog are summarised in Pustules in groin Table 2. Sixteen different home- Discharge of black wax from ear Ravenous appetite Lesions worse on right side of body opathic remedies were prescribed Pruritus, belly and nipples Hates thunder and noise throughout the course of the Erythema and lichenification Spices/rich food causes diarrhoea study. The most commonly pre- Seeks sun but warmth aggravates scribed remedy at the first con- Anticipates owner's actionsConsoles the sick sultation was Pulsatilla 200C Pruritus, inguinal region and all feet Very sensitive to noise (given to seven dogs), followed Arsenicum album 30C by Sulphur 30C (five dogs). Cold bathing ameliorates Phosphorus 200C was given to Will eat anything ravenously two dogs, and single dogs were Pruritus, inguinal area and all feet treated with Arsenicum iodide 30C, Lachesis 30C, Carcinosin Warmth aggravates 200C, Arsenicum album 200C, * Homeopathic prescribing is based on a peculiar form of notation used within the repertory. For example, an itching wrist is translated Sepia 200C and Natrum mur into the rubric of ‘Extremities, itching, upper limbs, wrists'; avoiding puddles becomes ‘Extremities, wetting, feet, aggravates.' For the 200C. All dogs were treated with purposes of this table, standard English terminology has been used, and the categories within the repertory known as Mental and a single remedy apart from one General signs are listed together as Constitutional signs. The letters C and M refer respectively to the centesimal and millesimal potencies dog, which was receiving con- of homeopathic dilution (that is, 30C is a 1:100 solution that has been serially diluted 30 times) ventional ciclosporin when it entered the study. This dog was given homeopathic ciclosporin given the option of either changing the remedy (if an alternative was (Atopica) 200C at the same time as Phosphorus 200C.
thought to be appropriate) or withdrawing from the study and reverting Fifteen dogs were given a different remedy at the second or subse- to conventional therapy.
quent consultations, either because the first remedy had not shown any effect, or because the presenting signs had changed. Remedies prescribed Blinded, randomised, placebo-controlled phase If owners considered at follow-up visits that had not been used in the primary consultation that there had been a substantial response to a homeopathic remedy included Kali sulph 30C, Kali carb 30C, Pulsatilla 30C, Pulsatilla 1M, prescribed during the open phase (defined as a reduction in the dog's Morgan 30C, Silicea 30C, Phosphorus 30C, Sepia 30C, Aconite 1M pruritus score of 50 per cent or more), they were invited to take part in and Staphisagria 200C.
a follow-up, blinded, randomised, placebo-controlled phase. The aim All the remedies were administered as either a split dose (three of this phase was to determine whether the responses reported to the pills given over a 24-hour period) or twice daily doses for up to five
homeopathic remedy could be distinguished from responses to a placebo days. In some cases, depending on the remedy, its potency and the
(simple lactose tablets, the vehicle pill used for all the homeopathic response seen by the owner, a second course was administered after a
remedies). For this phase, owners were given two vials of pills, labelled X gap of five to 14 days. No remedies were administered on a continu-
and Y, one containing the remedy and one containing the placebo. The ous daily basis.
owners were blinded to the content of the vials, and the order in which
the tablets were administered was randomised using an online random Clinical responses
number generator (Research Randomizer 2008). The owners were asked Open phase All 20 dogs were evaluated on days 0 and 30; 19 dogs were
to give the pills labelled X first and to score the level of pruritus seven evaluated on day 60. One dog did not attend on day 60, but was scored on
days later. The pills labelled Y were given two weeks after those labelled day 150. For this dog, the day 150 score was used both for the final analysis
X if the dog was still pruritic, or whenever pruritus recurred.
and for the analysis of day 60 scores. Fourteen owners elected to continue with the study until day 90, eight continued until day 120, five continued until day 150, one continued until day 180 and one continued until day The responses to treatment were analysed by intention-to-treat analy- 210. No cases were withdrawn from the study due to poor owner compli- sis, that is, the final pruritus scores for any dogs that were withdrawn ance or following the administration of conventional medications.
March 21, 2009 the VETERINARY RECORD
TABLE 3: Pruritus scores of the 20 dogs throughout the trial,
and changes in score between day 0 and the end of each dog's
participation in the study. The dogs have been ranked in order of
greatest to least percentage improvement. Scores were provided by
owners using a validated anchored visual analogue scale from 0 to 10.
The first homeopathic consultation took place on day 0.
Change of score (%) FIG 1: Pruritus scores of five dogs that showed a good response
to homeopathic remedies. The initial homeopathic consultation
took place on Day 0. Dog 6 had been receiving allergen-specific
immunotherapy and 30 mg prednisolone per month for over a year
before entering the study, but these treatments were discontinued
by day 60. Dog 15 was receiving 5 to 10 mg prednisolone per
day on day 0, but this was reduced to 2·5 mg prednisolone every
other day by day 90. Dogs 4, 9 and 12 had received intermittent
glucocorticoids for two to four years before entering the study, but
no glucocorticoids were given during the study period
The pruritus scores of the 20 dogs throughout the study are shown of remedy before an optimal treatment is established. Second, the time in Table 3. The scores varied widely, both on a group basis and for taken to effect a clinical response may be longer with homeopathic individual dogs. The pruritus scores on day 60 were significantly lower remedies than with conventional drugs, and the authors wanted to than on day 0 (Friedman's repeated measures analysis of variance with allow a degree of flexibility so that this phenomenon could be accom-Dunn's post hoc comparison; P=0·0127). Fourteen dogs had lower pru- modated. Third, the dermatologists wanted to observe the progress of ritus scores at the end of the study than the beginning, and six dogs had the dogs in an open study, so that they could gain a greater understand-higher scores at the end of the study. Five of the dogs had a decrease in ing of the likely outcomes in a typical clinical setting. Finally, this pruritus score of at least 50 per cent (Fig 1); these dogs were selected for was a pilot study, and it is not unusual for open clinical trials to report the second phase of the study.
preliminary data that can be used subsequently to justify larger ran-domised trials. The performance of an open pilot study is indispensable Blinded, randomised, placebo-controlled phase The owners of dog 6 did to allow a power analysis before a randomised controlled trial, and to not participate in the second phase of the trial because the dog's clinical enable the study design and choice of controls to be modified on the signs resolved and it did not require further medication. Dog 15 did not basis of the effect of the drug being tested. This approach was adopted participate because it was euthanased shortly after concluding the first during the introduction of ciclosporin as a treatment for canine atopic phase of the study when it suffered status epilepticus; this dog had suf- dermatitis (Fontaine and Olivry 2001, Olivry and others 2002a, b, fered seizures throughout its life and was receiving phenobarbital. The Steffan and others 2003).
remaining three dogs continued to receive homeopathic remedies on The addition of a blinded, randomised, placebo-controlled cross- an intermittent basis and could therefore be given either the remedy or over phase to investigate dogs that showed a substantial improvement placebo, as described above.
in the open phase was designed as one possible way to legitimise any The owner of dog 12 reported a 0·2 point reduction in the dog's such responses according to conventional criteria. Although this phase pruritus score following placebo treatment and a 2·4 point reduction satisfied conventional criteria for good clinical trial design, the authors following treatment with the remedy. The owner of dog 4 reported no were not aware at the outset how many dogs might progress to this change following the placebo and a 4·3 point reduction in pruritus score stage. In addition, a problem predicted by the homeopath in advance following the remedy. The owner of dog 9 reported a 0·8 point reduc- was that some dogs might undergo complete resolution of their clinical tion in pruritus score following the placebo and a 3·0 point reduction signs and thus not be eligible for further investigation. Homeopathic following the active remedy.
practitioners aspire to cure patients of their clinical signs by encourag-ing their bodies to heal and only a proportion of patients need to be given regular medications. However, in relation to the management of To the authors' knowledge, this is the first study in small animal vet- canine atopic dermatitis, the authors believed that the identification erinary medicine to combine conventional diagnostic approaches with of a subgroup of dogs that, in the opinion of their owners, responded individualised homeopathic prescribing. The aim was to design a pilot well to the intermittent administration of remedies, would be most study to generate data that could be interpreted by both homeopathic likely to yield answers about the effectiveness of homeopathy in the practitioners and conventional veterinary clinicians, and that could be management of the disease.
used to inform the design of a larger randomised controlled trial.
The results of the study are likely to provoke debate from both The design of the study was unusual in that only dogs that appar- homeopathic and conventional veterinary practitioners. Homeopathic ently showed a substantial response to the initial treatment were put practitioners may interpret the results as providing evidence that forward to a randomised controlled phase. This departure from a stand- the prescribed remedies were effective in 25 per cent or more of the ard clinical trial design, in which blinding, randomisation and a con- dogs included in the study. The magnitude of these clinical responses trol group would be used from the outset, was examined for a number (between 64 and 100 per cent improvement in the pruritus scores of five of reasons. First, the authors wanted to allow true homeopathic pre- dogs, with a smaller improvement in another nine dogs), together with scribing principles to be used, which may entail a number of changes the ability of the owners of the three dogs that completed the second the VETERINARY RECORD March 21, 2009
phase to distinguish correctly between a placebo and an active remedy, Although these factors need to be borne in mind when designing would strengthen the argument for this view.
future studies, the authors consider that the overall success or failure Conventional clinicians who are sceptical about homeopathy rate in this study is somewhat irrelevant. The objective of this study was might interpret the results differently, and attribute the responses to to determine whether homeopathic remedies appeared to be beneficial chance and ‘wishful thinking' on behalf of the owners. Seventy-five in enough cases of canine atopic dermatitis to justify a larger trial. Even per cent of the dogs showed clinically insignificant responses or dete- with a cautious interpretation, the preliminary data appear to support rioration in response to the homeopathic treatment, and any mild that view, and the authors believe that a large randomised and control-improvements noted could have been due to natural waxing and wan- led trial is required to confirm or refute the findings. If a similar balance ing of their condition. However, a sceptical analysis of the five dogs of responders and non-responders were obtained in the future, it is likely that showed what appeared to be a good response to the remedies that the trial would need to be performed at several centres in order to is more problematic. One dog's skin condition resolved completely recruit enough dogs.
following homeopathic treatment, allowing the discontinuation of One final point that must be emphasised is that this study has looked conventional treatments (immunotherapy and glucocorticoids) that it at one sign (pruritus) of one disease (atopic dermatitis) in one species had received for two years. Although spontaneous resolution could be (dogs), and readers are urged not to make inferences about homeopathy proposed as the explanation for this improvement, canine atopic der- in general. There is no justification for using the findings reported here matitis is regarded as an incurable disease requiring lifelong manage- to substantiate or repudiate the overall efficacy of homeopathy in either ment (Scott and others 2001), and the chances of a sudden resolution veterinary or human medicine.
occurring coincidentally after the remedies had been administered would be small. The owners of another three dogs correctly distin- guished between a homeopathic remedy and a placebo pill. A sceptical This study was part-funded by the British Homeopathic Association.
interpretation might put this down to chance, although the probabil-ity of it occurring randomly is only 12·5 per cent.
The authors' interpretation of the results is that they provide data to ALBRECHT, H. & SCHÜTTE, A. (1999) Homeopathy versus antibiotics in metaphylaxis justify a larger study to determine whether the findings are repeatable. of infectious diseases: a clinical study in pig fattening and its significance to consumers.
Alternative Therapies in Health and Medicine 5, 64-68
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seen in three-quarters of the dogs were not clinically relevant. The mild CRACKNELL, N. R. & MILLS, D. S. (2008) A double-blind placebo-controlled study into to moderate fluctuations in pruritus score could have occurred due to the efficacy of a homeopathic remedy for fear of firework noises in the dog (Canis famil- well known phenomena such as regression to the mean or waxing and iaris). Veterinary Journal 177, 80-88
waning of disease severity, but it was impossible to assess this without DEBOER, D. J. & HILLIER, A. (2001) The ACVD task force on canine atopic derma- titis (XV): fundamental concepts in clinical diagnosis. Veterinary Immunology and the inclusion of an untreated control group for comparison. However, Immunopathology 81, 271-276
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ticoids, for between one and six years in an attempt to control their DROSDOVECH, M., NEUMANN, S., EVANS, D., BLAKE, S., PECK, L. S., YEAROUT, atopic dermatitis. Dogs 6 and 9 had been assessed by specialist veterinary D. R., ULBRICH, B., FACINELLI, J., DELGADO, R., HOBERG, L., HARMAN, J., STHAMANN, M., LINDSAY, M., KWONG, H., LAMPRU, A., LAMB, J., STAGMEIER, dermatologists in the past and their clinical signs were not considered by K., DOYLE, J. L., ELLIOT, J. & SIEMON, L. (2002) Not classical homeopathy. Canadian their owners to be under satisfactory control, despite the dogs receiving Veterinary Journal 43, 908-909
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pathic remedies. One further owner (of dog 2) believed that a significant ERNST, E. (2002) A systematic review of systematic reviews of homeopathy. British Journal improvement had occurred in the dog, even though a reduction in pruri- of Clinical Pharmacology 54, 577-582
FONTAINE, J. & OLIVRY, T. (2001) Treatment of canine atopic dermatitis with tus score of only 27 per cent was obtained during the formal trial period. cyclosporine: a pilot clinical study. Veterinary Record 148, 662-663
This dog was not put forward to the placebo-controlled phase, but sub- GRIFFIN, C. E. & DEBOER, D. J. (2001) The ACVD task force on canine atopic derma- sequent telephone follow-up indicated that the dog went into remission titis (XIV): clinical manifestations of canine atopic dermatitis. Veterinary Immunology and and no longer required conventional treatment. Furthermore, according Immunopathology 81, 255-269
to the owner, a minor flare-up occurring several months later responded HEKTOEN, L. (2005a) Homeopathic veterinary medicine. Veterinary Record 157, 391-392
promptly to a repeat dose of the original homeopathic remedy.
HEKTOEN, L. (2005b) Review of the current involvement of homeopathy in veterinary practice and research. Veterinary Record 157, 224-229
In a study such as this, a consideration of the failure rate is required HEKTOEN, L., LARSEN, S., ØDEGAARD, S. A. & LØKEN, T. (2004) Comparison of as well as of the potential successes. The success rate was lower than homeopathy, placebo and antibiotic treatment of clinical mastitis in dairy cows – meth- the 60 to 70 per cent predicted by the homeopath at the outset of the odological issues and results from a randomized-clinical trial. Journal of Veterinary Medicine study. There are four potential explanations for this discrepancy. First, Series A 51, 439-446
the group of dogs studied was derived from a referral population. These HILL, P. B., LAU, P. & RYBNICEK, J. (2007) Development of an owner-assessed scale to cases are typically more severe than those seen in general practice, and measure the severity of pruritus in dogs. Veterinary Dermatology 18, 301-308
HILLIER, A. & DEBOER, D. J. (2001) The ACVD task force on canine atopic dermatitis many require potent drugs or complex treatment regimens to keep them (XVII): intradermal testing. Veterinary Immunology and Immunopathology 81, 289-304
in remission. Furthermore, recruitment of cases on to the study was HOLMES, M. A., COCKCROFT, P. D., BOOTH, C. E. & HEATH, M. F. (2005) Controlled voluntary, and owners appeared more eager to participate if they had clinical trial of the effect of a homoeopathic nosode on the somatic cell counts in the milk already exhausted a number of other treatment options; thus, a group of of clinically normal dairy cows. Veterinary Record 156, 565-567
dogs that was particularly difficult to manage may have been selected. JOUPPI, R. (2002) Studies of homeopathic treatments need to involve both homeopaths Secondly, many of the dogs had received, or were receiving, glucocorti- and allopaths. Canadian Veterinary Journal 43, 910
KUJALA, C. (2002) A poor test of homeopathy. Canadian Veterinary Journal 43, 909
coids or ciclosporin. Homeopaths believe that these immunosuppressive LINDE, K., CLAUSIUS, N., RAMIREZ, G., MELCHART, D., EITEL, F., HEDGES, L. V. drugs can interfere with the action of homeopathic remedies. Thirdly, & JONAS, W. B. (1997) Are the clinical effects of homoeopathy placebo effects? A meta- the anticipated success rate when treating canine atopic dermatitis with analysis of placebo-controlled trials. Lancet 350, 834-843
homeopathic remedies may have been based on previous clinical impres- MATHIE, R. T., HANSEN, L., ELLIOTT, M. F. & HOARE, J. (2007) Outcomes from sion, rather than recorded data, and the response rates obtained in this homeopathic prescribing in veterinary practice: a prospective, research-targeted, pilot study may represent the true outcomes that can be expected. Fourthly, if study. Homeopathy 96, 27-34
OLIVRY, T., DEBOER, D. J., GRIFFIN, C. E., HALLIWELL, R. E., HILL, P. B., HILLIER, the beneficial responses were due to spontaneous recoveries and chance A., MARSELLA, R. & SOUSA, C. A. (2001) The ACVD task force on canine atopic der- occurrence, the failure rate would merely reflect the fact that homeopa- matitis: forewords and lexicon. Veterinary Immunology and Immunopathology 81, 143-146
thy is not an effective treatment for canine atopic dermatitis.
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CADESI-03, a severity scale for clinical trials enrolling dogs with atopic dermatitis. SCOTT, D. W., MILLER, W. H., SENTER, D. A., COOK, C. P., KIRKER, J. E. & COBB, Veterinary Dermatology 18, 78-86
S. M. (2002) Treatment of canine atopic dermatitis with a commercial homeopathic OLIVRY, T., RIVIERRE, C., JACKSON, H. A., MURPHY, K. M., DAVIDSON, G. & remedy: a single-blinded, placebo-controlled study. Canadian Veterinary Journal 43, 601-
SOUSA, C. A. (2002a) Cyclosporine decreases skin lesions and pruritus in dogs with atopic dermatitis: a blinded randomized prednisolone-controlled trial. Veterinary Dermatology 13,
SEARCY, R., REYES, O. & GUAJARDO, G. (1995) Control of subclinical bovine mastitis. Utilization of a homoeopathic combination. British Homoeopathic Journal 84, 67-70
OLIVRY, T., STEFFAN, J., FISCH, R. D., PRELAUD, P., GUAGUÈRE, E., FONTAINE, J., STEFFAN, J., ALEXANDER, D., BROVEDANI, F. & FISCH, R. D. (2003) Comparison CARLOTTI, D. N. & EUROPEAN VETERINARY DERMATOLOGY CYCLOSPORINE of cyclosporine A with methylprednisolone for treatment of canine atopic dermatitis: a GROUP (2002b) Randomized controlled trial of the efficacy of cyclosporine in the treat- parallel, blinded, randomized controlled trial. Veterinary Dermatology 14, 11-22
ment of atopic dermatitis in dogs. Journal of the American Veterinary Medical Association TAYLOR, L. (2002) Study defies the most basic tenets of homeopathy. Canadian Veterinary 221, 370-377
Journal 43, 911-912
PRÉLAUD, P., GUAGUÈRE, E., ALHAIDARI, Z., FAIVRE, N., HÉRIPRET, D. & TAYLOR, M. A., REILLY, D., LLEWELLYN-JONES, R. H., MCSHARRY, C. & GAYERIE, A. (1998) Reevaluation of diagnostic criteria of canine atopic dermatitis. Revue AITCHISON, T. C. (2000) Randomised controlled trials of homoeopathy versus placebo de Médecine Vétérinaire 149, 1057-1064
in perennial allergic rhinitis with overview of four trial series. British Medical Journal 321,
RAO, M. L., ROY, R., BELL, I. R. & HOOVER, R. (2007) The defining role of structure (including epitaxy) in the plausibility of homeopathy. Homeopathy 96, 175-183
VAN AS, F. M. (2002) Homeopathic principles not followed. Canadian Veterinary Journal RESEARCH RANDOMIZER (2008) www.randomizer.org. Accessed June 10, 2008 RIJNBERK, A. & RAMEY, D. W. (2007) The end of veterinary homeopathy. Australian WEATHERLEY-JONES, E., THOMPSON, E. A. & THOMAS, K. J. (2004) The placebo- Veterinary Journal 85, 513-516
controlled trial as a test of complementary and alternative medicine: observations from SCOTT, D. W., MILLER, W. H. & GRIFFIN, C. E. (2001) Skin immune system and allergic research experience of individualised homeopathic treatment. Homeopathy 93, 186-189
skin disease. In Muller and Kirk's Small Animal Dermatology. 6th edn. W. B. Saunders. WILLEMSE, T. (1986) Atopic skin disease – a review and a reconsideration of diagnostic criteria. Journal of Small Animal Practice 27, 771-778
the VETERINARY RECORD March 21, 2009

Source: http://www.vetpath.co.uk/voodoo/hill.pdf

Hra expenses

Your Health Reimbursement Arrangement (HRA) dollars may be able to be used to pay for co-payments, co-insurance, and deductibles. But that's not all. You may also be able to use your HRA money to pay for many expenses in the following categories: Medical, Dental Care, Eye Care, and Over-the-Counter (OTC) medications. Eligible items can vary by employer, so check the specifics of your particular HRA plan.

Antibiotic resistance among bacterial pathogens in central africa: a review of the published literature between 1955 and 2008

ARTICLE IN PRESS International Journal of Antimicrobial Agents xxx (2009) xxx–xxx Contents lists available at International Journal of Antimicrobial Agents Antibiotic resistance among bacterial pathogens in Central Africa: a reviewof the published literature between 1955 and 2008 E. Vlieghe , M.F. Phoba , J.J. Muyembe Tamfun , J. Jacobs a Department of Clinical Sciences, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgiumb Institut National de Recherche Biomédicale (INRB), Avenue de la Démocratie (ex Huileries), Kinshasa/Gombe B.P. 1197 Kinshasa 1, Democratic Republic of the Congo