May 7, 1988 - beclomethasone and flunisolide were of no help, and short courses of 1% aqueous ephedrine nasal drops and xylometazoline nasal drops ...
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Advisory Committee on Nutritional Education and the Committee on Medical Aspects of Food Policy and the effects on blood pressure, lipids, and mortality monitored. The multiple risk factor intervention trial compared in 12 000 middle aged high risk men the effects of a vigorously applied health education programme and minimal health education.2 It showed no saving of lives. The Lipid Research Clinics coronary primary prevention trial tested a bile sequestrant against placebo3; both groups were given a cholesterol lowering diet which was regularly and individually monitored. The decline in serum cholesterol concentration in the diet only (placebo) group over seven years was less than 5%. The Helsinki heart study tested a drug which inhibits very low density lipoprotein secretion against placebo and again both groups received repeated and vigorously followed up dietary advice.4 After five years the placebo group had a 2% rise in serum cholesterol concentration. Although these trial data do not constitute "absolute proof," they support strongly the notion that even in carefully supervised, well motivated, middle aged men at known high risk of ischaemic heart disease dietary counselling aimed at altering the amount and quality of the fats consumed is labour intensive while having only a marginal effect on the amount and quality of fats in the blood. Such costly activity should be reserved for the minority of the population whose risk factors have been actively assessed. Dr Black makes a plea for a united front on some form of planned evolution in the NHS. There can be no disagreement with the principle that doctors and other primary health care providers, whether they work for the state or the private sector, should be given incentives to apply established screening techniques to members of the community at risk of preventable chronic degenerative disease by virtue of their age, inheritance, or environment. Only then should advice and treatment be offered to those in whom some divergence from the norm can be identified; its correction would serve as a personal objective for the individual. There surely can be no more egalitarian solution to getting better value for money and avoiding waste while, at the same time, espousing the basic self serving tenets of Thatcherism. ALEXANDER MACNAIR London WIM 7AD 1 Williams GH, Braunwald E. Hypertensive vascular disease. In: Harmison's pnrnciples of internal medicine. 11th ed. New York: McGraw-Hill, 1987. 2 Multiple Risk Factor Intervention Trial Research Group. Multiple risk factor intervention trial: risk factor changes and mortality results. JAMA 1982;248:1465-77. 3 Lipid Research Clinics Program. Lipid Research Clinics coronary primary prevention trial results. 1. Reduction in incidence of coronary heart disease. JAMA 1984;251:351-64. 4 Frick MH, Elo 0, Haapa K, et al. Helsinki heart study: primaryprevention trial with gemfibrozil in middle-aged men with dyslipidaemia. N Engl7 Med 1987;317:1237-45.
7 MAY 1988
taneously shoot oneself in the performance in- medical and surgical emergencies. It is important that an appropriate method is developed as soon as dicator foot? JOHN ROSE possible because the problem is an important one. To treat the maximum number of patients in a Department of Radiology, Harrogate District Hospital, given fixed number of beds, spurred on by the need Harrogate HG2 7SX to reduce waiting lists, and at the same time to meet 1 Fowkes FGR, Davies ER, Evans KT, et al. Compliance with the the needs of all emergencies requiring admission Royal College of Radiologists guidelines on the use of pre- are mutually antagonistic goals. Unplanned operative chest radiographs. Clin Radiol 1987;38:45-8. attempts to reconcile these lead to queues of ill 2 WHO Scientific Group on the Indications for and Limitations of Major X-Ray Diagnostic Investigations. A rational approach patients waiting on trolleys in accident and to radiodiagnostic investigations. Geneva: WHO, 1983. (WHO emergency departments while a frantic search for Technical Report Series No 689.) beds takes place and the last minute cancellation of admissions for elective procedures. Neither is acceptable in a service which is supposed to be giving proper regard to the concept of "quality Peaks and troughs in demands on hospitals
assurance."
SIR,-I am grateful to Dr Bill Kirkup (9 April, p 1070) for his criticism of my statistical approach to the examination of the peaks and troughs in
M F H BUSH East Suffolk Health Authority, Ipswich IP3 8NN
Drug points Lorazepam induced pancytopenia Drs S EL-SAYED and R P SYMONDS (Beatson Oncology Centre, Belvidere Hospital, Glasgow G31 4PG) write: Bone marrow depression associated with lorazepam treatment is uncommon. Although this anxiolytic agent is prescribed widely, only five cases of thrombocytopenia and none of leucopenia have been reported to the Committee on the Safety of Medicines or the manufacturers (Wyeth) in the past 13 years. A 47 year old patient was treated by hysterectomy and bilateral salpingo-oophorectomy for an adenocarcinoma of the uterus. She began a course of postoperative radiotherapy on 12 January 1987. Five days earlier she had begun to take lorazepam 1 mg at night to help her sleep, and she had been taking thyroxine tablets 0 5 mg daily for several years. On 23 January she was noticed to have a mild pancytopenia (table) and her lorazepam tablets were stopped on 26 January. Her radiation fields covered the true pelvis, Blood countsduringradiotherapyand lorazepam treatment White cell
7 Jan Lorazepam started 14 Jan 21 Jan 23 Jan 26 Jan Lorazepam stopped 28 Jan 29 Jan 30 Jan 6 Feb
count (x 109/1)
Haemoglobin
Platelets
6-3 5-5 3-4 3-1
131 136 126 125
181 202
2-3 3-6 3-9 4-1 407
112 114 123 126 138
113 90 115 100 128
(g/1)
(x 109/1)
150
and the volume of bone marrow irradiated was very small. It was felt that the radiotherapy had little part to play in the pancytopenia and it was not interrupted. When the radiotherapy finished on 6 February a total tumour dose of 4250 cGy had been given in 20 fractions. After the withdrawal of lorazepam the patient's blood count returned to normal and remained normal despite the continuation of radiotherapy and Performance indicators thyroxine tablets and diphenoxylate hydrochloride which the patient had taken as required from SIR,-Dr Stella Lowry urges doctors to turn per- tablets, formance indicator figures to their own advantage 20 January to 6 February. (2 April, p 992). In the same issue Mr R M Kirk
refuses to alter his clinical management so as to make his indices look good (p 999). I wonder if either of them could tell me what to do about preoperative chest radiographs? The routine use of this investigation has been discredited. 1 2 Nevertheless it is "ordered" routinely by our anaesthetists despite advice from the radiologists. Preoperative chest radiographs are quick to do, easy to report, and worth valuable performance indicator points. Is it wise to challenge the clinical freedom of one's colleagues and simul-
VOLUME 296
times a day but was accompanied by a rash (September 1986) in the presence of normal haematological values, blood viscosity, and urine values. Two months after the onset of the rash (which affected his collar area, both hands, and scalp) he developed a blocked nasal airway, which proved to be due to grossly oedematous nasal linings. The postnasal space was not visible, but his sense of smell was preserved. Within two weeks of onset the clear watery nasal discharge had become disabling, causing excoriation of the philtrum, and interfered with daily activities and sleep. Intranasal beclomethasone and flunisolide were of no help, and short courses of 1% aqueous ephedrine nasal drops and xylometazoline nasal drops produced no benefit; nor did ephedrine tablets. Examination by an ear, nose, and throat surgeon six months after the onset of nasal discharge showed no obvious cause, though a deflected nasal septum was said to be aggravating the condition. A skin biopsy was performed, resulting in a diagnosis of pemphigus foliaceus. Penicillamine treatment was stopped immediately and within three weeks the nasal discharge ceased, the nasal airway became patent, and the mucosa appeared macroscopically normal. Concurrent bilateral blepharitis first noticed two years after the onset of penicillamine treatment also cleared spontaneously when the drug was stopped. Penicillamine is known to be associated with widespread cutaneous problems, including varieties of pemphigus.' It has also been associated with conjunctivitis and buccal ulceration2 and severe cheilosis.3 No cases of rhinitis associated with penicillamine have been described in published reports or reported to the Committee on Safety of Medicines. The prompt resolution of the rhinitis when penicillamine was stopped in our patient and the long association between the condition and penicillamine treatment suggested an association between the two. Because of the patient's age and the discomfort caused by the suspected reaction I thought it unethical to confirm the association by rechallenge. I Scherak 0, Kolarz G, Holubar K. Pemphigus erythematosuslike rash in a patient on penicillamine. BrMedJ 1977;i:838. 2 Pegum JS, Pembroke AC. Benign mucous-membrane phemphigoid associated with penicillamine treatment. Br Med 7 1977;i:473. 3 Bennett RA, Harbilas E. Wilson's disease with aseptic meningitis and penicillamine related cheilosis. Arch Intem Med 1%7;120: 374-6.
Penicillamine induced rhinitis
Exfoliative dermatitis after amiodarone treatment
Dr A P PRESLEY (Gloucester GL1 lHX) writes: We describe what we believe to be the first case of rhinitis associated with penicillamine. A 76 year old man had developed seropositive rheumatoid arthritis affecting his shoulders, wrists, and neck in 1966. After several anti-inflammatory drugs had been used together with physiotherapy, intra-articular steroids, and systemic analgesia he started taking penicillamine in October 1985. This produced subjective and objective improvements in his joint symptoms at a dose of 125 mg three
Drs R J MOOTs and A BANERJEE (Departments of Medicine and Surgery, Northwick Park Hospital, Harrow, Middlesex) write: Amiodarone is an iodinated cardiac antiarrhythmic drug being used with increasing frequency in the United Kingdom, and with this use is coming experience of adverse reactions. We report here two cases of exfoliative dermatitis arising in conjunction with amiodarone treatment. Case I-A 68 year old man was admitted in
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congestive cardiac failure with atrial fibrillation. He had been well controlled for two years on frusemide 80 mg once a day and potassium supplementation. Soon after admission he developed a ventricular tachycardia, which responded to direct current cardioversion. Multiple ventricular extrasystoles occurred and amiodarone was started. He reverted to sinus rhythm within 72 hours and was discharged on a maintainence dose of 200 mg amiodarone daily. Five weeks later he developed an itchy, macular, erythematous rash on his face, limbs, and trunk. This progressed rapidly to a confluent exfoliative dermatitis covering about 70% of his body. Amiodarone was discontinued and he was admitted two weeks later because of deterioration in his general clinical state. He was treated with topical steroids and made a steady recovery. Case 2-A 78 year old man started taking amiodarone for newly diagnosed drop attacks secondary to the sick sinus syndrome. His history included an anterior myocardial infarction 10 years earlier and mild hypertension for which he had been taking nifedipine (slow release) 20 mg three times a day for four years with no side effects. Within six days of starting amiodarone 200 mg three times a day he developed a florid symmetric peripheral desquamating and erythematous rash, which was diagnosed as exfoliative dermatitis and spread to more than 70% of his body. The amiodarone was stopped two days later and the patient improved rapidly on a regimen of intravenous fluids, corticosteroids, and antihistamines. The cardiovascular condition was subsequently managed by the insertion of a permanent transvenous cardiac pacemaker. Several dermatological side effects have already been described after amiodarone: photosensitivity (in up to 70%) is the best recognised association, but blue-grey skin pigmentation, Lyell's disease (toxic epidermal necrolysis), psoriasis, erythema nodosum, and non-specific rashes have also been reported. '-4 Exfoliative dermatitis is a serious condition in which infective or metabolic complications can prove fatal. In both our patients the rashes occurred after treatment with amiodarone, and all other medication had been taken for a number of years without adverse effects. To our knowledge this side effect of amiodarone treatment has not been reported before. There is no doubt that amiodarone is a useful, and in some circumstances indispensable, drug. We feel, however, that clinicians should be aware of this further, potentially dangerous, adverse effect. I Cetnarowski AB, Rihn TL. A review of adverse reactions to amiodarone. CardiovascularReviews 1985;6:1206-22. 2 Harris L, McKenna WJ, Rowland E, Holt DW, Storey GC, Krikler DM. Side effects of long-term amiodarone therapy. Circulation 1983;67:45-5 1. 3 Bencini PL, Crosti C, Sala F, Bertani E, Nobili M. Toxic epidermal necrolysis and amiodarone treatment. Arch Dermatol 1985;121:838. 4 Raeder EA, Podrid PJ, Lown B. Side effects and complications of amiodarone therapy. Am Heart:7 1985;109:975-83.
Points Underuse of theatres Professor JOHN C PEARSON (Department of Community Medicine, West Virginia University, Morgantown, West Virginia 26506, USA) writes: Reference to
Dispersal of resources in surgical services: beds and operating sessions 1967' No of operating sessions per week No of beds 615 -20 -25 -30 -35 -40 -50 ¢51
Total
s2
3
4
5
11 4 5 4 2 1
-
-
-
5 7
1 -
-
1
2 1
-
-
-
1 2
1 3 -
-
-
6 3 3 3 1 -
27
16
7
4
-
-
1 4 1 -
18
6
7/8
Total
-
-
-
-
2 -
11 16 16 9 9 7 7 2
5
77
2
7 MAY 1988
1333
mended that births should be concentrated in the largest obstetric hospitals, with the consequent closure of smaller units and the further phasing out of home deliveries. Evaluations of results lead to the conclusion that increased hospitalisation has not caused the secular decline in the perinatal mortality rate.2'3 The safety of birth depends primarily on the health of the mother and in most cases is not improved by the interventions of high technology. The committee's decision that birth was safest in the largest hospitals was based on data for 1978, which showed that the average stillbirth rate per 1000 births in the larger hospitals (8 9) was significantly higher than that in the smaller hospitals (3 4), which in turn was significantly higher than that in the unattached 1 Logan RFK, Ashley JSA, Klein RE, Robson DM. Dynamics of general practitioner units (1 -6).4 Disparities this large medical care: the Liverpool study into use of hospital resources. cannot be explained by any excess of high risk births in London: London School of Hygiene and Tropical Medicine, larger hospitals.2 I hope that in the present inquiry 1972. into perinatal and infant deaths the committee will accept only claims supported with evidence and resist the temptation to recommend expenditure on Psychiatric illness among British advanced technological equipment when lesser expenAfro-Caribbeans diture on ensuring adequate nutrition for underprivileged mothers,5 6 together with a decrease in Drs GABRIELLE MILNER and G HAYES (All Saints' obstetric interventions, would more certainly lead to Hospital, Birmingham B18 5SD) write: The article by healthier births. Drs Roland Littlewood and Maurice Lipsedge (2 Perinatal and April, p 950) prompts us to draw attention to a pilot I House of Commons Social Services Committee. neonatal mortality. Second report from the social services commitstudy we are doing at this hospital, which serves tee. Vol I. London: HMSO, 1980. (Crnnd 663-I.) a large multiethnic inner city population. We are 2 Tew M. Do obstetric intranatal interventions make birth safer? examining prospectively the diagnosis and initial BrJf Obstet Gynaecol 1986;;93:659-74. treatment of newly admitted psychiatric patients with 3 Campbell R, Macfarlane A. Where to be born? The debate and the evidence. Oxford: National Perinatal Epidemiology Unit, 1987. reference to their ethnic state. The data have yet to undergo proper statistical analysis, but during a three 4 Tew M. Facts, not assertions of belief. Health and Social Services J3ournal 1980;90:1194-7. month period we have formed the following pre- 5 Baird D. Changing problems and priorities in obstetrics. liminary impressions. The Afro-Caribbeans do not BrJ7 ObstetGynaecol 1985;92:115-21. receive more antipsychotic drugs than other groups 6 Black D, Morris JN, Smith C, Townsend P. Inequalities in and may in fact receive less. The diagnosis of "cannabis health. The Black report. Harmondsworth: Penguin, 1980. psychosis" has not arisen in any of the patients seen so far. Admissions among Afro-Caribbeans tend to be of young men with a diagnosis of an "acute psychotic episode." This may be changed to "schizophrenia" Blood pressure in the elderly if repeated admissions support that diagnosis. Depression is rare. These points need to be clarified Professor C M CASTLEDEN and Dr J SNAPE (Departbefore alarm is raised needlessly within the black ment of Geriatric Medicine, Leicester General community. Hospital, Leicester LES 4PW) write: We support Professor Kari Mattila and others' conclusion that hypertension may not be a risk factor in very old women (26 Should the pill be stopped preoperatively? March, p 887). We have recently completed a casecontrol study comparing 172 patients in hospital Dr BRUCE V STADEL (Department of Health and because of a recent stroke (102 of them women) with Human Services, Food and Drug Administration, 341 age and sex matched controls in the community Rockville, MD 20857) writes: Mr H Sue-Ling and (204 women). All were more than 70 years old. Professor L E Hughes (13 February, p 447) are Analysis of mean blood pressure in the two groups premature in recommending that "the pill should (at admission and one week after stroke in the not be withheld from young women who require patients) showed that isolated systolic hypertension abdominal surgery." Before considering such a major was inversely related to the incidence of stroke (odds change in policy we need to see results from new ratio 0 19, 95% confidence interval 0-48 to 0-08, epidemiological studies designed to re-evaluate the p
