to be advantageous. Similarly, Montague and Glucksman found that casualty officers prescribed tetanus immunisation more appropriately if patients' immune state had been previously recorded by a triage nurse.4 Casualty officers seem to benefit from gentle reminders, especially when they are busy. I firmly believe that radiographers should be encouraged to triage accident and emergency radiographs; this has been shown to decrease the false negative error rate.' I K DUKES Accident and Emergency Department, Selly Oak Hospital, Birmingham B29 6JD 1 Renwick IGH, Butt WP, Steele B. How well can radiographers triage x ray films in accident and emergency departments? BMJ 1991;302:568-9. (9 March.) 2 Vincent CA, Driscoll PA, Audley RJ, Grant DS. Accuracy of detection of radiographic abnormalities by junior doctors. Arch EmergMed 1988;5:101-9. 3 Berman L, da Lacey G, Twomey E, Twomey B, Welch T, Eban R. Reducing errors in the accident and emergency department; a simple method using radiographers. BMJ 1985;290:421-2. 4 Montague A, Glucksman E. Influences on tetanus immunization in accident and emergency. Arch EmergMed 1990;7:163-8.
SIR,-Dr I G H Renwick and colleagues state that their objective was to assess radiographers' ability to identify abnormal radiographs.' This has already been done2; their study merely adds another category to the flagging system-namely, "insignificantly abnormal." This group was not defined. The importance of any abnormality is presumably a judgment for the clinician responsible for the patient. Therefore if the 58 radiographs in which radiographers in fact noted abnormalities but disagreed with the radiologists, saying that they were insignificant, are not included as false negatives, the false negative rate falls to 10% of abnormal radiographs and the overall error rate to 8%. Furthermore, Dr Renwick and colleagues made no assessment of the radiologists' accuracy. They state that they used the radiologists' reports as a gold standard, but in the next sentence refer to a paper which reports a 4% error rate and a 1% equivocal rate for radiologists reporting radiographs in accident and emergency departments.3 Indeed, Seltzer et al stated in their study that 6-3% of junior radiologists' reports were altered by senior colleagues.4 Radiographers' seniority has likewise been shown to affect their accuracy,2 but no assessment was made of this by the authors. This is particularly important as accident and emergency departments are commonly staffed with a large proportion of junior radiographers. Consequently, although we do not disagree wholeheartedly with the concluding statement of Dr Renwick and colleagues, we believe that their results suggest that there is a small total error rate ofdetection by radiographers, who are not specifically trained to diagnose radiographic abnormalities. Therefore there exists a considerable potential for radiographers to undergo a short period of training and provide an accurate means of identifying abnormal radiographs. Whether radiologists and radiographers will have the courage to attempt this and to evaluate the experience remains to be seen. H J NAWROCKA
Radiography Education Cenitre, Guy's Hospital, London J D NAWROCKI
l)epartment of Surgery King's Collcge Hospital, London I Renwick IGH, Butt WI', Steele B. How well can radiographers' triage x ray films in accident and emergency departments?
B.A11J 1991;302:568-9. 9,NMarch.) 2 Berman L, dc Lacey G, Twomev E, 'womey B, Welch T, Eban R. Reducing crrors in the accident and emergency department: a simple method tusing radiographers. BAIJ 1985;290:421-2. 3 De Lacey (iJ, Barker A, Harper J, Wignall B. An assessment of
1024
the clinical efforts of reporting accident and emergency radiographs. BrJ Radiol 1980;53:304-9. 4 Seltzer SE, Hessel SJ, Herman PG, Swensson RG, Sheriff CR. Resident film interpretation and staff review. AIR 1981;137: 129-33.
War and medicine SIR, - I was concerned to read the letter on the war in Iraq from members of the North East Thames Medical Practitioners Union.' I think it is worth noting that most of the 100 000 dead they quote were members of the Iraqi armed forces and not civilians. It was obvious at the time of the conflict that the allied forces took great pains to avoid unnecessary civilian casualties. The Iraqi "compliance" with the United Nations resolution to withdraw from Kuwait was in fact a precipitate rout of an incompetently led and outclassed army. As soon as the political aims of the resolution had been achieved the allied advances ceased; if the allies had been out to inflict "gratuitous" casualties this would have occurred as the retreating Iraqi army withdrew into central Iraq. It has become increasingly obvious since Iraq's withdrawal from Kuwait that the Iraqi leadership has a total contempt for human life and also for the environment both locally within the Gulf and on a more global scale, with the firing of oil wells and the release of a large oil slick. Dr Anna Livingstone and colleagues would do better to devote their sympathies to the unfortunate Kurds who are being attacked by the helicopter gun ships of the Iraqi army, most of the victims in this case being unarmed civilians. Perhaps Iraq's oil revenues would be better spent improving the country's own humanitarian and medical infrastructure rather than on a genocidal war within its own boundaries.
is on record; and reports should be written at regular intervals by trainers, the accumulated information (facts about experience and opinions about performance) creating a much clearer picture of the candidate's true worth than the current selective and partial referehces. It is unfortunate that so much resistance (by both trainers and trainees) to these two potentially helpful reforms to our training arrangements still exists. JOHN R BENNETT
Gastrointestinal Unit, Hull Royal Infirmary, Hull HU3 2JZ I Arnold F. The research fetish. B.M7 1991;302:855. (6 April.)
ChanIges to thle NHS
SIR,-Considerable attention has been paid recently to the slowing of the reform of the NHS,' slowed further by the replacement of Mr Clarke with Mr Waldegrave at the Department of Health and then Mrs Thatcher with Mr Major as Prime Minister. There are, however, trends, identified with the white paper Working for Patients, that point to a change in attitudes to the NHS by policy makers and managers. Firstly, the white paper calls for explicit rationing of care (according to priorities) by purchasers to replace implicit or tacit rationing by providers after a process of free referral. Now we learn that the chief executive of the NHS Management Executive, Mr Duncan Nichol, has instructed regional health authorities to set conditions for access to waiting lists.2 However minor these may be in practice (for political reasons), an important precedent has been set in implementing the white paper's philosophy. T J JONES Secondly, the language of consumer choice is Department of Histopathology and Cytology, Royal Shrewsbury Hospital North, increasingly deployed, but in inverse proportion to Shrewsbury, the possibilities for choice by consumers and Shropshire SY3 8XQ patients since the implementation of the NHS and Community Care Act. This also shadows the white 1 Livingstone A, Patel RAJ, Lehmann AB. Pollen R, Owen A. paper's emphasis on working for patients in its War and medicine. BMJ 1991;302:849. (6 April.) rhetoric yet on making the manager (rather than the patient's advocate, the doctor) responsible for translating needs and priorities into contracts with providers. Yet a basic fact remains: in Britain The research fetish contracts made by purchasers with providers SIR,-Research should be performed and reported reflect the need for economy as a first priority. It is in the gradual abandonment of a radical for the right reasons, as Mr Frank Arnold cogently and wittily argued, and it is obviously undesirable market strategy, internal or otherwise, that if the selection of candidates by appointments undoubtedly the brakes have been applied. But the committees is based on the number of their use of the white paper as a tool for managers to publications and so encourages a valueless paper- enforce economy and reorient employee relations chase. A problem does exist and deserves public throughout the NHS, just as the competitive tendering process instigated in 1983 did in a debate; I should like to make two points. The precept that "research trains the mind" limited sphere, is increasingly developed. The purchaser-provider separation is a myth should not too readily be abandoned. Aspiring specialists who have never thought of a question except where NHS trusts are the providers-and, they would like to answer or a hypothesis they even there, Mr Waldegrave has recently announced should like to test are unlikely to become consult- significant restrictions on the freedom of trusts to ants who will properly assess the worth of new pay market rates and invest via capital markets. developments rather than simply follow fashion. For purchasers (districts) in fact employ and train Systematic audit is going to demand those the key workforce-doctors-employed by analytical faculties that are learnt as research providers. In practice, closely linked providing techniques. Unfortunately, too many trainees have and purchasing management teams will be an not attempted to devise a project but have asked expanded bureaucratic force against which other to be "given" some research-thus does dull, voices have less of a hearing. So, less change than uninspiring toil displace the alternating excitement expected in one direction but more in another. Markets require competition to provide and frustration that characterise original research. Secondly, appointments committees may use efficiency. If "unnecessary" investments, failures, publications as a measure of ability because they and closures are not permitted there will be no have so few other objective data by which to assess competitive market. That is no bad thing. So why candidates. More important considerations- not admit that strategic planning is not a discredited technical ability, judgment, consistency of per- adjunct of pre-1990 eastern Europe but the formance-can in most cases be estimated only essential tool of the modern general management from the candidate's own statements and perhaps of the NHS? Then we could allow provision of gleaned from selective references. Two fairly services to reflect agreement among doctors, simple measures could correct this and perhaps put managers, and patients' advocates within allowed the publication record where it belongs: all trainees budgets. Moreover, the government would not should keep log books so that their true experience have the worst of both worlds-opprobrium it no
BMJ VOLUME 302
27 APRIL 1991
longer deserves (although it certainly did from 1988 to 1990) for indiscriminately encouraging markets, and also opprobrium it certainly does deserve (currently) for interfering obsessively in increasing central control of a supposedly newly devolved NHS. In the end we are left with the contracting process and the purchaser's ability to identify need-yet the rhetoric of consumerism. This may produce two forces for higher spending. Firstly, rationing based on purchasers' priorities translated into contracts with providers may still be politically unacceptable (hence the recent problems over interleukin at the Christie Hospital, Manchester). Yet, secondly, consumers will demand "production line" medicine and "trendy" procedures, whether they meet need, defined by experts, or not. In aggregate these forces will push for higher NHS spending. This may be fine. After all, Britain is a very low spender on health. And public spending is the most effective and efficient way to increase expenditure on health. The problem hitherto has been the conventional wisdom, on the right and the left, that only moving to an insurance based or partly private financing system could boost aggregate spending. It would be an ironv to be savoured if the long term fallout of the review was higher public spending and little or no reliance on competitive markets. CALUM R PATON
Cenitre tor Hcalth Planning and Management, Keele University, Keele, Staftfordshire SF5 5SP
11am C. Revisiting the initcrnial ntarket. BAI7 1991;302:250-1. (2 Februarv.) 2 Brindle D. I'atients facc February 12 1991:6.
httrdlc to joinl NHS quietues. (Guardiant
Drug Points Digoxin toxicity presenting as dysphagia and dysphonia Drs M F CORDEIRO and K G ARNOLD (Geriatric Department, University College Hospital, London NW1 OPE) write: A 93 year old woman was referred by her general practitioner with a two month history of worsening dysphagia (initially solids but progressing to liquids), dysphonia, nausea, anorexia, and weight loss (13 kg in four months). Six months previously her general practitioner had started treatment with digoxin for rapid atrial fibrillation. On admission to hospital she was taking 0 125 mg digoxin a day. On examination she was found to be cachectic, but no other abnormal clinical signs were present. Her plasma urea and electrolyte concentrations were normal, as was her chest x ray film, and an electrocardiogram confirmed her to be in atrial fibrillation. A barium swallow examination two days later showed no abnormality apart from evidence of oesophageal muscle incoordination. She was referred to the ear, nose, and throat department for investigation of her dvsphonia. Indirect laryngopharyngoscopy showed no abnormalities, as did oesphagopharyngoscopy. Serum digoxin concentration on the day of admission was extremely high at 6 1 nmol/l (normal range 0-9-2 6 nmolll nine hours after dose). Digoxin was therefore stopped and electrocardiography was performed daily to monitor her cardiac state. Four days after digoxin was stopped her serum digoxin concentration was 1 3 nmol/l. Over the next few days her dysphagia and dvsphonia progressively improved and she was discharged three weeks later without any medication but with a normal electrocardiogram and complete resolution of her presenting symptoms.
BMJ VOLUME 302
27 APRIL 1991
The cause of this patient's dysphagia and dysphonia could, after investigation, be attributed only to her toxic serum concentration of digoxin.' Once the digoxin had been discontinued her symptoms resolved. There has been one previous report of digoxin toxicity manifested by dysphagia,2 but no mechanism of oesophageal dysfunction has been elucidated. Perhaps, in the light of the above, further investigations into the effects of digoxin on smooth muscle (other than cardiac or intestinal sphincteric muscle') should be undertaken. Dysphagia and dysphonia may be occasional symptoms of digoxin toxicity. I Park (iD, Spector R, (iold erg MJ, Feldman RD. Digoxin toxicity in patients with high serum digoxin concentrations.
Am 71ed Sci 1987;294:423-8.
hemiparesis (Committee on Safety of Medicines, personal communication, 1990). Slow acetylator state has been implicated as a predisposing factor in the development of some toxic reactions induced by sulphasalazine,' but the acetylator status was not determined in our patient. Several drugs have been incriminated as causing chorea.4 We have been unable to find any reports of chorea produced by sulphasalazine. Digoxin is unlikely to have been responsible in our patient as she had been taking the same dose for some time before the onset of the chorea. We cannot, however, exclude a synergistic effect. If a person taking sulphasalazine develops fidgetiness or frank chorea for which no other cause can be found, we would suggest that this drug should also be considered as a possible cause.
2 Kelton JG, Sctullin DC. Digitalis toxicity manifested by dvs-
phagia. JIMA 1978;239:613-4. 3 Gazes PC, Holmes CR, Moseley \V, Pratt-Thomas HR. Acute haemorrhage and necrosis of the intestines associated with digitalization. Circulatton 1961;24:358-64.
Chorea precipitated by sulphasalazine Drs A G QUINN and W R ELLIS (Department of Medicine, Dryburn Hospital, Durham) and Drs D BURN and N CARTLIDGE (Department of Neurology, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP) write: A 70 year old woman was admitted to hospital for investigation of a five month history of diarrhoea. Involuntary movements of her right arm had been present for four weeks. Six weeks before admission she had started taking sulphasalazine 1 g four times daily. There was no history of movement disorder, rheumatic fever, or psychiatric illness, and no family history of chorea. She had undergone partial thyroidectomy five years before. She was also taking digoxin and a frusemide and potassium combination diuretic (Lasikal). Her general practitioner confirmed that no other drugs had been prescribed in the past two years and that she had never received neuroleptics. On examination she appeared well and was alert and fully orientated. Her pulse was 76 beats/min and blood pressure 140/80 mm Hg, and she had a soft pansvstolic murmur. She had mild choreiform movements of her right upper arm but no other focal neurological signs. Results of a full blood count, erythrocyte sedimentation rate, and biochemical profile including thyroid function tests were all normal. Results of an autoantibody screen were negative and serum magnesium concentration was within normal limits. No pathogens were found on stool culture or microscopy. She was discharged, taking the same drugs, and readmitted four weeks later for flexible sigmoidoscopy. Repeat neurological examination at that time showed a generalised choreiform movement disorder. No other neurological signs were detected. The reflexes were symmetrical and not depressed, and there were no other focal signs. Flexible sigmoidoscopy and mucosal biopsy showed no evidence of inflammatory bowel disease. The possibility of a drug induced chorea was considered in view of the temporal relation between the onset of the symptoms and starting sulphasalazine. Sulphasalazine was withdrawn; other drugs, including digoxin, were continued. Over the next eight weeks the chorea slowly improved. Repeat neurological examination four months later had entirely normal results. Our patient developed a progressive movement disorder two weeks after starting sulphasalazine, which resolved when this drug was discontinued. We believe that the time course and response to withdrawal incriminates sulphasalazine as the cause of the movement disorder. A number of adverse neurological reactions associated with sulphasalazine use have been described. These include sensorimotor neuropathy, ataxia, tremor, encephalopathy, and
1 Price TR. Sensorimotor neuropathy with sulphasalazine. Postgrad.Medj 1985;61:147-8. 2 Hermann GG. Sulphasalazine: adverse effects. Dig Dis Sci 1984;29:781-2. 3 Skeith KJ, Russell AS. Adverse reactions to sulphasalazine. J Rheumatol 1988;15:529-30. 4 Padberg GW, Bruyn GW. Chorea: differential diagnosis. In: Handbook of clinical neurology. Vol 5. 1986:549-64.
Influence of oral contraceptives on body temperature Dr R H B MEYBOOM (Netherlands Pharmacovigilance Centre, PO Box 5406, 2280 HK Rijswijk, The Netherlands) writes: One of the physiological effects of progesterone is a slight rise in body temperature, up to 0 5°C. " Mid-cycle temperature rise may be used as evidence of ovulation and the formation of a corpus luteum. Although progestagens are a basic constituent of oral contraceptives, the possibility of an influence on temperature is not mentioned in the usual sources of information on side effects. 3 6 A recent case report to The Netherlands Pharmacovigilance Centre described a 35 year old woman with longstanding rise in body temperature of about 0 5°C, which in the evening reached subfebrile values up to 38°C, in suspected association with Microgynon 30 (levonorgestrel 150 itg, ethinyloestradiol 30 [tg). No medical cause was found and the course of the temperature after stopping and during rechallenge, as established by daily rectal assessment of morning temperature, was consistent with an effect of the contraceptive agent. Although the influence of progesterone on temperature is well known, there is a remarkable paucity of data in current physiology textbooks concerning this effect.2 With regard to oral contraceptives, only one reference was found in the medical literature, but without quantification and comment.9 A body temperature raised by 0 5&C may be mistaken for a subfebrile temperature and may be a cause of unnecessary concern and medical investigations. More information on the influence of progestagens on temperature is needed. The product information of all oral contraceptives containing a progestagen should mention the possibility of a slight rise in body temperature. I De Mouzon J, Iestart J, lcfe reB Pouly Jl., Frsdman B. Iitllne relationships between basal body temperature and ovulation or plasma progestins. Fertil Steril 1984;41:254-9. 2 Keele CA, Neil E, Joels N. Samson W'right's applied phs'siologv. Oxford: Oxford University Press, 1983. 3 Association of the British Pharmaccutical Industry. ABPI data sheet compendium. London: Datapharm, 1990. 4 Wade A. Martindale: the extra pharmacopoeia. 29th ed. Lotsdon: Pharmaceutical Plress, 1989. 5 Dukes MN, ed. Mevler's side effects of drugs. 11th cd. Amstcrdam: Elsevier, 1988. 6 Dasies D)M. Texthook of adverse drug reactions. 3rd ed. Oxtord: Oxford University P'ress, 1985. 7 Meyboom RHB, M\artin DJ. 136ienvltedittg van de lichaatnstemperatuur door orale anticotcceptisa. Huisarts Wet 199(0;33:
488-90. 8
GUtvton AC. Iexibook of' medical physiologv. I'hiladelpilia:
Saunders, 1986. 9 Spona J, Schneider WHF. Central and peripheral parametcrs of the menstrual cy,cle under the influence of a new combined oral
cotttraceptive. A-cta Obstet (vnecol Scand 1976;suppl 54:45-5(0.
1025
SIR,-Dr I G H Renwick and colleagues state that their objective was to assess radiographers' ability to identify abnormal radiographs.' This has already been done2; their study merely adds another category to the flagging system-namely, "insignificantly abnormal." This group was not defined. The importance of any abnormality is presumably a judgment for the clinician responsible for the patient. Therefore if the 58 radiographs in which radiographers in fact noted abnormalities but disagreed with the radiologists, saying that they were insignificant, are not included as false negatives, the false negative rate falls to 10% of abnormal radiographs and the overall error rate to 8%. Furthermore, Dr Renwick and colleagues made no assessment of the radiologists' accuracy. They state that they used the radiologists' reports as a gold standard, but in the next sentence refer to a paper which reports a 4% error rate and a 1% equivocal rate for radiologists reporting radiographs in accident and emergency departments.3 Indeed, Seltzer et al stated in their study that 6-3% of junior radiologists' reports were altered by senior colleagues.4 Radiographers' seniority has likewise been shown to affect their accuracy,2 but no assessment was made of this by the authors. This is particularly important as accident and emergency departments are commonly staffed with a large proportion of junior radiographers. Consequently, although we do not disagree wholeheartedly with the concluding statement of Dr Renwick and colleagues, we believe that their results suggest that there is a small total error rate ofdetection by radiographers, who are not specifically trained to diagnose radiographic abnormalities. Therefore there exists a considerable potential for radiographers to undergo a short period of training and provide an accurate means of identifying abnormal radiographs. Whether radiologists and radiographers will have the courage to attempt this and to evaluate the experience remains to be seen. H J NAWROCKA
Radiography Education Cenitre, Guy's Hospital, London J D NAWROCKI
l)epartment of Surgery King's Collcge Hospital, London I Renwick IGH, Butt WI', Steele B. How well can radiographers' triage x ray films in accident and emergency departments?
B.A11J 1991;302:568-9. 9,NMarch.) 2 Berman L, dc Lacey G, Twomev E, 'womey B, Welch T, Eban R. Reducing crrors in the accident and emergency department: a simple method tusing radiographers. BAIJ 1985;290:421-2. 3 De Lacey (iJ, Barker A, Harper J, Wignall B. An assessment of
1024
the clinical efforts of reporting accident and emergency radiographs. BrJ Radiol 1980;53:304-9. 4 Seltzer SE, Hessel SJ, Herman PG, Swensson RG, Sheriff CR. Resident film interpretation and staff review. AIR 1981;137: 129-33.
War and medicine SIR, - I was concerned to read the letter on the war in Iraq from members of the North East Thames Medical Practitioners Union.' I think it is worth noting that most of the 100 000 dead they quote were members of the Iraqi armed forces and not civilians. It was obvious at the time of the conflict that the allied forces took great pains to avoid unnecessary civilian casualties. The Iraqi "compliance" with the United Nations resolution to withdraw from Kuwait was in fact a precipitate rout of an incompetently led and outclassed army. As soon as the political aims of the resolution had been achieved the allied advances ceased; if the allies had been out to inflict "gratuitous" casualties this would have occurred as the retreating Iraqi army withdrew into central Iraq. It has become increasingly obvious since Iraq's withdrawal from Kuwait that the Iraqi leadership has a total contempt for human life and also for the environment both locally within the Gulf and on a more global scale, with the firing of oil wells and the release of a large oil slick. Dr Anna Livingstone and colleagues would do better to devote their sympathies to the unfortunate Kurds who are being attacked by the helicopter gun ships of the Iraqi army, most of the victims in this case being unarmed civilians. Perhaps Iraq's oil revenues would be better spent improving the country's own humanitarian and medical infrastructure rather than on a genocidal war within its own boundaries.
is on record; and reports should be written at regular intervals by trainers, the accumulated information (facts about experience and opinions about performance) creating a much clearer picture of the candidate's true worth than the current selective and partial referehces. It is unfortunate that so much resistance (by both trainers and trainees) to these two potentially helpful reforms to our training arrangements still exists. JOHN R BENNETT
Gastrointestinal Unit, Hull Royal Infirmary, Hull HU3 2JZ I Arnold F. The research fetish. B.M7 1991;302:855. (6 April.)
ChanIges to thle NHS
SIR,-Considerable attention has been paid recently to the slowing of the reform of the NHS,' slowed further by the replacement of Mr Clarke with Mr Waldegrave at the Department of Health and then Mrs Thatcher with Mr Major as Prime Minister. There are, however, trends, identified with the white paper Working for Patients, that point to a change in attitudes to the NHS by policy makers and managers. Firstly, the white paper calls for explicit rationing of care (according to priorities) by purchasers to replace implicit or tacit rationing by providers after a process of free referral. Now we learn that the chief executive of the NHS Management Executive, Mr Duncan Nichol, has instructed regional health authorities to set conditions for access to waiting lists.2 However minor these may be in practice (for political reasons), an important precedent has been set in implementing the white paper's philosophy. T J JONES Secondly, the language of consumer choice is Department of Histopathology and Cytology, Royal Shrewsbury Hospital North, increasingly deployed, but in inverse proportion to Shrewsbury, the possibilities for choice by consumers and Shropshire SY3 8XQ patients since the implementation of the NHS and Community Care Act. This also shadows the white 1 Livingstone A, Patel RAJ, Lehmann AB. Pollen R, Owen A. paper's emphasis on working for patients in its War and medicine. BMJ 1991;302:849. (6 April.) rhetoric yet on making the manager (rather than the patient's advocate, the doctor) responsible for translating needs and priorities into contracts with providers. Yet a basic fact remains: in Britain The research fetish contracts made by purchasers with providers SIR,-Research should be performed and reported reflect the need for economy as a first priority. It is in the gradual abandonment of a radical for the right reasons, as Mr Frank Arnold cogently and wittily argued, and it is obviously undesirable market strategy, internal or otherwise, that if the selection of candidates by appointments undoubtedly the brakes have been applied. But the committees is based on the number of their use of the white paper as a tool for managers to publications and so encourages a valueless paper- enforce economy and reorient employee relations chase. A problem does exist and deserves public throughout the NHS, just as the competitive tendering process instigated in 1983 did in a debate; I should like to make two points. The precept that "research trains the mind" limited sphere, is increasingly developed. The purchaser-provider separation is a myth should not too readily be abandoned. Aspiring specialists who have never thought of a question except where NHS trusts are the providers-and, they would like to answer or a hypothesis they even there, Mr Waldegrave has recently announced should like to test are unlikely to become consult- significant restrictions on the freedom of trusts to ants who will properly assess the worth of new pay market rates and invest via capital markets. developments rather than simply follow fashion. For purchasers (districts) in fact employ and train Systematic audit is going to demand those the key workforce-doctors-employed by analytical faculties that are learnt as research providers. In practice, closely linked providing techniques. Unfortunately, too many trainees have and purchasing management teams will be an not attempted to devise a project but have asked expanded bureaucratic force against which other to be "given" some research-thus does dull, voices have less of a hearing. So, less change than uninspiring toil displace the alternating excitement expected in one direction but more in another. Markets require competition to provide and frustration that characterise original research. Secondly, appointments committees may use efficiency. If "unnecessary" investments, failures, publications as a measure of ability because they and closures are not permitted there will be no have so few other objective data by which to assess competitive market. That is no bad thing. So why candidates. More important considerations- not admit that strategic planning is not a discredited technical ability, judgment, consistency of per- adjunct of pre-1990 eastern Europe but the formance-can in most cases be estimated only essential tool of the modern general management from the candidate's own statements and perhaps of the NHS? Then we could allow provision of gleaned from selective references. Two fairly services to reflect agreement among doctors, simple measures could correct this and perhaps put managers, and patients' advocates within allowed the publication record where it belongs: all trainees budgets. Moreover, the government would not should keep log books so that their true experience have the worst of both worlds-opprobrium it no
BMJ VOLUME 302
27 APRIL 1991
longer deserves (although it certainly did from 1988 to 1990) for indiscriminately encouraging markets, and also opprobrium it certainly does deserve (currently) for interfering obsessively in increasing central control of a supposedly newly devolved NHS. In the end we are left with the contracting process and the purchaser's ability to identify need-yet the rhetoric of consumerism. This may produce two forces for higher spending. Firstly, rationing based on purchasers' priorities translated into contracts with providers may still be politically unacceptable (hence the recent problems over interleukin at the Christie Hospital, Manchester). Yet, secondly, consumers will demand "production line" medicine and "trendy" procedures, whether they meet need, defined by experts, or not. In aggregate these forces will push for higher NHS spending. This may be fine. After all, Britain is a very low spender on health. And public spending is the most effective and efficient way to increase expenditure on health. The problem hitherto has been the conventional wisdom, on the right and the left, that only moving to an insurance based or partly private financing system could boost aggregate spending. It would be an ironv to be savoured if the long term fallout of the review was higher public spending and little or no reliance on competitive markets. CALUM R PATON
Cenitre tor Hcalth Planning and Management, Keele University, Keele, Staftfordshire SF5 5SP
11am C. Revisiting the initcrnial ntarket. BAI7 1991;302:250-1. (2 Februarv.) 2 Brindle D. I'atients facc February 12 1991:6.
httrdlc to joinl NHS quietues. (Guardiant
Drug Points Digoxin toxicity presenting as dysphagia and dysphonia Drs M F CORDEIRO and K G ARNOLD (Geriatric Department, University College Hospital, London NW1 OPE) write: A 93 year old woman was referred by her general practitioner with a two month history of worsening dysphagia (initially solids but progressing to liquids), dysphonia, nausea, anorexia, and weight loss (13 kg in four months). Six months previously her general practitioner had started treatment with digoxin for rapid atrial fibrillation. On admission to hospital she was taking 0 125 mg digoxin a day. On examination she was found to be cachectic, but no other abnormal clinical signs were present. Her plasma urea and electrolyte concentrations were normal, as was her chest x ray film, and an electrocardiogram confirmed her to be in atrial fibrillation. A barium swallow examination two days later showed no abnormality apart from evidence of oesophageal muscle incoordination. She was referred to the ear, nose, and throat department for investigation of her dvsphonia. Indirect laryngopharyngoscopy showed no abnormalities, as did oesphagopharyngoscopy. Serum digoxin concentration on the day of admission was extremely high at 6 1 nmol/l (normal range 0-9-2 6 nmolll nine hours after dose). Digoxin was therefore stopped and electrocardiography was performed daily to monitor her cardiac state. Four days after digoxin was stopped her serum digoxin concentration was 1 3 nmol/l. Over the next few days her dysphagia and dvsphonia progressively improved and she was discharged three weeks later without any medication but with a normal electrocardiogram and complete resolution of her presenting symptoms.
BMJ VOLUME 302
27 APRIL 1991
The cause of this patient's dysphagia and dysphonia could, after investigation, be attributed only to her toxic serum concentration of digoxin.' Once the digoxin had been discontinued her symptoms resolved. There has been one previous report of digoxin toxicity manifested by dysphagia,2 but no mechanism of oesophageal dysfunction has been elucidated. Perhaps, in the light of the above, further investigations into the effects of digoxin on smooth muscle (other than cardiac or intestinal sphincteric muscle') should be undertaken. Dysphagia and dysphonia may be occasional symptoms of digoxin toxicity. I Park (iD, Spector R, (iold erg MJ, Feldman RD. Digoxin toxicity in patients with high serum digoxin concentrations.
Am 71ed Sci 1987;294:423-8.
hemiparesis (Committee on Safety of Medicines, personal communication, 1990). Slow acetylator state has been implicated as a predisposing factor in the development of some toxic reactions induced by sulphasalazine,' but the acetylator status was not determined in our patient. Several drugs have been incriminated as causing chorea.4 We have been unable to find any reports of chorea produced by sulphasalazine. Digoxin is unlikely to have been responsible in our patient as she had been taking the same dose for some time before the onset of the chorea. We cannot, however, exclude a synergistic effect. If a person taking sulphasalazine develops fidgetiness or frank chorea for which no other cause can be found, we would suggest that this drug should also be considered as a possible cause.
2 Kelton JG, Sctullin DC. Digitalis toxicity manifested by dvs-
phagia. JIMA 1978;239:613-4. 3 Gazes PC, Holmes CR, Moseley \V, Pratt-Thomas HR. Acute haemorrhage and necrosis of the intestines associated with digitalization. Circulatton 1961;24:358-64.
Chorea precipitated by sulphasalazine Drs A G QUINN and W R ELLIS (Department of Medicine, Dryburn Hospital, Durham) and Drs D BURN and N CARTLIDGE (Department of Neurology, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP) write: A 70 year old woman was admitted to hospital for investigation of a five month history of diarrhoea. Involuntary movements of her right arm had been present for four weeks. Six weeks before admission she had started taking sulphasalazine 1 g four times daily. There was no history of movement disorder, rheumatic fever, or psychiatric illness, and no family history of chorea. She had undergone partial thyroidectomy five years before. She was also taking digoxin and a frusemide and potassium combination diuretic (Lasikal). Her general practitioner confirmed that no other drugs had been prescribed in the past two years and that she had never received neuroleptics. On examination she appeared well and was alert and fully orientated. Her pulse was 76 beats/min and blood pressure 140/80 mm Hg, and she had a soft pansvstolic murmur. She had mild choreiform movements of her right upper arm but no other focal neurological signs. Results of a full blood count, erythrocyte sedimentation rate, and biochemical profile including thyroid function tests were all normal. Results of an autoantibody screen were negative and serum magnesium concentration was within normal limits. No pathogens were found on stool culture or microscopy. She was discharged, taking the same drugs, and readmitted four weeks later for flexible sigmoidoscopy. Repeat neurological examination at that time showed a generalised choreiform movement disorder. No other neurological signs were detected. The reflexes were symmetrical and not depressed, and there were no other focal signs. Flexible sigmoidoscopy and mucosal biopsy showed no evidence of inflammatory bowel disease. The possibility of a drug induced chorea was considered in view of the temporal relation between the onset of the symptoms and starting sulphasalazine. Sulphasalazine was withdrawn; other drugs, including digoxin, were continued. Over the next eight weeks the chorea slowly improved. Repeat neurological examination four months later had entirely normal results. Our patient developed a progressive movement disorder two weeks after starting sulphasalazine, which resolved when this drug was discontinued. We believe that the time course and response to withdrawal incriminates sulphasalazine as the cause of the movement disorder. A number of adverse neurological reactions associated with sulphasalazine use have been described. These include sensorimotor neuropathy, ataxia, tremor, encephalopathy, and
1 Price TR. Sensorimotor neuropathy with sulphasalazine. Postgrad.Medj 1985;61:147-8. 2 Hermann GG. Sulphasalazine: adverse effects. Dig Dis Sci 1984;29:781-2. 3 Skeith KJ, Russell AS. Adverse reactions to sulphasalazine. J Rheumatol 1988;15:529-30. 4 Padberg GW, Bruyn GW. Chorea: differential diagnosis. In: Handbook of clinical neurology. Vol 5. 1986:549-64.
Influence of oral contraceptives on body temperature Dr R H B MEYBOOM (Netherlands Pharmacovigilance Centre, PO Box 5406, 2280 HK Rijswijk, The Netherlands) writes: One of the physiological effects of progesterone is a slight rise in body temperature, up to 0 5°C. " Mid-cycle temperature rise may be used as evidence of ovulation and the formation of a corpus luteum. Although progestagens are a basic constituent of oral contraceptives, the possibility of an influence on temperature is not mentioned in the usual sources of information on side effects. 3 6 A recent case report to The Netherlands Pharmacovigilance Centre described a 35 year old woman with longstanding rise in body temperature of about 0 5°C, which in the evening reached subfebrile values up to 38°C, in suspected association with Microgynon 30 (levonorgestrel 150 itg, ethinyloestradiol 30 [tg). No medical cause was found and the course of the temperature after stopping and during rechallenge, as established by daily rectal assessment of morning temperature, was consistent with an effect of the contraceptive agent. Although the influence of progesterone on temperature is well known, there is a remarkable paucity of data in current physiology textbooks concerning this effect.2 With regard to oral contraceptives, only one reference was found in the medical literature, but without quantification and comment.9 A body temperature raised by 0 5&C may be mistaken for a subfebrile temperature and may be a cause of unnecessary concern and medical investigations. More information on the influence of progestagens on temperature is needed. The product information of all oral contraceptives containing a progestagen should mention the possibility of a slight rise in body temperature. I De Mouzon J, Iestart J, lcfe reB Pouly Jl., Frsdman B. Iitllne relationships between basal body temperature and ovulation or plasma progestins. Fertil Steril 1984;41:254-9. 2 Keele CA, Neil E, Joels N. Samson W'right's applied phs'siologv. Oxford: Oxford University Press, 1983. 3 Association of the British Pharmaccutical Industry. ABPI data sheet compendium. London: Datapharm, 1990. 4 Wade A. Martindale: the extra pharmacopoeia. 29th ed. Lotsdon: Pharmaceutical Plress, 1989. 5 Dukes MN, ed. Mevler's side effects of drugs. 11th cd. Amstcrdam: Elsevier, 1988. 6 Dasies D)M. Texthook of adverse drug reactions. 3rd ed. Oxtord: Oxford University P'ress, 1985. 7 Meyboom RHB, M\artin DJ. 136ienvltedittg van de lichaatnstemperatuur door orale anticotcceptisa. Huisarts Wet 199(0;33:
488-90. 8
GUtvton AC. Iexibook of' medical physiologv. I'hiladelpilia:
Saunders, 1986. 9 Spona J, Schneider WHF. Central and peripheral parametcrs of the menstrual cy,cle under the influence of a new combined oral
cotttraceptive. A-cta Obstet (vnecol Scand 1976;suppl 54:45-5(0.
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