BRITISH MEDICAL JOURNAL
1323
27 NOVEMBER 1976
these fields are already well served by full-time specialists (medical and lay respectively). It is most unlikely that the "promotion of professional credibility, enhancement of job satisfaction, maintenance of professional competence, and . . . encouragement of recruitment" would follow such a move away from specialist status. SPENCER HAGARD Glasgow
SIR,-There is no future for community medicine if Dr D H Stone's ideas are adopted (30 October, p 1086). There are circumstances in which necessity compels people trained in a certain way to act in a manner foreign to their training. For example, the first policeman, fireman, or ambulanceman on the scene of a major disaster has to discipline himself to ignore injured individuals or those uttering the loudest cries for help and concentrate on making an accurate assessment of the situation in order to maximise the early provision of appropriate and adequate rescue services. Anyone who feels unable to accept such a responsibility is unlikely to function satisfactorily in those particular circumstances. In the same way someone in community medicine must accept that their contribution to the health of the community is to perform those functions which are not carried out by any other members of the profession. These may be organisational or epidemiological or advisory. Equal contributions are made by the strong swimmer who rescues a drowning child (the general practitioner), the first-aider who carries out immediate resuscitation (the clinician in an acute specialty), and the planner (the community physician) who, partly from his own experience and partly from advice given by the life guard and the first-aider, arranges for the fencing off of the dangerous pool. Two of these people have dealt with an individual in danger: the third has helped to safeguard many children. The planner does not have to be active in lifesaving or first aid, though it would be as well if he had experience of both since he is likely to be given conflicting advice by the many swimmers and resuscitators with whom he will of necessity come in contact. I do not think that any of these people can be said to be wasting their time. N H N MILLS Ebbw Vale, Gwent
Angiotensin II blockade with saralasin SIR,-The description by Dr R Beckerhoff and his colleagues (9 October, p 849) of hypotension developing during saralasin infusion is surely not a side effect of saralasin but a direct consequence of infusing large amounts of a competitive inhibitor of angiotensin II in a situation where one might expect total angiotensin II dependency of blood pressure to be present. It is unclear from their description why, having demonstrated angiotensin II dependency in their patient after the loss of 350 mmol of sodium, they chose to subject her to further volume depletion and reinfuse with saralasin. Even patients with low-renin hypertension have been reported to respond to saralasin after sufficient sodium and water depletion.'
Hypotension in just the same situation as they describe has been previously reported.2 Hypotension about to develop during saralasin infusion in untreated patients with malignant hypertension and on dialysis has also been reported3 and may possibly occur in patients with cirrhosis.4 The fall in blood pressure that may occur with saralasin can be controlled by using an incremental infusion starting at much lower infusion rates-for example, 0 05-0-25 Fcg/kg/min-and increasing the infusion rate progressively.5 The incremental infusion has the added advantage of minimising the agonist effect on blood pressure in low-renin patients and increasing the sensitivity of the test.6 A further way of increasing the sensitivity of the test and also reducing the risk of hypotension is to infuse patients sitting upright in a chair that can be tipped back. If hypotension is seen to be developing the patient can be tipped back, so restoring a more reasonable blood pressure. Any manoeuvre, such as low-sodium diet or diuretics, that removes sodium and water prior to saralasin infusion to increase or produce angiotensin II dependency brings with it problems in interpreting falls in blood pressure that may occur with angiotensin II blockade as these must necessarily be interpreted back on the basis of the patients' normal sodium and water balance. By minimising the agonist effect of saralasin by using an incremental infusion and infusing patients upright perhaps prior sodium and water depletion may be unnecessary. In any case, to "exclude vigorously volume depleted patients from screening programmes" would appear to be sensible not on the grounds of hypotension, which can be avoided, but because of difficulties in interpretation of the result. GRAHAM A MACGREGOR Department of Medicine, Charing Cross Hospital Medical School, London W6
Gavras, H, et al, Clinical Research, 1976, 24, 419A. Fagard, R, et al, Lancet, 1976, 1, 1136. 3MacGregor, G A, and Dawes, P M, Lancet, 1975, 2, 923.
Schroeder, E T, et al, Kidney International, 1976, 9, 511. 5MacGregor, G A, Lancet, 1975, 2, 181. 6 MacGregor, G A, and Dawes, P M, British Journal of Clinical Pharmacology, 1976, 3, 483.
***We sent a copy of this letter to Dr Beckerhoff, whose reply is printed below.-ED, BM7. SIR,-It has been reported and has also been our own experience that the infusion of saralasin into patients with "angiotensindependent hypertension" restores the recumbent blood pressure to normal in most cases only after the patient has also been volumedepleted.'-3 Such balance studies provide new information concerning the contribution of sodium and of angiotensin II to the high blood pressure. Although several investigators chose experimental protocols similar to ours, combining saralasin infusions with a lowsodium diet and/or diuretics, severe hypotensive episodes had not been reported in recumbent patients not being treated with vasodilating agents when we performed our studies.' 2 4 5 Drs MacGregor and Dawes, who had obviously seen such episodes, did not provide any detailed information or data on their cases.6 Thus the event reported by us was unexpected and we considered it worth publishing in detail. We agree with Dr MacGregor that incremental infusions will minimise the agonistic
effect of saralasin. We have not infused saralasin into sitting or standing patients. We assume, however, that this is a very refined procedure during which every patient has to be carefully monitored by a physician, making it probably an unsuitable screening procedure for detecting cases of "angiotensin-dependent hypertension" among the hypertensive population. RAINER BECKERHOFF University Department of Medicine, Kantonsspital, Zurich Brunner, H R, et al, Circulation Research, 1974, 34, suppl I, p 1. 2 Donker, A J M, and Leenen, F H H, Lancet, 1974, 2, 1535. 3 Beckerhoff, R, et al, Deutsche medizinische Wochenschrift, 1976, 101, 398. 4 Streeten, D H P, et al, Circulation Research, 1975, 36, suppi I, p 1. Gavras, H, et al, New England J7ournal of Medicine, 1974, 291, 817. MacGregor, G A, and Dawes, P M, Lancet, 1975, 2, 923.
Incomplete NHS prescriptions SIR,-The British National Formulary 1976-8, official since 1 June, omits footnotes indicating strengths and quantities of systemic drugs to be dispensed on incomplete prescriptions. Instead its compilers recommend, on p 10, reliance upon pharmacists' judgment to meet patients' needs when these details have been omitted. However, Family Practitioner Notice 114, which accompanied the BNF, contradicts this principle by directing pharmacists "always to attempt to contact the prescriber." If he succeeds in making contact, at the expense of time and money, the pharmacist may fill in the missing details and must initial the script "pc" (prescriber contacted). If he fails he may use his discretion but dispense up to five days' supply only, endorsing the script "pnc' (prescriber not contacted). Such limited supplies cause patients aggravation and mistrust of pharmacists. Omission of the magic "pc" or "pnc" results in 4%x' of all prescriptionsabout one million per month-being returned to pharmacists. Final payment for these (and other undisputed items on the same forms) is thereby delayed up to six months. Pharmacists are incensed by this legislative bungling and rightly feel that they are being cheated and insulted. Although FPN 114 emphasises the obligation upon doctors to complete all details in their prescriptions, pharmacists are being penalised for doctors' omissions. FPN 114 was obviously produced by unimaginative officials from the DHSS and the professions, the majority of whom are out of touch with front-line pharmacy procedures. It is ludicrous to suggest that a pharmacist could or should always attempt to contact the doctor before using his own common sense, professional knowledge, and intelligence. Even with his local doctors it is possible to make contact only at surgery times, when pharmacists receive little thanks for interrupting patient interviews with trivialities. Pharmacists scorn this ridiculous insistence upon prescriber contact when receptionists usually answer queries satisfactorily. Much worse is the direct insult to pharmacists, who are no longer trusted to act conscientiously, using tact and discretion to avoid loss of time and temper of physicians, patients, and pharmacists alike. In most cases pharmacists can fill omissions from data sheets, compendia, nomen proprium labelling, and their personal
1323
27 NOVEMBER 1976
these fields are already well served by full-time specialists (medical and lay respectively). It is most unlikely that the "promotion of professional credibility, enhancement of job satisfaction, maintenance of professional competence, and . . . encouragement of recruitment" would follow such a move away from specialist status. SPENCER HAGARD Glasgow
SIR,-There is no future for community medicine if Dr D H Stone's ideas are adopted (30 October, p 1086). There are circumstances in which necessity compels people trained in a certain way to act in a manner foreign to their training. For example, the first policeman, fireman, or ambulanceman on the scene of a major disaster has to discipline himself to ignore injured individuals or those uttering the loudest cries for help and concentrate on making an accurate assessment of the situation in order to maximise the early provision of appropriate and adequate rescue services. Anyone who feels unable to accept such a responsibility is unlikely to function satisfactorily in those particular circumstances. In the same way someone in community medicine must accept that their contribution to the health of the community is to perform those functions which are not carried out by any other members of the profession. These may be organisational or epidemiological or advisory. Equal contributions are made by the strong swimmer who rescues a drowning child (the general practitioner), the first-aider who carries out immediate resuscitation (the clinician in an acute specialty), and the planner (the community physician) who, partly from his own experience and partly from advice given by the life guard and the first-aider, arranges for the fencing off of the dangerous pool. Two of these people have dealt with an individual in danger: the third has helped to safeguard many children. The planner does not have to be active in lifesaving or first aid, though it would be as well if he had experience of both since he is likely to be given conflicting advice by the many swimmers and resuscitators with whom he will of necessity come in contact. I do not think that any of these people can be said to be wasting their time. N H N MILLS Ebbw Vale, Gwent
Angiotensin II blockade with saralasin SIR,-The description by Dr R Beckerhoff and his colleagues (9 October, p 849) of hypotension developing during saralasin infusion is surely not a side effect of saralasin but a direct consequence of infusing large amounts of a competitive inhibitor of angiotensin II in a situation where one might expect total angiotensin II dependency of blood pressure to be present. It is unclear from their description why, having demonstrated angiotensin II dependency in their patient after the loss of 350 mmol of sodium, they chose to subject her to further volume depletion and reinfuse with saralasin. Even patients with low-renin hypertension have been reported to respond to saralasin after sufficient sodium and water depletion.'
Hypotension in just the same situation as they describe has been previously reported.2 Hypotension about to develop during saralasin infusion in untreated patients with malignant hypertension and on dialysis has also been reported3 and may possibly occur in patients with cirrhosis.4 The fall in blood pressure that may occur with saralasin can be controlled by using an incremental infusion starting at much lower infusion rates-for example, 0 05-0-25 Fcg/kg/min-and increasing the infusion rate progressively.5 The incremental infusion has the added advantage of minimising the agonist effect on blood pressure in low-renin patients and increasing the sensitivity of the test.6 A further way of increasing the sensitivity of the test and also reducing the risk of hypotension is to infuse patients sitting upright in a chair that can be tipped back. If hypotension is seen to be developing the patient can be tipped back, so restoring a more reasonable blood pressure. Any manoeuvre, such as low-sodium diet or diuretics, that removes sodium and water prior to saralasin infusion to increase or produce angiotensin II dependency brings with it problems in interpreting falls in blood pressure that may occur with angiotensin II blockade as these must necessarily be interpreted back on the basis of the patients' normal sodium and water balance. By minimising the agonist effect of saralasin by using an incremental infusion and infusing patients upright perhaps prior sodium and water depletion may be unnecessary. In any case, to "exclude vigorously volume depleted patients from screening programmes" would appear to be sensible not on the grounds of hypotension, which can be avoided, but because of difficulties in interpretation of the result. GRAHAM A MACGREGOR Department of Medicine, Charing Cross Hospital Medical School, London W6
Gavras, H, et al, Clinical Research, 1976, 24, 419A. Fagard, R, et al, Lancet, 1976, 1, 1136. 3MacGregor, G A, and Dawes, P M, Lancet, 1975, 2, 923.
Schroeder, E T, et al, Kidney International, 1976, 9, 511. 5MacGregor, G A, Lancet, 1975, 2, 181. 6 MacGregor, G A, and Dawes, P M, British Journal of Clinical Pharmacology, 1976, 3, 483.
***We sent a copy of this letter to Dr Beckerhoff, whose reply is printed below.-ED, BM7. SIR,-It has been reported and has also been our own experience that the infusion of saralasin into patients with "angiotensindependent hypertension" restores the recumbent blood pressure to normal in most cases only after the patient has also been volumedepleted.'-3 Such balance studies provide new information concerning the contribution of sodium and of angiotensin II to the high blood pressure. Although several investigators chose experimental protocols similar to ours, combining saralasin infusions with a lowsodium diet and/or diuretics, severe hypotensive episodes had not been reported in recumbent patients not being treated with vasodilating agents when we performed our studies.' 2 4 5 Drs MacGregor and Dawes, who had obviously seen such episodes, did not provide any detailed information or data on their cases.6 Thus the event reported by us was unexpected and we considered it worth publishing in detail. We agree with Dr MacGregor that incremental infusions will minimise the agonistic
effect of saralasin. We have not infused saralasin into sitting or standing patients. We assume, however, that this is a very refined procedure during which every patient has to be carefully monitored by a physician, making it probably an unsuitable screening procedure for detecting cases of "angiotensin-dependent hypertension" among the hypertensive population. RAINER BECKERHOFF University Department of Medicine, Kantonsspital, Zurich Brunner, H R, et al, Circulation Research, 1974, 34, suppl I, p 1. 2 Donker, A J M, and Leenen, F H H, Lancet, 1974, 2, 1535. 3 Beckerhoff, R, et al, Deutsche medizinische Wochenschrift, 1976, 101, 398. 4 Streeten, D H P, et al, Circulation Research, 1975, 36, suppi I, p 1. Gavras, H, et al, New England J7ournal of Medicine, 1974, 291, 817. MacGregor, G A, and Dawes, P M, Lancet, 1975, 2, 923.
Incomplete NHS prescriptions SIR,-The British National Formulary 1976-8, official since 1 June, omits footnotes indicating strengths and quantities of systemic drugs to be dispensed on incomplete prescriptions. Instead its compilers recommend, on p 10, reliance upon pharmacists' judgment to meet patients' needs when these details have been omitted. However, Family Practitioner Notice 114, which accompanied the BNF, contradicts this principle by directing pharmacists "always to attempt to contact the prescriber." If he succeeds in making contact, at the expense of time and money, the pharmacist may fill in the missing details and must initial the script "pc" (prescriber contacted). If he fails he may use his discretion but dispense up to five days' supply only, endorsing the script "pnc' (prescriber not contacted). Such limited supplies cause patients aggravation and mistrust of pharmacists. Omission of the magic "pc" or "pnc" results in 4%x' of all prescriptionsabout one million per month-being returned to pharmacists. Final payment for these (and other undisputed items on the same forms) is thereby delayed up to six months. Pharmacists are incensed by this legislative bungling and rightly feel that they are being cheated and insulted. Although FPN 114 emphasises the obligation upon doctors to complete all details in their prescriptions, pharmacists are being penalised for doctors' omissions. FPN 114 was obviously produced by unimaginative officials from the DHSS and the professions, the majority of whom are out of touch with front-line pharmacy procedures. It is ludicrous to suggest that a pharmacist could or should always attempt to contact the doctor before using his own common sense, professional knowledge, and intelligence. Even with his local doctors it is possible to make contact only at surgery times, when pharmacists receive little thanks for interrupting patient interviews with trivialities. Pharmacists scorn this ridiculous insistence upon prescriber contact when receptionists usually answer queries satisfactorily. Much worse is the direct insult to pharmacists, who are no longer trusted to act conscientiously, using tact and discretion to avoid loss of time and temper of physicians, patients, and pharmacists alike. In most cases pharmacists can fill omissions from data sheets, compendia, nomen proprium labelling, and their personal
