Document gDqbRM9zYxyNN61KN1NRMX5Ya

244 BRITISH MEDICAL JOURNAL VOLUME 290 19 JANUARY 1985 sightly nodule in the side of the neck alongside increase is to be noted as blood lead varies influence of community physicians in the past the superior border of the thyroid cartilage. from 0-6 pmol/l to 1*1 pmol/I. In our study has derived from their ability to bring to a blood lead values are significantly related to local public the messages of health backed by R E Ma y blood pressure; this correlation, highly signi their professional standing and uninfluenced Frcnchay Hospital, ficant in young subjects (24-34 years), decreases by managerial responsibilities. Bristol BS16 1LE with age (not significant in 45-55 year olds). Community medicine is concerned with ah Thus, we may hypothesise that the increase matterswhichaffect health, and its practitioners Blood lead concentration and blood pressure in blood lead concentration parallels the in must be enabled to study these and present crease in blood pressure until some limit value, their findings to the public and profession alike. so that such a trend is apparent only when other This is unlikely to occur when community SlR;--We read with great interest the paper by Dr S J Pocock and others (6 October, p 872), dealing with the relation between blood lead concentration and blood pressure, a contro versial subject.11 A relation was not found by Dr Pocock and others. However, data dis played in their fig 1, showing the variations of systolic blood pressure in relation to blood lead concentrations, seem to indicate that an increase in the blood lead value might result in an increase in systolic blood pressure up to a limiting value, while higher lead concentra tions do not relate to blood pressure. Results from one of our recent studies support this hypothesis. Our population study consisted of 431 men attached to a section of the Paris civil service, aged 24-55 years (mean 41*4 years), living in the same urban area, and not occupationally exposed to lead. We measured blood lead values by fiameless atomic absorption spectrometry (graphite furnace atomiser), blood pressure after resting (with a factors (such as age) do not competitively increase blood pressure by greater amounts. This would be apparent in our study but not in that of Dr Pocock and colleagues. Further studies would be needed to confirm or elucidate this point. G Or s s au d J R Cl a u d e Laboratoire de Recherche dc la DASS, 7501? Paris T Mo r e a u J Le l l o u c h Inserm--U 169, 94807 Villejuif B JUGUET B Fe s t y Laboratoire d'Hygiine de la Ville de Paris, 75004 Paris, France 1 Beeven DG, Erskine E, Robertson M, et el. Blood lead and hypertension. Lancet 1976;ii:l-3. 2 Felderman EJ. Blood lead and hypertension. Lancet !976;ii:lJ35. physicians are enmeshed in chains of account ability leading to a general manager. An uncertain distinction between professional and managerial responsibilities may be insufficient protection for what might be critical views. D H Va u g h a n North Western Regional Health Authority, Manchester M60 7LP 1 Acheson R, Campbell H. "... and community health." J Epidemiol Community Health 1984;38:263-4. 2 Miles D. Under threat from Griffiths. BMA News Review 1984;10 (12};23. Doctors, drugs, and the DHSS V Sir ,--The government has indicated that the range of NHS prescribable drugs will be restricted. Among 100 consecutive adult patients admitted for elective procedures to Southampton Eye Hospital in 1983, 14 admitted regularly taking medicines bought in mercury apparatus), weight, and height. Daily chemists. Their mean age was 71-9 years, alcohol and tobacco consumption was: assessed by questionnaires. The logarithms of blood lead values were used in calculating the correlation coefficients. As in the work of Dr Pocock and others, the systolic blood pressures were adjusted for body mass index, age, and alcohol consumption using analysis of covariance. The results arc summarised in the table, where blood lead was On the state of the public ill health Sir ,--Professor John C Catford and Dr Sherm Ford (15 December, p 1668) draw attention to the need to look behind the and the commonest drugs were vitamins (9 patients), followed by analgesics (6), laxatives (2), and antacids (2). Some elderly patients eligible for exemption from pre scription charges are already buying simple remedies despite similar products being available on prescription. Imminent political comfortable statements of wellbeing in the decisions require larger scale similar research Systolic blood pressure means in relation to blood had concentrations Blood (umol/1) Systolic blood pressure Mean (and 2 SE) Adjusted (mm Hg) mean No of subjects people's health. Arguments about percentages of gross national product, the impact of demographic changes on required levels of expenditure, the need to seek value for money, the improved efficiencies of the service, and plans to spend more on patient care seem recently to have obscured the facts now to be undertaken urgently. University Department of Ophthalmology, Bristol Eye Hospital, Bristol BS1 2LY CMP Cl a o u e <0-60 0-61-0-89 0-90-119 1-20-1*49 1-50-1-79 34-80 127 (3-6) 130 (1-8) 133 (2-4) 139 (4-8) 143 (13-6) 130 (5-4) 129 46 presented in their article. "He is not better, Sir ,---Sorbitol has been known' to be an 130 212 be is much the same." effective laxative agent for at least 40 years at 132 126 138 34 The authors rightly ask why the public and daily doses of 30-50 g.` It is found naturally 142 7 politicians have not raised their voices hut in fruits and other foodstuffs and is used in 129 6 suggest no answer. To some extent this may many `'sugar free" sweets and chewing gum.2 be because the facts are not widely known. Its use as a food additive has been reviewed grouped into the same classes as those used by Dr Pocock and others. The blood pressure means, not adjusted and adjusted, are shown by blood lead Campaigns for improvement need facts even ifunderlying causes may be obscure. Professor Catford and Dr Ford belong to a specialty by the World Health Organisation and their estimated acceptable daily intake for man is "not limited."3 It is thus remarkable that our group: overall they differ significantly (p< 0-001). which has historically taken a leading role in own Committee on Safety of Medicines has They increase from the first blood lead class bringing unpalatable facts of life and death not licensed sorbitol for use as a laxative. In (<0*60 ftmol/l) to the fourth (1-20-1-49 /xmol/1); to public notice, but recently it has used comparison with other osmotic laxatives the last two means, corresponding to 1*50 pmol/1 and over, do not yield much information because of the small numbers of subjects. The overall correlation coefficient between systolic blood pressure and blood lead concentration is 0*23 (p<0-001). Its values in the age classes 24-34 years (145 subjects), 35-44 years (143 subjects), and muted tones. The editorial in the latest issue of the Journal of Epidemiology and Community Health has specifically drawn attention to the diminishing number of contributions in its pages from leaders of the specialty presenting sorbitol is cheap (about a quarter of the cost of lactulose in the UK). Its use as a laxative could lead to impressive savings for the NHS. Although one is unable to buy sorbitol (for its laxative effect) from pharmacies, many sweets containing sorbitol are openly advertised for 45-55 years (142 subjects) are 0-29 (p< 0*001), a critical analysts of health and health services their laxative effect. Perhaps instead of 0-20 (p<0*05), and 0*14 (not significant), respec today.1 It suggests that a reason for this may banning NHS prescription of most existing tively. Adjusting for alcohol consumption and be a reluctance to cause embarrassment to licensed laxatives the DHSS should consider body mass index does not modify these results. political and administrative paymasters. introducing cheaper and effective drugs such Our results in fact agree with those of Dr The present introduction of the general as sorbitol to replace similar but more ex Pocock and his colleagues provided the follow management function into the National Health pensive drugs. ing observations are made. The mean systolic Service seems likely to change the orientation Jo h n H Be a v e n blood pressure in their study is much higher than in ours, which might at least partly of some community physicians, and the chairman of the Central Committee for Royal Cornwall Hospital, Treliske. be explained by the different age ranges in the two studies (40-59 years in theirs, 24-55 in Community Medicine and Community Health has suggested that this may result in their Truro, Cornwall TRJ 3LJ ours). In their study no overall correlation spending less time on management and more 1 Ellis FV7, Kramz JC. Sugar alcohols. XXII. Meta was found between blood lead values and on the exercise of their other skills.2 This systolic blood pressure, although a slight would be a welcome change. Much of the bolism and toxicity studies with mannitol and sorbitol in man and 147-54. TEH 0350238 DU P 050298875