Notes: A case of quinine poisoning is described. Stellate ganglion block was performed immediately on the basis of the clinical history of visual disturbance without waiting for physical signs to develop. There was no residual field defect despite the presence of toxic levels of the drug. It is suggested that stellate ganglion block may prevent development of visual field defects.

Notes: 8.38. The above condensed overview of the effects of air pollution in adults with asthma is only of relevance to the effects on worsening symptoms or airflow in patients with pre-existing asthma. There is no doubt that ozone/acid/particulate events have an effect although of slight and variable degree in adults but there is some evidence that with increasing age, airway responses to ozone attenuate. This would also be supported by the finding that adults with longer outdoor dwell times showed greater effects, and that in some studies no effect at all can be demonstrated in adults. Effect to be more in those patients who are more symptomatic or who have increased bronchial reactivity. In patients with severe asthma the ameliorating effect of treatment might be expected to mask any worsening of symptoms or peak flow induced by air pollution. Acutely, therefore, adults with asthma are less likely to show an effect of air pollution episodes than children and such an effect is likely to attenuate further with increasing age. However, those with severe disease are likely to react more although the combined effect of age and disease has not been specifically studied. What we do not know is whether related exposure to ozone/acid/particulate events or to winter SO2/NO2/particulate events will have a cumulative effect on asthmatics pushing them to the more severe end of the spectrum. 8.39 The question as to whether there is epidemiological evidence for air pollution causing an increase inn the prevalence of asthma remains open. The American Six Cities Study and its successor, The 24 Cities Study, are cross-sectional studies considering respiratory disease in a range of cities of varying pollution experience. As yet they have asthma prevalence and increased pollution, although the 24 Cities Study has yet to report on this particular aspect. There has been one longitudinal study of asthma prevalence where air pollution has been taken into consideration. The advantage of this study is that it included a population of Seventh Day Adventists who are non-smokers. The results are slightly conflicting in that males (but not females) with higher ozone exposures had a slightly increased risk of developing asthma, but the effects of passive cigarette exposure was equally important as was the presence of airflow obstruction before the age of 16 years. These findings are compatible with the hypothesis that ozone exposure can‘cause’ asthma but the finding could also be explained by shift of the distribution of bronchial reactivity towards the more severe end. 8.40. There are many questions that need to be addressed. The most pressing is to determine whether air pollution experiences, as a combination of both summer and winter types, can lead to the development of asthma in otherwise unaffected individuals. Such studies must include assessments of non-specific reactivity and take into consideration atopic status, allergen exposure, Cross-sectional studies are unlikely to be able to provide this information so longitudinal studies are needed. These should include both children and adults, perhaps focusing on younger adults in the first instance. 8.41.Further panel studies of older patients need to be undertaken to assess whether they truly do show a lesser response to summer air pollution and whether their responses to winter pollution differs from younger adults and children. In all these studies the effect of acid aerosols should be assessed in view of the recent work from Birmingham showing an effect of summer acid on symptoms and peak flow in adults with asthma. This would enable estimates to be made of the likely health load on each group in terms of hospital admission, etc., an important step before assessing the possible benefits from reducing pollution levels.

Notes: Background An association between psychological morbidity and asthma is well recognized and an increase in negative psychosocial factors in brittle asthma has been previously reported. Stich factors, apart from affecting patient perceptions, may alter patients’ self-management of their condition.Methods We have undertaken a case-control study on 29 well characterized brittle and non-brittle asthmatics in the West Midlands Region to assess their level of psychological morbidity, using the General Health Questionnaire (GHQ) and the living with asthma questionnaire, and their responses to changes in asthma symptoms, using the Asthma Symptom Checklist and a taped interview.Results Significant differences in GHQ (mean score brittle 19.5 vs non-brittle 7.2, P = 0.0002) and living with asthma (mean score brittle 1.30 vs non-brittle 1.00, P = 0.002) reinforced the presence of psychological factors in this group of patients with severe asthma. Interviews regarding responses to hypothetical asthma attacks showed that patients with brittle asthma delayed seeking medical attention more often than those with non-brittle asthma and instead preferred to self-administer beta-agonist medication. Sixteen (55.2%) of the 29 patients with brittle asthma would have delayed 7 days before seeking medical attention in a slow onset attack compared with 6/29 (20.7%) in the non-brittle group. In a fast onset attack 14 (48.3%) patients with brittle asthma would not have summoned help, despite finding it difficult to walk to the kitchen for a drink whereas in the non-brittle group 24 out of 29 (82.8%) would have summoned help. Levels of family support tended to be lower in patients with brittle asthma (mean family APGAR 7.3 vs 8.65 P = 0.09).Conclusions Brittle asthma is associated with greater psychological morbidity and altered strategies for coping with deteriorating asthma symptoms. Attention should be paid to the presence of such factors in the management of patients with brittle asthma.

Notes: Ayres JG. Trends in air quality in the UK.Many problems are encountered when assessing trends in air quality, including changes in methods of measuring pollutants over time, different sampling timeframes, and the number and distribution of monitoring sites. Nevertheless, reasonable projections have been established for trends in sulphur dioxide (SO2), particulate matter, nitrogen dioxide (NO2), and ozone levels in the UK, which allow some estimate of future levels. The major source of SO1 is coal-fired power stations. Since the Clean Air Act of 1956, SO2 levels have decreased substantially. Nevertheless, a small but progressive increase in SO2 emissions is predicted over the next 15 years, but this is unlikely to exceed current UK air quality standards on a frequent basis. Particulate pollution (as black smoke) has also decreased dramatically since the 1960s, when the main source was fossil fuel burning. In the 1990s, the main source of particle emissions is from heavy goods vehicles. If measures currently under consideration in the UK are implemented, annual emissions may decrease to below 60 kT over the next decade, but a progressive increase is predicted thereafter. No significant changes have occurred with respect to oxides of nitrogen (NOx) and ozone levels over the last 20 years. It is predicted that NOx emissions will decline in the future due in part to the introduction of catalytic converters, while trends in ozone levels will depend on substrate supply (NOx and hydrocarbons) and weather conditions. Despite short-term trends downwards in air pollutant levels, trends may reverse in the next millennium, and continued efforts must be made to develop new ways of reducing ambient air pollutant levels.

Notes: Background:  Patients with poorly controlled asthma have greater morbidity and mortality. This study evaluated the efficacy and tolerability of omalizumab in patients with poorly controlled, moderate-to-severe allergic asthma.Methods:  This was a randomized, open-label, multicentre, parallel-group study. A total of 312 patients (12–73 years) receiving ≥400 μg/day (adolescent) or ≥800 μg/day (adult) inhaled beclomethasone dipropionate, or equivalent were included. Patients received best standard care (BSC) with or without omalizumab [at least 0.016 mg/kg/IgE (IU/ml) every 4 weeks] for 12 months.Results:  The annualized mean number of asthma deterioration-related incidents was reduced from 9.76 with BSC alone (n = 106) to 4.92 per patient-year with omalizumab (n = 206) (P 〈 0.001). Mean clinically significant asthma exacerbation rates were 2.86 and 1.12 per patient-year, respectively (P 〈 0.001). Omalizumab-treated patients (41.4%) required rescue medication 〈1 day/week compared with 20.7% for BSC alone (P 〈 0.001). Omalizumab improved absolute forced expiratory volume in 1 s (FEV1) compared with BSC alone (2.48 and 2.28l, respectively; P 〈 0.05) and reduced symptom scores relative to BSC alone (decrease of 6.5 and 0.7 respectively; P 〈 0.001). Omalizumab was well-tolerated.Conclusions:  Omalizumab administered as add-on therapy to BSC benefits patients with poorly controlled, moderate-to-severe allergic asthma.

Notes: Abstract The aim of the study was to compare the efficacy, tolerability and patient acceptability of bambuterol (Bambec®) against controlled release (CR) salbutamol (Volmax®) in the treatment of nocturnal asthma. One hundred and fifty two asthmatic patients aged 17–78 years, using ≥800 μg/day of an inhaled steroid, with nocturnal asthma symptoms, openly received three weeks of bambuterol 20 mg nocte and three weeks of salbutamol CR 8 mg b.i.d. in a randomised, cross over sequence. Both bambuterol and salbutamol CR treatment produced a significant 63% decrease in the severity of baseline nocturnal asthma symptoms. This improved control of nocturnal asthma was reflected by significant improvements in baseline lung function. Both the severity and number of days of tremor during the first week of treatment was significantly lower with bambuterol than with salbutamol CR. Patients considered bambuterol to cause less shakiness and treatment preference was bambuterol 49%, salbutamol CR 36%, no preference 15%. The predominant reason for patient treatment preference was control of asthma symptoms, however a significant sub-group of patients (27%) chose bambuterol because of fewer adverse effects compared to 11% chosing salbutamol CR. Fifty six percent of patients preferred taking their medication once-daily and 7% preferred twice-daily. This study shows that both bambuterol and salbutamol CR are equally effective treatments for nocturnal asthma in patients already receiving inhaled steroid. The most important factor in terms of patient treatment acceptability appears to be control of symptoms. Sub-groups of patients may chose bambuterol due to its better adverse effect profile and once-daily regimen.

Notes: Summary A simple modification to the silver staining technique for the demonstration of nucleolar organizer region associated proteins is described. Polyethylene glycol 20 000 is used instead of gelatin as the colloidal developer. This modified technique remains a one stage procedure that is quick and easy to perform. It results in reduced precipitate and less non-specific staining with specimens in which it had been previously difficult to demonstrate these intranuclear silver staining structures.

Notes: A method is described for the determination of terbutaline and salbutamol in plasma from patients given maximal therapy for brittle asthma. The analytes were isolated by solid phase extraction on alkali-treated Bond-Elut, unmodified, silica columns and measured by high performance liquid chromatography with fluorescence detection (excitation wavelength 200 nm). The limits of detection for a 1 mL sample containing salbutamol and terbutaline were 1 μg/L and 2.5 μg/L, respectively. The intra-assay precision (CV) for samples containing 25 μg/L was 3.6 and 5.0% respectively. This method was applied to the measurement of terbutaline in samples from patients given continuous infusions of the drug to assess whether this treatment might result in toxicity.