Home-Monitoring of Peak Expiratory Flow Rate using Mini-Wright Peak Flow Meter in Diagnosis of Asthma1

Home-monitoring of peak expiratory flow rate using the mini-Wright peak flow meter is a useful technique for determining whether or not unexplained respiratory symptoms are caused by asthma. It is of particular value when airflow obstruction cannot be demonstrated at the time of consultation.

Sleep Apnoea in Diabetic Patients with Autonomic Neuropathy

Breathing during sleep was monitored in 8 diabetic patients with objective evidence of autonomic neuropathy and in 8 diabetic patients without neuropathy. Thirty or more periods of apnoea lasting 10 seconds or longer during one night's sleep were demonstrated in 3 of the diabetic patients with autonomic neuropathy. Such apnoeic periods may be related to the high incidence of cardiorespiratory arrests reported in such patients, particularly in association with anaesthesia or pneumonia.

Effect of Inhaled Alpha-Blocker on Airflow Obstruction in Asthma1

A controlled study of the effect on airflow obstruction of 30 mg of the alpha-blocker thymoxamine given by inhalation is reported in 10 patients with chronic stable asthma. No significant change in peak expiratory flow rate was seen with either thymoxamine or placebo in any patient. Alpha-adrenergic receptors are therefore unlikely to contribute significantly to resting bronchomotor tone in chronic stable asthma.

Review article : The late effects of poliomyelitis: aetiology and rehabilitation

Decades after their acute infection, many polio survivors are suffering renewed muscle weakness, increasing respiratory difficulties, musculoskeletal pain, fatigue and cold intolerance which lead to a 'second disability'. Some symptoms are due to chronic mechanical strain caused by using joints rendered unstable after the acute infection. The cause of others, such as postpoliomyelitis muscular atrophy, is . unknown although overuse, ageing, disuse atrophy and metabolic fatigue of axon sprouts in the abnormally large motor units may play a role. The aim of rehabilitation is to halt the progress of the condition and reduce its physical and psychological impact. Reduction in strenuous activity is important. The use of orthoses or a wheelchair may help to reduce pain and the energy cost of mobility. Respiratory aids such as the cuirasse can improve health. Counselling and peer group support can help the patient to accept his physical limitations.

Evaluation of a voice activated environmental control system for disabled people

Advances in speech recognition technology may in future allow the severely disabled to gain greater control over their environment. VADAS (Voice activated domestic appliance system) is a voice recognition and mains signalling system that was marketed for use by the disabled. We have evaluated VADAS using 19 severely disabled patients living in the community. Only seven of the 19 found VADAS to be an effective environmental control system over a period of four weeks. Major difficulties in achieving voice recognition leading to annoyance and frustration were experienced by the remaining 12. Only one of the eight long-term users of Possum PSU 3 preferred VADAS. The over-the-mains signalling system functioned well in 18 of the 19 homes. We suggest that over-the-mains signalling should be incorporated into 'standard' environmental control systems available from the DHSS, allowing a reduction in cost and size. VADAS is one available option for switching, although further development work is necessary to make it easier and safer to operate.

Psychological disorder in asthma is associated with poor control and poor adherence to inhaled steroids

Previous studies have linked psychological morbidity to poor control of asthma, but have not objectively measured adherence to treatment, and have linked poor adherence to depression, but have not measured asthma severity. This study assessed asthma and psychological morbidity and objectively measured adherence to medication and showed that psychological morbidity in those with asthma is significantly increased when control of asthma is poor, especially when control is poor and adherence to inhaled steroid regimen is low.

Compliance in asthma

Low rates of compliance with medication pose a major challenge to the effective management of most chronic diseases, including asthma. The high medical and social costs of non-compliance, and the apparent lack of effective methods for dealing with it, has stimulated renewed interest in this complex issue. Two broad categories of non-compliance have been identified, namely unintentional (or 'accidental') and intentional (or 'deliberate'). Unintentional non-compliance may result from poor doctor-patient communication or a lack of ability to follow advice. Intentional non-compliance occurs when the patient knows what is required but decides not to follow this to some degree. Healthcare professionals need to be aware of the various issues affecting compliance in all patients. The reasons for non-compliance are many and varied, and include factors such as complexity of the treatment regimen, administration route, patient beliefs about therapy and other psychological factors. Improvement in patient compliance with therapy will require better doctor-patient communication, improved patient education, the tailoring of therapy to the individual and possible novel strategies such as offering feedback to the patients on their level of compliance.

Evaluation of an electronic hand-held spirometer in patients with asthma

In this pilot study we assessed patient compliance and acceptability of data recorded in the home environment by asthmatics using a Vitalograph 2110 spirometer which measures peak expiratory flow rate (PEFR) and forced expiratory volume in 1 s (FEV1). This meter automatically time and date stamps all measurements and can also assess the technical acceptability of results. Data are uploaded to a personal computer for review and analysis. We recruited 30 patients (10 male and 20 female, age range 21-72 years) from the chest clinic at Guy's Hospital (n = 20) and from a GP clinic (n = 10). Patients were asked to record spirometry data using the meter at set times (8.00 a.m. and 8.00 p.m.) for 2 weeks. The spirometer incorporated an alarm to remind patients to take measurements. All patients completed the study. Mean (SD) compliance with spirometer use was 100.8% (49.9%). Nineteen patients had a compliance rate of between 80% and 120% of expected use. Timing of recordings was compared with the scheduled times of 8.00 a.m. and 8.00 p.m. Values recorded with +/- 2 h were judged as acceptable. For morning recordings 67.4% of all values and for evening recordings 71.7% of all values met this criterion. Technical acceptability of spirometry data was also assessed by using quality assurance criteria recorded by the spirometer. Valid tests were performed for 75.2% of all recordings. Twenty-two patients performed valid tests for 80-100% of the time. We suggest that the use of an electronic meter in the home environment is practical and is likely to generate more accurate and reliable data.

Single centre open study to compare patient recording of PRN salbutamol use on a daily diary card with actual use as recorded by the MDI compliance monitor

The aim of this study was to assess the patients' use of inhaled short acting bronchodilators as rescue therapy during a 4-week study period. In this study an electronic metered-dose inhaler compliance monitor (MDI-CM) was used to measure the time and date of actuations of the device and this information was then compared with the patients' self reporting diary card (DC). Salbutamol canisters were used in the compliance monitor. The study was approved by the local ethics committee, and written informed consent was obtained from all patients. Patients aged 18 years and over who were either receiving, or in the investigators opinion required, inhaled salbutamol on a PRN basis were enrolled for a 4-week monitoring phase during which all rescue salbutamol used was obtained from the MDI-CM. Patients were recording their use of salbutamol in the DC each morning and evening. There was a 2-week follow-up period following completion of the monitoring phase or withdrawal from the study. Forty-four patients were enrolled and 35 patients completed the study. The mean age (range) was 43 (20-76) years and mean FEV1 2.32 (0.7-4.0) 1, with male:female ratio of 19:25. Comparison of MDI-CM and DC recordings showed patients fell into three categories: (1) patients who used rescue salbutamol appropriately and whose MDI-CM and DC recordings matched closely; (2) patients who used rescue salbutamol for acute relief but whose MDI-CM and DC recordings did not correlate and (3) patients whose use of rescue salbutamol was inappropriate or erratic according to the MDI-CM but whose DC indicated good compliance. This category of patients include those who 'dumped' all their salbutamol before attending clinic appointments. There was no significant difference in the demographic details or the severity of disease in the three groups. Recorded use of 'rescue' bronchodilator is frequently used as an indicator of efficacy for new anti-asthma therapies. This study comparing electronic data monitoring and remembered rescue salbutamol highlights the potential errors that can occur without accurate recording systems.

Home nebulized therapy for patients with COPD: patient compliance with treatment and its relation to quality of life

STUDY OBJECTIVES

To assess compliance with home nebulized therapy in patients with COPD.

DESIGN

Patients' home nebulizers were replaced with nebulizers that recorded the date and time of each treatment over a period of 4 weeks. Poor compliance was defined as taking <70% of the prescribed dose (or <60% for those prescribed treatments five or more times daily).

SETTING

Patients were seen at the hospital COPD outpatient clinic. The compliance data obtained were recorded while they were at home.

PATIENTS

Ninety-three patients aged 44 to 76 years (mean, 64.9 years) were recruited from the hospital nebulizer database.

MEASUREMENTS

Patients completed a self-reported quality of life scale, the St. George's Respiratory Questionnaire (SGRQ), both before (SGRQ1) and after (SGRQ2) the 4-week study period to look at whether quality of life was either predictive of or subsequent to level of compliance.

RESULTS

Data were obtained from 82 patients. Mean compliance was 57% (range, 0 to 124%). Thirty-six (44%) patients were compliant and 46 (56%) were poorly compliant. There was no difference between the two groups in age or sex distribution. Compliance was negatively correlated with the total score on the SGRQ2 (p=0.03).

CONCLUSION

The study shows that levels of compliance with nebulized therapy are low in a large proportion of patients with COPD and that patients with low levels of compliance report greater impairment in their quality of life.

Corticosteroids restore the balance between locally produced Th1 and Th2 cytokines and immunoglobulin isotypes to normal in sarcoid lung

In this study, we have investigated the balance between Th1- and Th2-like activity in the lungs in sarcoidosis and have determined the effect of corticosteroid treatment on this. Twenty-one patients with acute untreated sarcoidosis were investigated by bronchoalveolar lavage (BAL) and compared with 11 normal volunteers. Sixteen of the sarcoid patients required corticosteroid therapy and seven of these were reinvestigated after 2-3 months' treatment. In order to assess Th1- and Th2-like activity in the lungs, IgG subclasses and IgE were measured in BAL fluid and serum, and IL-2, IL-4 and interferon-gamma (IFN-gamma) in BAL. In patients with untreated sarcoidosis, albumin-corrected BAL/serum ratios for IgG4 and IgE were significantly reduced (IgG4, 1.04 +/- 0.18 (mean +/- s.e.m.); IgE 9.58 +/- 3.11) compared with those in normal controls (IgG4 5.3 +/- 0.72, P < 0.001; IgE 67.7 +/- 28.9, P < 0.01). Estimates of actual levels of immunoglobulins produced in the lungs were also made and showed extremely high levels of total IgG in sarcoid patients (39.56 +/- 8.2 mg/l) compared with controls (1.17 +/- 0.5 mg/l, P < 0.001). Although there was no difference between the groups in amount of IgG4 locally produced, the proportion of total IgG which was IgG4 was greatly reduced in those with sarcoidosis (1.6 +/- 0.4% compared with 38.5 +/- 3.2%; P < 0.001). Lavage levels of IL-4 were also reduced in sarcoid patients (IL-4 2.103 +/- 0.21 pg/ml) compared with those in normals (IL-4 6.8 +/- 1.05; P < 0.001). Levels of IL-2 were lower (7.63 +/- 0.51 pg/ml compared with 9.4 +/- 0.95 pg/ml), but this difference was not significant. IFN-gamma, however, could not be detected above 0.4 pg/ml in any of the normal lavage fluid, but was detectable in 12/21 patients with sarcoidosis (chi2 = 7.74; P < 0.001). These changes reverted towards normal on treatment with oral corticosteroids. The mean albumin-corrected BAL/serum ratio for IgG4 before treatment was 0.88 +/- 0.33 compared with 5.5 +/- 2.1 (P < 0.05) on treatment, and for IgE before treatment 9.52 +/- 2.15 compared with 50.8 +/- 17.9 (P < 0.05) on treatment. Total IgG produced in the lung fell from 26.16 +/- 7.9 to 6.12 +/- 2.4 mg/l (P < 0.001) on treatment, and the proportion of IgG4 locally produced rose from 2.3 + 0.8% to 23.9 +/- 6.1% (P < 0.01). The mean level of IL-4 in lavage before treatment was 2.53 +/- 0.34 pg/ml compared with 4.7 +/- 0.34 (P < 0.001) on treatment. Levels of IL-2 also rose significantly on treatment from 8.74 +/- 0.95 pg/ml before to 14.44 +/- 1.38 pg/ml (P < 0.001) on treatment. Levels of IFN-gamma fell from 1.65 +/- 0.43 pg/ml before treatment to undetectable levels in all patients (P < 0.001) on treatment. These results demonstrate an imbalance between Th1- and Th2-like activity in the lungs in sarcoidosis, with suppression of Th2 and increase in Th1. Corticosteroid therapy restores the normal balance between Th1 and Th2 cytokines and immunoglobulins in the lungs, suggesting an effect on local immune regulation.

Psychological factors associated with use of home nebulized therapy for COPD

This study examined the relationship between adherence to domiciliary nebulized therapy and psychological factors; patient attitudes, anxiety, depression, and quality of life. Ninety three patients aged 45-77 yrs with chronic obstructive pulmonary disease (COPD) and using domiciliary nebulizers were recruited from a hospital database. They completed the St George's respiratory questionnaire (SGRQ)-1 and the hospital anxiety and depression scale (HADS) and attended a semistructured interview. Their usual nebulizers were replaced by Dataloggers, which record the date, time and duration of each treatment, to use for 4 weeks. The SGRQ was then repeated (SGRQ-2). Eighty two patients completed the study. Fifty six percent were poorly adherent; taking less than 70% of the dose prescribed (or less than 60% on regimens of > or = 5 times daily). The total scores on the SGRQ-2 were negatively correlated with percentage adherence. Multiple regression analysis showed that the SGRQ-2 total score was associated with percentage adherence, depression score, feeling supported by clinic staff, and patients feeling that they tried to ignore their chest disease. Patients who report poor quality of life are more likely to be depressed, feel unsupported by clinic staff and be poorly adherent to treatment. Increased levels of clinic support, with the addition of psychological treatments, may be of benefit to some patients with chronic obstructive pulmonary disease.

Compliance and outcomes in patients with asthma

The severity of asthma varies within and between individuals, and the disease has a variable impact on quality of life. Disease severity can be modified but not cured by long term anti-inflammatory therapy. Compliance with, or adherence to, such therapeutic regimens is difficult, and it is affected by a number of factors. Patterns of compliance are variable; some patients take only half the prescribed drug all the time, while others take all their prescribed medication for a while and then "take a break'. Understandably, there is no single factor that would account for such a variety of human behaviour, but generally the frequency and ease of drug administration, as well as adverse effects (real or imagined), can affect compliance. Poor communication regarding the precise regimen will also impair compliance. Psychosocial factors such as depression, poor interpersonal skills and coping strategies, and rejection of the diagnosis will lead to lower levels of compliance. Interventional programmes using a combination of education, skills training and methods to modify behaviour are needed to improve the quality of life in asthmatics. The role of the newer generations of once-/twice-daily oral anti-inflammatory preparations in improving compliance requires further investigation.

The psychological factors associated with poor compliance with treatment in asthma

Poor patient compliance with inhaled medication is known to cause morbidity and mortality in asthma. The reasons for nonadherence are not fully understood. We wondered whether psychological factors, such as patient attitudes to asthma and its treatment, anxiety, depression, and interpersonal problems, may be related to asthma self-care and compliance. In a prospective study, 102 patients with asthma, aged 18-70 yrs, requiring treatment with regular inhaled corticosteroids and beta-agonists were recruited from a hospital out-patient clinic and four general practices in South East London. They underwent psychological assessment using the Hospital Anxiety and Depression Scale (HADS), the Inventory of Interpersonal Problems (IIP), and a semi-structured interview focusing on patient attitudes, self-care, compliance, social support and treatment beliefs. Patients were given terbutaline and budesonide turbohalers to use twice daily over 12 weeks. Turbohaler Inhalation Computers (TICs) recorded each inhalation, providing a measurement of compliance. Seventy two patients completed the study. Thirty seven took less than 70% of the prescribed dose over the study period or omitted doses for 1 week and were defined as noncompliant. The noncompliant group had a higher mean (SD) score for depression (4.7 (3.3)) than the compliant group (3.2 (2.5)). The sample had a high mean (SD) score for anxiety (8.3 (4.4)), but there was no significant difference between the compliant and noncompliant groups. Patients' self-report and clinicians' impressions of compliance were not good predictors of actual compliance. Using discriminant analysis, a model was obtained from the questionnaires and interview items, which correctly classified 74% of the patients as compliant or non-compliant.(ABSTRACT TRUNCATED AT 250 WORDS)

The psychological factors associated with poor compliance with treatment in asthma

Poor patient compliance with inhaled medication is known to cause morbidity and mortality in asthma. The reasons for nonadherence are not fully understood. We wondered whether psychological factors, such as patient attitudes to asthma and its treatment, anxiety, depression, and interpersonal problems, may be related to asthma self-care and compliance. In a prospective study, 102 patients with asthma, aged 18-70 yrs, requiring treatment with regular inhaled corticosteroids and beta-agonists were recruited from a hospital out-patient clinic and four general practices in South East London. They underwent psychological assessment using the Hospital Anxiety and Depression Scale (HADS), the Inventory of Interpersonal Problems (IIP), and a semi-structured interview focusing on patient attitudes, self-care, compliance, social support and treatment beliefs. Patients were given terbutaline and budesonide turbohalers to use twice daily over 12 weeks. Turbohaler Inhalation Computers (TICs) recorded each inhalation, providing a measurement of compliance. Seventy two patients completed the study. Thirty seven took less than 70% of the prescribed dose over the study period or omitted doses for 1 week and were defined as noncompliant. The noncompliant group had a higher mean (SD) score for depression (4.7 (3.3)) than the compliant group (3.2 (2.5)). The sample had a high mean (SD) score for anxiety (8.3 (4.4)), but there was no significant difference between the compliant and noncompliant groups. Patients' self-report and clinicians' impressions of compliance were not good predictors of actual compliance. Using discriminant analysis, a model was obtained from the questionnaires and interview items, which correctly classified 74% of the patients as compliant or non-compliant.(ABSTRACT TRUNCATED AT 250 WORDS)

Swallowing in motor neurone disease

Ninety-two patients with motor neurone disease have been assessed clinically and radiologically for evidence of swallowing problems. At the time of examination, moderate or severe swallowing difficulty was present in 89% of those whose disease had presented as bulbar palsy, in 45% of those in whom the disease began many months before as progressive muscular atrophy and in 29% of those with amyotrophic lateral sclerosis. Patients with more severe swallowing symptoms appeared more likely to have abnormal findings on videofluoroscopy overall. However, not all patients with an abnormal radiological picture had swallowing difficulties. It is suggested that radiological signs should only be used within the context of clinical symptoms and signs in the selection of patients for palliative surgery. Thirteen patients with pseudobulbar symptoms and signs had a cricopharyngeal myotomy performed: two suffered major post-operative complications. However, the satisfaction rate was 89% and we recommend cricopharyngeal myotomy for such patients. Pharyngostomy was performed for seven patients unable to initiate swallowing, six had post-operative complications.

Patient compliance with inhaled medication: does combining beta-agonists with corticosteroids improve compliance?

Patient compliance with an inhaled corticosteroid may be greater if it is combined with a beta-agonist. This study compared compliance with an inhaled corticosteroid (budesonide), and a short-acting inhaled beta-agonist (terbutaline sulphate), and a Turbuhaler inhaler containing a combination of the two drugs. In an open, multicentre, parallel group study 102 asthmatic patients were randomly divided into two groups, either receiving the two drugs in separate Turbuhalers or combined into one Turbuhaler. A twice daily regimen was prescribed and a preweighed metered-dose inhaler (MDI) of salbutamol was provided for rescue use. Compliance was measured using the Turbuhaler Inhalation Computer (TIC), which recorded the time and date of each inhalation over a 12 week period. Forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) measurements were carried out at week 0, 6 and 12. Results from 72 patients were analysed. The average compliance was 60-70%. Treatment was taken as prescribed on 30-40% of the study days, and over-usage occurred on less than 10% of days. Only 15% of patients took the drugs as prescribed for more than 80% of the days. Compliance was no greater in patients using the combined inhalers. Other ways of improving patient self-management need further investigation.

Compliance with prescribed drug therapy in asthma

Morbidity and mortality from asthma in the Western world is increasing despite effective prophylactic drugs. Beta agonists are increasingly considered causal; while under-prescribing of inhaled steroids or other anti-inflammatories are accepted as causes for the problems, but the role of non-compliance with inhaled asthma therapy is rarely mentioned. Using a novel electromechanical counter MDI actuations have been recorded in three small (9-11 patients), short (2-3 weeks) studies. When aware compliance with prescribed inhaled steroids was under scrutiny, six patients were fully compliant, two took just 70% of the prescribed regimen, but two did not follow the prescribed regimen at all. When unaware of scrutiny, six out of 11 were compliant but five patients were estimated as taking less than 30-51% of the prescribed dose of inhaled steroid. When asked to monitor rescue bronchodilator usage patients consistently under-recorded. Under-use as well as under prescription of inhaled steroids and under-estimation (8) of beta 2-agonists use may be contributory factors to the present increase in asthma mortality and morbidity. These potential problems of poor compliance need larger scale studies to show how and if behaviour can be altered to improve compliance.

A study of self poisoning with oral salbutamol--laboratory and clinical features

1. The recent increase in asthma mortality coupled with reports of fatal asthma associated with beta-2-agonist therapy, has stimulated interest in the plasma concentrations of beta-2-agonists that produce systemic toxicity. 2. We prospectively studied 17 patients (9 male), mean age 23 years (range 2-72), who attended the emergency departments of hospitals throughout the United Kingdom having recently ingested an overdose of salbutamol. 3. Clinical, laboratory, ECG data, plasma and urine samples were obtained from each patient. Plasma was assayed for salbutamol concentration using a high performance TLC-photodensitometric method. 4. The mean (+/- s.d.) salbutamol dose reported to have been ingested was 89(+83)mg and the mean plasma salbutamol concentration was 166 (range 18-449) ng ml-1. The mean plasma potassium was 2.9 (s.d. +/- 0.6) mM (n = 16). None of the patients in this study developed serious cardiac dysrrhythmias. 5. There were significant correlations between the plasma salbutamol concentration and plasma potassium concentration (r = -0.85; P < 0.00005) and between plasma salbutamol concentration and pulse rate (r = 0.66; P < 0.005). 6. We conclude that in these patients, without respiratory decompensation, suprapharmacological plasma concentrations of salbutamol were tolerated without serious cardiac arrhythmias or any fatalities.

Impact of education on treatment compliance in patients with asthma

Poor or non-compliance with therapy is a common problem, in patients with asthma, but one which has been poorly and infrequently studied both in clinical trials and in general practice. A common reason proposed for poor compliance is that if the patient fails to understand their disease process and the mode of action of therapy, then there is little motivation to follow the prescribed regimen. There has been a wealth of asthma educational programmes developed over the last 10 yrs. Booklets, audio cassettes and, more recently, videos, explaining asthma, have all become available, but there is still some doubt as to whether such knowledge alters patient behaviour and improves compliance with therapy. Modifying behaviour and improving asthma control may be achieved with specific instruction, such as a self-management plan where the patient has greater control of his or her own condition.

Differential in vitro regulation by glucocorticoids of monocyte-derived cytokine generation in glucocorticoid-resistant bronchial asthma

We previously described a 3 kD neutrophil priming activity (NPA) derived from peripheral blood monocytes that is suppressed by glucocorticoid treatment of monocytes derived from individuals with corticosteroid-sensitive (CS) but not corticosteroid-resistant (CR) asthma. We compared the effects of glucocorticoids on the in vitro generation of other cytokines by monocytes of CS and CR asthmatic individuals. A total of 11 CS and 8 CR asthmatic subjects were studied. Monocytes were cultured overnight in the presence or absence of 5 micrograms/ml of lipopolysaccharide (LPS) with or without hydrocortisone (HC) or dexamethasone. TNF-alpha, IL-1 beta, and GM-CSF were measured by ELISA, mRNA for these cytokines were detected by northern analysis, and NPA was identified by its capacity to enhance ionophore-induced LTB4 generation from neutrophils. In the absence of LPS there was no significant difference in the generation of cytokines between monocytes derived from CS and CR individuals. Treatment of monocytes by 10(-6) M HC suppressed NPA generation from CS (72%, p = 0.002) but not CR subjects (10%, p = 0.47). In contrast there was no effect of glucocorticoids on the generation of other cytokines from monocytes of either CS or CR subjects. In the absence of LPS, mRNA for IL-1 beta and GM-CSF were not detected by northern analysis, and glucocorticoids had no significant effects on mRNA for TNF-alpha in either group. LPS at 5 micrograms/ml enhanced cytokine but not NPA generation and markedly increased cytokine mRNA in monocytes of both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Genetic analysis of the linkage between chromosome 11q and atopy

Previous work has suggested that there is a genetic predisposition for the development of both asthma and atopy. A recent study has also shown that there is a striking link between chromosome 11q and the IgE response underlying asthma and rhinitis. To further assess the linkage between chromosome 11q and atopy, we have studied nine families of two and, in many instances, three generations with the index case having asthma and/or atopy. Using two restriction fragment length polymorphism probes associated with the regions 11q12-q13.2, namely PYGM and INT2, we have been unable to confirm a significant link between this region of chromosome 11q and atopy as defined by a positive skin-prick test and/or a raised specific IgE and/or a raised total IgE.

Therapeutic compliance in asthma; its magnitude and implications

Failure to heed medical advice is common, but the precise extent is poorly understood and barely investigated. Factors leading to poor compliance are not known but claims of lack of education are frequently mentioned. However these have yet to be scientifically substantiated. The frequency of medication and social and economic factors, allied to poor communication, are probably involved but do not account for it entirely as non-compliance may vary between 20-80% of patient populations. Asthma mortality is not decreasing despite effective medication and increasingly there are worries that poor compliance may be a significant factor.

Therapeutic compliance in asthma; its magnitude and implications

Failure to heed medical advice is common, but the precise extent is poorly understood and barely investigated. Factors leading to poor compliance are not known but claims of lack of education are frequently mentioned. However these have yet to be scientifically substantiated. The frequency of medication and social and economic factors, allied to poor communication, are probably involved but do not account for it entirely as non-compliance may vary between 20-80% of patient populations. Asthma mortality is not decreasing despite effective medication and increasingly there are worries that poor compliance may be a significant factor.

A flow interruption device for measurement of airway resistance

Unlike conventional methods, the interrupter method for measuring airway resistance is non-invasive and requires minimal patient co-operation. It can therefore be applied in critically ill patients, acute asthmatics, neonates, pre-school children, geriatric patients and unconscious patients. The method is based on transient interruption of airflow at the mouth for a brief period during which alveolar pressure equilibrates with mouth pressure. Measurement of mouth pressure is used to estimate alveolar pressure prior to interruption and the ratio of this to flow prior to interruption gives airway resistance. Using the interrupter method we have developed a portable device for measuring airway resistance which is simple to use and gives a direct instantaneous reading. Measurements of airway resistance obtained using the new device were compared with those obtained using conventional body plethysmograph methods in 43 adult patients. A close correlation was seen (r = 0.86). The two methods appear equally sensitive in detecting changes in airway resistance following bronchodilator therapy. The device has been used successfully in pre-school children unable to co-operate with conventional methods.

A flow interruption device for measurement of airway resistance

Unlike conventional methods, the interrupter method for measuring airway resistance is non-invasive and requires minimal patient co-operation. It can therefore be applied in critically ill patients, acute asthmatics, neonates, pre-school children, geriatric patients and unconscious patients. The method is based on transient interruption of airflow at the mouth for a brief period during which alveolar pressure equilibrates with mouth pressure. Measurement of mouth pressure is used to estimate alveolar pressure prior to interruption and the ratio of this to flow prior to interruption gives airway resistance. Using the interrupter method we have developed a portable device for measuring airway resistance which is simple to use and gives a direct instantaneous reading. Measurements of airway resistance obtained using the new device were compared with those obtained using conventional body plethysmograph methods in 43 adult patients. A close correlation was seen (r = 0.86). The two methods appear equally sensitive in detecting changes in airway resistance following bronchodilator therapy. The device has been used successfully in pre-school children unable to co-operate with conventional methods.

A comparative trial of two walking systems for paralysed people

A trial has been performed to compare two designs of reciprocal walking orthosis for paralysed people--the hip guidance orthosis (HGO) from Oswestry, England, and the reciprocating gait orthosis (RGO) from New Orleans, USA. Eighteen male and 4 female paraplegic subjects used each orthosis for 4 months, in a crossover study. All aspects of the provision and use of the devices were monitored, and a variety of assessments were made. Fifteen subjects were able to use both orthoses, 5 were unable to use either and 2 succeeded with the HGO but not the RGO. At the end of the trial 12 subjects chose to keep the RGO, 4 the HGO, and 6 kept neither. Those choosing the RGO liked its appearance; those choosing the HGO liked the speed of donning and doffing. The RGO was about 50% more expensive to supply than the HGO.

Bronchial asthma and the role of beta 2-agonists

Asthma is defined as reversible airflow obstruction; the mechanism for this airflow obstruction is considered to be caused by a combination of an inflammatory process leading to a thickened edematous airway lining and bronchial smooth muscle constriction. The identification of specific beta-receptors in the autonomic system led to the development in the early 1960s of selective beta 2-agonists with their precise effects on the bronchial smooth muscle without direct action on cardiac muscle. The early beta 2-agonists such as salbutamol have a comparatively short bronchodilator action but a rapid onset of action, making them useful as "rescue" bronchodilators. Regular beta 2-agonists alone may mask the underlying pathogenesis of asthma and may be associated with tachyphylaxis or rebound bronchial hyperreactivity. The observation that a thickened airway lining may lead to disproportionate increases in airways resistance with small changes in bronchial muscle shortening suggests beta 2-agonists should be given in conjunction with anti-inflammatory therapy. With their long duration of action but slow onset the new beta 2-agonists may have a role in prophylaxis of asthma rather than rescue bronchodilation.

Attenuation of nocturnal asthma by cromakalim

In a randomised, double-blind, crossover study, single oral doses of cromakalim, a potassium-channel activator, or placebo were given to 23 patients with nocturnal asthma. There was a significant reduction (p less than 0.005) in the early morning fall in forced expiratory volume in 1 s (FEV1) after 0.5 mg cromakalim (fall 9.8% [SEM 3.2%]) compared with placebo (18.5 [2.8]%). In a repeat dosing study, administration of 0.25 mg and 0.5 mg cromakalim on 5 consecutive nights to a further group of 8 asthmatic subjects significantly reduced the early morning fall in FEV1 from 28.7 (6.5)% after placebo to 19 (4.2)% after 0.25 mg and 14.9 (6.5)% after 0.5 mg. Potassium-channel activators may be useful in the treatment of asthma, especially for nocturnal symptoms.

Plasma concentrations of salbutamol in acute severe asthmatics

We studied prospectively 11 asthmatic patients presenting to the Accident and Emergency department with acute asthma. (Four patients reported historically that they were taking some form of oral salbutamol as part of their maintenance therapy.) Standard cardiovascular and respiratory parameters and plasma salbutamol concentrations were measured before and one hour after treatment with five milligrams of nebulised salbutamol. The median plasma salbutamol concentration before treatment was below the level of detection of the assay (less than 3 micrograms.l-1) with a range from less than 3 micrograms.l-1 to 34.6 micrograms.l-1. One hour post treatment the median plasma salbutamol concentration was 7.4 micrograms.l-1 (range less than 3.0 micrograms.l-1 to 56.0 micrograms.l-1) p less than 0.05. (Wilcoxons test). Correlations were investigated between the measured pretreatment physiological variables and pre-treatment plasma salbutamol concentrations. None were found to be significant. Similar analysis of the measured post-treatment physiological variables and post-treatment plasma salbutamol concentrations again revealed no significant correlations. However, a significant negative correlation was noted between the change in plasma salbutamol concentration with treatment and the change in respiratory rate (Rs = -0.56, p = 0.04). If asthmatics do indeed use high doses of inhaled beta-2-agonists (salbutamol) in an attempt to abort an acute attack (as many clinicians suspect), little, if any, of the drug appears to reach the systemic circulation. In this study the administration of five milligrams of nebulised salbutamol to acute asthmatics did not produce excessive increases in plasma salbutamol concentration, even in those patients taking oral salbutamol as part of their maintenance therapy.

Can the morbidity of asthma be reduced by high dose inhaled therapy? A prospective study

A community based, prospective study of the value of high dose inhaled therapy for the reduction of the morbidity of asthma has been undertaken. One hundred and sixty adults with airflow obstruction were treated for up to 9 months with increasing doses of salbutamol. Two thirds of the patients also received increasing doses of beclomethasone dipropionate in a 'partially double-blind' manner. The FEV1 rose by at least 10 per cent of that predicted in one third of the total patients and the overall mean domiciliary peak expiratory flow rates rose by approximately 50 l/min-1. All chronic symptoms were abolished in half of the patients and acute attacks of asthma in the majority. Asthma was controlled in a greater proportion of patients more effectively and rapidly by a combination of inhaled steroids and beta agonist than by salbutamol alone, particularly when inhaled steroids were started in relatively high dosage.

Compliance with inhaled therapy and morbidity from asthma

Patient compliance with a standardized incremental regimen of inhaled anti-asthma therapy has been assessed in a large, prospective study in general practice. Urine salbutamol estimations were made in 30 patients who had the largest improvement with therapy (mean increase in FEV1 0.45 l above baseline: Responsive) and in 30 patients whose airflow obstruction failed to improve (FEV1-0.14 l: Nonresponsive). The urine salbutamol concentrations rose over the 9 month period in the responsive patients as expected with the incremental doses prescribed, and were significantly higher than urine levels in nonresponsive patients at two dose levels. Poor compliance with prescribed inhaled therapy is an important cause of persistent morbidity from asthma.

Motor neurone disease

Motor neurone disease is one of the incurable diseases; it is a tragic and distressing condition, leading from full health through paralysis to death within a few years. Although powerless to prevent or arrest the disease, doctors and all who work with those affected and their families can do much to ameliorate and bring comfort and understanding to sufferers of this disease.

Does urinary salbutamol reflect compliance with the aerosol regimen in patients with asthma?

Compliance with inhaled beta agonist therapy in a group of asthmatic patients in general practice has been monitored using a high performance thin layer chromatographic assay of salbutamol in urine. Urine salbutamol levels were lower than expected in five of 51 patients and much higher than expected in a further 11 patients. These results suggest the assay may be clinically useful for monitoring compliance of asthmatic patients with inhaled salbutamol.