Search

OBJECTIVES: To assess the distribution of personal exposures to nitrogen dioxide (NO2) in school children, and to investigate factors that might influence personal exposure. METHODS: NO2 exposures were assessed by use of passive diffusion tubes for 46 children aged 9-11 years, selected from two Southampton schools. The tubes were worn for seven days, and parallel measurements were made with static samplers in the child's kitchen, living room, classroom, and playground. Information about potential exposures was collected by questionnaire. RESULTS: Personal exposures to NO2, averaged over seven days, ranged from 11 to 257 micrograms/m3 (6 to 137 ppb) with a geometric mean of 36 micrograms/m3 (19 ppb). Exposures correlated with concentrations of NO2 recorded in the home, but the relation was far from exact. Factors associated with increased personal exposure included the use of gas appliances in the home, living with one or more smokers, and travel to school by means other than a car. However, together these variables only explained a small part of the variation in personal exposures. CONCLUSIONS: These findings reinforce the need for personal monitoring of exposure in studies investigating potential health effects of NO2 in children.

OBJECTIVE--To evaluate the efficacy and safety of immunotherapy (hyposensitisation) in patients with severe summer hay fever. DESIGN--A randomised, double blind, placebo controlled study of a biologically standardised depot grass pollen extract. SETTING--Allergy clinic, Royal Brompton and National Heart Hospital, London. PATIENTS--40 adults (mean age 35 years) with a history of severe grass pollen allergy uncontrolled by standard antiallergic drugs. Patients with perennial asthma were specifically excluded. INTERVENTION--Patients were randomised to receive either an active preparation (Alutard SQ, a grass pollen (Phleum pratense) extract) or placebo at a rate of two subcutaneous injections a week in increasing doses until a maintenance dose was reached. This maintenance dose was given once a month. MAIN OUTCOME MEASURES--Clinical efficacy was evaluated by symptom and drug diary cards, visual analogue scores during the grass pollen season, and a postseasonal assessment by the patients and a doctor. Conjunctival and skin sensitivity to local allergen provocation was measured before and after eight months of treatment. RESULTS--There was a highly significant decrease (median Alutard SQ v median placebo (95% confidence interval for difference between medians] in total symptom scores (p=0.001) in the Alutard SQ treated group (360 v 928 (238 to 825]. Significant differences were also found in total drug use (p=0.002, 129 v 627 (178 to 574]. Visual analogue symptom scores were also reduced in the active group (p=0.02, 2.2 v 5.5 (-4.8 to -0.5]. The postseasonal assessment, by either the doctor or the patients, showed a large improvement (p less than 0.001) in favour of Alutard SQ. Provocation tests showed a greater than 10-fold reduction for the active group in immediate conjunctival allergen sensitivity (p=0.001), a 40% decrease in early phase response (p=0.02), and a 57% decrease in the late phase (p=0.001) cutaneous response after intradermal allergen. A total of 523 active injections were given. There was one systemic reaction at 10 minutes after injection, which was rapidly reversed with intramuscular adrenaline. There was one mild delayed urticarial reaction at 2 1/2 hours. CONCLUSION--Immunotherapy is effective in patients with severe summer hay fever, but immediate anaphylactic reactions limit its use to specialised centres. Patient selection is extremely important, and chronic perennial asthma should be specifically excluded. As serious reactions occur within minutes a two hour wait for all patients after each injection seems unnecessary.

Specialists in clinical immunology and clinical allergy work with a wide range of illnesses, from very common and relatively mild conditions such as hay fever, to rarer and serious conditions such as anaphylaxis, vasculitis, and primary immunodeficiency. In Britain the specialties are small, and these conditions have often been managed by general practitioners or organ based specialists such as chest physicians, dermatologists, or ear, nose, and throat specialists largely for historical reasons. Many of these doctors are knowledgeable about allergic diseases, but others are not; the way patientso problems are handled may depend greatly on where they live and the interests of the doctor who is consulted. This variation, the rising prevalence of allergic conditions, and the advent of the Calman report all gave impetus to a fundamental re-examination of future training in immunology and allergy Until recently, immunology has really meant “immunopathology”, with posts being based in clinical immunology laboratories, the incumbent consultants predominantly laboratory oriented and trained under the auspices of the Royal College of Pathologists. Clinical work was limited. Allergy fared even less well, and most current practising “clinical allergists” in Britain were trained as organ based specialists (mainly in respiratory medicine) and developed their allergy interest in post. Academic posts have provided niches for clinical scientists with specific immunology or allergy interests who have often developed clinical services from their academic positions. After much consultation, a joint committee of the Royal Colleges of Physicians and Pathologists has drawn up two training programmes, one in immunology, and one in allergy, both of which will lead to the certificate of completion of specialist training (CCST). Flexibility of the programme to meet the needs of trainees with differing skills and interests will be a key feature of these programmes. Training posts have been allocated to major regional centres where …