Neutrophils recruited to the airways in chronic obstructive pulmonary disease (COPD) are thought to mediate tissue destruction. Neutrophil recruitment is increased during bacterial exacerbations. The inflammatory process was studied in patients with an acute exacerbation of COPD in order to ascertain the role of leukotriene B 4 (LTB 4 ).The sputum of eight subjects with a bacterial exacerbation of COPD was analysed for neutrophil products (myeloperoxidase, elastase) and chemoattractants (interleukin-8 (IL-8) and LTB 4 ). The contribution of LTB 4 to the chemotactic activity of the sputum sol phase was determined using the LTB 4 receptor antagonist LY293111. The concentrations of the serum acute phase proteins a 1 -proteinase inhibitor, a 1 -antichymotrypsin and C-reactive protein were measured. All patients received appropriate broad-spectrum antibiotic treatment for 7±14 days.Initially, the sputum myeloperoxidase activity was high, indicating neutrophil influx; this was associated with high levels of IL-8 and LTB 4 . All these concentrations fell with treatment (p<0.01). The chemotactic activity of the sputum was raised on presentation and fell with treatment (p<0.01). LTB 4 contributed~30% of the total chemotactic activity on presentation; this diminished with therapy. All acute phase proteins were raised on presentation and fell with therapy (p<0.01).These findings suggest that leukotriene B 4 contributes to neutrophil influx into the airway in chronic obstructive pulmonary disease and may influence disease progresgression. Eur Respir J 2000; 15: 274±280.

Patients with COPD should be reassured that the influenza vaccination is safe and does not cause an increase in exacerbations. They should be encouraged to take up the vaccination annually before the onset of winter.

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One hundred and seventy-six consecutive patients with moderate or severe pain of suspected myocardial infarction were randomized to receive nalbuphine less than or equal to 20 mg or diamorphine less than or equal to 5 mg intravenously with metoclopramide 10 mg and were observed over 2 hours. One hundred and forty-two patients (81%) received the test drug outside hospital. The median time from symptom onset to treatment was 135 minutes for the nalbuphine group and 125 minutes for the diamorphine group. Satisfactory pain relief (grade 0 or 1) was similar for both groups at each time assessment. In particular, within 10 minutes of the drug's administration 77% of those receiving nalbuphine and 68% who received diamorphine had satisfactory pain relief. The number of doses of each drug, the number of patients withdrawn from the trial because of unsatisfactory pain relief or recurrence of chest pain were similar for both groups. For those with myocardial infarction there was similar satisfactory pain relief with nalbuphine as diamorphine. No significant deleterious haemodynamic effects or other side-effects occurred. The noncontrolled classification and low addiction potential of nalbuphine allow for its more widespread use in the control of pain of suspected myocardial infarction.

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