Fifty-eight patients with chronic asthma in whom airflow obstruction was relieved by bronchodilator aerosols but not by oral corticosteroids were compared with 58 other chronic asthmatics who responded equally well to both treatments. The two groups were matched for age and sex. The only significant clinical differences between the two groups were that in the "corticosteroidresistant" patients there was a more frequent family history of asthma and a longer duration of symptoms. Resistant patients also had a relatively lower peak expiratory flow rate in the morning than later in the day and a greater degree of bronchial reactivity to methacholine. Such features, however, may not be specific criteria of corticosteroid resistance since they were also observed in untreated asthmatics who subsequently responded well to corticosteroids. The failure of prednisolone to inhibit a monocyte-mediated bronchial reaction may explain why some chronic asthmatics do not respond to corticosteroids.Patients with corticosteroid-resistant asthma should be recognised at an early stage so that regular treatment with oral corticosteroids may be withdrawn. Failure to do this results in needless exposure to the risk of developing serious side effects.

CommentThe cause of uraemic pruritus is unknown. In some cases it may be due to secondary hyperparathyroidism. Only in these patients is parathyroidectomy indicated.2 The mechanisms of other treatments such as ultraviolet light3 or cholestyramine4 are unknown and are effective in only some cases. In our patient the rapid and complete disappearance of pruritus after lowering the dialysate magnesium concentration suggests a causative relation between itching and serum magnesium concentration. Lowering the dialysate magnesium concentration is known to restore nerve conduction velocity towards normal in patients receiving CHD,5 and this could be the reason for the complete disappearance of the pruritus in our patient.

SummaryThe bronchodilator and cardiac effects produced by aerosols of 0G5% salbutamol and 0(5% and 1% rimiterol administered for three minutes in 40% oxygen by intermittent positivepressure ventilation (I.P.P.V.) were compared in 15 asthmatic patients. Salbutamol and both the concentrations of rimiterol were equipotent in peak bronchodilator effect, but salbutamol had a significantly longer duration of bronchodilator action. There was significantly less increase in heart rate after rimiterol than after salbutamoL Aerosols of 0-5% rimiterol, 0 5% salbutamol, and saline were administered by I.P.P.V. to 10 normal volunteers. There was no difference between the mean heart rates after 0 5% rimiterol and saline but a highly significant increase in mean heart rate was observed after 05% salbutamol. It was concluded that 0(5% rimiterol was an effective short-acting bronchodilator drug with little or no cardiac beta1-adrenergic activity when administered for three minutes by I.P.P.V. in 40% oxygen.

In a double blind crossover study oral prednisolone was compared with intramuscular depot triamcinolone in the treatment of 20 patients with severe chronic asthma. A short term study comparing each treatment over four weeks showed only minor differences in therapeutic efficacy, but at the end of 24 week periods on each of the two treatments triamcinolone was significantly more effective than prednisolone in terms of forced expiratory volume in one second and forced vital capacity. Better control of asthma was accompanied by a significant fall in weight and some evidence of reduced adrenal suppression (improved cortisol response following a short tetracosactrin test). Side effects, including menstrual irregularities, muscle pain, and hirsuitism, were, however, more common during treatment with triamcinolone.Although treatment with corticosteroids by inhalation controls symptoms in many patients with chronic asthma, those with either severe asthma or a poor response to inhaled corticosteroid aerosols often require supplementary systemic treatment. Traditionally this is given in the form of oral prednisolone. A maintenance dose of 10 mg or more a day is required in only a small proportion of patients with chronic asthma, but such patients form a significant number of those attending asthma clinics and they are prone to develop side effects that may be seriously disabling and occasionally life threatening.It has been suggested in an open study' that better control is achieved, with no greater incidence of side effects, when corticosteroid treatment is given in the form of injections of depot triamcinolone at intervals of four weeks. This paper describes the results of studies designed to compare treatment with oral prednisolone and intramuscular triamcinolone in patients with poorly controlled asthma. A double blind crossover study of four weeks of each treatment was undertaken first, but as it showed only Address for reprint requests: Dr RF Willey, Royal Lancaster Infirmary, Lancaster LA1 4RP.Accepted 4 January 1984 minor differences in therapeutic efficacy it was followed by a study of the same design in which each treatment was continued for 24 weeks. Patients and methodsTwenty outpatients (8 male and 12 female) with chronic bronchial asthma were included in the study. Their ages ranged from 15 to 76 years (mean 48.9).Informed consent for inclusion in the study was obtained in all cases.All the patients had previously shown an improvement in FEV, of at least 25% after treatment with an aqueous salbutamol aerosol (5 mg) delivered by intermittent positive pressure breathing (IPPB). They all had an FEV, of less than 75% of the predicted normal despite regular treatment with oral prednisolone, 10 mg daily, and inhaled beclomethasone, 400 ,ug daily. At the time of entry all had required at least two courses of prednisolone in increased dosage for exacerbations of asthma in the preceding 12 months but not in the last four weeks.Initially a short term double blind crossover study was performed on 20 patients. T...

In a study of 100 patients undergoing rigid bronchoscopy under intravenous general anaesthesia with oxygen Venturi ventilation no major complications were observed. Minor complications included one adverse reaction to alphaxalone-alphadolone acetate (Althesin), one prolonged episode of laryngeal spasm after removal of the bronchoscope, and subsequent muscle pain attributed to suxamethonium in 36 patients. The last complication occurred significantly less frequently (p < 0-025) in those patients who were pretreated with a small dose of a nondepolarising neuromuscular blocking agent.