Background Although the need for corticosteroids in acute severe asthma is well established the appropriate dose is not known. Methods The response to intravenous hydrocortisone 50 mg (low dose), 100 mg (medium dose), and 500 mg (high dose), administered every six hours for 48 hours and followed by oral prednisone, was compared in patients with acute asthma in a double blind randomised study. After initial emergency treatment with bronchodilators subjects received oral theophylline or intravenous aminophylline and nebulised salbutamol four hourly. The widely accepted regimen of intravenous hydrocortisone 200-300 mg every six hours appears to be based on work by Collins et al in 1975.2 On the basis of earlier descriptive work on cortisone metabolism in steroid dependent asthmatic patients during acute severe episodes,3 Collins suggested that doses of corticosteroids equivalent to hydrocortisone 300 mg four times a day would achieve "therapeutic" serum concentrations. The authors found that higher doses were no more effective,4 and this has been confirmed in other studies.' Few studies have explored the response to lower doses.89Apart from the problem of cost, high doses of corticosteroids may cause more steroid related side effects than low doses. Shee,'°for example, suggests that a high total dose may be a factor in acute myopathy in patients with acute severe asthma.We have therefore compared, in a double blind randomised trial, three doses of intravenous hydrocortisone six hourly in patients with acute severe asthma. The doses were 50 mg (low dose, equivalent to prednisone 50 mg a day), 200 mg (medium dose), and 500 mg (high dose). Parenteral treatment was followed by matched low, medium, or high doses of oral prednisone (20, 40, or 60 m daily), which were then tapered over 12 days.
MethodsWe studied subjects with acute severe asthma presenting to the accident and emergency departments of two general hospitals. Subjects were aged 18-65 years with an unequivocal history of asthma and previously or subsequently showed short term variability in forced expiratory volume in one second (FEVy) of at least 15%. Patients with complicating factors such as a pneumothorax or consolidation on the chest radiograph, asthma that warranted admission to the intensive care unit, or other major illness were excluded, as were subjects who had been taking more than 10 mg prednisone a day before admission. The study received the approval of the ethics committee and all subjects gave informed consent.The patients assessed the severity of their dyspnoea on a 100 mm visual analogue scale"(100 mm = no symptoms; 0 mm = maximum symptoms) and recorded peak expiratory flow
SummaryWe report the case of a 41-year-old mentally retarded male with recurrent pilomatrix carcinoma of the occipital region which invaded the occipital bone, left cerebellum and left temporal lobe. At his initial presentation the patient had a craniotomy and subtotal excision of the lesion with positive margins. He received no adjuvant therapy. After an early intracranial recurrence he had subtotal debulking and was referred for external beam radiotherapy. At 27 months follow-up after adjuvant external beam radiotherapy the intracranial component has not progressed and the patient remains clinically well.
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