479

1. Editorial. 5-HT3 receptor antagonists: a new class of antiemetics. Lancet1987; i: 1470-71.

2. Gralla RJ, Hri LM, Pisko SE. Antiemetic efficacy of high-dosemetoclopramide: randomized trials with placebo and prochlorperazinein patients with chemotherapy-induced nausea and vomiting. N Engl JMed 1981; 305: 905-09.

3. Triozzi PL, Laszlo J. Optimum management of nausea and vomiting incancer chemotherapy. Drugs 1989; 34: 136-49.

4. Cunningham D, Turner A, Hawthorn J, Rosin RD. Ondansetron withand without dexamethasone to treat chemotherapy-induced emesis.Lancet 1989; i: 1323.

5. Marty M. Ondansetron in the prophylaxis of acute cisplatin-inducednausea and vomiting. Eur J Cancer Clin Oncol 1989; 25 (suppl 1):541-45.

Injected corticosteroids inrefractory asthma

Most patients with asthma have mild symptomsthat are usually controlled by a combination of inhaled&bgr;2 agonist and low-dose inhaled corticosteroid.1 Whensymptoms are more severe, other agents may be addedto or substituted for baseline treatment;l.2 examplesinclude cromoglycate, nedocromil sodium,methylxanthines, anticholinergic bronchodilators,high-dose inhaled steroids, and oral steroids. Oralcorticosteroids are reserved mainly for deterioratingasthma or for acute life-threatening exacerbations.However, a few patients require continuous oralcorticosteroid treatment because of chronic severeasthma. This condition may become life threateningand is almost always associated with considerablemorbidity-eg, frequent hospital admissions and

respiratory failure requiring mechanical ventilation.The chronicity of the asthma may additionally lead tolong-term complications of corticosteroid treatment.Concern over the chronic administration of oralcorticosteroids in patients with refractory asthma hasled to the introduction of other treatments includingmethotrexate,3 3 gold,4 4 troleandomycin,S andintramuscular triamcinolone..The use of high-dose intramuscular triamcinolone

was lately supported by a placebo-controlled, double-blind, cross-over study in twelve patients with chronicsevere asthma, in which the effects of this drug in adose of 360 mg given over 3 days were compared withprednisone 15 mg daily over 3 months.8 All thepatients had progressive worsening of their asthmadocumented over 1-7 years. They requiredprednisone 5-20 mg daily while receiving inhaledcorticosteroids and other standard treatment. The

severity of their asthma can be gauged from the factthat eleven of the patients had sixty hospitaladmissions over the preceding year; five of these

episodes required mechanical ventilation. At the timeof entry to the study there were clear side-effects ofcorticosteroid treatment; nine had the facies ofCushing’s syndrome; three were hypertensive; twohad diet-controlled diabetes; and one was very obese.Intramuscular triamcinolone improved lung function,with the peak flow reaching an average of 91-5% ofpredicted compared with 75 % while the patients werereceiving prednisone. There were no visits to theemergency room and no hospital admissions during

the triamcinolone period of treatment vs twenty-oneemergency visits and ten hospital admissions with twoepisodes of ventilatory failure during the prednisoneperiod. Other benefits of triamcinolone were that totalcorticosteroid treatment during the period oftriamcinolone treatment was reduced, although therewas a tendency to more steroid-related side-effectsafter treatment with triamcinolone.The researchers concluded that high-dose

intramuscular triamcinolone was more effective thanlow-dose prednisone in patients with severe chroniclife-threatening asthma, but were cautious aboutrecommending such treatment other than in patientswith this type of asthma. At the time of reporting, inthe 13 months since the study began only four patientshad required repeated injections of triamcinolone, andin the remaining eight patients corticosteroids wereneeded only infrequently for acute exacerbations; nopatient required daily maintenance doses of oralsteroids. These results suggest that triamcinolone mayhave advantages in refractory asthma in patients withchronic severe symptoms who require chronic oralcorticosteroids. Studies are now needed to show

longer term benefits with respect to asthma and to thecorticosteroid-induced side-effects, and to define thelowest dose of triamcinolone that will achieve lastingsymptomatic relief.

1. Higgins BG, Tattersfield AE. Modern management of asthma. HospUpdate 1989 (May): 341-18.

2. British Thoracic Society, Research Unit of the Royal College ofPhysicians of London, Kings Fund Centre, National Asthma

Campaign. Guidelines for the management of asthma in adults.I-chronic persistent asthma. Br Med J 1990; 301: 651-53.

3. Mullarkey MF, Blumenstein BA, Andrade WP, Bailey GA, Olason I,Wetzel CE. Methotrexate in the treatment of corticosteroid-dependentasthma: a double-blind crossover study. N Engl J Med 1988; 31:603-07.

4. Muranaka M, Miyamoto T, Shida T, et al. Gold salt in the treatment ofbronchial asthma—a double-blind study. Ann Allergy 1978; 40:132-37.

5. Wald JA, Friedman BF, Farr RS. An improved protocol for the use oftroleandomycin (TAO) in the treatment of steroid-requiring asthma.J Allergy Clin Immunol 1986; 78: 36-43.

6. Peake MD, Cayton RM, Howard P. Triamcinolone in corticosteroid-resistant asthma. Br J Dis Chest 1979; 73: 39-44.

7. Willey RF, Fergusson RJ, Godden DJ, Crompton GK, Grant IWB.Comparison of oral prednisolone and intramuscular depottriamcinolone in patients with severe chronic asthma. Thorax 1984; 39:340-44.

8. Ogirala RGO, Aldrich TK, Prezant DJ, Sinnett MJ, Enden JB, WilliamsMH. High-dose intramuscular triamcinolone in severe, chronic,life-threatening asthma. N Engl J Med 1991; 324: 585-89.

Testing for carpal tunnelsyndrome

Although median nerve compression within thecarpal tunnel is usually easy to diagnose clinically,many patients are subjected to electrophysiologicalinvestigation before operation. The need for

electrodiagnosis has been questioned and less painfulprovocative tests have been suggested; there are

potential pitfalls with such an approach.Typically, the patients present with pain,

paraesthesiae, and numbness of the median-nerve-innervated fingers on awakening. Pain may radiate up