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Preservation of physiological growth hormone (GH) secretion in idiopathic short stature after recombinant GH therapy

This study was undertaken to assess the recovery of spontaneous GH secretion 48 h after the cessation of GH therapy in children with idiopathic short stature treated with recombinant DNA-generated human GH (rhGH-M). Eleven prepubertal children with GH responses of 10.0 ng/mL or more after provocation were divided into therapeutic (n = 7) and control (n = 4) groups. GH was sampled every 20 min for 24 h in six treated and three control patients. One treated and one control patient had 12-h overnight studies because of their weight. The sampling studies were carried out before GH therapy was initiated and 48 h after rhGH was discontinued after 12 months of therapy. Three patients in the treated group also underwent a 24-h study at the 6 month time point. The treated group started treatment with rhGH (0.1 mg/kg), given three times a week. The results showed that pre- and posttreatment GH secretory profiles were comparable with respect to the number of peaks, mean concentrations, peak amplitude, and secretory rate. At the 6 month point, the mean GH and peak GH amplitude (n = 3) were greater than the means of the treatment group (n = 7) at the 0 and 12 month points, but the difference was not statistically significant. Somatomedin-C rose in the treated group from 0.42 +/- 0.1 to 1.25 +/- 0.3 U/mL (mean +/- SD; P less than 0.01). In the control group it rose from 0.56 +/- 0.1 to 1.16 +/- 0.8 U/mL (mean +/- SD; P greater than 0.05) because one patient entered puberty in the 12-month period of observation; his somatomedin-C level rose from 0.72 to 2.5 U/mL. We conclude that exogenous GH therapy does not interfere with the maintenance of endogenous pulsatile secretion of GH. These data show that exogenous GH therapy does not interfere with the maintenance of endogenous pulsatile secretion of GH and provide evidence for the resilience of the GH secretory system in the growing child.

Augmentation of the effect of doxorubicin with low-dose tumor necrosis factor in experimental liver metastasis

The antitumor activity of recombinant human tumor necrosis factor was studied in vivo as a single agent and in combination with a conventional chemotherapeutic agent. Dosages of tumor necrosis factor of 100 micrograms, 50 micrograms, and 25 micrograms were injected intraportally in Sprague-Dawley rats containing hepatic implants of Walker carcinosarcoma. An effect on the tumor was seen but was associated with a significant acute mortality. Lower dosages of tumor necrosis factor, 10 micrograms, 5 micrograms, and 1 microgram, administered with 10 mg/kg of doxorubicin (Adriamycin) significantly enhanced the antitumor effect of doxorubicin without an acute mortality. This suggests that lower dosages of tumor necrosis factor with conventional chemotherapy may augment the latter's effect without any added toxicity.

How investors evaluate the creditworthiness of hospitals

Responding to health care's turbulent economy of the 1980s, investors in hospital bonds have revised the way they conduct a hospital credit analysis. This new thinking is reflected in a 10-step method that examines the hospital's operating margin and cash from operations; its Medicare and Medicaid receivables; occupancy and admission levels; security provisions of the bond; and other important factors. Healthcare financial managers can use the analysis as a guide to self-assessment.

Sex differences in cognitive processing in children treated with CNS prophylaxis for acute lymphoblastic leukemia

Evaluated cognitive processing in 51 children (27 female, 24 male) who had been treated for acute lymphoblastic leukemia (ALL) with CNS prophylaxis (cranial radiation in combination with intrathecal chemotherapy) and were continuously disease-free for 5 to 12 years. The control group comprised 15 children treated for Wilm's tumor. Functions assessed included visuoperceptual skills, generation of organizational strategies, sensitivity to organizational structure, and attention. The ALL group showed performance deficits relative to the solid tumor controls in appreciating the organization inherent in complex visuospatial material and alertness, with females more severely affected than males. Sex differences favoring males on IQ and academic achievement were related to these cognitive processes.

The natural history of untreated hyperprolactinemia: a prospective analysis

This report describes the results of a long term prospective study of 30 women with hyperprolactinemia who were not treated and who underwent yearly clinical, hormonal, and radiographic evaluation for an average of 5.2 yr (range 3-7 yr). At entry into the study 18 women had amenorrhea, 8 had oligomenorrhea, and 4 had regular menstrual periods. The initial mean serum PRL levels did not differ in women grouped according to menstrual function. Nine women (35%) had improvement in clinical symptoms. Serum PRL decreased, and menstrual periods normalized more often in those who initially had oligomenorrhea or regular menstrual periods. In most amenorrheic women serum PRL levels did not decline, and menstrual symptoms did not improve. Six of 30 women had an increase in serum PRL, 14 had no change, and 10 had a decrease, in 6 of whom serum PRL was normal at the last observation. Twenty-seven women had serial radiographic studies. Four (15%) of the 13 women with initially abnormal radiographic findings had normal studies later, 2 had tumor progression, and 7 no change. Four of 14 women who had normal radiographic studies initially developed radiographic evidence of a pituitary tumor, although the radiographic changes were minimal, and no patient developed a macroadenoma or pituitary hypofunction. Increases or decreases in serum PRL did not accurately predict changes in tumor size. Prior estrogen use and previous pregnancies did not increase the likelihood of tumor appearance or enhance tumor growth. The clinical presentation of the patient was an important factor in predicting which patients had a decline in serum PRL and resolution of symptoms. We conclude that patients with hyperprolactinemia are unlikely to have progression of their disease and may, in fact, have clinical and radiographic improvement.

Determination of fitness in children with asthma. Use of standardized tests for functional endurance, body fat composition, flexibility, and abdominal strength

Children with asthma frequently have exercise-induced disease that can limit their participation in both organized sports and vigorous free play. We measured fitness in a group of children with moderately severe to severe asthma with an instrument that is used widely and is available to clinicians for assessment of the physical capability of their patients. Abnormalities in physical fitness were present primarily in the area of endurance, with performance in the nine-minute run frequently found to be low. Increased skin-fold thickness was also present more frequently than in the normal population. Abdominal strength and flexibility were normal. Abnormalities in fitness were not well explained by measures indicating the presence of poorly controlled disease. All children with significant asthma probably should be tested to document the level of fitness so that appropriate intervention can be initiated.

Three-year results of a randomized prospective trial of methionyl human growth hormone and oxandrolone in Turner syndrome

Seventy girls with Turner syndrome, 4 to 12 years of age, participated in a prospective, randomized study to determine the effects on growth of methionyl human growth hormone (met-hGH) or oxandrolone. Subjects were randomly assigned to receive either no treatment (control) or met-hGH (0.125 mg/kg three times per week), oxandrolone (0.125 mg/kg/day), or combination met-hGH plus oxandrolone. At the end of an initial period of 12 to 20 months, patients in the original control and oxandrolone groups were given combination met-hGH plus oxandrolone. At that time the dosage of oxandrolone was lowered to 0.0625 mg/kg/day. Sixty-five subjects have now completed the first 3 years of the study. Compared with the control growth rate for year 1 (3.8 cm/yr), significant increases in growth rate were seen in all 3 years of combination therapy (9.8, 7.4, and 6.1 cm/yr, respectively) and in the first 2 years of treatment with met-hGH alone (6.6, 5.4, and 4.6 cm/yr). When growth velocity was expressed as standard deviation for age in girls with Turner syndrome, significant increases relative to the control group for year 1 (-0.1 SD) were seen in all three years of both combination therapy and met-hGH alone (combination, +6.6, +4.3, +3.0 SD; met-hGH, +3.1, +2.0, +1.4 SD). After 3 years of treatment, predicted adult height by the method of Bayley-Pinneau increased 4.5 cm in the met-hGH group and 8.2 cm in the combination group.

Carbohydrate and lipid metabolism in Turner syndrome: effect of therapy with growth hormone, oxandrolone, and a combination of both

To evaluate the effects of growth-promoting therapy on carbohydrate metabolism in girls with Turner syndrome, we determined glucose and insulin concentrations during oral glucose tolerance tests (OGTTs) at baseline and after 5 days, 2 months, and 12 months of treatment with growth hormone (GH), oxandrolone, or a combination of GH and oxandrolone, or after the same intervals with no therapy. Before therapy, subjects had a significantly greater glucose response during OGTT than published normal control values. There were no significant changes in mean fasting glucose, cholesterol, or triglyceride concentrations in any of the treatment groups. The integrated glucose concentrations rose significantly over baseline values in the oxandrolone group at 2 and 12 months and in the combination group at 5 days. There were significant increases in the mean integrated insulin concentrations at 2 and 12 months for the group receiving oxandrolone alone and at all three times for the group receiving combination therapy. Thus oxandrolone, alone or in combination with GH, had significant effects on carbohydrate metabolism in subjects with Turner syndrome, whereas GH alone did not.

Extrapulmonary effects of maintenance corticosteroid therapy with alternate-day prednisone and inhaled beclomethasone in children with chronic asthma

Extrapulmonary effects of alternate-day prednisone and inhaled beclomethasone dipropionate therapy were examined in 24 and 32 children with asthma, respectively. Early morning serum cortisol values were significantly lower among patients receiving alternate-day prednisone than among patients receiving inhaled beclomethasone dipropionate and control subjects at 24 hours but not at 48 hours after an alternate-day prednisone dose. Urinary-free cortisol output during the second 24 hours of the alternate-day prednisone regimen were similar to values among patients receiving inhaled beclomethasone and were significantly lower than among control subjects for both groups. Mean heights among patients before being placed on maintenance corticosteroids were at the thirty-fifth percentile and were similar for both regimens. This was significantly lower than initial measurements for control subjects who, on average, were near the fiftieth percentile for both children with asthma not requiring maintenance corticosteroids and normal healthy Iowa children. Mean heights for both corticosteroid-treated groups remained at the thirty-fifth percentile after more than a 2-year average duration of follow-up. Heights of children with chronic asthma not requiring maintenance corticosteroids were initially significantly higher (fifty-first percentile) than the patients who subsequently required maintenance corticosteroids and increased significantly to the sixty-first percentile during a mean 2.7-year follow-up. Heights of healthy Iowa children remained near the fiftieth percentile during a mean 7-year follow-up. Disproportionate weight gain, although it was not consistently present, was significantly more likely with the alternate-day prednisone. Other extrapulmonary effects of the corticosteroid regimens appeared not to be of clinical importance during the time period of the study.

Results from the first 2 years of a clinical trial with recombinant DNA-derived human growth hormone (somatrem) in Turner's syndrome

A total of 70 subjects with Turner's syndrome from 11 centres were enrolled in a study of somatrem. After an initial observation period, they were randomly assigned to one of four groups, receiving no treatment (Group 1, control); oxandrolone, 0.125 mg/kg/day (Group 2); somatrem, 0.125 mg/kg 3 times/week (Group 3); or a combination of somatrem and oxandrolone on the above dose regimens (Group 4). After 12-20 months, Groups 1 (control), 2 (oxandrolone) and 4 (combination) were treated with somatrem, 0.125 mg/kg 3 times/week, and oxandrolone, 0.0625 mg/kg/day; Group 3 remained on somatrem, 0.125 mg/kg 3 times/week. All three treatment groups showed a statistically significant increase during year 1 in growth velocity over both their pretreatment growth rates and the control group growth rate. These increases were slightly less in year 2 for the somatrem and combination therapy groups, but remained significantly higher than the year 1 control group growth rate. Plasma IGF-1 levels were elevated in years 1 and 2 in the somatrem and combination groups. Adverse events were few with the somatrem group, though mild virilization occurred with oxandrolone, alone or in combination. Bone age advancement was observed with all treatments but was greater with combination therapy; it was accompanied by height age advancement. The effect of this therapy on predicted adult height was also evaluated.

A comparison of adrenal cortical function in patients with depressive illness and Cushing's disease

We measured total and free plasma cortisol, 24-hour urinary cortisol excretion, and corticosteroid-binding globulin in 21 normal subjects, 25 patients with depressive illness, and 6 patients with Cushing's disease. Patients with depression had mean 24-hour plasma (8.3 +/- 2.7 micrograms/dl) and urinary (36 +/- 33.55 micrograms/g creatinine) cortisol levels that did not differ from those of normal subjects (6.6 +/- 1.7 microgram/dl; 24.6 +/- 15.4 micrograms/g creatinine), but were significantly lower than those of patients with Cushing's disease (14.4 +/- 2.4 micrograms/dl; 215 +/- 101 micrograms/g creatinine). Not all patients with depression had hypercortisolemia, and the 1-mg dexamethasone suppression test identified some of those with adrenal hyperfunction. 17 of 25 patients had normal 8 a.m. and/or 4 p.m. plasma cortisol after dexamethasone (suppressors), while 8 patients had values greater than 5 micrograms/dl (nonsuppressor). Suppressors had normal total 24-hour plasma and urinary cortisol, while nonsuppressors had levels that were in the range seen in Cushing's disease. Patients with depression showed the expected circadian variation in total and free cortisol, but nonsuppressors had elevated levels in evening and early a.m. hours when levels in normal subjects were low. Patients with Cushing's disease had elevated levels throughout the day. The mean binding capacity of corticosteroid-binding globulin was not different in normal and depressed subjects (23.9 +/- 3.2 vs. 22.2 +/- 3.4 micrograms/dl), but was significantly decreased in patients with Cushing's disease (15.7 +/- 3.5 micrograms/dl). Although total cortisol levels were similar, nonsuppressors had significantly lower mean 24-hour plasma free cortisol (1.01 +/- 0.27 microgram/dl) than patients with Cushing's disease (2.4 +/- 0.54 microgram/dl).(ABSTRACT TRUNCATED AT 250 WORDS)

Differences in plasma ACTH and cortisol between depressed patients and normal controls

Although studies have repeatedly demonstrated that depressed patients average higher baseline and postdexamethasone serum cortisol than normal controls, studies examining similar trends in adrenocorticotrophic hormone (ACTH) have produced conflicting results. The current study uniquely employs 48 hr of every 20-min serum sampling: the first 24 hr prior to dexamethasone administration and the second 24 hr subsequent. The depressed patients showed higher baseline cortisol levels than normal controls, with the greatest differences between 2 AM and 6 AM. After an 11 PM dose of dexamethasone, the difference was greatest between the hours of 8 AM and 4 PM. Among the depressed patients, those who reported recent weight loss had significantly higher plasma ACTH and cortisol levels than those without weight loss. Depressed patients without weight loss had higher baseline plasma ACTH than normal controls, and the differences reached significance during some time periods.

Pituitary-adrenal axis rhythm disturbances in psychiatric depression

We studied disturbances in the circadian pattern of plasma corticotropin and cortisol concentrations in 25 depressed patients (eight dexamethasone suppression test [DST] nonsuppressors and 17 suppressors) and 21 normal control subjects. Blood samples were drawn every 20 minutes for 24 hours before the administration of dexamethasone, and for a second 24 hours after the administration of 1 mg of dexamethasone. The corticotropin and cortisol level rhythms were examined using three different statistical methods. Nonsuppressors averaged greater elevations in plasma cortisol and corticotropin levels than did subjects in the other two groups, both before and after administration of the dexamethasone. The cortisol levels of the suppressors were virtually identical to those of the control subjects. However, the suppressors had significant elevations of corticotropin levels compared with normal control subjects, especially on the day before taking dexamethasone. Before taking dexamethasone, the depressed patients reached a daily nadir of cortisol concentration approximately two hours earlier than did the normal control subjects. The DST nonsuppressors also exhibited a blunting in the expected circadian rhythm of the corticotropin level.

Age-related changes in the circadian rhythm of plasma cortisol in man

We studied the effect of age on the circadian rhythm of plasma cortisol in 34 normal subjects, aged 18-75 yr. Blood was sampled at 20-min intervals beginning at 2000 h, and the data were analyzed using the PULSAR program and the cosinor method. There was a negative correlation between age and the time of the maximum cortisol concentration (r = -0.548; P = 0.001), the time of the nadir cortisol concentration (r = -0.543; P = 0.001), and the acrophase (r = 0.528; P = 0.001). When the subjects were divided into those 39 yr of age and younger and 40 yr of age and older, the times of the cortisol nadir, maximum, and acrophase were significantly earlier in the older group. The interval between the nadir and peak cortisol levels was not significantly different, consistent with an age-related phase advance of the cortisol circadian rhythm. Quantitative indices of adrenal function, including the 24-h mean cortisol concentration and the number of cortisol peaks as well as their amplitude and duration, were not different in the two groups. There was a significant negative correlation between age and customary bedtime (r = -0.686; P = 0.001) that may explain, in part, the phase advance in the older subjects. This observation strengthens the evidence that sleep onset is a major factor contributing to synchronization of the cortisol rhythm. Alternative explanations are that age-related changes in the control of hormonal and other rhythms have important influences on sleep and activity schedules, or that sleep and cortisol variables do not influence each other, but are both the final expression of some central change.

Lymphocyte glucocorticoid receptor binding in depressed patients with hypercortisolemia

Despite elevated levels of serum and urinary cortisol, patients with depressive illness manifest none of the clinical stigmata of glucocorticoid excess. This hypercortisolemia in the absence of clinical effects suggests a state of hormone resistance and could be mediated by alterations in the glucocorticoid receptor. Earlier studies have shown that small doses of glucocorticoids cause a decrease in glucocorticoid receptor binding in normal human lymphocytes. White cells from depressed patients with significant hypercortisolemia would be expected to show a similar change in receptor concentration if peripheral tissues are adequately exposed to and sensitive to the hormone. In this study we compared the binding of [3H]dexamethasone to lymphocytes from normal subjects and depressed patients with hypercortisolemia. Lymphocytes from normal subjects had a mean receptor concentration of 10.2 +/- 0.66 fm/10(6) cells (S.E.M.) and a dissociation constant of 4.8 +/- 0.47 nM. Lymphocytes from depressed patients with abnormal 0800 h serum cortisol after dexamethasone had a mean receptor concentration of 8.8 +/- 0.75 fm/10(6) cells, which was not significantly different from that in lymphocytes from normal subjects or from depressed subjects with normal post-dexamethasone cortisol levels (9.4 +/- 0.95 fm/10(6) cells). Lymphocytes from depressed patients with elevated urinary free cortisol excretion (UFC) also had normal receptor concentration and binding affinity for dexamethasone. The lack of a change in lymphocyte glucocorticoid receptor concentration in the presence of cortisol excess suggests the possibility that hypercortisolemia in depressive illness represents a state of peripheral glucocorticoid resistance.

A New Approach to Athletic Training in Southern Wisconsin High Schools

In brief: The authors surveyed a random sample of 50% of Wisconsin high schools in each of the three classes to see how they were handling (1) organization of medical coverage, (2) first aid and initial care of sports injuries, and (3) follow-up care and reconditioning of sports injuries. The data showed that the medical coverage of the athletes was poorly organized and supervised. To help alleviate this problem, the University Hospital Sports Medicine and Fitness Center developed an outreach program in which 19 schools contract for (1) twice-weekly visits by an athletic trainer; (2) educational programs for coaches, athletes, and parents; and (3) trainer coverage at competitive events. This program provides the expertise and services of a certified trainer to schools that would otherwise go without.

Platelet and fibroblast monoamine oxidase in alcoholism

Monoamine oxidase (MAO) activity has been reported to be low in platelets (MAO B) and brain (MAO A and B) of some patients with alcoholism compared to control subjects. Whether the decreased platelet MAO activity found in alcoholism is secondary to the effect of alcohol or exists before alcohol abuse is not clear. The hypothesis that altered MAO A activity is determined by an abnormality in the genetic regulation of the enzyme can be tested by measuring MAO A activity in human fibroblasts cultured under controlled conditions. We first studied the kinetic parameters of platelet MAO B activity in patients hospitalized for treatment of alcoholism. Vmax was 38% lower in the patients (n = 14) than in normal controls (n = 22), but the enzyme affinity (Km) for the substrate tyramine was unchanged. Patients with the five lowest levels of platelet MAO activity had MAO activity measured from fibroblasts cultured from skin punch biopsies. Their fibroblast MAO activity was within the normal range, showing a dissociation between platelet MAO B and fibroblast MAO A activities and suggesting that MAO A activity is not low for genetic reasons in alcoholic subjects who do have low platelet MAO B activity.

Characterization of a cytosolic steroid-binding protein in the liver of the winter flounder, Pseudopleuronectes americanus

The winter flounder liver contains significant concentrations of estrogen binding protein(s) that fulfill some of the criteria normally assigned to receptor proteins, in that these proteins are saturated at low substrate concentrations (less than 5 nM) and have a high affinity for ligand (Kd approximately 6 X 10(-10) M for [3H]17 beta-estradiol). Sedimentation analysis of the 17 beta-estradiol-binding protein complex on 5-20% sucrose density gradients detected an 8 S form of the binding protein under low salt conditions. Nonspecific sites sedimented in the 4 S region. These sedimentation characteristics are similar to those observed for the estrogen receptor and nonspecific binding sites in mammalian tissues. In contrast to mammalian estrogen receptor, which binds selectively to estrogens, the binding protein(s) investigated in our studies also binds other steroids. Competitive binding studies demonstrated that 10-fold excess of unlabeled testosterone and progesterone displaced 50 and 45% of [3H]17 beta-estradiol from the binding protein, respectively. These studies demonstrate the presence of steroid-binding protein in liver of female winter flounder which might play a role in regulating hepatic steroid hormone action.

Circadian analysis of plasma cortisol levels before and after dexamethasone administration in depressed patients

Pituitary-adrenal regulation in healthy subjects and in depressed patients is very dynamic. Interpretation of results of the 1-mg dexamethasone suppression test has usually depended on the result of a single blood cortisol level measurement obtained in the morning or afternoon. We analyzed circulating cortisol concentrations by obtaining blood samples at 20-minute intervals for 24 hours before and after dexamethasone administration in depressed patients. The results illustrate the variability in patterns of escape from the effects of dexamethasone among depressed patients; they also indicate the influence of the sampling time on the test results and thus on the relationship of the test result to various clinical classifications. Finally, these results provide the basis for understanding the consequences of alternative sampling strategies.

Bone density in amenorrheic women with and without hyperprolactinemia

To determine whether decreased bone density in patients with PRL-secreting pituitary tumors is specifically related to hyperprolactinemia or is a consequence of disordered pituitary-gonadal function common to all amenorrheic states, we measured the bone mineral content of the radius by photon absorptiometry in normal subjects, in women with amenorrhea and normal serum PRL levels, and in women with PRL-secreting pituitary tumors. The women did not differ significantly in mean age, height, weight, or serum calcium, phosphorous, gonadotropin, testosterone, vitamin D, or PTH concentrations, and all had normal renal and thyroid function. The bone mineral content in women with amenorrhea and normal serum PRL levels (0.91 +/- 0.02 g/cm) was not significantly different from that in control subjects (0.88 +/- 0.01 g/cm). Patients with PRL-secreting tumors studied 2-5 yr after transsphenoidal surgery had significantly diminished bone mineral content whether they were cured (0.82 +/- 0.02 g/cm) or had persistent amenorrhea and hyperprolactinemia (0.81 +/- 0.02 g/cm). Serum estradiol concentrations did not differ significantly in the four groups, and there was no correlation between estradiol concentration and bone mineral content or between PRL concentration and bone mineral content in the amenorrheic women. The presence of decreased bone mineral content in hyperprolactinemic patients suggests that PRL may have a direct effect on bone and may be another indication for early treatment of PRL-secreting pituitary tumors.

Estrogen use and breast cancer. Interaction with body mass

With few exceptions, most epidemiologic studies do not show an excess relative risk of breast cancer associated with menopausal estrogen therapy. Other studies show a relationship of breast cancer to obesity, which is characterized by increased endogenous estrogen production. This study explored the possibility of an interaction between ponderosity and exogenous estrogen use in a case-control study of 113 postmenopausal breast cancer patients and pair-matched hospital control subjects. In this series, neither menopausal estrogen use nor relative weight were significantly associated with breast cancer risk. However, among estrogen users, the relative risk of breast cancer was strikingly influenced by the ponderosity of the subjects; the relative risk was 0.41 for women whose relative weight was less than the median, compared with 1.29 for those whose relative weight exceeded the median. The mean age was also examined at diagnosis in order to explore the potential of exogenous estrogen as a tumor promotor. The mean age at breast cancer diagnosis in estrogen users, 58.1 years, was significantly lower than in nonusers, 63 years. A significant linear relationship was found between age at diagnosis and body weight among estrogen users. Estrogen-treated women in the lowest tertile of body weight had the diagnosis of breast cancer made seven years earlier than those in the highest tertile of weight. There was no significant difference in the distribution of clinical stages at diagnosis between estrogen users and nonusers. These data suggest that relative body weight is an important modifier of the effect of exogenous estrogens on breast cancer biology.

Further studies of the effects of inhaled glucocorticoids on pituitary-adrenal function in healthy adults

We compared the effects of increasing doses of beclomethasone dipropionate (BDP) and fluocortin butylester (FCB) on several indices of pituitary-adrenal function in healthy adult subjects. Significant depression of urinary free cortisol excretion and the response to metyrapone was seen only at the highest dose (1600 mg/day) of BDP. This depression was not reflected by frequent measurement of the serum cortisol concentration. FCB used well in excess of its presumed therapeutic dose range showed no evidence of any effect on pituitary-adrenal function. These results confirm that at high doses BDP causes pituitary adrenal suppression. Differences from studies showing reduced adrenal function in children on BDP doses of 400 to 800 mg/day probably reflect differences in the dose per kilogram of body weight. Since the use of FCB was not accompanied by any adverse side effects or evidence of reduced pituitary-adrenal function, it may be a variable alternative for asthmatics who require high doses of inhaled glucocorticoid.