Adult acute leukemia. The Rochester (NY) Experience.

A ten-year retrospective study of adult acute leukemia was performed in nonieukemia-specialized centers to determine prognostic factors, length and quality of survival, cause of death, and response to different modes of therapy. Of 200 patients, 9.5% achieved complete remission, 14.0% obtained partial remission, and no response was present in 76.5%. Patients who were 50 years old or more (64.5%) had a significantly lower response rate (P less than .005) and survival (P less than .05) than the younger age group. Aggressive chemotherapy significantly improved the response rate, as well as survival (P less than .001). Quality of life was similar for responders and nonresponders, both spending only one fourth of their survival time in the hospital. Infection as the leading cause of death. The overall ten-year response rate of 23.5% represents a realistic rate in nonleukemia-specialized centers in which the treatment of adult acute leukemia is variable.

An alternative algorithm for dosing transdermal fentanyl for cancer-related pain.

Many cancer patients are undermedicated and inappropriately managed for pain, leading to a diminished quality of life. Patients with moderate to severe pain often require opioid analgesics. Recently published guidelines emphasize individualization of opioid treatment to provide the drug and route of administration that meet the needs of the particular patient. Intolerable side effects, ineffective pain relief, or a change in the patient's clinical status can dictate the need for a new pain management regimen. Physicians must be able to readily quantify relative analgesic potency when converting from one opioid to another or from one route of administration to another. Transdermal fentanyl (Duragesic) is an opioid agonist that has been shown to be safe and effective for the treatment of cancer pain. However, clinicians should realize that the manufacturer's recommendations for equianalgesic dosing of transdermal fentanyl may result in initial doses that are too low in some patients, and in a titration period that is too long. Under these circumstances, the patient is likely to experience unrelieved pain. An alternative dosing algorithm that considers both a review of the literature and our combined clinical experience with transdermal fentanyl should help clinicians individualize the treatment of pain.

Detection of soft x rays with NEA III-V photocathodes.

We describe the experimental energy response of a negative electron affinity (NEA) III-V photocathode to x rays with energies from approximately 0.8 to approximately 3 keV. Energy resolutions, E/DeltaE, from approximately 1 to approximately 3 are obtained, together with approximately 100% quantum efficiency. Theoretical calculations based on an electron diffusion model are shown to be in good agreement with the experimental results. The use of NEA III-V photocathodes as efficient soft x-ray detectors with good energy and spatial resolution is discussed for imaging applications in x-ray astronomy.

Pain control in the ambulatory elderly.

Pain control in the elderly, no matter what the etiology or setting, can be a major clinical challenge. Aging causes unique physiologic changes, eg, a decreased perception of pain and an enhanced sensitivity to opioid analgesics. Principles regarding evaluation of patients with pain are reviewed, including the use of an objective instrument for pain assessment from the viewpoint of both physician and patient. Good pain control can be achieved with the nonopioids, such as acetaminophen and the nonsteroidal anti-inflammatory drugs, the opioid analgesics, and, in some cases, adjuvant agents. Discussed also are the concerns for patient addiction and the WHO Cancer Pain Relief program.

The last few days.

In the dying patient, coma is preceded by either progressive sedation or the development of the organic brain syndrome of delirium. More than one-third of dying patients experience some difficulties during the last 48 hours of life with noisy and moist breathing, pain, and agitation and restlessness the most common. The great majority of these terminal symptoms can be managed by reassurance or drug intervention. Sublingual lorazepam and continuous subcutaneous infusion of midazolam can be effective in controlling terminal restlessness.

Prognostication of survival in hospice care.

In summary, based on this review of the literature, the following conclusions are offered: Prognostication of survival for the terminally ill cancer patient is an inexact science. Utilization of a performance scale such as the Karnofsky scale may be helpful both in the initial as well as the ongoing assessment of prognosis.

Physicians, palliative care, & health care reform.

As hospice programs have grown, they somehow left physicians out of the loop. As the health care system faces reform proposals and eventually undergoes changes, physicians need to be more involved in what happens to hospice care.