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As usual for him, Dr. Michael Norins made all the correct observations ('Hospitalists vs. Internists,' Letters, Jan. 15, 2005, p. 13). The real danger of 100% hospitalist care is the [...]

A randomized controlled trial was initiated in 1972 to compare two chemotherapeutic regimens [1–3-bis (2-chloroethyl) 1-nitrosourea (BCNU), cyclophosphamide, and prednisone versus melphalan and prednisone], to determine whether the two regimens are cross-resistant, and to evaluate the effectiveness of sodium fluoride, vitamin D, calcium gluconate, and fluoxymesterone in the promotion of bone healing. Initial responses (50%) and survival (36 mo median) for patients treated with the two chemotherapeutic regimens were the same. Patients on either regimen who failed to respond after 6 mo had a very low response rate to the alternative regimen (approximately 10%). Initially responding patients were randomly assigned to either an active drug regimen (sodium fluoride, vitamin D, calcium gluconate, fluoxymesterone) or placebo tablets. There was no significant difference in the low percentage of patients demonstrating bone improvement. Thus, the BCNU, cyclophosphamide, prednisone regimen is as effective as melphalan and prednisone. Fluoride, calcium, vitamin D, and androgenic steroids should not be routinely recommended in myeloma, as they seem to add little to effective chemotherapy and may contribute to morbidity.

Until now there has not been a treatise summarizing the management of oncologic emergencies in the aged. All of the well-described acute complications of malignancy occur in the elderly. Such clinical events are best labeled urgent rather than emergent, and some may be less well tolerated in the older patient because of normal physiologic changes of aging. However, all should be recognized as early as possible and can be treated, when it is appropriate to do so, as has been detailed for 14 problems discussed in this article. The authors also address two important topics, the quality of life and the use of intensive care units, both germane to the difficult question of whom and when to treat.

The elderly patient with malignancy is often considered a poor risk for treatment. To assess the effect of age on the treatment of one such disease, multiple myeloma (a disease with increased incidence in the elderly), a study was made of 280 patients treated with 1,3‐bis (2‐chloroethyl)‐1‐nitrosourea (BCNU), cyclophosphamide and prednisone on a Southeastern Cancer Study Group protocol. Initial response rates after six months of treatment were equivalent for the older compared with the younger age groups, with a slightly longer remission duration for those over 70. Likewise, survival was equivalent for the older patients. This was not the result of selection of older patients with less advanced disease, since the proportion with both good and poor risk factors are not significantly different in the various age groups. Moreover, for patients with each of the prognostic factors, older patients responded at least as well as younger patients. There were no significant differences among the age groups in gastrointestinal, skin, hair, or hematologic toxicity, although there was a slightly higher incidence of mild granulocyte and platelet toxicity in patients over 60. These findings are in contrast to the widely held belief that older patients cannot tolerate chemotherapy. On the contrary, they suggest that the elderly patient with myeloma may be expected to respond and survive, without excessive toxicity, at least as well as a younger counterpart with similar prognostic factors.

In order to study the effectiveness of the drug combination BCNU, cyclophosphamide, and prednisone (BCP) in myeloma, the Southeastern Cancer Study Group entered 126 previously untreated and 33 previously treated patients in this study. Patients received cyclophosphamide, 400 mg/sq m, BCNU, 75 mg/sq m, and prednisone, 80 mg/sq m, for 7 days, every 4 wk, and were evaluated for response after 6 mo of therapy. Responding patients were continued on therapy and followed for evaluation of survival. Previously untreated patients were evaluated for good and poor risk status as well as clinical stage by calculation of tumor cell mass. These calculated values, as well as the individual components such as blood urea nitrogen (BUN), immunoglobulin (Ig) type, and hemoglobin (Hb), were evaluated for correlation with response and survival. The response rate was approximately 50% for all untreated patients regardless of cell mass or risk status. Toxicity was not excessive, and no case of acute leukemia was seen. Median survival for untreated patients was 27.8 mo; good risk patients, 44 mo; and poor risk, 12 mo. Though cell mass status did not correlate well with survival, individual factors of BUN, IgAλ, and IgGκprotein types had strong predictive value. Using these factors, a model for survival predication was created that had high predictive value in this group of patients. The study indicates that this treatment regimen is effective and could be used as an alternative to standard chemotherapy or in sequential combinations. Since it does not contain melphalan, it might be attractive if melphalan-contain-ing regimens prove to be particularly leuke-mogenic. The survival-predictive model may be useful in assessment of patient prognosis and will be further evaluated in subsequent group studies.

The major clinical and pathological features and the long-term follow-up of 27 patients with Felty's syndrome who were treated with splenectomy for severe granulocytopenia and for acute, chronic, or recurrent infection were studied. Granulocyte counts rose within days in most patients, although slow responses and transient granulocytopenia did occur; only 12% of the patients had persistent or recurrent granulocytopenia. Infections resolved promptly in 77% of the patients, more slowly in the remainder, and only one patient had new problems of infection after splenectomy.Splenic enlargement, present in all but one case, was attributable to expansion of the sinusoidal pulp. The most substantial pathological features of immune stimulation included germinal center hyperplasia and prominent clusters of plasma and preplasma cells within sinuses.(Arch Intern Med 138:597-602, 1978)

A study of prednisone therapy in 18 patients with chronic lymphocytic leukemia is reported. 1. Antileukemic effects consisting of subjective improvement, decrease in organ infiltration, improvement in hemoglobulin and absolute neutrophil count occurred. 2. These effects were transient. 3. An increase, often marked, in the number of circulating lymphocytes occurred in 16 of the 18 patients. 4. The administration of prednisone was attended by an increase in the severity of infections. Some increase in the frequency of infections was also observed, but this was not statistically significant (p > 0.05). It is concluded that corticosteroids should not be used electively in patients with chronic lymphocytic leukemia except in the presence of hemolytic anemia, significant thrombocytopenia or in the presence of advanced disease associated with bone marrow failure.

Indomethacin (Indocin), a new nonsteroid, anti-inflammatory, antipyretic agent, was evaluated in nine patients with fever due to Hodgkin's disease. Each patient had significant and prolonged fever despite treatment by cytotoxic chemotherapy, salicylates, and corticosteroids. In all instances, prompt and continuous suppression of fever was achieved without untoward effects. The course of the disease in these cases was not apparently altered. This agent could be a useful adjunct in the symptomatic treatment of fever in Hodgkin's disease.