Is bone marrow examination in small-cell lung cancer really necessary?

Of 403 patients with small-cell lung cancer, we identified by aspiration, biopsy, or both 67 with bone marrow involvement and found the two procedures to be complementary in detecting marrow involvement. The mean surface area of the positive biopsy specimens was significantly greater than that of a randomly selected group of negative biopsy specimens, suggesting that the larger the specimen, the greater the chance of detecting tumour. Patients with marrow involvement had only a slightly worse prognosis compared with other patients who had extensive disease. Only 7 of the 403 patients (1.7%) had extensive disease based on marrow involvement alone. Because bone marrow examination rarely changes the stage of cancer in noninvasively assessed patients, and has no impact on the tolerance of chemotherapy and only a small effect on length of survival, we do not recommend this procedure in the routine staging of small-cell lung cancer.     

Spontaneous remission of multilobated non-Hodgkin lymphoma.

A 67-year-old previously well man was admitted with hypercalcemia after a 7-day history of fever, night sweats, and back pain. The blood showed 5% multilobated lymphoid cells. A multilobated non-Hodgkin lymphoma associated with marked reticulin fibrosis was diagnosed on a bone marrow biopsy. During the next 7 days, in the absence of specific therapy, his symptoms disappeared. Three weeks after admission his biochemical abnormalities had resolved and after 9 weeks his bone marrow examination was normal. He remains in clinical and laboratory remission 16 months after presentation.     

Development and evaluation of an inner city mental health team

The objective of this study was to examine the development and activity of a Community Mental Health Team, originally targeted to meet the needs of African Caribbean, Asian and homeless populations in an inner city area. The study was based on all (n =1046) client referrals to the Bristol Inner City Community Mental Health Team between 1987 and 1994. Additional qualitative interviews were held with general practitioners (GPs) from each of the nine practices in the area. The setting was the inner city area of Bristol, an area with a population of around 35,000 27% of whom are from ethnic minority communities. This is an area shown in previous research to have a high level of mental health problems. Trends in referral rates, demographic characteristics and seriousness of psychiatric illness amongst those referred to the Inner City Mental Health Team were the main outcome measures used. In the years studied there were significant increases in the number and proportion of overall referrals from GPs and psychiatrists and decreases in referrals from other agencies. In particular, there were reductions in the referral both of clients from the originally identified target groups and of patients with serious mental illness. GPs tended to refer a greater proportion of patients with less serious mental illness. The results of the study showed that a team originally developed to meet the needs of the homeless and those from ethnic minorities has, with the removal of special project funding, shifted its focus away from the client groups for whom it was originally developed to those with less serious mental health problems. These changes are partially attributable both to changes in the remit of the team, making it more acceptable to GPs, and to a growing acceptance of community-based mental health services among GPs and their patients. Changes in the geographic catchment area served by the team has also played a role in the observed trends. Commissioners of mental health services need to bear in mind the needs of high-risk groups when making contracts. It may be that in order to meet effectively the needs of inner city populations with a high prevalence of mental health problems, there is a need for specialist teams with a specific remit. Accepted: 13 May 1997     

The morbidity of bicoronal flaps in maxillofacial surgery

Bicoronal flaps have been used in neurosurgery to gain access to the anterior cranium for over a century. A previous paper by Henderson and Jackson (1973) described the good access afforded by the flap for Le Fort II osteotomies. This paper reviews the morbidity of the procedure in 24 patients in whom bicoronal flaps were raised for access to the mid and upper facial skeleton.     

Correction of preexisting astigmatism at the time of small incision cataract surgery

To reduce preexisting astigmatism in patients having cataract surgery, paired keratotomy incisions of graded lengths were performed at the time of cataract extraction. Small incisions, made possible by foldable silicone implants, were used to make the correction more accurate. The results obtained in 48 patients are analyzed. It appears that this technique is safe, quick, and helpful in reducing preexisting astigmatism.     

Gastric cancer below the age of 55: implications for screening patients with uncomplicated dyspepsia

Aims—To test the hypothesis that gastric cancerpresenting with uncomplicated dyspepsia is rare below the age of 55.
Patients and methods—The area studied was thepostcode defined catchment area of a district general hospital(Gloucestershire Royal) serving a population of 280 500. An openaccess endoscopy service has been available in this district for morethan 17 years. All cases of gastric cancer during a seven year period(1986-92) were drawn from the local pathology database. The databaseof the neighbouring hospital and the South West Cancer Registry were searched for missed cases from the postcoded area. Hospital and generalpractitioner records were retrospectively reviewed with respect toduration of symptoms, and previous consultation and investigation fordyspepsia; and alarming symptoms and signs suggestive of underlyingmalignancy (unexplained recent weight loss, dysphagia, haematemesis ormelaena, anaemia, previous gastric surgery, palpable mass, and perforation).
Results—Twenty five of 319 cases of gastric cancerdetected during the seven year period were aged less than 55. Twentyfour of these 25 patients presented with one or more suspicioussymptoms or signs. Only one patient (4%) aged less than 55 presentedwith uncomplicated dyspepsia. In two patients there was a delay in diagnosis of more than six months after first presenting to the generalpractitioner. Both these patients had significant symptoms at presentation.
Conclusion—Gastric cancer is rare below the age of55 (7.8% of all cases) and, even in the presence of established openaccess endoscopy, presents with suspicious symptoms or signs in 96% of cases. The age limit for screening uncomplicated dyspepsia can beraised safely to 55.

Keywords:gastric cancer; open access endoscopy; diseaseprevention; disease control; general practice; epidemiology; diagnosis