Long-term cost-effectiveness of weight management in primary care.

BACKGROUND: As obesity prevalence and health-care costs increase, Health Care providers must prevent and manage obesity cost-effectively. METHODS: Using the 2006 NICE obesity health economic model, a primary care weight management programme (Counterweight) was analysed, evaluating costs and outcomes associated with weight gain for three obesity-related conditions (type 2 diabetes, coronary heart disease, colon cancer). Sensitivity analyses examined different scenarios of weight loss and background (untreated) weight gain. RESULTS: Mean weight changes in Counterweight attenders was -3 kg and -2.3 kg at 12 and 24 months, both 4 kg below the expected 1 kg/year background weight gain. Counterweight delivery cost was pound59.83 per patient entered. Even assuming drop-outs/non-attenders at 12 months (55%) lost no weight and gained at the background rate, Counterweight was 'dominant' (cost-saving) under 'base-case scenario', where 12-month achieved weight loss was entirely regained over the next 2 years, returning to the expected background weight gain of 1 kg/year. Quality-adjusted Life-Year cost was pound2017 where background weight gain was limited to 0.5 kg/year, and pound2651 at 0.3 kg/year. Under a 'best-case scenario', where weights of 12-month-attenders were assumed thereafter to rise at the background rate, 4 kg below non-intervention trajectory (very close to the observed weight change), Counterweight remained 'dominant' with background weight gains 1 kg, 0.5 kg or 0.3 kg/year. CONCLUSION: Weight management for obesity in primary care is highly cost-effective even considering only three clinical consequences. Reduced healthcare resources use could offset the total cost of providing the Counterweight Programme, as well as bringing multiple health and Quality of Life benefits.

The Counterweight programme: Prevalence of CVD risk factors by body mass index and the impact of 10% weight change.

OBJECTIVES: To examine relationships between body mass index (BMI), prevalence of physician-recorded cardiovascular disease (CVD) risk factors in primary care, and changes in risk with 10% weight change. METHODS: The Counterweight Project conducted a baseline cross-sectional survey of medical records of 6150 obese (BMI ≥ 30 kg/m(2)), 1150 age- and sex-matched overweight (BMI 25 to <30 kg/m(2)), and 1150 age- and sex-matched normal weight (BMI 18.5 to <25 kg/m(2)) controls, in primary care. Data were collected for the previous 18 months to examine BMI and disease prevalence, and then modelled to show the potential effect of 10% weight loss or gain on risk. RESULTS: Obese patients develop more CVD risk factors than normal weight controls. BMI ≥ 40 kg/m(2) exhibits increased prevalence of type 2 diabetes mellitus (DM), odds ratio (OR) men: 6.16 (p < 0.001); women: 7.82 (p < 0.001) and hypertension OR men: 5.51 (p < 0.001); women: 4.16 (p < 0.001). Dyslipidaemia peaked around BMI 35 to <37.5 kg/m(2), OR men: 3.26 (p < 0.001); women 3.76 (p < 0.001) and CVD at BMI 37.5 to <40 kg/m(2) in men, OR 4.48 (p < 0.001) and BMI ≥ 40 kg/m(2) in women, OR 3.98 (p < 0.001). A 10% weight loss from the sample mean of 32.5 kg/m(2) reduced the OR for type 2 DM by 30% and CVD by 20%, while 10% weight gain increased type 2 DM risk by more than 35% and CVD by 20%. CONCLUSION: Obesity plays a fundamental role in CVD risk, which is reduced with weight loss. Weight management intervention strategies should be a public health priority to reduce the burden of disease in the population.

Empowering primary care to tackle the obesity epidemic: the Counterweight Programme.

OBJECTIVE: To improve the management of obese adults (18-75 y) in primary care. DESIGN: Cohort study. SETTINGS: UK primary care. SUBJECTS: Obese patients (body mass index > or =30 kg/m(2)) or BMI> or =28 kg/m(2) with obesity-related comorbidities in 80 general practices. INTERVENTION: The model consists of four phases: (1) audit and project development, (2) practice training and support, (3) nurse-led patient intervention, and (4) evaluation. The intervention programme used evidence-based pathways, which included strategies to empower clinicians and patients. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation. MAIN OUTCOME MEASURES: Proportion of practices trained and recruiting patients, and weight change at 12 months. RESULTS: By March 2004, 58 of the 62 (93.5%) intervention practices had been trained, 47 (75.8%) practices were active in implementing the model and 1549 patients had been recruited. At 12 months, 33% of patients achieved a clinically meaningful weight loss of 5% or more. A total of 49% of patients were classed as 'completers' in that they attended the requisite number of appointments in 3, 6 and 12 months. 'Completers' achieved more successful weight loss with 40% achieving a weight loss of 5% or more at 12 months. CONCLUSION: The Counterweight programme provides a promising model to improve the management of obesity in primary care.

Nutritional status and its relationship to quality of life in a sample of chronic hemodialysis patients.

OBJECTIVE: To assess the relationship between nutritional status and quality of life in a sample of chronic hemodialysis patients. DESIGN: Cross-sectional study. SETTING: Haemodialysis Units of St Vincent's and St George Hospitals, Sydney, Australia. PATIENTS: Sixty-four patients participated in the nutritional assessment, of which 53 completed the quality of life questionnaire. INTERVENTION: Nutritional status was assessed using subjective global assessment in addition to a number of anthropometric and biochemical parameters. Quality of life was assessed by means of a patient questionnaire and assessment of physical functioning. MAIN OUTCOME MEASURES: Nutrition status, 6 quality of life subscales related to general well-being, health and functioning, social and economic, psychological/spiritual well-being, and family life, employment status, income, participation in recreational/sports activities, the number of hospital admissions, days of hospitalization, and lengths of hospital stay. RESULTS: Sixty-four percent of patients were well nourished, 23% were moderately malnourished, and 13% were severely malnourished. Malnutrition was associated with poorer subjective quality after controlling for the affects of sociodemographic and medical variables. Severe malnutrition was also independently associated with poorer physical function, and resulted in significantly more hospital admissions, more days of hospitalization, and longer average lengths of hospital stay. CONCLUSION: Malnutrition is common in chronic hemodialysis patients and is associated with poorer quality of life when the degree of malnutrition becomes severe. Prospective studies are required to determine whether improving the nutritional status of these patients will result in meaningful improvements in quality of life and other medical outcomes.

Comparison of electrodessication with CO2 laser for the treatment of actinic cheilitis.

BACKGROUND: Actinic cheilitis is a common premalignant condition that is most often treated with destructive therapy. The most effective technique is usually considered to be CO2 laser resurfacing. Little has been written on the use of electrodessication for this condition. OBJECTIVE: We designed a study to compare these two treatment modalities for the treatment of biopsy-confirmed actinic cheilitis. METHODS: A random half of the lower lip was treated with electrodessication. The contralateral half was then treated with CO2 laser. Healing time, subjective pain during healing, and clinical outcome at 3 months was compared. RESULTS: The side treated with electrodessication took significantly longer to heal than the side treated with the CO2 laser (23 versus 14 days, P <.001). There was no difference in subjective pain or clinical appearance at 3 months. CONCLUSION: Although the healing time is longer with electrodessication, this modality represents an inexpensive practical ablative treatment method for actinic cheilitis.

Traumatic arteriovenous fistula of the upper lip.

Traumatic arteriovenous fistulas can present days to years following penetrating trauma and are often challenging to diagnose and manage. Patients may present to the dermatologist with unilateral varicose veins or a pulsatile mass. Our case illustrates the value of palpation in a careful systematic approach to any new lesion, especially in the context of previous penetrating trauma. We also discuss the nomenclature of arteriovenous communications and review their current management.

Alabaster skin after carbon dioxide laser resurfacing with histologic correlation.

BACKGROUND: Carbon dioxide laser resurfacing has gained popularity as a relatively safe and effective method of facial rejuvenation. Original reports describe mostly reversible side effects and a low incidence of scarring. Only very recently have reports of delayed hypopigmentation surfaced. This effect is not visible until several months after resurfacing, and most likely represents a permanent change. OBJECTIVE: To provide an additional clinical description of the complication of delayed hypopigmentation along with the first published histologic correlation. METHODS: Clinical records along with a preprocedure and 7-month postprocedure full-thickness skin biopsy were used for this report. RESULTS: This patient experienced a striking leukoderma 6 months after a full facial carbon dioxide laser resurfacing procedure done for widespread actinic keratoses. There was a zone of dermal fibrosis extending approximately 0.4 mm on the postprocedure biopsy. Comparison of the preprocedure and postprocedure biopsies revealed no difference in the number of melanocytes by MART-1 immunohistochemical staining, but there was a significant decrease in epidermal melanin as determined by Fontana-Mason staining. CONCLUSION: This patient experienced a profound expression of an increasingly recognized and reported complication of carbon dioxide laser resurfacing. Histologic correlation is similar to the results previously reported after phenol chemical peels, demonstrating a normal number of melanocytes but a decrease in epidermal melanin.

Dermatoses of the glans penis and prepuce.

A wide range of infectious, neoplastic, and inflammatory dermatoses can affect the glans penis or prepuce. Some are unique to the genitalia. Other more common dermatoses may have a unique appearance when they involve genital skin and mucosa. A thorough understanding of regional anatomy and a systematic diagnostic approach are helpful in the management of a refractory penile dermatosis. We review embryology and regional anatomy, drug-induced eruptions, allergic and irritant dermatitis, infection, neoplasia, and traumatic and inflammatory dermatoses as they relate to the glans and prepuce. Our discussion focuses on the clinical features, office laboratory studies, and histopathologic findings that assist in diagnosis and treatment.