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.

Cyclic adenosine 3',5'-monophosphate increases the open probability of potassium channels in activated human T cells.

In the present report we describe a cAMP-responsive K channel in activated human T cells. Single channel events were recorded using the patch-clamp technique in cell-attached-patch configuration. The channel was K selective, as determined by reversal potentials under different K gradients, and displayed voltage-independent gating. When the applied potential (Vp) was equal to zero, the conductance of the channel was 21.8 +/- 0.9 pS with 150 mM K in the electrode. Typical patches contained between two and seven channels that were relatively quiet, or silent, before agonist stimulation. Adenosine (20-30 microM) increased the average open time probability from 0.017 +/- 0.008 to 0.108 +/- 0.054 over a period of 108 s. Subsequent addition of the phosphodiesterase inhibitor Ro 20-1724 (0.5 mM) increased the probability of being in the open state to 1.155 +/- 0.407 over a period of 180 s. Channel kinetics were well described by assuming two open and two closed states. Exponential time constants for the open states were 0.51 +/- 0.06 and 4.34 +/- 0.31 ms, and closed state time constants were 0.58 +/- 0.05 and 10.1 3 +/- 2.32 ms. In addition, extracellular ATP (0.3-1.0 mM) decreased channel activity. Moreover, Rp-cAMP (0.5-1.0 mM), an antagonist that specifically blocks the ability of cAMP to bind and activate protein kinase A, failed to inhibit adenosine- and Ro 20-1724-induced increases in channel activity, implying a direct action of cAMP on channel gating.

Spontaneous hepatic hemorrhage in preeclampsia: treatment with hepatic arterial embolization.

Four patients with spontaneous rupture of the liver due to preeclampsia of pregnancy underwent diagnostic angiography followed by successful transcatheter embolization of the hepatic artery with gelatin particles. All patients stopped bleeding and were discharged in good condition. Transcatheter embolization of the hepatic artery may be an attractive alternative to surgery for control of spontaneous rupture of the liver in preeclampsia.

Relation of observer agreement to accuracy according to a two-receiver signal detection model of diagnosis.

A long-standing problem of medical diagnosis is why rates of observer disagreement are so high. To study this question a model of test interpretation is defined which accounts for disagreement when observers use identical diagnostic strategies. Test subjects are assigned to one of two disease classes on the basis of two parameters: the test score and lambda, the diagnostic certainty, a parameter analogous to signal-to-noise ratio. The rate of disagreement and the mean error rate of independent ideal observers are derived as a function of diagnostic strategy. It follows from the model that: 1) Maximization of the ratio of disagreement to error defines an optimal diagnostic strategy with advantages over maximum likelihood and Bayes diagnostic strategies. 2) Disagreement exceeds error if the sensitivity and specificity of independent observers exceed one-half for all lambda. 3) The ratio of disagreement to error can be no greater than two if test interpretation is dichotomous but can approach infinity for trichotomous interpretation, i.e., if observers are allowed to interpret cases as indeterminate.

Transpancreatic catheterization of the right hepatic artery for chemoembolization using a new infusion system.

The right hepatic artery was catheterized for chemoembolization in a patient with liver-dominant metastatic breast carcinoma and occlusion of the celiac artery by tumor compression. This was accomplished by use of a new coaxial infusion catheter-steerable guidewire system passed through the superior mesenteric artery and posterior pancreatic arcade.

Reliability of selective pulmonary arteriography in the diagnosis of pulmonary embolism.

To test the reliability of conventional selective pulmonary arteriography in the diagnosis of pulmonary embolism, three angiographers reviewed the arteriograms of a series of 60 patients retrospectively, independently, and without benefit of additional data. Pulmonary arteriograms had been interpreted as positive for pulmonary embolism in 25 of these patients during their hospitalizations. Angiographers A, B, and C judged the arteriograms of 24, 29, and 25 patients, respectively, as positive for pulmonary embolism. Mean interobserver agreement was 86%. Interobserver agreement was not associated significantly with the quality of the arteriogram or with selective injection of a lobar vs a pulmonary artery, but was associated strongly with the magnitude of thromboembolism. All angiographers agreed that the arteriograms were positive in 18 cases of pulmonary embolism graded as massive, lobar, or segmental, but agreed in only two of 15 cases graded as subsegmental. We conclude that conventional selective pulmonary arteriography is reliable in the detection of embolus in segmental or larger pulmonary arteries. Observer disagreement becomes considerable for embolus limited to subsegmental pulmonary arteries, indicating that emboli of this size are at the resolution limit of the technique.

Traumatic laceration of the ascending aorta: angiographic assessment.

Radiographic evaluation of ascending aortic injuries is rare because they are almost always immediately fatal. We report three cases of ascending aortic laceration studied by angiography, with a review of the literature and discussion of mechanisms of injury. The type of deceleration trauma resulting in ascending aortic laceration differs from the usual driver deceleration injury in that no attenuation of force on the victim occurs at the time of impact. Traction-torsion forces on the aorta at points of fixation and increased intraluminal aortic pressure are the likely mechanisms of rupture. Adequate angiographic evaluation of these patients requires visualizing the entire aortic arch from aortic valve to diaphragm.

Spectral shifting by dyes to enhance algae growth.

The photosynthetic growth action spectrum of a green alga at three bands of visible light (blue, orange, and red) at fixed quanta input and under light-limiting conditions was measured in a batch cultivation system. Quantum efficiencies (biomass dry weight increment per quanta absorbed) were better in the yellow-red region than in the blue region. Results served as a basis for the design and optimization of a dye system that would shift the energy of solar radiation to the required wavelength range by absorbing ultraviolet to blue radiation and emitting in the yellow-red, thus enhancing algae growth. Direct incorporation of dyes into the growth medium, although theoretically expected to enhance growth, in fact resulted in dye decomposition, toxicity to algae and consequently in growth inhibition. Indirect application of dyes in a double tubular reactor (algae inside and dye solution outside) demonstrated growth enhancement for certain dyes with high quantum yields and stability, which had suitable absorption/emission spectra for artificial light sources used. The maximum indirect growth enhancement was obtained using rhodamine 6G at a concentration of 3x10(-5)M with tungsten filament lamp sources.

Patterns of resolution in successfully treated hepatic amebic abscess: sonographic evaluation.

Gray-scale sonography has provided a means of following cases of successfully treated hepatic amebic abscess, allowing new insights into the natural history of this entity. In this study the majority of cases (23 of 32) resolved over a variable time period (1.5-23 months, median 7 months) to a normal sonographic hepatic parenchymal pattern. It is important that the transient, persistent abnormality seen after successful treatment not prompt reinstitution of therapy or further diagnostic testing in these patients. A smaller subgroup (six of 32) had sonographically persistent residua that appeared identical to benign simple cysts of the liver. The remaining three lesions showed slightly increased or decreased hepatic echogenicity after treatment.

Sonographic findings in hepatic amebic abscess.

Sonograms of 143 hepatic amebic abscesses in 106 patients were analyzed retrospectively. A strongly suggestive but not pathognomonic pattern was noted in 54 abscesses (37.8%), consisting of (a) lack of significant wall echoes, (b) a round or oval configuration, (c) less echogenicity than the normal parenchyma, with fine, homogeneous low-level echoes throughout at high gain, (d) a location contiguous to the liver capsule, and (e) distal sonic enhancement. Most other hepatic abscesses (53.1%) had all but one or two of these features. Thirteen patients (9%) had bizarre sonographic findings. Peripheral or central areas of increased echogenicity occurred more frequently than previously reported. At normal gain settings, most lesions (53.8%) were predominantly anechoic. The above pattern and trans-diaphragmatic pleural involvement were helpful in the diagnosis.

Predicting the cause of common bile duct obstruction with sonographic data: analysis of binary variables.

A retrospective analysis of 71 patients with proven common bile duct obstruction, who had not undergone previous biliary surgery, was performed. To determine optimal criteria for differentiating stone from nonstone obstruction by ultrasonography, five sonographic signs were analyzed as binary variables. These signs are the demonstration of (1) common duct stones, (2) mass at the site of the common bile duct, (3) gallbladder stones, (4) gallbladder volume greater than a critical value, and (5) common duct diameter greater than a critical value. Maximum expected accuracy was 85% achieved by prediction based on a set of three variables: common duct stone, common duct mass, and gallbladder stones. This was not significantly better than the accuracy (82%) achieved by prediction on the basis of gallbladder stones alone. Three signs in combination, ie, demonstration of gallbladder stones, gallbladder volume less than 52 ml, and common duct diameter less than 14 mm, had predictive value equal to demonstration of a common duct stone as an indicator that common bile duct obstruction is the result of a stone.

Prospective evaluation of the sonographic Murphy sign in suspected acute cholecystitis.

The sonographic Murphy sign, the presence of maximal tenderness elicited over a sonographically localized gallbladder, has been considered useful in the evaluation of patients with suspected acute cholecystitis. We prospectively evaluated this sign in 427 consecutive patients referred for evaluation of acute cholecystitis. The overall accuracy of the sonographic Murphy sign in the 219 patients with sufficient confirmation to be included in the statistical analysis was 87.2%. Sensitivity was 63% and specificity was 93.6%. The predictive value of a positive sign was 72.5%, while the predictive value of a negative sign was 90.5%. The sonographic Murphy sign is a useful, albeit imperfect, adjunct in the assessment of patients with suspected acute cholecystitis.

Sonography of pyogenic splenic abscess.

Pyogenic splenic abscess is an uncommon lesion associated with high mortality. Diagnosis may be difficult, especially in deep-seated abscesses. Plain radiographs and nuclear medicine techniques may be helpful, but can be insufficiently specific. Sonography, which images morphologic changes, is useful in assessing splenic abscesses. Five of six abscesses had a predominantly anechoic pattern with internal foci of higher echogenicity. In one gas-containing lesion, there were high amplitude echoes throughout the abscess. The abscesses were easily distinguishable from the surrounding homogeneous normal spleen. Sonography, while not definitive, is an effective tool in reaching an early diagnosis of splenic abscess. This allows prompt splenectomy, ameliorating prognosis.

Thickening of the gallbladder wall in acute hepatitis: ultrasound demonstration.

Thirty-six patients with acute hepatitis and 25 normal volunteers were examined by ultrasound to determine the thickness of the gallbladder wall. Liver enzymes were measured at the time of the examination in all patients. Ten were excluded, since they had other diseases which could lead to wall thickening. The mean thickness in 13 patients with SGOT and SGPT above 500 IU was 3.5 mm, compared to 2.6 mm in 13 patients with levels below 500 IU. This difference is statistically significant (P less than 0.01). Patients with acute hepatitis also had significantly thickened gallbladder walls compared to the volunteers (P less than 10(-8)).

Sonography in the diagnosis and management of hepatic amebic abscess in children.

Hepatic amebic abscess is a potentially fatal infection which is difficult to diagnose in children. Sonography is an ideal non-invasive imaging tool which can prove invaluable in the diagnosis and management of hepatic amebic abscess. Sonographic findings should suggest the correct diagnosis in most instances. This allows prompt initiation of therapy, forestalling life-threatening complications. Sonography is also an extremely useful non-invasive means of following response to therapy in children with hepatic amebic abscesses.