Nutritional counselling in general practice: a cost effective analysis.

STUDY OBJECTIVE: To study the clinical and cost outcomes of providing nutritional counselling to patients with one or more of the following conditions: overweight, hypertension and type 2 diabetes. DESIGN: The study was designed as a random controlled trial. Consecutive patients were screened opportunistically for one or more of the above conditions and randomly allocated to one of two intervention groups (doctor/dietitian or dietitian) or a control group. Both intervention groups received six counselling sessions over 12 months from a dietitian. However, in the doctor/dietitian group it was the doctor and not the dietitian who invited the patient to join the study and the same doctor also reviewed progress at two of the six counselling sessions. SETTING: The study was conducted in a university group general practice set in a lower socioeconomic outer suburb of Perth, Western Australia. PATIENTS: Of the 273 patients randomly allocated to a study group, 198 were women. Age ranged from 25 to 65 years. Seventy eight per cent of patients resided in the lower two socioecnomic quartiles, 56 per cent described their occupation as home duties and 78 per cent were partnered. RESULTS: Both intervention groups reduced weight and blood pressure compared with the control group. Patients in the doctor/dietitian group were more likely to complete the 12 month programme than those in the dietitian group. Patients in the doctor/dietitian group lost an average of 6.7 kg at a cost of $A9.76 per kilogram, while the dietitian group lost 5.6 kg at a cost of $A7.30 per kilogram. CONCLUSION: General practitioners, in conjunction with a dietitian, can produce significant weight and blood pressure improvement by health promotion methods.

Normative corrections for the Halstead Reitan Neuropsychological Battery.

This article investigates the adequacy of the Heaton-Grant-Matthews norms in correcting age and education effects in the Halstead Reitan Neuropsychological Battery. Two hundred and ninety neurological and 346 psychiatric patients were administered the Halstead Reitan Neuropsychological Battery. Raw scores were converted to standard scores using the Heaton-Grant-Matthews norms. Ten percent of the variance in standard score profiles could be predicted by patient age and education. The primary effect of age was to decrease the overall level of the profile; the primary effect of education was to increase relative scores on the Aphasia test. When these standard scores were converted to age- and education-corrected T-scores, less than 1% of the variance could be predicted by age and education. When individual tests were examined, the Heaton-Grant-Matthews norms failed to correct 2% of the variance in the Speech Sounds test. Discussion focuses on the usefulness of the Heaton-Grant-Matthews norms in interpreting performance on the Halstead Reitan Neuropsychological Battery.

Performance scales for the Luria-Nebraska Neuropsychological Battery-Form I.

Regression equations were developed to adjust raw scores on Luria-Nebraska Neuropsychological Battery-Form I (LNNB-I) clinical scales for the effects of age and education. Corrected raw scores were then used to develop performance scales for the LNNB-I on which normal individuals anchored the low end of the scales and increasingly impaired patients occupied higher intervals. The resulting scales represent equal intervals of age- and education-corrected test impairment for each LNNB-I clinical scale and should facilitate interpretation of LNNB-I test performances.

Neuropsychological information in the Wechsler Adult Intelligence Scale-Revised.

The relationships among Wechsler Adult Intelligence Scale-Revised profiles (WAIS-R), Luria-Nebraska Neuropsychological Battery (LNNB) profiles and Halstead Retian Neuropsychological Battery (HRNB) profiles were examined in two samples of patients referred for neuropsychological evaluation. Canonical correlation analysis suggested that the average level of WAIS-R profiles was related to the average level and scatter of LNNB profiles, Overall performance on the HRNB was less strongly related to overall performance on the WAIS-R than was the LNNB. Patients who were similar to a WAIS-R modal profile characterized by relative deficits on performance subtests were more likely to be similar to LNNB modal profiles characterized by relative impairments on sensorimotor subtests. Patients who were similar to a WAIS-R modal profile characterized by relative deficits on verbal subtests were more likely to be similar to LNNB modal profiles characterized by relative impairments on either language subtests or conceptual subtests. Patients classified into an HRNB profile type characterized by strengths on the Aphasia Screening subtest were more likely to show strengths on WAIS-R verbal subtests. However, less than 8 % of the total samples could be jointly classified into both the requisite WAIS-R profile clusters and one of the associated LNNB or HRNB profile clusters. WAIS-R subtest profile level may be a useful statistic to screen for neuropsychological deficits, but WAIS-R patterns are essentially useless for neuropsychological screening. Discussion focuses on the role of the WAIS-R in neuropsychological evaluations.

Modal profiles for the Halstead-Reitan Neuropsychological Battery for Children.

Modal Profile Analysis was used to cluster students (aged 9 to 14 years) on 16 subtest scores from the Halstead-Reitan Neuropsychological Battery for Children (HRNB-C). This analysis produced eight modal profile types, all of which were replicated in multiple samples. An initial attempt to establish external validity indicated that the modal groups display dissimilar patterns of performance on independent variables. The present typology is compared to similar typologies developed with adult neuropsychological data. In sum, the current classification system provided less coverage than the adult typologies, but produced more unique or homogeneous modal groups. Discussion focuses on potential clinical and research uses of the modal HRNB-C profiles.

Cost-effectiveness of interventions to promote cervical screening in general practice.

A cost-effectiveness study of three different interventions to promote the uptake of screening for cervical cancer in general practice was carried out in Perth in 1991. Women eligible for a Pap smear were randomly allocated to one of four groups: one receiving letters with specific appointments to attend a screening clinic staffed by female doctors, one receiving letters informing them of the availability of the clinic and suggesting they make an appointment, one whose files were tagged to remind a doctor to offer a smear during a consultation, and a comparison control group that received opportunistic screening only. Variable and fixed costs for each group were itemised and summarised to give an average cost per smear taken. The cost and effectiveness of each intervention were then compared with those of the control group. Sensitivity analysis was performed on the major component of the costs, the doctor's time. Opportunistic screening cost $14.60 per smear and attained 16 per cent recruitment. Tagging files was the cheapest intervention ($14.75 per smear) although it was the least effective in recruiting women (20 per cent). This result held true for different scenarios of doctor's time allocated. Intervention by invitation letter with no appointment cost $45.35 per smear and attained 26 per cent recruitment, and intervention with a specific appointment cost $48.21 per smear and attained 30 per cent recruitment. Compared with the control group, the incremental cost-effectiveness for the tagged group was $15.40, for the letter-without-appointment group $97.75 and for the letter-with-appointment group $86.50.

Modal profiles for the Halstead-Reitan Neuropsychological Battery.

Modal profile analysis was used to cluster subjects on 11 scores from the Halstead-Reitan Neuropsychological Battery. The final analysis produced 18 modal profile types, of which 12 were replicated in multiple samples of subjects with differing clinical diagnoses. Subjects who had been assigned to modal types according to their correlations with the modal profiles were more similar to the centroid of their assigned groups than to the centroids of all other groups. Assigned subjects were eight times more likely to belong to their assigned groups than to any of the other groups. Fifty-four percent of subjects were assigned to a modal profile group according to the adopted similarity rule. Discussion includes a comparison of the present typology with a similar typology of Luria-Nebraska Neuropsychological Battery profiles.

Cervical screening in general practice.

This study examined the effect of three interventions for encouraging women to have a Pap smear in a general practice: tagging the medical record to remind the doctor to offer a Pap smear, sending an invitation to make an appointment for a Pap smear, and sending an invitation with an appointment to attend for a Pap smear at a special screening clinic staffed by women. The study took place in a university general practice at Lockridge, near Perth. A computerised practice age-sex register provided 2139 women in the age range 36 to 69 inclusive. Of these, 757 were eligible for inclusion in the study and were allocated randomly to one of three intervention groups or a control group. In total, 177 women had a Pap smear during the study. Significantly more Pap smears were taken for the appointment-letter and letter-only groups than the control group (odds ratio (OR) 2.13, 95% confidence interval (CI) 1.34 to 3.57, and OR 1.67, CI 1.01 to 2.77 respectively), but there was no significant difference between the tagged-notes and the control groups. Women who attended the screening clinic rated the experience positively. Attendance, however, was inadequate for the clinic's viability in a private practice.

Modal profiles for the Luria-Nebraska Neuropsychological Battery.

Modal Profile Analysis was used to cluster subjects on the clinical scales of the Luria-Nebraska Neuropsychological Battery, Form I (LNNB). The analysis produced 22 modal profile types, of which seven were replicated in multiple samples of subjects with single criterion diagnoses. Subjects who had been assigned to modal types according to their correlations with the modal profiles were more similar to the modal profile of their assigned groups than to other modal profiles. Assigned subjects were more likely to belong to their assigned group than to other groups and were more similar to other subjects who had been assigned to the same group than to subjects assigned to other groups. Eighty-two percent of subjects in the derivation sample were assigned empirically to a modal profile group; 77% of subjects in a cross-validation sample were assigned to a modal profile group. The discussion focuses on the potential research and clinical use of the modal LNNB profiles.

A general-practice study of the efficacy and tolerability of metoprolol in mild essential hypertension.

The efficacy and tolerability of metoprolol (100 mg once a day) were assessed in general practice in 6713 newly-diagnosed or previously-treated hypertensive patients in an open study of eight weeks' duration. In 3534 mildly-hypertensive patients who were eligible for the efficacy analysis, the mean blood pressure level was reduced by 19/10 mmHg; 68% of the patients achieved diastolic blood pressures below 90 mmHg by the end of the assessment period. Of 6557 patients who were eligible for the tolerability analysis, only 5.6% of patients withdrew because of adverse events. The incidence of adverse events diminished considerably from the clinic assessment at four weeks (20%) to that at eight weeks (11%). At the completion of the study, 92% of the mildly-hypertensive patients were to continue with metoprolol, either as monotherapy (including 64% of patients who were receiving 100 mg once a day and 6% of patients who were receiving 50 mg once a day), or as combination therapy. Analysis of the large subgroup of mildly-hypertensive elderly patients (n = 1214) and of moderately-hypertensive patients, whose diastolic pressures exceeded the set upper limits (n = 2505), showed similar efficacy and tolerability results. Sixty-eight per cent of the former and 47% of the latter demonstrated satisfactory control of blood pressure. These results show that the majority of mildly-hypertensive patients can be controlled with 50-100 mg of metoprolol once a day.

Risk factors for ischemic stroke: a prospective study in Rochester, Minnesota.

A cohort of 1,804 residents of Rochester, Minnesota, who were at least 50 years old, free of stroke, and who underwent examination at the Mayo Clinic in 1960, was followed for 13 years. During this period, there were 110 first ischemic strokes and 616 deaths without stroke. The time of onset, if available, or the time of diagnosis of potential risk factors was determined for all patients during the study and was used to construct a proportional hazards model of time to occurrence of stroke with time-dependent risk factors. The model included 8 risk factors (2 fixed and 6 time-dependent). For these, the individual relative risks are: 1.6 for age (per 10 years), 2.0 for males, 4.0 for definite hypertension, 3.9 for transient ischemic attacks, 2.2 for hypertensive heart disease, 2.2 for coronary heart disease, 1.7 for congestive heart failure, and 1.7 for diabetes mellitus. Atrial fibrillation was not a significant risk factor using time-dependent multivariate analysis.

Surgical treatment of congenital pelvic arteriovenous malformation.

Congenital arteriovenous fistulas often pose difficult diagnostic and management problems. Surgical therapy has been associated with a propensity for incomplete obliteration and recurrence. A case of a large congenital pelvic arteriovenous malformation, initially misdiagnosed as an atrial septal defect, was defined by selective roentgenographic and contrast echographic techniques and successfully treated by total surgical excision.

Partial anomalous pulmonary venous connection (intact atrial septum) associated with mitral regurgitation.

The association of partial anomalous pulmonary venous connection with intact atrial septum and isolated severe nonrheumatic mitral regurgitation is rare, this combination of lesions having been reported on only one other occasion. Two such cases have been presented, with each patient having experienced an episode resembling subacute bacterial endocarditis. At operation, however, the mitral valve had a congenital cleft in one case and was normal in the other. One patient underwent mitral valvuloplasty and the second patient had mitral valve replacement. The diagnosis of associated partial anaomalous pulmonary venous connection was established at cardiac catheterization, and successful surgical correction was achieved in each case by diversion of the anamolaous pulmonary venous drainage to the left atrium via a pericardial tunnel through a surgically created atrial septal defect.

Traumatic popliteal arteriovenous fistula. Diagnostic methods and surgical management.

The popliteal vessels rank second only to the external iliac system as the most frequent site of acquired arteriovenous communication. Direct trauma to the popliteal space is by far the most common cause, and surgical intervention is usually required to manage the defect. We present a recent illustrative case following meniscectomy. To our knowledge, the occurrence of an arteriovenous fistula complicating knee surgery has not been reported previously. This case outlines the potential value of B-mode ultrasound in diagnosis and the use of intraoperative angiography in assessing the adequacy of primary vascular reconstruction. Earlier experience of this vascular abnormality--six additional cases since 1941--is reviewed.

Peripheral arteriovenous fistula. Detection by contrast echocardiography.

A method for detecting peripheral arteriovenous fistulas using contrast echocardiography is described. The detection of intracardiac and intrapulmonary shunts by this technique has previously been documented. After injection of indocyanine green dye into the blood stream, a dense cloud of echoes can be detected downstream as well as at the injection site. This echo-producing effect is completely lost on a single transit through a capillary bed. Thus detection of resultant echoes in the systemic venous circuit after systemic arterial injection of dye would indicate the presence of an abnormal arteriovenous communication. We have recently tested this hypothesis for the confirmation of left-to-right shunts in two patients who had suspected traumatic lower extremity arteriovenous fistulas. After injection of indocyanine green dye through a small-gauge needle into the femoral artery, a dense cloud of contrast echoes appeared in the right ventricle, which indicated the presence of arteriovenous shunting. This procedure is safe and easily performed and represents a new and relatively noninvasive technique for the detection of peripheral arteriovenous fistulas.