Martini Prince, Anne S Bird, Robert A Blizard, Anthony H Mann
Abstract
Objective - To establish whether initiation of treatment with diuretic or Beta blocker is associated over 54 months with change in cognitive function.
Design - A cognitive substudy, nested within a randomised, placebo controlled, single blind trial.
Setting - 226 general practices from the Medical Research Council's general practice research framework.
Subjects - A subset of 2,584 subjects sequentially recruited from among the 4,396 participants aged 65-74 in the trial of treatment of hypertension in older adults. The 4,396 subjects were randomised to receive diuretic, Beta blocker, or placebo. Subjects had mean systolic pressures of 160-209 mm Hg and mean diastolic pressures under 115 mm Hg during an eight week run in.
Outcome measures - The rate of change in paired associate learning test (PALT) and trail making test part A (TMT) scores (administered at entry and at 1, 9,21, and 54 months) over time.
Results - There was no difference in the mean learning test coefficients (rate of change of score over time) between the three treatments: diuretic -0.31 (95% confidence interval -0.23 to -0.39), Beta blocker -0.33 (-0.25 to -0.41), placebo -0.30, (-0.24 to -0.36). There was also no difference in the mean trail making coefficients (rate of change in time taken to complete over time) between the three groups: diuretic -2.73 (95% confidence interval -3.57 to -1.88), Beta blocker -2.08 (-3.29 to -0.87), placebo -3.01, (-3.69 to -2.32). A less conservative protocol analysis confirmed this negative finding.
Conclusion - Treating moderate hypertension in older people is unlikely to influence, for better or for worse, subsequent cognitive function.
Section of Epidemiology and General Practice Institute of Psychiatry London SE5 8AF Martin J Prince lecturer in psychiatry Anthony H Mann professor of epidemiological psychiatry
Royal Free Hospital London NW3 2QG Anne S Bird consultant psychiatrist
Academic Department of Psychiatry Royal Free Hospital London NW3 2QG Robert A Blizard lecturer in statistics
Correspondence to: Dr Prince.
Low blood pressure and dementia in elderly people: the Kungsholmen project
Zhenchao Guo, Matti Viitanen, Laura Fratiglioni, Bengt Winblad
Abstract
Objective - To examine the relation between blood pressure and dementia in elderly people.
Design - Cross sectional, population based study.
Setting - Kungsholmen district of Stockholm, Sweden.
Subjects - 1,642 subjects aged 75-101 years.
Main outcome measures - Prevalence and adjusted odds ratio of dementia by blood pressure.
Results - People with systolic pressure under 140 mm Hg were more often diagnosed as demented than those with systolic pressure over 140 mm Hg: odds ratios (95% confidence Interval) adjusted for age, sex, and education were 2.98 (2.17 to 4.08) for all dementias, 2.91 (1.93 to 4.38) for Alzheimer's disease, 2.00 (1.09 to 3.65) for vascular dementia, and 5.07 (2.65 to 9.70) for other dementias. Similar results were seen in subjects with diastolic pressure under 75 mm Hg compared with those with higher diastolic pressure. When severity and duration of dementia were taken into account, only moderate and severe dementia were found to be significantly related to relatively low blood pressure, and the association was stronger In subjects with longer disease duration. Use of hypotensive drugs and comorbidity with cardiovascular disease did not modify the results for all dementias, Alzheimer's disease, and other dementias but slightly reduced the association between vascular dementia and diastolic blood pressure.
Conclusions - Both systolic and diastolic blood pressure were inversely related to prevalence of dementia In elderly people. We think that relatively low blood pressure is probably a complication of the dementia process, particularly Alzheimer's disease, although it is possible that low blood pressure may predispose a subpopulation to developing dementia.
Stockholm Gerontology Research Center and Department of Geriatric Medicine Karolinska Institute Dalagatan 9-11 S-113 82 Stockholm Sweden Zhenchao Guo guest researcher Matti Viitanen associate professor of geriatric medicine Laura Fratiglioni senior researcher Bengt Winblad professor of geriatric medicine
Correspondence to: Dr Guo.
Jackie Brown, Stirling Bryan, Ruth Warren
Abstract
Objective - To compare mammography reading by one radiologist with independent reading by two radiologists.
Design - An observational non-randomised trial at St Margaret's Hospital, Epping.
Subjects - 33,734 consecutive attenders for breast screening in the main trial and a sample of 132 attenders for assessment who provided data on private costs.
Interventions - Three reporting policies were compared: single reading, consensus double reading, and non-consensus double reading.
Main outcome measures - Numbers of cancers detected, recall rates, screening and assessment costs, and cost effectiveness ratios.
Results - A policy of double reading followed by consensus detected an additional nine cancers per 10,000 women screened (95% confidence interval 5 to 13) compared with single reading. A non-consensus double reading policy detected an additional 10 cancers per 10,000 women screened (95% confidence interval 6 to 14). The difference in numbers of cancers detected between the consensus and non-consensus double reading policies was not significant (95% confidence interval -0.2 to 2.2). The proportion of women recalled 10? assessment after consensus double reading was significantly lower than after single reading (difference 2.7%; 95% confidence interval 2.4% to 3.0%). The recall rate with the non-consensus policy was significantly higher than with single reading (difference 3.0%; 2.5% to 3.5%). Consensus double reading cost less than single reading (saving £4,853 per 10,000 women screened). Non-consensus double reading cost more than single reading (difference £19,259 per 10,000 women screened).
Conclusions - In the screening unit studied a consensus double reading policy was more effective and less costly than a single reading policy.
Health Economics Research Group Brunel University Uxbridge Middlesex UB8 3PH Jackie Brown research fellow Stirling Bryan research fellow
Breast Screening Service St Margaret's Hospital Epping CM16 6TN Ruth Warren consultant radiologist
Correspondence to: Dr Brown.
Psychological support for patients undergoing breast cancer surgery: a randomised study
June M C McArdle, W David George, Colin S McArdle, David C Smith, Alastair R Moodie, A V Mark Hughson, Gordon D Murray
Abstract
Objective - To evaluate the effect of support from a nurse specialising in breast care and a voluntary support organisation on prevalence of psychological morbidity after surgery for breast cancer.
Design - Prospective randomised study.
Setting - Three teaching hospitals in Glasgow with established breast clinics.
Subjects - 272 women aged less than 70 years undergoing surgery for breast cancer.
Interventions - Patients were randomly allocated to receive routine care from ward staff, routine care plus support from breast care nurse, routine care plus support from voluntary organisation, or routine care plus support from nurse and organisation.
Main outcome measures - Prevalence of psychological morbidity as assessed by self rating scales: 28 item general health questionnaire and its subscales, and hospital anxiety and depression scale. Measurements were made at first postoperative clinic visit and at three, six, and 12 months after surgery.
Results - On each self rating scale, psychological morbidity tended to fall over the 12 month period. For each scale, scores were consistently lower in patients offered support from breast care nurse alone compared with the other groups, which were similar to each other. Differences were significant or nearly so: P values were 0.015 (28 item general health questionnaire), 0.027 (anxiety and insomnia), 0.072 (severe depression), 0.053 (somatic symptoms), 0.031 (social dysfunction), 0.093 (hospital anxiety), and 0.003 (hospital depression).
Conclusion - Support from breast care nurse can significantly reduce psychological morbidity, as measured by self rating scales, In women undergoing breast cancer surgery.
University Department of Surgery Royal Infirmary Glasgow G31 2ER June M C McArdle research nurse Colin S McArdle honorary professor of surgery
University Department of Surgery Western Infirmary Glasgow G11 6NT W David George professor of surgery
Division of Surgery Victoria Infirmary Glasgow G42 9TY David C Smith consultant surgeon
Tak Tent 100 University Place Glasgow G12 6SQ Alastair R Moodie former chairman
Division of Psychiatry Leverndale Hospital Glasgow G53 7TU A V Mark Hughson consultant psychiatrist
Robertson Centre for Biostatistics University of Glasgow G12 8QQ Gordon D Murray director
Correspondence to: Dr Hughson.
Evidence based general practice: a retrospective study of interventions in one training practice
P Gill, A C Dowell, RD Neal, N Smith, P Heywood, A E Wilson
Abstract
Objectives - To estimate the proportion of interventions in general practice that are based on evidence from clinical trials and to assess the appropriateness of such an evaluation.
Design - Retrospective review of case notes.
Setting - One suburban training general practice.
Subjects - 122 consecutive doctor-patient consultations over two days.
Main outcome measures - Proportions of interventions based on randomised controlled trials (from literature search with Medline, pharmaceutical databases, and standard textbooks), on convincing non-experimental evidence, and without substantial evidence.
Results - 21 of the 122 consultations recorded were excluded due to insufficient data; 31 of the interventions were based on randomised controlled trial evidence and 51 based on convincing nonexperimental evidence. Hence 82/101 (81%) of interventions were based on evidence meeting our criteria.
Conclusions - Most interventions within general practice are based on evidence from clinical trials, but the methods used in such trials may not be the most appropriate to apply to this setting.
Centre for Research in Primary Care Leeds University Leeds LS2 9LN P Gill research tutor A C Dowell director R D NeaI research fellow N Smith research fellow P Heywood deputy director A E Wilson lecturer
Correspondence to: Dr Dowell.