Comparison of nurse- and physician-determined clinic blood pressure levels in patients referred to a hypertension clinic: implications for subsequent management.

BACKGROUND: When measuring BP, the physician induces a transient pressor response triggered by an alarm reaction. This 'white-coat effect' can influence therapeutic decisions. Whether it depends on the characteristics of the physician has not been evaluated. OBJECTIVE: To assess the 'white-coat effect' induced by several physicians in a large sample of patients, using the blood pressure measured by trained nurses as a reference. SETTING: Referral hypertension clinic. METHODS: Patients were selected for the study if they had been referred for the first time to the clinic and if they had had their supine systolic/diastolic blood pressure measured by a trained nurse (mean of the last two of three measurements taken every 1 min by an oscillometric device) and a physician (auscultatory method using a standard mercury sphygmomanometer). Physicians were included in the study provided they had seen at least 25 patients during the study period. The between-physician difference was assessed using linear regression analysis. Physician blood pressure was the dependent and nurse blood pressure was the independent variable. RESULTS: From 1 January 1997 to 15 September 1997, 1062 patients (50% male, aged 52 +/- 14 years), seen by 10 physicians (26-187 patients per physician) and one nurse were included for analysis. The mean systolic/diastolic blood pressure for physicians was 162 +/- 27/ 97 +/- 15 mmHg and that for the nurse was 155 +/- 24/ 88 +/- 14 mmHg. The nurse-physician differences were -6 mmHg (range -67 to +66) for systolic and -8 mmHg (-44 to +31) for diastolic blood pressures. Major differences were observed between individual physicians. Intercepts of the physician blood pressure versus nurse blood pressure relationship ranged from 0.1 -60.7 mmHg for systolic and from 13.3-55.3 mmHg for diastolic pressures. The slopes of this relationship differed less between physicians for systolic (0.72-1) than for diastolic pressures (0.56-0.97). There was no difference between the patients seen by physicians in patients' age, sex, tobacco consumption, anti-hypertensive treatment or target-organ damage. CONCLUSION: Large between-physician differences exist in the magnitude of the white-coat effect that cannot be explained by patient characteristics. Physicians should therefore not make any decisions based on blood pressure measured manually during a first encounter.

Tumor recurrence and hypertension persistence after successful pheochromocytoma operation.

Pheochromocytoma is a catecholamine-secreting tumor and a rare cause of hypertension that is usually curable. However, pheochromocytoma may recur as a benign or malignant tumor, and hypertension may persist after successful surgical intervention. The frequency of and risk indicators for tumor recurrence and hypertension persistence after successful surgical intervention have not been adequately studied. We determined tumoral and blood pressure outcome in 129 patients followed-up from initial pheochromocytoma resection to death or to 1994 (796 patient-years). We assessed several candidate indicators for their predictive value for the risk of tumor recurrence or hypertension persistence. Recurrence was defined as the reappearance of disease after normalization of biochemical tests. Pheochromocytoma caused death or persistent or recurrent disease in 28 patients. Of the 114 with benign tumors at initial operation, pheochromocytoma recurred as a benign or malignant tumor 17 to 194 months after initial operation in 16 cases. Kaplan-Meier estimates of pheochromocytoma-free survival were 92% and 80% at 5 and 10 years, respectively. In the 98 living patients without recurrence, Kaplan-Meier estimates of hypertension-free survival were 74% and 45% at 5 and 10 years. In the Cox model, familial pheochromocytoma and a low ratio of plasma epinephrine to total catecholamines were independently associated with recurrence. Familial hypertension and age were similarly associated with hypertension persistence. After surgery for pheochromocytoma, patients should be followed-up indefinitely, especially those with familial tumors or a low epinephrine secretion. Pheochromocytoma should not unreservedly be considered a surgically remediable cause of hypertension.

Legacy systems: managing evolution through integration in a distributed and object-oriented computing environment.

Legacy systems are crucial for organizations since they support key functionalities. But they become obsolete with aging and the apparition of new techniques. Managing their evolution is a key issue in software engineering. This paper presents a strategy that has been developed at Broussais University Hospital in Paris to make a legacy system devoted to the management of health care units evolve towards a new up-to-date software. A two-phase evolution pathway is described. The first phase consists in separating the interface from the data storage and application control and in using a communication channel between the individualized components. The second phase proposes to use an object-oriented DBMS in place of the homegrown system. An application example for the management of hypertensive patients is described.