Is a series of blood pressure measurements by the general practitioner or the patient a reliable alternative to ambulatory blood pressure measurement? A study in general practice with reference to short-term and long-term between-visit variability.

We studied the reproducibility of a series of blood pressure measurements by general practitioner (GP) and patient in comparison with that of ambulatory blood pressure measurement (ABPM), with reference to short-term and long-term between-visit variability using a prospective, comparative diagnostic study. The study group was 88 potentially hypertensive primary care patients (initial systolic blood pressure [SBP] between 160 and 200 mm Hg or with diastolic blood pressure [DBP] between 95 and 115 mm Hg). ABPMs were measured on 2 separate days (at a 6 month interval). Two series of measurements by the doctor (at 1 to 6 month intervals), and the patient (at a 1 week interval) were measured. Mean differences and standard deviations of mean differences (SDD) between two successive series of measurements, and between two ABPMs were computed. The Wilcoxon signed-ranks test was used to compare these standard deviations. Mean initial office-blood pressures were 161 (SBP) and 102 (DBP) mm Hg. Long-term between-visit variability (measurements by GP) was larger than short-term between-visit variability: SDDs were 16 v 11 mm Hg (SBP), and 10 v 8 mm Hg (DBP). The differences in average SBP and DBP between successive ABPMs and between successive series of office measurements by GP and home measurements by patient were not statistically significant. Mean differences between two series of measurements by GP and patient, and between two ABPMs, were 0 +/- 1 mm Hg. SDDs between successive ABPMs and series of measurements by GP and patient ranged from 8 to 11 mm Hg (SBP), and were 6 mm Hg (DBP). No statistically significant differences were found between the SDDs of the studied measurement procedures (SBP and DBP). In our study the reproducibility of ambulatory blood pressure measurement was not found to be better than that of a series of four duplicate measurements by GP or patient. Long-term (6 months interval) between-visit variability was larger than the short-term (1 week interval) between-visit variability.

No relevant seasonal influences on office and ambulatory blood pressure: data from a study in borderline hypertensive primary care patients.

Our objective was to study seasonal influences on office and ambulatory blood pressure. We therefore designed a prospective 7-month study of 47 borderline hypertensive patients in a primary care setting. We used no interventions. Our main outcome measures were the differences between summer and winter office and ambulatory blood pressures and 95% confidence intervals. Results showed that winter minus summer differences ranged from 0 to 3 mm Hg. Only one significant difference was found: ambulatory systolic daytime pressure was significantly higher (3 mm Hg) in winter than in summer. Our results do not confirm the data of earlier studies in hypertensives. In view of the small and clinically irrelevant winter-summer differences, it seems unnecessary to modify antihypertensive treatment of borderline hypertensives according to the season.

Are four duplicate remeasurements sufficient for diagnosing mild hypertension?

The aim of this study was to investigate if four duplicate blood pressure (BP) remeasurements are sufficient for diagnosing hypertension in potentially hypertensive subjects. The subjects were 99 outpatients who were included on the basis of elevated diastolic (95 < or = DBP < or = 115 mm Hg) or systolic (160 < or = SBP < or = 200 mm Hg) BP. After inclusion all patients underwent nine subsequent duplicate BP measurements over a period of 7 months. None of the patients received hypotensive drug treatment during the study. Between the first (initial) and second measurements there were significant reductions in systolic (161.0-152.5 mm Hg) and diastolic (101.5-97.1 mm Hg) BPs (P < 0.01). Differences between the subsequent measurements were not statistically significant. A linear regression analysis proved that the "conceptual average BP' (the average of the last five visits) which was chosen as the reference value was stable. The decline of standard deviations of differences between two, three and four duplicate remeasurements on one hand, and the reference value on the other was found to be strikingly small. After four duplicate remeasurements, there was misclassification in 56% (systolic) and 38% (diastolic). We conclude that the numbers of two, three or four BP measurements recommended by international guidelines for diagnosing hypertension are too low. Even after four duplicate remeasurements a considerable amount of misclassification remains.

A series of self-measurements by the patient is a reliable alternative to ambulatory blood pressure measurement.

BACKGROUND: Several studies have reported overdiagnosis and overtreatment of hypertensive patients, especially in borderline hypertensives. AIM: To find a blood pressure measurement procedure that reduces the risk of misclassification to an acceptable level. METHOD: Comparative, prospective study over seven months of primary care patients with elevated initial blood pressures. Blood pressure measurements made by general practitioners (GPs), practice nurses, and patients were compared with ambulatory blood pressure measurements. RESULTS: Ninety-nine patients completed the study. Mean differences (systolic blood pressure) between different measurement procedures and ambulatory measurement ranged from +10 mmHg (doctor) to -1 mmHg (patient), and (diastolic) from +4 mmHg (doctor) to -2 mmHg (patient). Standard deviations of mean differences ranged from 12 mmHg (doctor/systolic) to 10 mmHg (patient/systolic), and from 8 mmHg (doctor/diastolic) to 7 mmHg (patient/diastolic). CONCLUSION: Self-measurements by the patient appear to be a reliable alternative to ambulatory blood pressure measurement. In diagnosing and managing mild hypertension, we recommend the use of a valid self-measuring device.

[Physical diagnosis--pain elicited by percussion in the kidney area]. / Fysische diagnostiek--slagpijn in de nierloge.

Percussion of the kidney as a diagnostic method was first described by John Benjamin Murphy (1857-1916). The test is rapidly elicited, but can cause severe pain. Considering acute pyelonephritis or acute renal colic, it is common practice to perform fist percussion of the kidney, yet its diagnostic value is unknown. Finnish study results in 1998 suggest that in acute renal colic loin tenderness and erythrocyturia are more significant signs than renal tenderness. There is no scientific evidence for determining renal tenderness in diagnosing urinary tract infections and urolithiasis.

[Hypertension diagnosis by the family physician: measurements according to the NHG-standard (Dutch College of General Practitioners) compared with ambulatory blood pressure determination]. / Hypertensiediagnostiek door de huisarts: metingen volgens de NHG-standaard vergeleken met ambulante bloeddrukmeting.

OBJECTIVE: To compare the standard procedure (SP) for determining hypertension as described by the DCGP with the results of ambulatory blood pressure measurement (ABM). DESIGN: Prospective study. SETTING: Practices of 17 GPs in central and south Limburg, the Netherlands. METHOD: The SP of the DCGP was executed in 94 of 102 patients with possible hypertension. In each patient a 24-hour ABM was performed simultaneously as reference value. RESULTS: The correlation between the SP and the ABM was low (r = 0.51) and the blood pressure was mostly overestimated by the SP. Sensitivity and specificity of the SP were 0.67 and 0.52 respectively. When the first blood pressure measurement was high in a patient with probable hypertension (diastolic pressure 105-115 mmHg) SP correlated well with ABM. When the first blood pressure measured was relatively low (diastolic pressure 95-105 mmHg) correlation was also low. CONCLUSION: The difference in blood pressure measured by the physician in his office compared with measurement at home ('white coat effect') was observed in this study also. The results support the advice of the DCGP to check the blood pressure more often in hypertensive patients with low than in those with high initial diastolic values.

How many measurements are necessary in diagnosing mild to moderate hypertension?

OBJECTIVE: The aim of this study was to investigate how many blood pressure measurements are necessary in diagnosing mild to moderate hypertension. METHODS: The subjects were 99 outpatients who were included on the basis of elevated diastolic (95 < or = DBP < or = 115 mmHg) and/or systolic (160 < or = SBP < or = 200 mmHg) blood pressure. After the initial measurement all patients underwent nine subsequent blood pressure measurements over a period of 7 months. None of the patients received anti-hypertensive drug treatment during the study. RESULTS: Between the first (initial) and second measurements, there was a significant reduction in systolic (161.0 to 152.5 mmHg) and diastolic (101.5 to 97.1 mmHg) blood pressures (P < 0.01). The differences between pairs of subsequent measurements were not statistically significant. The average of the last five assessment sessions (two readings per session) was regarded as the "conceptual average blood pressure'. Comparing the blood pressure at repeat measurement with the conceptual average blood pressure revealed misclassification in 19% of cases, even after four repeat measurements (threshold value 95 mmHg). Analysis of the subgroups (95 < or = DBP < 105 mmHg and 105 < or = DBP < or = 115 mmHg) revealed that the proportion of misclassification greatly depended on the initial value and the accepted threshold value. At a threshold value of 95 mmHg, patients with "high' initial diastolic blood pressure (105 < or = DBP < or = 115 mmHg) required only two repeat measurements (misclassification in 7% of cases after four repeat measurements). Of those with initial diastolic blood pressure values between 95 and 105 mmHg, 24% were misclassified after four repeat measurements. CONCLUSIONS: For these "borderline' diastolic values, we propose larger numbers of measurements than are recommended in international guidelines. Our advice for values in this borderline region is to be reticent in starting antihypertensive drug treatment. The presence or absence of other cardiovascular risk factors should be taken into account when deciding whether treatment is required or not.

The pharmacokinetic profile of naproxen suppository in man.

After a rectal dose of 500 mg in a suppository, naproxen is 6-O-demethylated (20%) and glucuronidated (40%), the metabolites are subsequently excreted renally. The elimination half-life is 15.2 +/- 2.6 h. Ten out of 22 subjects show biphasic elimination kinetics with half-lives of 7 and 15 h, respectively. There is a wide range in the percentage of the dose that is glucuronidated and demethylated (20-70%). This variation does not deviate from a normal distribution.