The effects of talking, reading, and silence on the "white coat" phenomenon in hypertensive patients.

To explore the mechanisms of the "white coat" phenomenon, the effects of talking, reading, and silence were analyzed. Fifty essential hypertensive patients were randomly allocated to periods of stress talking and relaxing reading, alternating with three periods of silence. While talking, systolic/diastolic blood pressure increased sharply, from 142 +/- 0.7/97.7 +/- 0.5 mm Hg to 159 +/- 0.7/111 +/- 0.5 mm Hg (P < .0001). While reading, systolic/diastolic blood pressure decreased (P < .0001). Moreover, talking and reading had opposite residual effects. The silence and reading periods gave the best approximations of the daytime ambulatory period. The predictive value of clinical blood pressure can be improved if measured during a period without talking, thus decreasing the "white coat" phenomenon.

Neodymium:YAG laser cutting of intraocular lens haptics in vitro and in vivo.

Various complications following intraocular lens (IOL) surgery result in explantation of the lenses. Haptic fibrosis may necessitate cutting the IOL haptics prior to removal. In this study we used the neodymium: YAG (Nd:YAG) laser to cut polypropylene and poly(methyl methacrylate) (PMMA) haptics in vitro and in rabbit eyes. In vitro we were able to cut 100% of both haptic types successfully (28 PMMA and 30 polypropylene haptics). In rabbit eyes we were able to cut 50% of the PMMA haptics and 43% of the polypropylene haptics. Poly(methyl methacrylate) haptics were easier to cut in vitro and in vivo than polypropylene haptics, requiring fewer shots for transection. Complications of Nd:YAG laser use frequently interfered with haptic transections in rabbit eyes. Haptic transection may be more easily accomplished in human eyes.

Talking effect and "white coat" effect in hypertensive patients: physical effort or emotional content?

Talking has been shown to increase blood pressure instantaneously in hypertensive patients and to contribute to the white coat effect. The effects of talking were compared with those of counting aloud in 64 patients with essential hypertension who were randomly assigned to a period of stress talking and a period of counting aloud (active periods), alternating with three periods of silence (control). The same monitor was used for office measurements and 24-hour ambulatory blood pressure analysis. Systolic/diastolic blood pressures increased significantly more during talking (163/110 mmHg) than during counting aloud (152/102 mmHg, both p < .0001) in both treated and untreated patients and in sustained and clinical hypertension. Talking had a residual effect on systolic blood pressure that lasted 5.8 +/- 0.1 minutes. The emotional content seemed to be the only cause of the talking effect. Its instantaneous and residual effects on blood pressure and heart rate should be considered when measuring these variables.

Talking effect and white coat phenomenon in hypertensive patients.

Both white coat effect (the tendency of blood pressure to rise during a medical visit) and talking effect were analyzed in 42 patients with essential hypertension. Blood pressure was measured during the clinic visit and over the subsequent 24-hour ambulatory period, with the physician performing 49 +/- 4 measurements for each patient. Three silent periods and two talking periods (stress and relaxation) were randomly allocated in a crossover design and studied, using analysis of variance. During the initial 11-minute silent period, systolic/diastolic blood pressures increased by 6 mm Hg/5 mm Hg. During the subsequent talking periods, these variations were significantly greater: +22 mm Hg/+17 mm Hg. Measures of systolic/diastolic blood pressure were higher during stressful talking than during relaxed talking. The talking and its emotional contents seemed to explain 70% of the white coat phenomenon. To minimize the white coat phenomenon in the clinic, physicians, nurses, and clinicians are advised to measure blood pressure during an initial period of silence.

[Doppler parameters of systolic function and heart rate]. / Paramètres Doppler de fonction systolique et fréquence cardiaque.

This prospective study had two aims, to study the Doppler parameters of left ventricular systolic function with respect to heart rate, and to determine the influence of ischaemic heart disease on these variations. The Doppler indices (velocity time integral, maximum velocity and average acceleration of systolic flow in the left ventricular outflow tract) were measured and averaged over 3 beats after digitization: the measurements were repeated in 30 patients under basal conditions and after 2 minutes transoesophageal atrial pacing at 150 beats/min. These 30 patients were divided into 3 groups: group 1 control subjects with normal coronary arteries, n = 13, EF = 71 +/- 8.9%; group 2 coronary patients without myocardial infarction (greater than 70% stenosis on coronary angiography), n = 9, EF = 64.3 +/- 10.3%; group 3, coronary patients with previous infarction, n = 8, EF = 51.8 +/- 10.9% (p less than 0.0006). Variance analysis for repeated measurements showed significant decreases in velocity time integrals and maximum velocities after pacing (11.8% +/- 2.2 and 0.86 +/- 0.1 versus 18.3 +/- 2.2 and 0.91 +/- 0.1, p less than 0.0001 and p less than 0.05 respectively). This decrease was identical in the three groups. The variations observed were therefore related to the increase in heart rate and not to coronary status or left ventricular function.

["White-coat" effect in 35 consecutive patients with hypertension. Quantification method, role of physician-patient dialogue]. / L'effet "blouse blanche" chez 35 hypertendus consécutifs. Méthode de quantification, rôle du dialogue médecin-patient.

The "white coat" effect, an alarm reaction to the presence of a doctor, is an important cause of blood pressure variability, the frequency, amplitude and mechanisms of which are only partially understood. In order to evaluate these factors, a prospective study was undertaken in 35 consecutive patients referred for assessment of clinical hypertension. The alarm reaction was investigated during the consultation, at the time of interrogation, in periods of silence, in the sitting and upright positions. Twenty-four to forty-eight measurements (average 36.8) of the blood pressure and heart rate were performed in each patient with a Diasys 200 R monitor. The ambulatory period of 3 to 5 hours after the consultation provided 12 to 24 measurements (average 20.7) which were considered to be the reference for comparison with the consultation period. A total of 2,038 measurement were made and analysed. Analysis of variance (GLM) for each patient and for the whole group gave an assessment of the alarm reaction during the patient-doctor dialogue and periods of silence with reference to the ambulatory period. During the ambulatory period, the average and standard deviation for systolic pressure were 134 +/- 0.7 mmHg, and for diastolic pressure 93.1 +/- 0.6 mmHg. These pressures were significantly lower than during the two periods of consultation, with and without dialogue (p < 0.0001). During the consultation, the systolic and diastolic blood pressure values were significantly higher during the dialogue than during the periods of silence (p < 0.0001). During the dialogue, the systolic pressure attained 153.7 +/- 0.7 mmHg and the diastolic pressure: 107.2 +/- 0.6 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)

[Tolerance of amlodipine in left ventricular dysfunction of ischemic origin]. / Tolérance de l'amlodipine dans la dysfonction ventriculaire gauche modérée d'origine ischémique.

The aim of this study was to assess the effects of amlodipine on left ventricular function at rest and on effort, at least 30 days after myocardial infarction. The 30 patients included in the study had resting isotopic ejection fractions of 40 to 60%. At inclusion and after 15 days treatment with 10 mg of amlodipine, the patients underwent exercise stress testing with a standard Bruce protocol and resting and exercise isotopic left ventricular ejection fractions were measured. The association of betablockers was allowed but vasodilator therapy was prohibited. During the second exercise stress test, the duration of exercise increased (437 +/- 167 to 518 +/- 154 s; p < 0.002) and the work level rose from 140 +/- 56 to 169 +/- 60 Watts; p < 0.04. The number of electrically positive tests did not change significantly (33 vs 26.7%; NS). The resting ejection fraction did not increase after 15 days treatment with amlodipine (47.4 +/- 6.7 vs 48.3 +/- 8.9%; NS). Similar results were observed with respect to the exercise ejection fraction (51.4 +/- 10.4 vs 52.6 +/- 8.6%; NS). These patients may however be divided into two subgroups. In the first subgroup of 10 patients, the resting ejection fraction rose by more than 5% with amlodipine whereas the exercise ejection fraction remained unchanged (54.4 +/- 7.7% vs 54.5 +/- 7.5% with amlodipine). In the second subgroup of 20 patients, the resting ejection fraction decreased slightly with amlodipine (48 +/- 6.9% vs 45.3 +/- 8%; p = 0.04) but increased significantly on exercise (45.3 +/- 8% vs 51.7 +/- 9.1%; p < 0.0002). Therefore, amlodipine, a new generation calcium antagonist, does not induce any deleterious effect after myocardial infarction with mild left ventricular dysfunction.

[Mid-term results of bioprosthesis in patients over 65 years]. / Résultats à moyen terme des bioprothèses après 65 ans.

Between 1979 and 1985, 79 patients over 65 years of age (mean 70.8; range 65-82 years) underwent valvular replacement with a bioprosthesis (aortic: 48, mitral: 26, aortic and mitral: 5). Of the 84 valves implanted, 56 were porcine and 28 were pericardial bioprostheses. The average follow-up was 66 months (total: 434 patient-years; range: 2 months-12 years). Twenty-three patients (29%) died; 13 of these deaths were related to the prosthesis and 10 were not formally related to the bioprosthesis. Of the latter 10 deaths, 7 were caused by malignant disease. Seven patients were reoperated for a complication due to the prosthesis (1.6% per patient-year): 5 primary tissue failure, 1 endocarditis, 1 perivalvular leak. Sixteen patients (20.3%) received oral anti-coagulants for atrial fibrillation; 6 of them (7.6%) had severe haemorrhagic complications (3 deaths). The actuarial survival was 76.2% at 5 years and 53.4% at 10 years. Actuarial survival without reoperation was 76% at 5 years and 42% at 10 years. Analysis of survival with respect to the type of bioprosthesis (porcine of pericardial), the valve orifice (mitral or aortic) and age (under or over 70 years) did not show any significant differences. Follow-up of patients over 65 years of age showed a high rate of haemorrhagic complications related to oral anticoagulant therapy for atrial fibrillation (6.8% per patient-year), a low rate of primary tissue failure (1.1% per patient-year) and a low reoperative mortality (1 death for 7 reoperations).

[Can patients with severe left ventricular dysfunction be treated by coronary artery bypass surgery?]. / Peut-on ponter les coronariens ayant une dysfonction ventriculaire gauche sévère?

Forty three men and 3 women, with an average age of 59 years (13 to 78 years) underwent aorto-coronary bypass surgery despite severe left ventricular dysfunction (ejection fraction < 35%); 96% of the patients had previous infarction; 60% (N = 28) had unstable angina, 52% (N = 24) had had pulmonary oedema or an episode of congestive cardiac failure. The average ejection fraction was 29 +/- 4%, range 17 to 35%. Thirteen patients had ventricular aneurysms, 4 had grade 3 or 4 mitral regurgitation. The coronary lesions were usually multivessel left main coronary (6), triple vessel disease (27), double vessel disease (12), single vessel disease (1). The average number of bypass grafts per patient was 2.3. The average aorting clamping time was 63 minutes (range 26 to 133 minutes). There were 4 mitral valve replacements, 4 resections of ventricular aneurysms and 1 double procedure (aneurysmectomy and valve replacement). The operative mortality was 2.1% (1 death). During an average follow-up period of 27 months (range 3 to 90 months), there were: 2 recurrent infarctions, 13 episodes of cardiac failure and 8 cardiac deaths (cardiac failure: 5, sudden death: 2, recurrent infarction: 1). Two patients underwent cardiac transplantation. The regression of angina (90% of operated patients were asymptomatic) and the low operative risk, justify aortocoronary bypass surgery despite left ventricular dysfunction in patients with severe symptoms (unstable angina, chronic, invalidating angina). The medium-term results indicate a high risk of cardiac failure which is partially responsible for the secondary mortality rate of 17% at 2 years.

Fractures of the lateral process of the talus: two case reports and a comprehensive literature review.

Fractures of the lateral process of the talus are frequently overlooked and should be considered in the differential diagnosis of patients with acute and chronic ankle pain. Early diagnosis is emphasized in all series reviewed in the literature to prevent long-term complications. Thorough radiographic evaluation is necessary to determine the need for operative vs. nonoperative management. Small nondisplaced fractures are treated with cast immobilization, whereas large or displaced fractures usually require open reduction and internal fixation. Comminution of fragments may necessitate surgical excision. To achieve the best possible results, a timely diagnosis is required, and it is our belief that early treatment has better overall results.

[Arteriovenous fistula following surgery of intervertebral disk]. / Fistule artério-veineuse dans les suites de la chirurgie du disque intervertébral.

Vascular damage during intervertebral disc surgery is uncommon. It sometimes leads to the formation of an arteriovenous fistula and about one hundred cases have been reported in the literature. The diagnosis is often early, with signs of venous hypertension predominating. The authors report a case of arteriovenous fistula presenting late as apparently primary congestive cardiac failure. The mechanisms of this condition were demonstrated during preoperative instrumental manoeuvres. Surgical correction is the only treatment alternative. Repair must be arterial and venous, most often using prosthetic material. This generally enables total and permanent recovery, but overall mortality in pathology of this type is not nil.

[Kingella denitrificans endocarditis on an aortic valve prosthesis]. / Endocardite à Kingella denitrificans sur prothèse valvulaire aortique.

Kingella denitrificans is a Gram-negative bacillus which does not grow readily on the usual media. This organism, normally a commensal of the upper airways, may exceptionally be responsible for endocarditis. We report here the sixth case known in the literature. Cure was obtained with an intravenous combination of vancomycin and rifampicin.

Unusual breast lesions: radiologic-pathologic correlation.

Unusual lesions of the breast can present a diagnostic challenge. These lesions include systemic diseases, benign tumors, and primary and metastatic malignancies. Lymphadenopathy is the most common mammographic finding associated with collagen vascular disease. Wegener granulomatosis may manifest as an irregular, high-density mass simulating breast cancer. Diabetic fibrous mastopathy manifests at mammography as very dense breast tissue and at ultrasonography (US) as an irregular, hypoechoic mass with striking posterior acoustic shadowing simulating malignancy. Fibromatosis simulates malignancy at mammography as an irregularly shaped, uncalcified, high-density mass and at US as an irregular, hypoechoic mass with posterior acoustic shadowing. At US, granular cell tumor may manifest as a solid, poorly marginated mass with marked posterior acoustic shadowing or may appear more benign. At mammography, hamartomas are typically well-circumscribed, round to oval masses with a thin, radiopaque pseudocapsule; at US, they manifest as a sharply defined, heterogeneous oval mass or as normal glandular tissue. Phyllodes tumor manifests at mammography as a large, well-circumscribed oval or lobulated mass; at US, it usually manifests as an inhomogeneous, solid-appearing mass. At mammography, primary breast lymphoma manifests as a relatively circumscribed mass or a solitary, indistinctly marginated, uncalcified mass. Metastatic lesions may manifest mammographically as single or multiple masses or as diffuse skin thickening; at US, they tend to have circumscribed margins with low-level internal echoes. Radiologists should be familiar with the characteristic mammographic appearances of these lesions and should consider benign and systemic causes in the differential diagnosis when malignant-appearing findings are encountered.