T-cell-rich B-cell non-Hodgkin's lymphoma mimicking Hodgkin's disease

We report on a patient with recurrent T-cell-rich B-cell lymphoma (TCRBCL), initially misdiagnosed as a lymphocyte-rich Hodgkin's disease. This case exemplifies the diagnostic problems of TCRBCL and the need for immunophenotypic analysis to differentiate TCRBCL from Hodgkin's disease, nodular paragranuloma and peripheral T-cell lymphoma. A rather unusual aspect is the long disease-free interval between the excision of the node in and the late relapse in 1996. The significance of the abundant T-cell infiltration in this B-cell neoplasm will be discussed and the concepts concerning antitumor response will be reviewed. Based on epidemiological data and the clinical behaviour TCRBCL does not seem to represent a distinctive pathological entity.

[Disulfiram in the treatment of alcoholic patients]

In a retrospective investigation we report our experience with alcohol-dependent patients who were hospitalized between 1987 and 1990. There were 58 patients, 29% of them were hospitalized several times. In the middle of 1991 and 1992 we interviewed the family doctors and the social workers who cared for the patients. In 48% of the patients there was improvement, in 24% there was a stabilization, and in 28% we noted a deterioration. There was no difference in patients treated by the family doctor alone or in patients treated by the social workers. Comparing patients taking Disulfiram with patients taking no drug, there was no difference in improvement (48% versus 50%). But the good results in patients not taking disulfiram were nearly exclusively noted for those who had been hospitalized in a special clinic for alcohol-dependent persons. Patients who were hospitalized several times for alcohol withdrawal had a worse chance to improve their situation (-20%). The therapy with disulfiram in alcohol-dependent patients is helpful to cure chronic alcoholics. Programs in a specialized clinic improve also the chance to be cured of the addiction.

A new instrument for controlling pressure exerted on the sclera during contact Nd:YAG laser cyclodestruction

We tested the device described by Rol et al in their article in this issue, designed to define and precisely control the pressure applied to the sclera during contact cyclodestruction with a cw-Nd:YAG laser. Since scleral transparency, and hence transmission of laser energy, depends on the pressure applied, control of this parameter represents an important advance toward the goal of standardizing the cyclodestructive procedure. In eight of nine cadaver pig eyes, pressure was exerted on the sclera using the pressure-controlling device, with a setting of 0.25 N for two of these eyes, and one of 0.4 N for the other six. In the remaining eye, pressure was controlled intuitively by an experienced surgeon. Applying forces of 0.25 or 0.4 N yielded similar success rates, although these fluctuated greatly even under constant pressure conditions (from 17% to 50% at 0.25 N; from 27% to 42% at 0.4 N). The highest success rate (55%) was achieved by the intuitively controlled pressure irradiations of the experienced surgeon. The variation in coagulation intensity that occurred despite constant pressure suggests that additional factors contribute to the results achieved. Nonetheless, this pressure-controlling probe represents an important achievement. It will permit not only the novice but even experienced operators to adhere unambiguously to a protocol of quantitative, reproducible parameters, and will also help researchers to better understand the relationship between energy delivered and intraocular pressure reduction achieved in contact cyclophotocoagulation.

Comparison of casual, ambulatory and self-measured blood pressure in a study of nitrendipine vs bisoprolol

In a double-blind, placebo-controlled study the antihypertensive efficacy and tolerability of a single morning dose of either 10 mg bisoprolol (n = 26) or 20 mg nitrendipine (n = 27) were investigated. Blood pressure was measured by three techniques: (1) Casual blood pressure 24 h after the dose; (2) ambulatory 24-h whole-day monitoring; and (3) self-recorded blood pressure in the morning 24 h after the dose (6-8 a.m.) and in the evening (6-8 p.m.). After 4 weeks of therapy bisoprolol had produced a highly significant reduction in blood pressure as assessed by causal, ambulatory day- and night-time monitoring, and self-measured morning and evening readings. Bisoprolol was significantly more effective than nitrendipine, which did not induce a significant reduction in the ambulatory night-time recordings. Whole-day ambulatory blood pressure profiles showed an antihypertensive effect of bisoprolol throughout the entire 24-h period. 24-h blood pressure curves after nitrendipine demonstrated a markedly shorter duration of action, with no reduction in early morning blood pressure. Adverse effects and tolerability of the two drugs were comparable. The average changes in systolic and diastolic blood pressure after bisoprolol and nitrendipine in 2-h periods of ambulatory monitoring (6-8 a.m. and 6-8 p.m.) and self-measured blood pressure (6-8 a.m. and 6-8 p.m.) showed a good agreement between ambulatory and self-measured blood pressure determinations with no significant difference between the methods. The results show that 24 h antihypertensive efficacy was more pronounced for bisoprolol than for nitrendipine at the doses studied.(ABSTRACT TRUNCATED AT 250 WORDS)

[Sources of error in the diagnosis and therapy of hypertension]

Possible errors in the diagnosis and treatment of hypertension are discussed. The problems of blood pressure determinations are reviewed by comparing the results of sphygmomanometry in the doctor's office, of automated ambulatory blood pressure recording and of blood pressure self-measurement. In screening for renovascular hypertension one should be aware that no test is yet available which shows adequate sensitivity and specificity. Therefore, the only investigation that should be used to demonstrate a true stenosis is arteriography. When treating hypertensives it must be kept in mind that the benefits of antihypertensive medication, i.e. reducing morbidity and mortality from cardiovascular disease, should exceed the costs and side effects of the treatment. Finally, the effects of reduction in dose and discontinuation of antihypertensive medication are discussed.

Self-measured blood pressures at home and during consulting hours: are there any differences?

Home blood pressures are lower than casual blood pressures and this difference is probably due to physician-patient interaction in a clinical stress situation. In order to prove this assumption we compared the casual blood pressures of 127 subjects, measured by a physician and by the subjects themselves in the presence of the physician, with self-measured values obtained at home over a 7-day observation period. The casual pressures were higher than the home pressures (delta = 7.6/3.9 mmHg) regardless of whether they were taken by the physician or by the subjects themselves in the presence of the physician. The subjects' casual readings (132.9 +/- 17.5/87.6 +/- 12 mmHg) were slightly, but significantly, higher than those measured by the physician (131.9 +/- 18.4/86.3 +/- 12.6 mmHg) and both systolic and diastolic self-measured casual values were highly significantly correlated with the physician's readings (r = 0.92 and 0.91, respectively; P less than 0.01).

[Why are blood pressure values higher in the doctor's office than at home?]

Blood pressure values measured by the patients at home are lower than those measured during medical consultation. To test whether the person measuring the blood pressure is responsible for this difference, the blood pressure of 127 patients was measured first by the doctor and then by the patients themselves during the consultation. There was a good agreement and no significant difference between the two measurements. Values taken at home were however significantly lower. Our results indicate, that difference between clinic and home blood pressure values does not depend on the person performing the measurement.

[Self measurement of blood pressure: patient education]

Many patients measure their blood pressure without any instruction due to the availability of modern measuring devices. Although the technique can be mastered by most of the patients, some sources of error have to be eliminated. The aim of such an instruction is to explain these sources of error to the patients and to give them opportunity to practise the self measurement under medical supervision. An instruction sheet is handed out as a pamphlet. The patients are also directed to keep a record of all measurements which is periodically controlled by the physician. It is also advisable to reexamine the measuring technique of the patient from time to time and to check the accuracy of the patients measuring device.

[Diagnostic and prognostic aspects of home blood pressure measurement]

Up to now the diagnosis of hypertension has been based on a few casual blood pressure measurements in the physician's office according to WHO guidelines. Blood pressure measurements at home in the recent years have gained increasing popularity as a supplementary diagnostic tool. The establishment of an everyday blood pressure profile and exclusion of "white coat" hypertension are the main diagnostic indications. In borderline hypertension those patients with elevated home blood pressures can be identified. However world-wide epidemiologic studies are urgently needed to develop definitions of normal and pathological values for self-recorded blood pressure readings. From our experience diastolic home-recorded values higher than 90 mm Hg should be regarded as pathological.

Blood pressure self-measurement in normotensive and hypertensive patients

In this study casual blood pressure was compared with home blood pressure measurement in 41 normotensive, 39 hypertensive and 21 borderline hypertensive subjects. The average casual readings for the whole group were 8.6 mmHg higher for systolic and 4.0 mmHg higher for diastolic pressures than self-determined values. Casual and home-registered blood pressures showed a highly significant relationship (P less than 0.001) for both systolic and diastolic blood pressure readings. In the distribution of self-measured diastolic blood pressure readings, normotensive subjects rarely (5%) showed values higher than 90 mmHg, whereas hypertensive subjects had a relatively high percentage of diastolic readings above that level (55%). The results confirm previous reports of lower self-determined than casual blood pressure values. However, the high correlation between these two methods of blood pressure measurement indicates that in general there is a quantitative rather than a qualitative difference between casual and self-registered blood pressures. Finally, self-registered diastolic values exceeding 90 mmHg may be interpreted as hypertensive.

Effect of fish oil on blood pressure and serum lipids in hypertension and hyperlipidaemia

We studied the antihypertensive and hypolipidaemic effects of fish oil containing eico-sapentaenoic acid and docosahexaenoic acid in a capsule preparation in patients with mild to moderate essential hypertension and in patients with hypercholesterolaemia. In addition, we used two independent procedures to analyse changes in blood pressure, casual and self-recorded blood pressure measurements. A very moderate blood pressure lowering effect of fish oil was confirmed in this study, and a slight antihyperlipidaemic effect in plasma triglycerides was demonstrated. During the fish oil treatment, casual blood pressure values were consistently lower than self-recorded values. It is assumed that this was an observer error due to knowledge of the treatment.

Comparison of casual, ambulatory and self-determined blood pressure measurement

In this study, self-determined, ambulatory and casual blood pressure measurements were studied in patients with mild to moderate essential hypertension. 31 patients were studied during a 7-day period: casual blood pressures were taken on the 1st, 4th and 7th day. Pressure monitoring for 24 h using a noninvasive ambulatory blood pressure recorder was performed on the 1st and 7th day. Patients recorded blood pressure daily at home at least 3 times each day. On the 1st day, the mean casual blood pressure was significantly higher than either mean self-determined blood pressure or mean 24-hour ambulatory blood pressure. There was no significant difference between ambulatory daytime means and self-determined means. Casual blood pressures decreased from day 1 to day 7 significantly, while no significant difference in self-determined or ambulatory readings was observed. On the 7th day casual blood pressures were still significantly higher than self-determined measurements. Our results show that values obtained from daytime ambulatory measurements and self-determined measurements were equivalent. A fall in blood pressure with serial observations was found only in casual blood pressure, while no significant change occurred with either self-determined or ambulatory pressure. Since self-determined blood pressure measurements are easier and more economical to perform than ambulatory measurements, self-determined measurement is an excellent alternative to obtain representative blood pressure values for the diagnosis and treatment of hypertension.