It is widely believed that patients' compliance can be increased by persuading them to participate in their own care. We tested whether patients with hypertension could manage their own clinical records and whether their doing so would affect the quality of their care. Two hundred patients were randomly assigned to an intervention or a control group. Those in the intervention group were asked to complete a 10-page booklet containing a personal standardized medical record. All patients were scheduled for a follow-up appointment at the end of one year and were referred to their general practitioners for interim care. At the end of the follow-up period, the proportion of patients seen was comparable in the two groups. More of the patients in the intervention group than in the control group filled out a questionnaire as requested, and more added comments. Within the intervention group, the proportion of patients seen and the fall in systolic blood pressure were significantly higher among the 44 patients who had completed the personal record as requested than among the 57 who had not. Patients who completed the personal record also had fewer compliance problems.

An integrated approach, progressively implemented in the ARTEMIS system since 1975, is described for the computerized management of hypertensive patients. From a medical point of view, computerized programs can be used to memorize patients' individual records and profiles, to facilitate patient management and follow-up, to store medical knowledge about hypertension and to provide facilities for decision making at the level either of the individual patient or of the population followed up. From a technical point of view, the methodology used integrates data and knowledge management facilities into the same software. Five hypertension clinics are presently using the system in France and more than 22,000 records have been registered. Answer rates to 12 mandatory questions regarding past history and examination at first visit were superior to 95% in 19,601 records created between January 1976 and December 1987. Patient database interrogation can be used to evaluate the sensitivity and specificity of various signs and symptoms for the diagnosis of secondary hypertension, and to predict, for each patient, his/her cardiovascular risk, the risk of drop-out, the risk of insufficient blood pressure control and the probable blood pressure level. It also serves to test the content and validity of the associated expert system which is progressively built up. A prospective evaluation of the performance of the expert system on 80 cases of hypertension showed overall agreement between the specialists and the expert system ranging from 58 to 91% depending on the decision.(ABSTRACT TRUNCATED AT 250 WORDS)

An integrated approach is described for the computerized management of a nephrology department. On a medical point of view, the system comprises a minimum medical record for every patient, different specialized records and knowledge bases presently covering hypertension, diabetes and chronic renal failure. From a technical point of view, the methodology used integrates data and knowledge management techniques. Various individual reports facilitate patient management. For hypertensive patients, an expert system is combined with the record system. The results of a preliminary evaluation are reported and future developments considered.

The computerized medical specialized records covering the follow-up of hypertension (ARTEMIS), diabetes (MELLITEE), chronic renal failure and the minimum medical record of Nephrology (THESEE) using the temporal database management system LIED, have been developed in several units of University Hospitals. The authors show that these computerized records are usable in a Nephrology Unit in a General Hospital.

Alcohol consumption and glycosuria were found to be associated (p < 0.001) in a population of 6571 salaried employees who underwent a systematic examination. The prevalence of glycosuria was found to range from 1.3% among 2609 non-drinkers to 5% among 816 heavy drinkers (six glasses or more of alcoholic beverage daily). This association was still significant after adjustement for age, sex and body mass index. Similarly, a positive association was observed between fasting glycemia and alcoholic intake in a subgroup of 998 subjects when such a result was available (p < 0.05).

"ARTEMIS" is a standardized and computerized medical file which is intended for improving the follow-up of hypertensive patients, the efficacy of treatment and for realising national-wide surveys. The software "LIED" of data base for "ARTEMIS" is nowadays transposable on mini-computer. In Nephrology Unit of General Hospital from Colmar, the system has been working since September 1985 with MICRO-MEGA E 32 (Thomson). The administrative and medical data are directly acquired by the doctors and secretaries of the Unit on a conversational mode from six terminals. There is no writing collecting of data. An evaluation of the system was realized with the 113 first hypertensive patients. The results were compared to those obtained from patients of Paris area.

Six thousand six hundred thirty two subjects, employed in 420 small and medium-sized companies in the Paris region were examined in a cross-sectional study. Their alcohol consumption, as obtained by interview was found to be higher among males than among females, among workers than among managers, executives, and clerks. Alcohol consumption was positively associated with age, body mass index, coffee and cigarette consumption, occupational exposure to noise and working nights or alternating shifts. A positive, continuous, relationship was observed, for men and women, between alcohol intake and both systolic and diastolic blood pressure. This association was highly significant in the multivariate analysis (multiple linear regression) where alcohol intake, following age and body mass index, was the third predictive factor of blood pressure level in the stepwise regression. The positive association between alcohol consumption and prevalence of arterial hypertension was aggravated by the poor control of hypertension which was found among drinkers. Awareness of hypertension, compliance with an antihypertensive treatment and its efficacy, were negatively associated withg alcohol intake. The findings stress the importance of alcohol consumption which was found to be a major risk factor for arterial hypertension and noncompliance with antihypertensive treatment in this population.

Results of antihypertensive treatment were analyzed in a group of 5,209 hypertensive patients referred in two hypertension Clinics in Paris from 1976 to 1985. Patients were included in the study if they fulfilled the following criteria: 1) at least four visits in the clinic, 2) follow-up period greater than 6 months, 3) initial diastolic blood pressure greater than or equal to 90 mmHg and/or presence of an antihypertensive treatment. After a mean follow-up period of 43 months, blood pressure was reduced from 177/105 mmHg to 148/89 mmHg. However, in spite of at least two antihypertensive drugs, 16.7 p. 100 of these patients had a diastolic blood pressure above 95 mmHg at the end of the follow-up period and were defined as uncontrolled hypertensives (UH). By comparison with controlled hypertensives (CH), UH patients were more frequently males (67.9 vs 56.6 p. 100, p less than 0.001), had a greater known duration of hypertension (11.6 vs 8.7 years, p less than 0.001), and presented at the first visit with higher blood pressures (188/113 vs 174/103 mmHg, p less than 0.001/p less than 0.001), despite a higher rate of antihypertensive treatment (66.6 vs 53.8 p. cent, p less than 0.001), a higher ponderal index (26.3 vs 25.3/kg/m2, p less than 0.01) and a higher prevalence of end-organ damage (23.2 vs 16.3 p. 100, p less than 0.001). Sokolov index, serum creatinine and uric acid levels were higher among UH than among CH patients.(ABSTRACT TRUNCATED AT 250 WORDS)

For a finer assessment, by repeated blood pressure (BP) measurements, of the cardiovascular risk associated with BP levels, new instruments have been developed which provide multiple reading during periods of activity. However, the lack of epidemiological studies makes it necessary to determine reference ambulatory BP levels by another method. Twelve-hour recordings were taken with the Spacelabs instrument in 130 volunteers (45% males) aged from 20 to 90 years during their various activities. Mean systolic and diastolic BP values +/- SD were calculated per age-groups of 10 years each. That this sample was representative of the general population was confirmed by the fact that BP fluctuations and variations according to age and sex in these 130 subjects were identical with those observed in the population of an entire town (Framingham). The concept of hypertension, as defined by ambulatory BP recordings, is discussed. This study provides, for the first time, reference ambulatory BP values according to age and sex, measured in normotensive subjects with the Spacelabs instrument. These values constitute a preliminary step indispensable to evaluate this technique in hypertensive patients.

Results of antihypertensive treatment were analyzed in a group of 5,209 hypertensive patients referred in two hypertension Clinics in Paris from 1976 to 1985. Patients were included in the study if they fulfilled the following criteria: 1) at least four visits in the clinic, 2) follow-up period greater than 6 months, 3) initial diastolic blood pressure greater than or equal to 90 mmHg and/or presence of an antihypertensive treatment. After a mean follow-up period of 43 months, blood pressure was reduced from 177/105 mmHg to 148/89 mmHg. However, in spite of at least two antihypertensive drugs, 16.7 p. 100 of these patients had a diastolic blood pressure above 95 mmHg at the end of the follow-up period and were defined as uncontrolled hypertensives (UH). By comparison with controlled hypertensives (CH), UH patients were more frequently males (67.9 vs 56.6 p. 100, p less than 0.001), had a greater known duration of hypertension (11.6 vs 8.7 years, p less than 0.001), and presented at the first visit with higher blood pressures (188/113 vs 174/103 mmHg, p less than 0.001/p less than 0.001), despite a higher rate of antihypertensive treatment (66.6 vs 53.8 p. cent, p less than 0.001), a higher ponderal index (26.3 vs 25.3/kg/m2, p less than 0.01) and a higher prevalence of end-organ damage (23.2 vs 16.3 p. 100, p less than 0.001). Sokolov index, serum creatinine and uric acid levels were higher among UH than among CH patients.(ABSTRACT TRUNCATED AT 250 WORDS)

An expert system has been integrated to the data management system of the ARTEMIS programme for hypertensive patients. The patient database, which has been used since 1975, contains the medical records of about 20,000 patients. Information is interactively entered by physicians, nurses and secretaries on video display units. The computerised medical record has replaced the traditional handwritten medical record. The database management system is used to produce different summary reports (inpatient and outpatient care) and personalized recall letters which are mailed to the patients before their appointments. Suggestions provided by the expert system include additional information to be obtained (complementary patient interrogation, biological or radiological investigations, etc.), possible causes of hypertension, and medical prescriptions. The information base allows the description of both static knowledge (in the form of a semantic network) and dynamic knowledge (in the form of production rules). The inference system sequentially uses a combination of forward and backward chaining and performs both exact and approximate reasoning. The diagnostic performance of the expert system was evaluated in 100 cases of hypertension (50 of essential hypertension and 50 of secondary hypertension. Concordance between the diagnosis proposed by the expert system and the one proposed by the specialist was achieved in 92% of secondary hypertension cases and 88% of essential hypertension cases. It is suggested that the integration of data and knowledge management might enhance the overall acceptance by medical staff of a computerised system, and facilitate the validation of a knowledge base.

The long-term efficacy and tolerance of spironolactone in essential hypertension was evaluated among 20,812 patients referred to the Broussais and St. Joseph systemic hypertension clinics between 1976 and 1985 by using information prospectively collected in the computerized ARTEMIS data bank. In 182 patients (51 men, 131 women) treated with spironolactone alone during a mean follow-up period of 23 months, a mean dose of 96.5 mg decreased systolic and diastolic blood pressure (BP) by 18 and 10 mm Hg, respectively, below pretherapeutic levels. The BP decrease was greater with doses of 75 to 100 mg (12.4% and 12.2%) than with doses of 25 to 50 mg (5.3 and 6.5%, p <0.001), but no additional decrease was found with doses above 150 mg. Plasma creatinine level increased modestly (8.3 μmol/liters), as did plasma potassium level (0.6 mmol/liters) (both p <0.001); uric acid level increased, but not significantly (10.5 μ.mol/liter). Fasting blood glucose and total cholesterol levels did not change, triglyceride levels increased slightly (0.1 mmol/liter, p <0.05). These changes were similar in both sexes and were not influenced by length of follow-up. Among the 699 men prescribed spironolactone alone or in association with another ant1hypertensive treatment, 91 cases of gynecomastia developed (13%). Gynecomastia was reversible and dose-related; at doses of 50 mg or less the incidence was 6.9%, but 52.2% for doses of 150 mg or higher. Despite limitations inherent in the interpretation of data banks, it is concluded that spironolactone administered in daily practice reduced BP without inducing adverse metabolic adverse effects and that in patients with essential hypertension, doses should be kept below 100 mg.

Taking over a chronic disease like diabetes in a hospital clinic raises multiple problems. Large numbers of diabetic patients and prolonged follow-up periods result in a mass of data that only computers can control. MELLITEE is a computerized system developed to facilitate the longterm management of patients and to help in maintaining a high standard of care. It includes a structured and standardized medical record. Physicians of three Parisian hospital clinics agreed on the minimum content of the record. MELLITEE is operated at the Saint-Louis Hospital on a 68,000 based mini-micro computer (Fortune/Thomson Micromega-32), running under the Unix operating system and with the Lied data base management system. Data are keyed directly into the computer by physicians, nurses and dietitians from throughout the department. On-line registration of information allows the suppression of the corresponding part of the usual paper record. The clinical data base obtained from administrative and medical information can be used to facilitate more effective patient follow-up and clinic management. The system is to be set up in the other collaborating centres in the near future, allowing pooling of data. It will also provide long-term information which can be used for evaluation of care and epidemiological research.