This telecommunication service was efficacious in reducing the mean arterial pressure of patients with established essential hypertension.

A randomized controlled trial was conducted to assess the efficacy of a telemedicine service for the diagnosis of essential hypertension. The telemedicine service consisted of using an automatic home blood pressure monitor connected to an ordinary telephone line for the transmission of the data to a central computer. After use of the home monitor for a week, the results were converted to a report form and faxed to the patient's physician. The gold standard for assessment of true hypertension status was 24 h ambulatory blood pressure monitoring. A total of 74 patients from outpatient clinics were randomized into either the telemedicine service or usual care. Use of the telemedicine service significantly improved the detection of essential hypertension compared with usual care: in the telemedicine group, 64% of patients with essential hypertension were diagnosed; in the usual care group, 26% of patients with essential hypertension were diagnosed. Furthermore, diagnosis occurred earlier in the telemedicine group than in patients receiving usual care. Specificity and positive predictive value were similar in the two groups.

We present a 66-year-old woman with 2 months of visual hallucinations, unintentional weight loss, and short-term memory decline, whose clinical presentation and EEG supported a diagnosis of limbic encephalitis. Subsequent evaluation for a paraneoplastic etiology revealed a renal mass, which was resected and identified as clear cell renal carcinoma. The patient's clinical condition improved after resection of the mass. When patients present with incongruous subacute neuropsychiatric symptoms, clinicians should be mindful of paraneoplastic neurological disorders, as early diagnosis and treatment of malignancy may lead to symptomatic improvement. CASE DESCRIPTIONA 66-year-old woman presented with 2 months of new visual hallucinations. She initially saw spiders on the walls; at the time of her presentation, however, she was having more vivid hallucinations, including seeing known deceased people harm her neighbors. While these visions were disturbing to her, she recognized that they were hallucinations and did not respond to them. Over the same period, her family also noticed shortterm memory decline and an unintentional weight loss of 20 pounds. Her review of systems was otherwise normal, including a lack of symptoms suggestive of depression, and she had no medical, psychiatric, or relevant family history. She did not take medicines and denied use of tobacco, alcohol, and illicit drugs.On physical examination, the patient was hemodynamically stable and had a normal cardiovascular, respiratory, abdominal, and pulmonary examination. Detailed neurological examination revealed no focal neurological deficits, including normal cranial nerves, intact and symmetric strength throughout, normal reflexes, no nystagmus, intact finger-to-nose testing, normal gait, and no dysdiadochokinesia with rapid alternating movement. She performed poorly on the Montreal Cognitive Assessment 1 , having particular difficulty with visuospatial skills, naming, and both immediate and delayed recall. Comprehensive laboratory assessment was performed and revealed normal urinalysis, complete blood count, basic metabolic panel, hepatic function panel, thyroid-stimulating hormone, free thyroxine, ammonia, folate, and vitamin B12. HIV testing and urine toxicology screen were negative. Cerebrospinal fluid (CSF) was colorless, with only one white blood cell (monocyte), one erythrocyte, glucose level of 65 mg/dL (normal range, 40-85 mg/dL), and protein level of 43 mg/dL (normal range, 15-45 mg/dL). CSF was negative for herpes simplex virus via PCR, fungal staining, and New York State Viral Encephalitis panel. CSF cytology was negative, and CSF protein electrophoresis did not identify any oligoclonal bands. Serum electrophoresis detected a distinct monoclonal band in the gamma region, but immunofixation was not performed. MRI of the brain, with and without contrast, revealed mild diffuse atrophy and subcortical hyperintensities on T2 and FLAIR imaging, findings which were nonspecific and possibly related to microvascular disease, but also potentially co...

The INR measured with the point-of-care device in patients receiving concurrent LMWH and warfarin therapy may be inaccurate. Patients receiving LMWH in addition to warfarin should have INRs checked by means of the standard reference laboratory method.

P99 While the use of telecommunication systems in medicine has been increasing, there have been few trials to assess the efficacy of such technology for improving blood pressure (BP) in patients with essential hypertension. A randomized controlled trial (RCT) was conducted to assess the efficacy of an home monitoring service which utilized automatic transmission of BP data over telephone lines, conversion of the data into report form by computer, and facsimile transmission of the form weekly to physicians and patients. One hundred and eleven patients were randomized to either home service or usual care and followed for a median of 11 weeks. The primary endpoint was change in mean arterial pressure (MAP) which was assessed using a 24-hour ambulatory blood pressure monitoring (ABPM) device at both baseline and exit. There was a 3.0 mm Hg decline in MAP from baseline to exit for patients using the home service and a 1.5 mm Hg increase in MAP for patients receiving usual care (p=0.0139). There was a 2.1 mm Hg decline in average diastolic BP (DBP) in the home service group and a 2.3 mm Hg increase in the usual care group (p=0.0120). In addition, the proportion of 24-hour DBP readings above target levels decreased by 6.8% in patients receiving home service, but increased by 6.2% in patients receiving usual care (p=0.0057). The reduction in BP was evident for both genders, for each ethnic group, and for both younger and older patients. For African-Americans, MAP declined by 9.6 mm Hg for those receiving the home service and increased by 5.25 mm Hg for those receiving usual care (p=0.0469). The difference in MAP between the two study arms remained significant after adjustment for patient characteristics. The decrease in BP for home service was, in part, due to more frequent changes in dose and/or type of medication during the course of the trial. This was the first RCT of a home BP service that did not rely on patient self-report and which used 24-hour ABPM at baseline and at exit to assess usual BP. It is recommended that patients with essential hypertension, who are in the process of evaluation for a change in antihypertensive therapy, utilize a home monitoring service.