Interpretations of and management actions following ECGs in programmatic cardiovascular care in primary care: A retrospective dossier study.

BACKGROUND: The usefulness of routine electrocardiograms (ECGs) in cardiovascular risk management (CVRM) and diabetes care is doubted. OBJECTIVES: To assess the performance of general practitioners (GPs) in embedding ECGs in CVRM and diabetes care. METHODS: We collected 852 ECGs recorded by 20 GPs (12 practices) in the context of CVRM and diabetes care. Of all abnormal (n = 265) and a sample of the normal (n = 35) ECGs, data on the indications, interpretations and management actions were extracted from the corresponding medical records. An expert panel consisting of one cardiologist and one expert GP reviewed these 300 ECG cases. RESULTS: GPs found new abnormalities in 13.0% of all 852 ECGs (12.0% in routinely recorded ECGs versus 24.3% in ECGs performed for a specific indication). Management actions followed more often after ECGs performed for specific indications (17.6%) than after routine ECGs (6.0%). The expert panel agreed with the GPs' interpretations in 67% of the 300 assessed cases. Most often misinterpreted relevant ECG abnormalities were previous myocardial infarction, R­wave abnormalities and typical/atypical ST-segment and T­wave (ST-T) abnormalities. Agreement on patient management between GP and expert panel was 74%. Disagreement in most cases concerned additional diagnostic testing. CONCLUSIONS: In the context of programmatic CVRM and diabetes care by GPs, the yield of newly found ECG abnormalities is modest. It is higher for ECGs recorded for a specific reason. Educating GPs seems necessary in this field since they perform less well in interpreting and managing CVRM ECGs than in ECGs performed in symptomatic patients.

Interpretations of and management actions following electrocardiograms in symptomatic patients in primary care: a retrospective dossier study.

BACKGROUND: The electrocardiogram (ECG) has become a popular tool in primary care. The clinical value of the ECG depends on the appropriateness of the indication and the interpretation skills of the general practitioner (GP). OBJECTIVES: To describe the use of electrocardiography in primary care and to assess the performance of GPs in interpreting ECGs and making subsequent management decisions. METHODS: Three hundred ECGs, recorded during daily practice in symptomatic patients by 14 GPs who regularly perform electrocardiography, were selected. Corresponding data of the indications, interpretations and subsequent management actions were extracted from the associated medical records. A panel consisting of an expert GP and a cardiologist reviewed the ECGs and specified their agreement with the findings and actions of the study GPs. RESULTS: The most common indications were suspicion of a rhythm abnormality (43.7%), ischaemic heart disease (42.7%) and patient reassurance (14.3%). The study GPs interpreted 53.3% of the ECGs as showing no (new or acute) abnormality, whereas supraventricular rhythm disorders (12.3%), conduction disorders (7.7%) and repolarisation disorders (7.0%) were the most frequently reported pathological findings. Overall, the expert panel disagreed with the interpretations of the study GPs in 16.2% of cases, and with the GPs' management actions in 11.7%. Learning goals for GPs performing electrocardiography could be formulated for acute coronary syndrome, rhythm disorders, pulmonary embolism, reassurance, left ventricular hypertrophy and premature ventricular complexes. CONCLUSION: GPs who feel competent in electrocardiography performed well in the opinion of the expert panel. We formulated various learning objectives for GPs performing electrocardiography.

Student participation in the design of learning and teaching: Disentangling the terminology and approaches.

Background: Students are ever more involved in the design of educational practices, which is reflected in the growing body of literature about approaches to student participation. Similarities and differences between these approaches often remain vague since the terms are used interchangeably. This confusing and fragmented body of literature hampers our understanding the process and outcomes of student participation and choosing the most suitable approach for it. Method: We identified the three most frequently used terms related to the design of learning and teaching - design-based research (DBR), participatory design (PD), and co-creation - and disentangled the terminology by focusing on relevant definitions, aims, involvement of students, outcomes, and related terminology. Results: Differences between the approaches to student participation can be found in the degree to which students are the central actors and the degree to which the design is informed by educational theory. Conclusion: It is important to align the level of student participation with the purpose of the approach.

Non-response and external validity in a school-based quasi-experimental study 'The Healthy Primary School of the Future': A cross-sectional assessment.

Limited evidence is available about (non)-representativeness of participants in health-promoting interventions. The Dutch Healthy Primary School of the Future (HPSF)-study is a school-based study aiming to improve health through altering physical activity and dietary behaviour, that started in 2015 (registered in ClinicalTrials.gov on 14-06-2016, NCT02800616). The study has a response rate of 60%. A comprehensive non-responder analysis was carried out, and responders were compared with schoolchildren from the region and the Netherlands using a cross-sectional design. External sources were consulted to collect non-responder, regional, and national data regarding relevant characteristics including sex, demographics, health, and lifestyle. The Chi-square test, Mann-Whitney U test, or Student's t-test were used to analyse differences. The analyses showed that responders (n = 494) were comparable with non-responders (n = 348) and regional data (n = 6172) with regard to sex and health. Responders did not significantly differ from regional data with regard to lifestyle. Responders had significantly higher educated parents compared to non-responders and were more often of autochthonous ethnicity compared to regional data. Major differences were observed between responders and schoolchildren in the Netherlands, regarding, among others sex, ethnicity, and parental employment rates. We conclude that a potential healthy-volunteer effect in the HPSF-sample is limited. External validity is high when compared to the regional population but low when compared to the national sample. For future intervention studies, we advise to evaluate outcome measures according to regional/national standards and to cooperate with external parties in early stages of research to be able to assess and enhance generalisability.

Competence of general practitioners in requesting and interpreting ECGs - a case vignette study.

BACKGROUND: Performing electrocardiography is common in general practice, but the quality of indication setting and diagnostic accuracy have been disputed. OBJECTIVES: To assess the competence of general practitioners (GPs) in their decision-making process with regard to recording and interpreting an electrocardiogram (ECG) and evaluating the relevance of the result for management. METHODS: An online case vignette survey was performed among GPs and cardiologists (in 2015). Nine cases describing situations for which Dutch clinical guidelines recommend or advise against recording an ECG were presented. In each case, the participant had to make choices on recording an ECG, interpreting it, and using the result in a management decision. The reference standard for each ECG diagnosis was set by the expert author team. RESULTS: Fifty GPs who interpret ECGs themselves, eight GPs who do not and 12 cardiologists completed the survey. Adherence to guidelines recommending an ECG was high for suspected atrial fibrillation, suspected arrhythmia present during consultation, including bradycardia, but much lower for progressive heart failure and stable angina. Diagnostic accuracy of GPs was best in atrial fibrillation (96%), sick sinus syndrome (85%) and old myocardial infarction (82%), but poor in left anterior fascicular block (16%) and incomplete right bundle branch block (10%). GPs often acknowledged the low relevance of the results of a non-indicated ECG. CONCLUSION: GPs do not fully adhere to Dutch cardiovascular guidelines on indications for recording ECGs. Diagnostic accuracy was high for atrial fibrillation, sick sinus syndrome and old myocardial infarction and poor for left anterior fascicular block and incomplete right bundle branch block.

Configuration of unipolar atrial electrograms during electrically induced atrial fibrillation in humans.

BACKGROUND: During atrial fibrillation (AF), the atrium is activated by multiple wavelets that continuously change in size and direction. The aim of this study was to correlate the temporal variation in AF electrogram configuration with the varying spatial patterns of activation. METHODS AND RESULTS: In a group of 25 Wolff-Parkinson-White patients undergoing cardiac surgery, the free wall of the right atrium was mapped (244 points) during electrically induced AF. The unipolar electrograms recorded during 4 seconds of AF were classified into four categories: (1) single deflections, (2) short-double potentials, (3) long-double potentials, and (4) fragmented potentials. The proportion of these four types of electrograms during AF was as follows: singles, 77 +/- 12%; short-doubles, 7 +/- 3%; long-doubles, 10 +/- 7%; and fragmented, 6 +/- 4%. Electrogram morphology was an indicator for rapid uniform conduction (single potentials; positive predictive value [PPV] of 0.96), collision (short-double potentials; PPV of 0.33), conduction block (long-double potentials; PPV of 0.84), and pivoting points or slow conduction (fragmented potentials; PPV of 0.87). In type I, II, and III AF, the proportion of long-double potentials was 4 +/- 2%, 12 +/- 3%, and 18 +/- 7% (P < .05); the proportion of fragmented complexes was 2 +/- 2%, 6 +/- 3%, and 10 +/- 4% (P < .05), respectively. During electrically induced and self-terminating episodes of AF, no preferential anatomic sites for double or fragmented potentials were found in the right atrium. CONCLUSIONS: The morphology of single unipolar electrograms during AF reflects the occurrence of various specific patterns of conduction. This might be used to differentiate between different types of AF and to identify regions with structural conduction disturbances involved in perpetuation of chronic AF.

Understanding mothers' perceptions of what is important about themselves and parenting.

The purpose of this article is to report what mothers of young adolescents perceive as important about themselves and parenting. Their perceptions were identified from brief written statements from a sample of 538 mothers of young adolescents. The women's statements were analyzed using content analysis techniques. Six themes emerged. Mothers described the challenges of putting their ideals about parenting into practice, including incorporating or discarding the influence of their own upbringing and the seeking of knowledge and skills to improve their parenting. Mothers described their values and goals. Feelings of self-doubt were made apparent through self-critical comments. Expressions of frustration were evident as were the serious life stressors managed by the sample. Repeated comments identified mothers' emphases on the importance of open family communication. Mothers had developed styles of parenting based on decision-making methods and understanding the child's perspective. We suggest community health nurses use the themes as guidelines for anticipatory guidance with families during adolescence.

Unravelling the electrical mysteries of atrial fibrillation.

Animal experiments have confirmed that a short but variable excitable gap is present during induced atrial fibrillation. The existence of this gap allows atrial fibrillation to be locally captured by rapid pacing. An area of up to 4 cm in diameter can be activated by uniform wave fronts propagating away from the site of stimulation, although the size of this area may be limited by intra-atrial conduction block or by collision with fibrillation waves. Rapid pacing can accelerate atrial fibrillation by inducing local re-entry circuits with a cycle length shorter than the pacing interval. During pacing-induced atrial fibrillation in patients undergoing surgery for Wolff-Parkinson-White syndrome, three types of atrial activation have been identified, which vary in their degree of complexity and in the length of their fibrillation intervals. It appears that the spectrum of varying cycle lengths during atrial fibrillation might be explained by a mixture of different sorts of atrial re-entry patterns, comprising purely functional intra-atrial re-entry, random re-entry, anatomical re-entry, and nodal re-entry.

Electrophysiologic mechanisms of perpetuation of atrial fibrillation.

The presence of an excitable gap during atrial fibrillation (AF), although short and variable, may be of potential importance for the development of alternative techniques for termination of AF by rapid pacing. Also the notion that perpetuation of AF may be partly dependent on macroreentry around the natural atrial orifices, may provide a new therapeutic option for the permanent cure of AF by interrupting the anatomical circular pathways in the atria by radiofrequency ablation. In our opinion the rapidly growing understanding of the electrophysiologic mechanisms of AF certainly warrants some optimism about the possibility of cure of AF in the near future without causing too much discomfort and without carrying on unacceptable risk.

High-density mapping of electrically induced atrial fibrillation in humans.

BACKGROUND: Mapping studies in animals have suggested that atrial fibrillation (AF) is based on multiple reentering wavelets. Little information is available about the patterns of activation during AF in humans. The objective of the present study was to reconstruct and classify the patterns of human right atrial (RA) activation during electrically induced AF. METHODS AND RESULTS: AF was induced by rapid atrial pacing in 25 patients with Wolff-Parkinson-White syndrome undergoing surgery for interruption of their accessory pathway(s). The free wall of the RA was mapped using a spoon-shaped electrode containing 244 unipolar electrodes. The activation of the RA during AF showed large interindividual differences. Based on the complexity of atrial activation, three types of AF were defined. In type I (40% of patients), single broad wave fronts propagated uniformly across the RA. Type II (32%) was characterized by one or two nonuniformly conducting wavelets, whereas in type III (28%), activation of the RA was highly fragmented and showed three or more different wavelets that frequently changed their direction of propagation as a result of numerous arcs of functional conduction block. There were significant differences (P < .05) among the three types of AF in median intervals (174 +/- 28, 150 +/- 14, and 136 +/- 16 milliseconds), variation in AF intervals (P5-95) (54 +/- 25, 94 +/- 21, and 104 +/- 22 milliseconds), incidence of electrical inactivity (42 +/- 11%, 21 +/- 4%, and 8 +/- 4%) and reentry (3 +/- 7%, 36 +/- 28%, and 99 +/- 36%), and average conduction velocity during AF (61 +/- 6, 54 +/- 4, and 38 +/- 10 cm/s). CONCLUSIONS: During pacing-induced AF in humans, the RA is activated by one or multiple wavelets propagating in different directions. Three types of RA activation during AF were identified. From type I to type III, the frequency and irregularity of AF increased, and the incidence of continuous electrical activity and reentry became higher. These various types of AF in humans appear to be characterized by different numbers and dimensions of the intra-atrial reentrant circuits.

Regional entrainment of atrial fibrillation studied by high-resolution mapping in open-chest dogs.

BACKGROUND: It recently has been demonstrated that during atrial fibrillation, a short and variable excitable gap exists, allowing regional control of atrial fibrillation by local stimulation. In the present study, we visualized the process of excitation during regional entrainment of atrial fibrillation by rapid pacing. METHODS AND RESULTS: In six open-chest dogs, the excitation of the left atrial free wall was mapped using a spoon-shaped mapping electrode (248 points). Episodes of atrial fibrillation were induced by burst pacing (50 Hz, 2 seconds). During atrial fibrillation, the electrograms showed rapid irregular activity with a median cycle length of 98 +/- 16 ms (mean +/- SD, n = 6). Rapid pacing in the center of the mapping electrode at intervals slightly shorter or longer than the median atrial fibrillation interval resulted in regional capture of atrial fibrillation. The window of entrainment was 16 +/- 5 ms. Mapping of atrial fibrillation showed that the left atrium was activated by fibrillatory wavelets coming from different directions. During entrainment, a relatively large area with a diameter of about 4 cm was activated by uniform wave fronts propagating away from the site of stimulation. The area of entrainment was limited by intra-atrial conduction block and by collision with fibrillation waves. Regional control of atrial fibrillation was lost by pacing either too slowly or too rapidly. In the first case, retrograde invasion of the area of entrainment by fibrillatory waves resulted in depolarization of the pacing site prior to the stimulus. Pacing too rapidly caused acceleration of atrial fibrillation by induction of local intra-atrial reentry circuits with a revolution time shorter than the pacing interval. CONCLUSIONS: During atrial fibrillation, an area with a diameter of about 4 cm can be entrained by local pacing. The resulting reduction in fibrillating tissue mass was not sufficient to terminate atrial fibrillation. Extension of the area of entrainment was limited by intra-atrial conduction block, whereas entrainment at a too high rate resulted in acceleration of atrial fibrillation by induction of local microreentry.

Sustained monomorphic ventricular tachycardia: a single electrocardiographic expression of different patterns of reentry.

UNLABELLED: Sustained monomorphic ventricular tachycardia (SMVT) can be the electrocardiographic expression of a reentrant impulse in the ventricles. In this study we analyzed the different types of reentry that might lead to SMVT. METHODS: The pattern of activation of 73 episodes of SMVT induced in thin sheets of epicardium in 50 Langendorff perfused rabbit hearts were visualized with high resolution epicardial mapping (248 points). RESULTS: Five different patterns of reentry resulting in SMVT were identified: (1) Single-loop reentry around a fixed obstacle (n = 40); (2) Single-loop reentry around a functional arc of conduction block (n = 17); (3) Double-wave reentry around a fixed obstacle (n = 9); (4) Figure-of-eight reentry around two areas of functional block (n = 5); and (5) Multiple synchronized circuits around multiple areas of functional block (n = 2). CONCLUSION: SMVT is a single electrocardiographic expression of different patterns of reentry. Accurate mapping is mandatory to identify the reentrant pathway and the pathophysiological substrate of the arrhythmia.

Preop use of Golytely in pediatrics.

Polyethylene glycol-electrolyte lavage solution (PEG-ELS) is a whole gut lavage solution designed to cleanse the gastrointestinal tract prior to bowel surgery or endoscopy. This method relies on pediatric nurses safely administering a large volume of PEG-ELS, marketed as Golytely, to produce the flushing effect without significant absorption of the Golytely.

Determination of some pyridinium aldoxime compounds by means of ion-pair reversed-phase high-performance liquid chromatography: application in biological material.

Two reversed-phase high-performance liquid chromatographic systems are presented for the separation and assay of the pyridinium aldoximes benzyl-P2A, HI-6 and obidoxime in aqueous solutions and biological samples. The systems involve a 5-micrometer C18 silica gel stationary phase. The eluent consists of methanol, acetic acid buffer (pH 4.80), a counter ion (per-chlorate or n-octanesulphonate) and a surfactant. The compounds were detected spectrophotometrically at 304 nm. In the concentration range used, linear plots of concentration versus extinction were obtained, both in blood and in water. Detection limits plots of concentration versus extinction were obtained, both in blood and in water. Detection limits, even in blood are satisfactory (0.5-1 microM). Evidence of presented that, at least for HI-6, the addition of counter ions to the system does not lead to the formation of ion pairs to be retained by partition, but rather to a mechanism based on adsorption chromatography.