Correction to: How do Dutch general practitioners detect and diagnose atrial fibrillation? Results of an online case vignette study.

Following publication of the original article [1], the authors opted to remove the authors full name from.

How do Dutch general practitioners detect and diagnose atrial fibrillation? Results of an online case vignette study.

BACKGROUND: Detection and treatment of atrial fibrillation (AF) are important given the serious health consequences. AF may be silent or paroxysmal and remain undetected. It is unclear whether general practitioners (GPs) have appropriate equipment and optimally utilise it to detect AF. This case vignette study aimed to describe current practice and to explore possible improvements to optimise AF detection. METHODS: Between June and July 2017, we performed an online case vignette study among Dutch GPs. We aimed at obtaining at least 75 responses to the questionnaire. We collected demographics and asked GPs' opinion on their knowledge and experience in diagnosing AF. GPs could indicate which diagnostic tools they have for AF. In six case vignettes with varying symptom frequency and physical signs, they could make diagnostic choices. The last questions covered screening and actions after diagnosing AF. We compared the answers to the Dutch guideline for GPs on AF. RESULTS: Seventy-six GPs completed the questionnaire. Seventy-four GPs (97%) thought they have enough knowledge and 72 (95%) enough experience to diagnose AF. Seventy-four GPs (97%) could order or perform ECGs without the interference of a cardiologist. In case of frequent symptoms of AF, 36-40% would choose short-term (i.e. 24-48 h) and 11-19% long-term (i.e. 7 days, 14 days or 1 month) monitoring. In case of non-frequent symptoms, 29-31% would choose short-term and 21-30% long-term monitoring. If opportunistic screening in primary care proves to be effective, 83% (58/70) will support it. CONCLUSIONS: Responding GPs report to have adequate equipment, knowledge, and experience to detect and diagnose AF. Almost all participants can order ECGs. Reported monitoring duration was shorter than recommended by the guideline. AF detection could improve by increasing the monitoring duration.

Current practice of Dutch cardiologists in detecting and diagnosing atrial fibrillation: results of an online case vignette study.

INTRODUCTION: Detection of atrial fibrillation (AF) is important given the risk of complications, such as stroke and heart failure, and the need for preventive measures. Detection is complicated because AF can be silent or paroxysmal. Describing current practice may give clues to improve AF detection. The aim of this study was to describe how cardiologists currently detect AF. METHODS: Between December 2014 and May 2015, we sent Dutch cardiologists an online questionnaire. Firstly, we asked which tools for detection of AF their department has. Secondly, we presented six case vignettes related to AF, in which they could choose a diagnostic tool. Thirdly, we compared the results with current guidelines. RESULTS: We approached 90 cardiology departments and 48 (53%) completed the questionnaire. In asymptomatic patients with risk factors according to CHA2DS2-VASc, 40% of the cardiologists would screen for AF. In patients with signs or symptoms of AF, all but one cardiologist would start a diagnostic process. In both vignettes describing patients with non-frequent symptoms, 46% and 54% of the responders would use short-term (i. e. 24- or 48-hour) electrocardiographic monitoring, 48% and 27% would use long-term (i. e. 7 day, 14 day or one month) monitoring. In both cases describing patients with frequent symptoms, 85% of the responders would use short-term and 15% and 4% long-term monitoring. CONCLUSION: Dutch cardiologists have access to a wide variety of ambulatory arrhythmia monitoring tools. Nearly half of the cardiologists would perform opportunistic screening. In cases with non-frequent symptoms, monitoring duration was shorter than recommended by NICE.

Safety and efficacy of eptifibatide vs placebo in patients receiving thrombolytic therapy with streptokinase for acute myocardial infarction; a phase II dose escalation, randomized, double-blind study.

AIMS: Thrombolytic therapy restores coronary patency in patients with acute myocardial infarction, although normal perfusion (TIMI 3 flow) is not achieved in all patients. In an attempt to improve TIMI 3 flow, a combination of full-dose streptokinase, aspirin and escalating dosages of a platelet glycoprotein IIb/IIIa receptor blocker, eptifibatide, vs placebo were tested. METHODS AND RESULTS: A bolus of 180 microg. kg(-1)of eptifibatide was administered in each group, followed by a 72 h continuous infusion of 0.75 (44 patients), 1.33 (n=45) and 2.00 microg. kg(-1). min(-1)(n = 30); 62 patients received placebo. Normal perfusion (TIMI 3 flow) at 90 min was observed in 31% of placebo patients compared to 46, 42 and 45% in the ascending eptifibatide groups (44% for combined eptifibatide groups, P = 0.07). Patency (TIMI 2 and 3 flow combined) increased from 61% (placebo) to 78% for the combined eptifibatide groups (P = 0.02). Reocclusion was infrequent. No differences were observed in TIMI flow grades among eptifibatide groups. Major and minor bleeding was increased and occurred mainly at the arterial puncture site. CONCLUSION: A combination of full dose streptokinase with different eptifibatide regimens enhanced coronary perfusion, but bleeding risk was excessive. Additional trials are needed with different dosage regimens to determine the optimal combination of fibrinolytic agents and platelet glycoprotein IIb/IIIa receptor blockers.

First Report of Alternaria alternata Causing Leaf Spot on English Walnut.

A foliar disease of English walnut (Juglans regia L.) was observed in 1998 in an orchard in northern Italy. Symptoms consisted of circular, necrotic spots bordered with concentric zones of darker tissue. Average lesion diameter was 20 mm, although lesions could extend to half of the leaflet lamina. A fungus identified as Alternaria alternata (Fr.:Fr.) Keissl. (1) was observed on the necrotic tissue and was consistently isolated from the margins of the necrosis. Conidia from leaves were brown, ellipsoid to ovoid (primary conidia 28 to 60 × 8 to 15 µm; secondary conidia 10 to 30 × 7 to 13 µm), with walls often ornamented, 1 to 6 transversely septate and 0 to 3 longitudinally septate. For pathogenicity tests, three isolates were grown on potato dextrose agar for 2 weeks. Inoculations were performed on detached, surface-sterilized, healthy J. regia leaflets. Four drops (5 µl each) of a sterile water suspension of 1 × 105 conidia per ml were placed on each leaflet; three leaves per isolate were used. Leaves were incubated in a moist chamber. After 10 days, leaf spots similar to the original symptoms developed on all the inoculated points for all three isolates, and the pathogen was reisolated. Control leaflets inoculated with sterile, distilled water remained symptomless. The experiment was performed three times and the results were similar. Alternaria alternata is a well-known pathogen on many crops but a few records report this fungus as a causal agent of leaf spot on deciduous trees. This is the first report of A. alternata on English walnut. Reference: (1) E. G. Simmons. Mycotaxon 37:79, 1990.

First Report of Myrothecium verrucaria from Muskmelon Seeds.

Myrothecium verrucaria (Albertini & Schwein.) Ditmar:Fr. was isolated from muskmelon (Cucumis melo L.) seeds of Charentais-T, a culti var used as a differential host with no resistance to Fusarium oxysporum f. sp. melonis races. A white floccose mycelial mat developed on melon seeds during incubation on moist blotters. Mycelia were mass transferred from melon seeds onto potato dextrose agar (PDA) medium. At 25°C in the dark, a mycelial mat with characteristic annelations of greenish-black sporodochia, without setae, was produced. Conidia (2 to 3 × 6 to 10 µm) were lemon shaped, with a typical conical mucous appendage at one end, which was visible with Loeffer's flagella stain (1). Based on these characteristics, the fungus was identified as M. verrucaria. For pathogenicity studies, surface sterilized seeds of C. melo cv. Charentais-T were coated with M. verrucaria conidia by gently rubbing the seeds on sporodochia produced on 15-day-old cultures on PDA. Once coated, seeds were plated onto water agar and on sterile moist blotters in 9-cm-diameter petri dishes. Plates were incubated at 28°C in the dark. Five seeds per plate and three plates per experiment were used. Experiments were replicated three times. Control seeds were plated without coating. After 7 days, on water agar, 90% of melon seeds failed to germinate while the remaining 10% produced young seedlings that died from root rot and necrotic lesions on the hypocotyl. After 12 days on moist blotters, 100% of the melon seedlings died, showing necrotic lesions on the hypocotyl and on the main root. The pathogen was reisolated from symptomatic melon seedlings. All control seeds germinated and grew into healthy seedlings. M. verrucaria, known to be a seed-borne pathogen, has been isolated from soil and plants worldwide (2). This is the first report of M. verrucaria pathogen on muskmelon. This fungus is not a serious concern when seeds are dressed with fungicides. References: (1) K. V. A. Thompson and S. C. Simmens. Nature. 193:196, 1962. (2) S.-M. Yang and S. C. Jong. Plant Dis. 79:994, 1995.

A comparative study of once-daily amlodipine versus twice-daily diltiazem controlled release (CR) in the treatment of stable angina pectoris. Amlodipine Study Group.

A multicenter, double-blind study was performed to compare the efficacy and safety of the calcium antagonists, amlodipine and diltiazem controlled release (CR), in patients with stable angina pectoris. One hundred and thirty-two patients were randomized to receive either amlodipine (5-10 mg) once daily or diltiazem CR (90-120 mg) twice daily for 8 weeks. A standard bicycle exercise tolerance test was used for the primary efficacy assessment. The median time to 1 mm ST-segment depression and time to onset of chest pain were increased by 16% (P < 0.0001) and 13% (P < 0.0001) with amlodipine, and by 16% (P < 0.0001) and 7% (P = 0.009) with diltiazem CR, respectively. Amlodipine, but not diltiazem CR, also produced a significant improvement in the median time to end of exercise of 5% (P < 0.0002), although the between-treatment difference for this parameter was not statistically significant. The number of angina attacks and nitroglycerin (NTG) tablet consumption were similar with both agents. Amlodipine was withdrawn in 3% and diltiazem CR in 9% of patients due to adverse events. The adverse events were reported by 15% of patients on amlodipine and 26% of those on diltiazem CR. The results from this study demonstrate that both drugs have a comparable therapeutic effect and possibly that amlodipine was better tolerated in patients with stable angina. Furthermore, amlodipine has the advantage of once-daily dosing and so may also be beneficial in ensuring good patient compliance.