text:
Early or delayed cardioversion in recent-onset atrial fibrillation
Harry J.G.M. Crijns*, Nikki A.H.A. Pluymaekers, Elton A.M.P. Dudink, Justin G.L.M. Luermans, Joan G. Meeder, Timo Lenderink, Jos Widdershoven, Jeroen J.J. Bucx, Michiel Rienstra, Otto Kamp, Jurren M. Van Opstal, Marco Alings, Anton Oomen, Charles J. Kirchhof, Vincent F. Van Dijk, Hemanth Ramanna, Anho Liem, Lukas R. Dekker, Brigitte A.B. Essers, Jan G.P. Tijssen
Isabelle C. Van Gelder
Medical and Clinical Psychology
Patients with recent-onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion. However, whether immediate restoration of sinus rhythm is necessary is not known, since atrial fibrillation often terminates spontaneously.
In a multicenter, randomized, open-label, noninferiority trial, we randomly assigned patients with hemodynamically stable, recent-onset (<36 hours), symptomatic atrial fibrillation in the emergency department to be treated with a wait-and-see approach (delayed-cardioversion group) or early cardioversion. The wait-and-see approach involved initial treatment with rate-control medication only and delayed cardioversion if the atrial fibrillation did not resolve within 48 hours. The primary end point was the presence of sinus rhythm at 4 weeks. Noninferiority would be shown if the lower limit of the 95% confidence interval for the between-group difference in the primary end point in percentage points was more than −10.
The presence of sinus rhythm at 4 weeks occurred in 193 of 212 patients (91%) in the delayed-cardioversion group and in 202 of 215 (94%) in the early-cardioversion group (between-group difference, −2.9 percentage points; 95% confidence interval [CI], −8.2 to 2.2; P=0.005 for noninferiority). In the delayed-cardioversion group, conversion to sinus rhythm within 48 hours occurred spontaneously in 150 of 218 patients (69%) and after delayed cardioversion in 61 patients (28%). In the early-cardioversion group, conversion to sinus rhythm occurred spontaneously before the initiation of cardioversion in 36 of 219 patients (16%) and after cardioversion in 171 patients (78%). Among the patients who completed remote monitoring during 4 weeks of follow-up, a recurrence of atrial fibrillation occurred in 49 of 164 patients (30%) in the delayed-cardioversion group and in 50 of 171 (29%) in the early-cardioversion group. Within 4 weeks after randomization, cardiovascular complications occurred in 10 patients and 8 patients, respectively.
In patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.
https://doi.org/10.1056/NEJMoa1900353
SPONTANEOUS CONVERSION
TEMPORAL RELATIONSHIP
10.1056/NEJMoa1900353
Fingerprint Dive into the research topics of 'Early or delayed cardioversion in recent-onset atrial fibrillation'. Together they form a unique fingerprint.
Electric Countershock Medicine & Life Sciences
Atrial Fibrillation Medicine & Life Sciences
Hospital Emergency Service Medicine & Life Sciences
Equivalence Trials Medicine & Life Sciences
Confidence Intervals Medicine & Life Sciences
Random Allocation Medicine & Life Sciences
Crijns, H. J. G. M., Pluymaekers, N. A. H. A., Dudink, E. A. M. P., Luermans, J. G. L. M., Meeder, J. G., Lenderink, T., Widdershoven, J., Bucx, J. J. J., Rienstra, M., Kamp, O., Van Opstal, J. M., Alings, M., Oomen, A., Kirchhof, C. J., Van Dijk, V. F., Ramanna, H., Liem, A., Dekker, L. R., Essers, B. A. B., ... Van Gelder, I. C. (2019). Early or delayed cardioversion in recent-onset atrial fibrillation. New England Journal of Medicine, 380(16), 1499-1508. https://doi.org/10.1056/NEJMoa1900353
Crijns, Harry J.G.M. ; Pluymaekers, Nikki A.H.A. ; Dudink, Elton A.M.P. ; Luermans, Justin G.L.M. ; Meeder, Joan G. ; Lenderink, Timo ; Widdershoven, Jos ; Bucx, Jeroen J.J. ; Rienstra, Michiel ; Kamp, Otto ; Van Opstal, Jurren M. ; Alings, Marco ; Oomen, Anton ; Kirchhof, Charles J. ; Van Dijk, Vincent F. ; Ramanna, Hemanth ; Liem, Anho ; Dekker, Lukas R. ; Essers, Brigitte A.B. ; Tijssen, Jan G.P. ; Van Gelder, Isabelle C. / Early or delayed cardioversion in recent-onset atrial fibrillation. In: New England Journal of Medicine. 2019 ; Vol. 380, No. 16. pp. 1499-1508.
@article{5a5f41edcf45413ab4a93461be684ac4,
title = "Early or delayed cardioversion in recent-onset atrial fibrillation",
abstract = "BackgroundPatients with recent-onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion. However, whether immediate restoration of sinus rhythm is necessary is not known, since atrial fibrillation often terminates spontaneously.MethodsIn a multicenter, randomized, open-label, noninferiority trial, we randomly assigned patients with hemodynamically stable, recent-onset (<36 hours), symptomatic atrial fibrillation in the emergency department to be treated with a wait-and-see approach (delayed-cardioversion group) or early cardioversion. The wait-and-see approach involved initial treatment with rate-control medication only and delayed cardioversion if the atrial fibrillation did not resolve within 48 hours. The primary end point was the presence of sinus rhythm at 4 weeks. Noninferiority would be shown if the lower limit of the 95% confidence interval for the between-group difference in the primary end point in percentage points was more than −10.ResultsThe presence of sinus rhythm at 4 weeks occurred in 193 of 212 patients (91%) in the delayed-cardioversion group and in 202 of 215 (94%) in the early-cardioversion group (between-group difference, −2.9 percentage points; 95% confidence interval [CI], −8.2 to 2.2; P=0.005 for noninferiority). In the delayed-cardioversion group, conversion to sinus rhythm within 48 hours occurred spontaneously in 150 of 218 patients (69%) and after delayed cardioversion in 61 patients (28%). In the early-cardioversion group, conversion to sinus rhythm occurred spontaneously before the initiation of cardioversion in 36 of 219 patients (16%) and after cardioversion in 171 patients (78%). Among the patients who completed remote monitoring during 4 weeks of follow-up, a recurrence of atrial fibrillation occurred in 49 of 164 patients (30%) in the delayed-cardioversion group and in 50 of 171 (29%) in the early-cardioversion group. Within 4 weeks after randomization, cardiovascular complications occurred in 10 patients and 8 patients, respectively.ConclusionsIn patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.",
keywords = "ABLATION, ANTICOAGULATION, CATHETER, DESIGN, DEVICE, ECHOCARDIOGRAPHY, GUIDELINES, SPONTANEOUS CONVERSION, STROKE, TEMPORAL RELATIONSHIP",
author = "Crijns, {Harry J.G.M.} and Pluymaekers, {Nikki A.H.A.} and Dudink, {Elton A.M.P.} and Luermans, {Justin G.L.M.} and Meeder, {Joan G.} and Timo Lenderink and Jos Widdershoven and Bucx, {Jeroen J.J.} and Michiel Rienstra and Otto Kamp and {Van Opstal}, {Jurren M.} and Marco Alings and Anton Oomen and Kirchhof, {Charles J.} and {Van Dijk}, {Vincent F.} and Hemanth Ramanna and Anho Liem and Dekker, {Lukas R.} and Essers, {Brigitte A.B.} and Tijssen, {Jan G.P.} and {Van Gelder}, {Isabelle C.}",
note = "(Funded by the Netherlands Organization for Health Research and Development and others; RACE 7 ACWAS ClinicalTrials.gov number, NCT02248753.",
doi = "10.1056/NEJMoa1900353",
journal = "The New England Journal of Medicine",
publisher = "Massachussetts Medical Society",
Crijns, HJGM, Pluymaekers, NAHA, Dudink, EAMP, Luermans, JGLM, Meeder, JG, Lenderink, T, Widdershoven, J, Bucx, JJJ, Rienstra, M, Kamp, O, Van Opstal, JM, Alings, M, Oomen, A, Kirchhof, CJ, Van Dijk, VF, Ramanna, H, Liem, A, Dekker, LR, Essers, BAB, Tijssen, JGP & Van Gelder, IC 2019, 'Early or delayed cardioversion in recent-onset atrial fibrillation', New England Journal of Medicine, vol. 380, no. 16, pp. 1499-1508. https://doi.org/10.1056/NEJMoa1900353
Early or delayed cardioversion in recent-onset atrial fibrillation. / Crijns, Harry J.G.M.; Pluymaekers, Nikki A.H.A.; Dudink, Elton A.M.P.; Luermans, Justin G.L.M.; Meeder, Joan G.; Lenderink, Timo; Widdershoven, Jos; Bucx, Jeroen J.J.; Rienstra, Michiel; Kamp, Otto; Van Opstal, Jurren M.; Alings, Marco; Oomen, Anton; Kirchhof, Charles J.; Van Dijk, Vincent F.; Ramanna, Hemanth; Liem, Anho; Dekker, Lukas R.; Essers, Brigitte A.B.; Tijssen, Jan G.P.; Van Gelder, Isabelle C.
In: New England Journal of Medicine, Vol. 380, No. 16, 2019, p. 1499-1508.
T1 - Early or delayed cardioversion in recent-onset atrial fibrillation
AU - Crijns, Harry J.G.M.
AU - Pluymaekers, Nikki A.H.A.
AU - Dudink, Elton A.M.P.
AU - Luermans, Justin G.L.M.
AU - Meeder, Joan G.
AU - Lenderink, Timo
AU - Widdershoven, Jos
AU - Bucx, Jeroen J.J.
AU - Rienstra, Michiel
AU - Kamp, Otto
AU - Van Opstal, Jurren M.
AU - Alings, Marco
AU - Oomen, Anton
AU - Kirchhof, Charles J.
AU - Van Dijk, Vincent F.
AU - Ramanna, Hemanth
AU - Liem, Anho
AU - Dekker, Lukas R.
AU - Essers, Brigitte A.B.
AU - Tijssen, Jan G.P.
AU - Van Gelder, Isabelle C.
N1 - (Funded by the Netherlands Organization for Health Research and Development and others; RACE 7 ACWAS ClinicalTrials.gov number, NCT02248753.
N2 - BackgroundPatients with recent-onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion. However, whether immediate restoration of sinus rhythm is necessary is not known, since atrial fibrillation often terminates spontaneously.MethodsIn a multicenter, randomized, open-label, noninferiority trial, we randomly assigned patients with hemodynamically stable, recent-onset (<36 hours), symptomatic atrial fibrillation in the emergency department to be treated with a wait-and-see approach (delayed-cardioversion group) or early cardioversion. The wait-and-see approach involved initial treatment with rate-control medication only and delayed cardioversion if the atrial fibrillation did not resolve within 48 hours. The primary end point was the presence of sinus rhythm at 4 weeks. Noninferiority would be shown if the lower limit of the 95% confidence interval for the between-group difference in the primary end point in percentage points was more than −10.ResultsThe presence of sinus rhythm at 4 weeks occurred in 193 of 212 patients (91%) in the delayed-cardioversion group and in 202 of 215 (94%) in the early-cardioversion group (between-group difference, −2.9 percentage points; 95% confidence interval [CI], −8.2 to 2.2; P=0.005 for noninferiority). In the delayed-cardioversion group, conversion to sinus rhythm within 48 hours occurred spontaneously in 150 of 218 patients (69%) and after delayed cardioversion in 61 patients (28%). In the early-cardioversion group, conversion to sinus rhythm occurred spontaneously before the initiation of cardioversion in 36 of 219 patients (16%) and after cardioversion in 171 patients (78%). Among the patients who completed remote monitoring during 4 weeks of follow-up, a recurrence of atrial fibrillation occurred in 49 of 164 patients (30%) in the delayed-cardioversion group and in 50 of 171 (29%) in the early-cardioversion group. Within 4 weeks after randomization, cardiovascular complications occurred in 10 patients and 8 patients, respectively.ConclusionsIn patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.
AB - BackgroundPatients with recent-onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion. However, whether immediate restoration of sinus rhythm is necessary is not known, since atrial fibrillation often terminates spontaneously.MethodsIn a multicenter, randomized, open-label, noninferiority trial, we randomly assigned patients with hemodynamically stable, recent-onset (<36 hours), symptomatic atrial fibrillation in the emergency department to be treated with a wait-and-see approach (delayed-cardioversion group) or early cardioversion. The wait-and-see approach involved initial treatment with rate-control medication only and delayed cardioversion if the atrial fibrillation did not resolve within 48 hours. The primary end point was the presence of sinus rhythm at 4 weeks. Noninferiority would be shown if the lower limit of the 95% confidence interval for the between-group difference in the primary end point in percentage points was more than −10.ResultsThe presence of sinus rhythm at 4 weeks occurred in 193 of 212 patients (91%) in the delayed-cardioversion group and in 202 of 215 (94%) in the early-cardioversion group (between-group difference, −2.9 percentage points; 95% confidence interval [CI], −8.2 to 2.2; P=0.005 for noninferiority). In the delayed-cardioversion group, conversion to sinus rhythm within 48 hours occurred spontaneously in 150 of 218 patients (69%) and after delayed cardioversion in 61 patients (28%). In the early-cardioversion group, conversion to sinus rhythm occurred spontaneously before the initiation of cardioversion in 36 of 219 patients (16%) and after cardioversion in 171 patients (78%). Among the patients who completed remote monitoring during 4 weeks of follow-up, a recurrence of atrial fibrillation occurred in 49 of 164 patients (30%) in the delayed-cardioversion group and in 50 of 171 (29%) in the early-cardioversion group. Within 4 weeks after randomization, cardiovascular complications occurred in 10 patients and 8 patients, respectively.ConclusionsIn patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.
KW - ABLATION
KW - ANTICOAGULATION
KW - CATHETER
KW - DESIGN
KW - DEVICE
KW - ECHOCARDIOGRAPHY
KW - GUIDELINES
KW - SPONTANEOUS CONVERSION
KW - STROKE
KW - TEMPORAL RELATIONSHIP
U2 - 10.1056/NEJMoa1900353
DO - 10.1056/NEJMoa1900353
JO - The New England Journal of Medicine
JF - The New England Journal of Medicine
Crijns HJGM, Pluymaekers NAHA, Dudink EAMP, Luermans JGLM, Meeder JG, Lenderink T et al. Early or delayed cardioversion in recent-onset atrial fibrillation. New England Journal of Medicine. 2019;380(16):1499-1508. https://doi.org/10.1056/NEJMoa1900353


Will Obama's Last Nod to Israel Come as Pivotal Speech at J Street?
The president is expected to make some final attempt at influencing Israeli-Palestinian peace process and J Street's national gala in April might be just the opportunity.
Speculation abounds that President Obama may refocus his attention, during the final year of his presidency, on the failed Israeli-Palestinian negotiations. Observers now wonder where and when?
Election year initiatives are typically fraught with complications — in a world of complicated issues, Israel and the Middle East play in a league of their own. Two weeks ago, Israeli Prime Minister Benjamin Netanyahu declined an invitation to meet with President Obama at the White House prior to AIPAC's Policy Conference. The official reason was Netanyahu's desire to avoid interfering in U.S. elections by meeting with any of the presidential hopefuls addressing AIPAC.
The two leaders are in midst of negotiating a "Memorandum of Understanding" (MOU) security package. Gaps remain (The U.S. is offering $3.4 billion of annual aid, while Israel seeks $5 billion) and could have contributed to Netanyahu postponing a visit until an agreement can be signed in-person. But a WSJ report on March 7 pointed to another source of tension: an American administration discussing new ideas to revive peace talks before Obama leaves office, and an Israeli Prime Minister fearing an Oval Office ambush.
According to Alon Pinkas, a former Israeli diplomat who participated in Israeli-Palestinian negotiations following the Camp David summit in 2000, there's no doubt that at some point between now and January 2017, Obama will seek to outline his own version of the Bill Clinton parameters before leaving office.
One opportunity currently being discussed, according to a half dozen insiders interviewed for this story, is the upcoming J Street National Gala on April 18 in Washington, D.C. Whether the President will take the opportunity to address a group closely aligned with his administration's policies — that prides itself on being Obama's 'blocking back' in Congress — has yet to be confirmed.
J Street spokeswoman Jessica Rosenblum did confirm to Jewish Insider that the group reached out to the White House and eagerly awaits a decision on which administration official will keynote the Gala. Vice President Joe Biden and WH Chief of Staff Denis McDonough have addressed J Street's annual conference in prior years.
As detailed in Jeffrey Goldberg's recent article on 'The Obama Doctrine', the President shows little interest, and perhaps a strong dislike of the D.C. foreign policy establishment. The opportunity to elevate J Street with a presidential address may be too great to pass up during the final year in office.
Others were more dismissive, noting the challenge this would present to Democratic front-runner Hillary Clinton as she seeks to make additional inroads in a pro-Israel community weary of Donald Trump.
Aaron David Miller, an American Middle East analyst and Vice President for New Initiatives at the Woodrow Wilson International Center for Scholars, says there is no way Obama goes to J Street – or unveils anything prior the general election in the fall – that could potentially complicate Hillary Clinton's White House bid.


text:
> Apprenticeships > Exeter jobseekers to get connected with BT apprenticeships
Exeter jobseekers to get connected with BT apprenticeships
26 Feb 16 | Author Allie Anderson | Apprenticeships
Young people across the south west will be in line for a jobs and training boost, as the region becomes a focal point for a raft of new apprenticeships with BT.
Last week, the company announced a drive to recruit new apprentices and graduates to a range of roles and departments across the UK.
More than 50 will be in the south west, and of those, most will be in Exeter, a BT spokesman told the Exeter Express and Echo. Apprentices will be taken on in jobs as varied as engineering and customer service.
Helping the south west to prosper
Jon Reynolds, BT's south west regional director, said: "These apprenticeships and graduate jobs offer great opportunities for people in the south west to be part of one of the world's most exciting and rapidly developing industries and one of the UK's leading companies.
"The new recruits will play a vital role in providing essential services and helping the region's businesses and households make the most of technologies, which are transforming the way we live and work.
"High-quality careers such as these are essential to the future success and prosperity of the south west."
As well as in Exeter, apprentices will be recruited in Bristol, Taunton, Swindon, Plymouth, Truro, Salisbury, Bournemouth, Bath and Gloucester.

redpajama_set_name: RedPajamaCommonCrawl


A synovial cyst is a benign, fluid-filled sac that develops as a result of degeneration of the spine. The sac creates pressure inside the spinal canal, compressing the nerves and causing numbness, stiffness, weakness, and pain, especially when the patient is active. A synovial cyst is an uncommon cause of spinal stenosis in the lumbar part of the spine (lower back).
Because a synovial cyst develops from degeneration of the spine, it is most common in people over 65, and rarely seen in anyone under 45.
Surgery is recommended if there are signs that the spinal cord is compressed or there is significant risk that the spinal cord may become damaged. Surgery is necessary if neurological symptoms increase, such as difficulty with balance or walking.
The most reliable kind of spine surgery for synovial cysts is decompression surgery combined with spinal fusion, during which the cyst is removed then the joint is fused. Once the joint is fused, all motion is stopped in that particular area, so the cyst is unlikely to regenerate.


text:
============
Installation
============

Users
-----

If you only want to use agate, install it this way::

    pip install agate

.. note::

    Need more speed? If you're running Python 2.6, 2.7 or 3.2, you can :code:`pip install cdecimal` for a significant speed boost. This isn't installed automatically because it can create additional complications.

Developers
----------

If you are a developer that also wants to hack on agate, install it this way::

    git clone git://github.com/onyxfish/agate.git
    cd agate
    mkvirtualenv agate
    pip install -r requirements.txt
    python setup.py develop
    tox

.. note::

    agate also supports running tests with coverage::

        nosetests --with-coverage --cover-package=agate

Supported platforms
-------------------

agate supports the following versions of Python:

* Python 2.6+
* Python 3.2+
* Latest `PyPy <http://pypy.org/>`_

It is tested on OSX, but due to it's minimal dependencies should work fine on both Linux and Windows.

redpajama_set_name: RedPajamaGithub