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New England Journal of Medicine

Influenza Cataclysm, 1918
New England Journal of Medicine, Volume 379, Issue 24, Page 2285-2287, December 2018.
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MACRA’s Patient Relationship Codes — Measuring Accountability for Costs
New England Journal of Medicine, Volume 379, Issue 24, Page 2288-2290, December 2018.
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Disclosing Prescription-Drug Prices in Advertisements — Legal and Public Health Issues
New England Journal of Medicine, Volume 379, Issue 24, Page 2290-2293, December 2018.
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Remembering William
New England Journal of Medicine, Volume 379, Issue 24, Page 2293-2295, December 2018.
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Heartbeat: heart failure induced by cancer therapy
Heart failure (HF) is the most common and serious cardiovascular complication of cancer therapy. As succinctly stated in an editorial by Lyon, ‘Success in the diagnosis and treatment of many cancers has resulted in a growing population of people living either cured of cancer or with their cancer controlled as a chronic disease by long-term treatment. This success story in modern medicine has created a new problem with some survivors developing cardiovascular disease (CVD) as a result of their cancer treatment.’1 CVD outcomes in patients with HF induced by cancer therapy are addressed in this issue of Heart.2 Comparing 75 patients with HF induced by cancer therapy (anthracycline chemotherapy or chest irradiation) to 894 patients with HF due to other causes, cancer therapy patients were younger, had fewer CVD comorbidities and a higher left ventricular (LV) ejection fraction but more severe LV diastolic dysfunction. Global longitudinal...
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Is incentivising stroke prevention therapy in atrial fibrillation the key?
Atrial fibrillation (AF) is a condition of global importance with significant and progressive effects on morbidity, mortality and healthcare expenditure.1 The prevalence of AF is rising, and it is projected to at least double over the next 30 years due to advancing age and increasing risk factors for developing AF including cardiovascular illness and adverse lifestyle factors. AF is the leading cause of stroke, and by comparison to other types of stroke,2 AF-related stroke is more severe; yet highly preventable. Although we have overwhelming evidence that oral anticoagulation (OAC) is highly effective in preventing stroke in patients with AF,3 therapy has remained underused until recently. In their Heart paper, Adderley et al4 report the results of temporal trends in age-sex standardised AF prevalence and use of stroke prevention therapy among 744 primary care practices across the UK from 2000 to 2016. Once again, this demonstrates...
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JACC Instructions for Authors
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Survival After Alcohol Septal Ablation in Patients With Hypertrophic Obstructive Cardiomyopathy
AbstractBackground Alcohol-induced infarction for treatment of symptomatic hypertrophic obstructive cardiomyopathy (HOCM) was discussed as a risk factor for increased cardiac mortality during follow-up. Objectives This study sought to report on long-term survival after echo-guided alcohol septal ablation (percutaneous transluminal septal myocardial ablation [PTSMA]) in symptomatic patients with HOCM. Methods Between May 2000 and June 2017, PTSMA with alcohol injection was performed in 952 patients (age 55.7 ± 14.9 years; 59.2% men; 73.3% New York Heart Association functional class III or IV; 50.3% syncope; 10.3% sudden cardiac death in family). Clinical follow-up after 6.0 ± 5.0 years was achieved in all patients. Results We injected 2.1 ± 0.4 cc of alcohol. Maximal creatine kinase rise was 872 ± 489 U/l. Two (0.21%) patients died 3 and 33 days after ablation. Permanent pacemaker was implanted in 100 (10.50%) patients. Echo gradients were acutely reduced from 63.9 ± 38.2 mm Hg to 33.6 ± 29.8 mm Hg at rest and from 104.6 ± 44.0 mm Hg to 56.5 ± 41.0 mm Hg at Valsalva (p < 0.0001, each). During follow-up, 164 (17.2%) patients underwent reablation due to the planned staged procedure, 18 (1.9%) patients underwent surgical myectomy, and 49 (5.10%) patients underwent cardioverter-defibrillator implantation. Seventy patients died: causes of death were identified as noncardiovascular in 50, stroke related in 6, and cardiac in 14 patients. Estimated 5-year survival was 95.8%, estimated 5-year survival free of cardiovascular events was 98.6%, and an estimated 5-year survival free of cardiac events was 98.9%. Corresponding values at 10 years were 88.3%, 96.5%, and 97.0%, and at 15 years were 79.7%, 92.3%, and 96.5%. Conclusions In this study, PTSMA could be proofed as a safe procedure with ongoing symptomatic improvement and excellent long-term survival. Therefore, PTSMA is a reasonable alternative to surgical myectomy in HOCM.
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Septal Reduction Therapy for Hypertrophic Obstructive Cardiomyopathy
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Prevention of Arrhythmia Device Infection Trial: The PADIT Trial
AbstractBackground Infection of implanted medical devices has catastrophic consequences. For cardiac rhythm devices, pre-procedural cefazolin is standard prophylaxis but does not protect against methicillin-resistant gram-positive organisms, which are common pathogens in device infections. Objective This study tested the clinical effectiveness of incremental perioperative antibiotics to reduce device infection. Methods The authors performed a cluster randomized crossover trial with 4 randomly assigned 6-month periods, during which centers used either conventional or incremental periprocedural antibiotics for all cardiac implantable electronic device procedures as standard procedure. Conventional treatment was pre-procedural cefazolin infusion. Incremental treatment was pre-procedural cefazolin plus vancomycin, intraprocedural bacitracin pocket wash, and 2-day post-procedural oral cephalexin. The primary outcome was 1-year hospitalization for device infection in the high-risk group, analyzed by hierarchical logistic regression modeling, adjusting for random cluster and cluster-period effects. Results Device procedures were performed in 28 centers in 19,603 patients, of whom 12,842 were high risk. Infection occurred in 99 patients (1.03%) receiving conventional treatment, and in 78 (0.78%) receiving incremental treatment (odds ratio: 0.77; 95% confidence interval: 0.56 to 1.05; p = 0.10). In high-risk patients, hospitalization for infection occurred in 77 patients (1.23%) receiving conventional antibiotics and in 66 (1.01%) receiving incremental antibiotics (odds ratio: 0.82; 95% confidence interval: 0.59 to 1.15; p = 0.26). Subgroup analysis did not identify relevant patient or site characteristics with significant benefit from incremental therapy. Conclusions The cluster crossover design efficiently tested clinical effectiveness of incremental antibiotics to reduce device infection. Device infection rates were low. The observed difference in infection rates was not statistically significant. (Prevention of Arrhythmia Device Infection Trial [PADIT Pilot] [PADIT]; NCT01002911)
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Heart Rhythm