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New England Journal of Medicine

Caught in the Web — U.S. Immigration and Compound Disadvantage
New England Journal of Medicine, Volume 381, Issue 11, Page 993-995, September 2019.
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Parenting during Graduate Medical Training — Practical Policy Solutions to Promote Change
New England Journal of Medicine, Volume 381, Issue 11, Page 995-997, September 2019.
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Breaching the Professional–Personal Boundary — An Unrecognized Risk for Burnout
New England Journal of Medicine, Volume 381, Issue 11, Page 998-999, September 2019.
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Roxadustat for Anemia in Patients with Kidney Disease Not Receiving Dialysis
New England Journal of Medicine, Volume 381, Issue 11, Page 1001-1010, September 2019.
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Heartbeat: telemedicine and outcomes in patients with an acute coronary syndrome
In patients with an acute coronary syndrome (ACS), prehospital transmission of the ECG offers the potential to reduce the time delay between symptom onset and initiation of treatment. However, the effect of this telemedicine intervention on clinical outcomes has not been well validated. In a systematic review and meta-analysis, Marcolino and colleagues1 identified 30 non-randomised controlled and 7 quasi-experimental studies of telemedicine for ACS that included a total of almost 17 000 patients. In these studies, prehospital ECG transmission (compared with usual care) was associated with a lower in-hospital mortality (relative risk (RR) 0.63 (95% CI 0.55 to 0.72)), door-to-balloon time (mean difference –28 min (95% CI –35 to –20)), 30-day and long-term mortality (RR 0.61 (95% CI 0.40 to 0.92)) (figure 1). However, there was moderate to large heterogeneity for all these findings suggesting that more rigorous evaluation of telemedicine strategies for improving outcome is...
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Hypertension in patients with repaired aortic coarctation: the long and puzzling road from Morgagni to stent implantation
Aortic coarctation (CoAo) is a common congenital heart disease that may occur isolated or associated to complex malformations. Giovan Battista Morgagni first described it in the XVIII letter of his book De sedibus and causis morborum per anatomen indagatis published in Venice in 1761. This publication represented one of the first systematical efforts to use anatomopathology as a tool to understand and explain clinical manifestations. In fact, before Morgagni, a disease was considered as an imbalance of ‘humours’ and fluids. Nowadays, following a mechanistic approach, treatment of CoAo aims to get rid of the stenotic segment. Treatment depends on many factors including patient size and age, type of lesion and individual anatomy. In older children, adolescents and adults, a transcatheter approach is usually preferred to the surgical treatment. Percutaneous procedures include balloon angioplasty and stent implantation. Even if balloon angioplasty has been shown favourable results, it may be complicated by...
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JACC Instructions for Authors
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Novel Transcatheter Mitral Valve Prosthesis for Patients With Severe Mitral Annular Calcification
AbstractBackground Treatment of mitral regurgitation (MR) in the setting of severe mitral annular calcification (MAC) is challenging due to the high risk for fatal atrioventricular groove disruption and significant paravalvular leak. Objectives The objective of this study was to evaluate the potential for transcatheter mitral valve replacement in patients with severe MAC using an anatomically designed mitral prosthesis. Methods Nine patients (77 ± 6 years of age; 5 men) were treated with the valve, using transapical delivery performed under general anesthesia and with guidance from transesophageal echocardiography and fluoroscopy. Results Device implantation was successful with relief of MR in all 9 patients. There were no procedural deaths. In 1 patient, left ventricular outflow tract obstruction occurred due to malrotation of the prosthesis, and successful alcohol septal ablation was performed. During a median follow-up of 12 months (range 1 to 28 months), there was 1 cardiac death, 1 noncardiac death, no other mortality, and no prosthetic dysfunction, and MR remained absent in all treated patients. Rehospitalization for heart failure occurred in 2 patients who did not die subsequently. Clinical improvement with mild or no symptoms occurred in all patients alive at the end of follow-up. Conclusions Transcatheter mitral valve replacement in severe mitral annular calcification with a dedicated prosthesis is feasible and can result in MR relief with symptom improvement. Further evaluation of this approach for these high-risk patients is warranted.
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Mitral Valve Disease With Severe Mitral Annulus Calcification: Transcatheter Therapy May Be the Solution
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Oral Fluoroquinolones and Risk of Mitral and Aortic Regurgitation
AbstractBackground Recent studies have linked fluoroquinolones (FQs) to cardiac adverse events, including aortic dissection and aneurysm. To date, whether FQs can increase the risk of aortic or mitral regurgitation has not been studied. Objectives This disproportionality analysis and case-control study examined whether FQs increase the risk of aortic and mitral regurgitation. Methods Data from the U.S. Food and Drug Administration’s adverse reporting system database was used to undertake a disproportionality analysis, and a random sample of 9,053,240 patients from the U.S. PharMetrics Plus database (IQVIA) was used for the matched nested case-control study. Current FQ exposure implied an active prescription at the index date or 30 days prior to the event date. Recent FQ exposure was defined as FQ use within days 31 to 60 and past within days 61 to 365 prior to the event date. Rate ratios (RRs) were compared to users of amoxicillin and azithromycin. Conditional logistic regression was used to compute RRs adjusting for confounders. Results The reported odds ratio for the disproportionality analysis was 1.45 (95% confidence interval [CI]: 1.20 to 1.77). A total of 12,505 cases and 125,020 control subjects were identified in the case-control study. The adjusted RRs for current users of FQ compared with amoxicillin and azithromycin users were 2.40 (95% CI: 1.82 to 3.16) and 1.75 (95% CI: 1.34 to 2.29), respectively. The adjusted RRs for recent and past FQ users when compared with amoxicillin were 1.47 (95% CI: 1.03 to 2.09) and 1.06 (95% CI: 0.91 to 1.21), respectively. Conclusions These results show that the risk of aortic and mitral regurgitation is highest with current use followed by recent use. No risk was observed with past use of FQs. Future studies are necessary to confirm or refute these associations.
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Heart Rhythm