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New England Journal of Medicine

The NAM and the Quality of Health Care — Inflecting a Field
New England Journal of Medicine, Volume 383, Issue 6, Page 505-508, August 2020.
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Care Churn — Why Keeping Clinic Doors Open Isn’t Enough to Ensure Access to Abortion
New England Journal of Medicine, Volume 383, Issue 6, Page 508-510, August 2020.
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Mental Health and the Covid-19 Pandemic
New England Journal of Medicine, Volume 383, Issue 6, Page 510-512, August 2020.
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Preventing a Parallel Pandemic — A National Strategy to Protect Clinicians’ Well-Being
New England Journal of Medicine, Volume 383, Issue 6, Page 513-515, August 2020.
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Heartbeat: weather, air pollution and cardiac arrest
Outcomes of patients with an out-of-hospital cardiac arrest (OHCA) remain poor despite considerable efforts in many countries directed towards rapid access defibrillation, emergency medical services and advanced supportive care in those who survive to reach the hospital. Clearly, out long-term goal should be prevention of OHCA which requires an understanding of the environmental factors contributing to this condition, as well as prevention at the individual patient level. In a study from Korea of 38 928 OHCAs due to cardiac disease, Kim and colleagues1 found significant associated between OHCA and average temperature in the summer, temperature range in the winter and particulate matter (PM) ≤2.5 µm (PM2.5) air pollution levels. However, only PM2.5 was independently associated with the risk of OHCA regardless of seasonal changes (figure 1). Figure 1 Generalised additive model with cubic splines for the effects of selected meteorological factors on the...
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Air pollution, climate and cardiac arrest
Sudden cardiac death (SCD) refers to a sudden or unexpected death or arrest attributable to a cardiovascular cause. SCD is estimated to account for 15%–20% of global mortality and the majority of these deaths are out-of-hospital cardiac arrests (OHCAs).1 Despite secular improvements, the incidence of SCD and OHCA remains high and public health strategies to mitigate its risk are critical. Air pollution and meteorological factors have long been associated with adverse health outcomes.2 Particular matter (PM) with an aerodynamic diameter of 2.5 µm or less (PM2.5) has been of specific interest as these particles are estimated to be small enough to reach pulmonary alveoli.3 Elevations in PM2.5 have been associated with increased cardiovascular mortality and morbidity, including ventricular arrhythmia and heart failure.4 5 In addition to air pollution, meteorological factors such as temperature variability have also been linked to cardiovascular mortality,...
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Long-Term Adverse Cardiac Outcomes in Patients With Sarcoidosis
AbstractBackground It is estimated that 5% of patients with sarcoidosis have clinically manifest cardiac involvement, although autopsy and imaging studies suggest a significantly higher prevalence of cardiac involvement. There is a paucity of contemporary data on the risk of adverse cardiac outcomes, particularly heart failure (HF), in patients with sarcoidosis. Objectives The purpose of this study was to examine the long-term risk of HF and other adverse cardiac outcomes in patients with sarcoidosis compared with matched control subjects. Methods In this cohort study, all patients age ≥18 years with newly diagnosed sarcoidosis (1996 to 2016) were identified through Danish nationwide registries and matched 1:4 by age, sex, and comorbidities with control subjects from the background population without sarcoidosis. Results Of the 12,042 patients diagnosed with sarcoidosis, 11,834 patients were matched with 47,336 subjects from the background population (median age: 42.8 years [25th to 75th percentile: 33.1 to 55.8 years], 54.3% men). The median follow-up was 8.2 years. Absolute 10-year risks of outcomes were as follows: HF: 3.18% (95% confidence interval [CI]: 2.83% to 3.57%) for sarcoidosis patients and 1.72% (95% CI: 1.58% to 1.86%) for the background population; the composite of ICD implantation, ventricular arrhythmias, and cardiac arrest: 0.96% (95% CI: 0.77% to 1.18%) for sarcoidosis patients and 0.45% (95% CI: 0.38% to 0.53%) for the background population; the composite of pacemaker implantation, atrioventricular block, and sinoatrial dysfunction: 0.94% (95% CI: 0.75% to 1.16%) for sarcoidosis patients and 0.51% (95% CI: 0.44% to 0.59%) for the background population; atrial fibrillation or flutter: 3.44% (95% CI: 3.06% to 3.84%) for sarcoidosis patients and 2.66% (95% CI: 2.49% to 2.84%) for the background population; and all-cause mortality: 10.88% (95% CI: 10.23% to 11.55%) for sarcoidosis patients and 7.43% (95% CI: 7.15% to 7.72%) for the background population. Conclusions Patients with sarcoidosis had a higher associated risk of HF and other adverse cardiac outcomes compared with matched control subjects.
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Cardiovascular Outcomes in Sarcoidosis
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Lipoprotein(a) and Family History Predict Cardiovascular Disease Risk
AbstractBackground Elevated lipoprotein(a) (Lp[a]) and family history (FHx) of coronary heart disease (CHD) are individually associated with cardiovascular risk, and Lp(a) is commonly measured in those with FHx. Objectives The aim of this study was to determine independent and joint associations of Lp(a) and FHx with atherosclerotic cardiovascular disease (ASCVD) and CHD among asymptomatic subjects. Methods Plasma Lp(a) was measured and FHx was ascertained in 2 cohorts. Elevated Lp(a) was defined as the highest race-specific quintile. Independent and joint associations of Lp(a) and FHx with cardiovascular risk were determined using Cox regression models adjusted for cardiovascular risk factors. Results Among 12,149 ARIC (Atherosclerosis Risk In Communities) participants (54 years, 56% women, 23% black, 44% with FHx), 3,114 ASCVD events were observed during 21 years of follow-up. FHx and elevated Lp(a) were independently associated with ASCVD (hazard ratio [HR]: 1.17; 95% confidence interval [CI]: 1.09 to 1.26, and HR: 1.25; 95% CI: 1.12 to 1.40, respectively), and no Lp(a)-by-FHx interaction was noted (p = 0.75). Compared with subjects without FHx and nonelevated Lp(a), those with either elevated Lp(a) or FHx were at a higher ASCVD risk, while those with both had the highest risk (HR: 1.43; 95% CI: 1.27 to 1.62). Similar findings were observed for CHD risk in ARIC, in analyses stratified by premature FHx, and in an independent cohort, the DHS (Dallas Heart Study). Presence of both elevated Lp(a) and FHx resulted in greater improvement in ASCVD and CHD risk reclassification and discrimination indexes than either marker alone. Conclusions Elevated plasma Lp(a) and FHx have independent and additive joint associations with cardiovascular risk and may be useful concurrently for guiding primary prevention therapy decisions.
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Family History and Lipoprotein(a) Contribute Independently to Risk Assessment and Clinical Management
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Heart Rhythm