US Border Crisis Is A National Security Crisis: Former ICE Chief Tom Homan

 by Adam Michael Molon via The Epoch Times,

Tom Homan, former acting director of U.S. Immigration and Customs Enforcement (ICE), has criticized what he described as lax border security policies under the Biden administration, arguing that the surge in illegal immigration “is on purpose.”

Homan, who served as head of ICE from 2017 to 2018, described the border crisis as one that amounted to public safety, public health, and national security crises.

“What’s behind the scenes?” Homan told The Epoch Times in an interview.

“People are going to say, ‘Okay, illegal aliens are crossing the border. They say they’re going to send them to see the judge.’ There’s more to this. What’s the ugly underbelly of this?”

An October op-ed co-authored by Homan and Mark Morgan, who served as acting commissioner of US Customs and Border Protection (CBP) from 2019 to 2021 noted, “In just 18 months, Customs and Border Protection has recorded more than 4 million apprehensions— more than the previous four fiscal years combined. The encounters since last October have totaled more than 2.7 million, plus nearly 600,000 known got-aways and likely hundreds of thousands who entered completely undetected.”

“They’ve arrested 114 known and suspected terrorists who tried to get into the country since Joe Biden’s been in the White House … Border Patrol’s arrested people from 161 countries, [and] some of those countries sponsor terrorism,” Homan told The Epoch Times.

“Since Joe Biden’s taken office, there’s a recorded over 1 million got-aways based on camera traffic, drone traffic, sensor traffic. Recorded got-aways. So, if they arrest 114, how many of that 1 million came from a country that sponsors terrorism and is coming to do us harm?”

He added, “Sadly, I think it’s going to take a national security incident to wake them up.”

Tom Homan, former acting ICE director, at a press conference in Anzalduas Park in Mission, Texas, on March 30. 2021. (Charlotte Cuthbertson/The Epoch Times)

‘On Purpose’

Homan believes that the border crisis “is on purpose,” and has been caused by policies formulated by the Department of Homeland Security (DHS) under Secretary Alejandro Mayorkas and the Biden administration.

“[Secretary Mayorkas] has the same data I have,” said Homan, who previously served as the head of ICE’s Enforcement and Removal Operations during the Obama administration, before being named head of ICE by then-President Donald Trump.

“When [Mayorkas] was a deputy secretary [at DHS] in 2014, 2015 under Obama, he was deputy secretary under [then-DHS secretary] Jeh Johnson. When we had a thousand entrants a day, Jeh Johnson called us all and said, ‘What the hell’s going on? This is a bad day.’ A thousand.

“Now they’ve got seven, eight thousand and [Mayorkas is] saying the border’s secure.”

“How did we stop it in 2014, 2015? We built detention facilities. We held [illegal aliens] long enough to see a judge. 90 percent lost, we put them on an airplane and sent them home, boarding them as well,” Homan added.

“[Mayorkas] was the deputy secretary back then, he knew what we did. Now he’s the secretary. What is he doing now? He’s not using detention facilities, he’s shutting them down. They’re releasing [illegal aliens]. Many of them are released without even a court date, so they’re not seeing a judge … He’s doing the complete opposite of what worked in 2014, 2015.”

“This isn’t mismanagement, this isn’t incompetence. This is on purpose,” Homan alleged.

DHS, ICE, and the White House did not return requests for comment.

For his part, Mayorkas has maintained that the border is secure and defended the department’s record amid the record illegal border crossings.

“The immigration system, our laws, have not been reformed for more than 40 years. The problem from administration to administration, regardless of party, is the fact that we are fundamentally working within a broken immigration system, and that is the foundational challenge, with respect to the border,” the secretary said in early December.

Mayorkas said DHS was working to improve the efficiency of processing illegal aliens.

“We are devoting tremendous resources to address the border in a way that achieves its security and upholds its values,” Mayorkas said. “We are modernizing our systems at the border to expedite processing, bringing greater efficiency to it. We are intensely focused on this mission set, just as we are intensely focused on the mission sets that we confront as a department from top to bottom.”

A U.S. Border Patrol agent instructs immigrants who had crossed the Rio Grande into El Paso, Texas, as seen from Ciudad Juarez, Mexico, on Dec. 19, 2022. (John Moore/Getty Images)

‘Political Power’

A native of West Carthage, New York, Homan served as a police officer in his hometown and became a border patrol agent in 1984 before rising to become head of ICE three decades later.

“I was the first ICE director who actually came up through the ranks,” said Homan, who is a visiting fellow at The Heritage Foundation, a conservative think tank, and authored the book “Defend the Border and Save Lives: Solving Our Most Important Humanitarian and Security Crisis.” “So when I commanded ICE, I didn’t ask any of the 20,000 men and women who worked for me to do anything that I didn’t do myself as an agent.”

As head of ICE’s Enforcement and Removal Operations, Homan received the 2015 Presidential Rank Award for Distinguished Service, the country’s highest civil service award. In June 2018, the month that he retired from ICE, Homan received the Distinguished Service Medal from then-President Trump, and in January 2021 was awarded the National Security Medal by Trump in the Oval Office “for distinguished achievement in the field of national security through exceptionally meritorious service.”

Homan pointed to expectations that illegal aliens will one day vote for Democrats as a factor driving accommodative immigration enforcement policies under the Biden administration, saying, “it’s all about future political power.”

“They truly believe [illegal aliens] are future Democratic voters, number one, and number two, they certainly perceive a future political benefit. Because remember, President Biden also overturned Trump’s census rule,” Homan said.

“Now illegal aliens will be counted in the census. So look, already five million have crossed the border [during the Biden administration] … many will flock to sanctuary cities that are protected, which are going be counted in that jurisdiction, which will result in more seats for the Dems.”

On his first day in office, President Joe Biden issued an executive order revoking a 2020 memorandum issued by President Trump that would have excluded illegal aliens from states’ apportionment bases for congressional representation following the 2020 Census.

Homan said that  “millions of Americans … don’t even realize there’s a crisis on the border,” and pointed to a need for citizens to become better informed and educated on this issue.

“I’ll say it a thousand times, regardless of what your opinion is on illegal immigration, when you create a crisis this big, you create a public safety crisis, a public health crisis, and a national security crisis,” he said.

“You can’t turn a blind eye to it.”

U.S. Homeland Security Secretary Alejandro Mayorkas answers a reporter’s question during a news conference with Mexican counterparts at the State Department in Washington on Oct. 13, 2022. (Chip Somodevilla/Getty Images)

Releasing Illegal Aliens

Homan criticized the administration’s “alternatives to detention” (ATD) program, colloquially known as “catch and release,” under which the majority of illegal aliens are released into the country while they await their court dates.

“Not only are they letting [illegal aliens] in, they’re setting them up so they’ll never be removed because they’re not in custody,” Homan said.

There are currently about 378,000 illegal aliens under the ATD program, according to ICE’s latest statistics. Most of them, about 290,000, are monitored by ICE through an app known as SmartLINK. Nearly 70,000 are not monitored by any technology, while 16,000 are monitored through telephone calls, and nearly 7,000 are monitored by GPS.

ICE says that ATD “effectively increases court appearance rates, [and] compliance with release conditions.” Mayorkas has characterized such policies as part of an effort by the administration to ensure the more humane processing of illegal aliens.

A 2022 report by the U.S. Government Accountability Office annalyzing the ATD program from 2015 to 2020, found that about a quarter of the illegal aliens placed in the program absconded, or fled the address at which they were staying “and could not be located,” including 33 percent in fiscal year 2020, which stretched across the Trump and Biden administrations.

Homan said that while large numbers of illegal aliens are being released into the United States, “there’s thousands of beds right now in ICE’s inventory” available for use in the detention of illegal aliens “that are empty, already paid for.”

According to a 2020 DHS Enforcement Lifecycle Report (pdf), illegal aliens encountered in 2014 to 2019 who were held in DHS custody for the entire time until court proceedings were repatriated 98 percent of the time. Only 0.5 percent received court orders allowing them to stay in the United States. One percent of those continuously detained illegal aliens received removal orders from the court that were not executed by ICE.

The report noted that in contrast, illegal aliens who were never detained were repatriated 30 percent of the time. Meanwhile, 15 percent received court orders allowing them to stay, while 55 percent of the cases were unresolved at the time of the report’s publication.

“The detention pattern yielding the greatest share of unresolved cases were encounters initially placed in detention but then released prior to a final enforcement outcome,” the report added.

“These ‘partially detained’ encounters resulted in repatriations just 3 percent of the time and relief just 12 percent of the time, with 85 percent still unresolved, including 18 percent with unexecuted removal orders.”

“They know this,” Homan said. “They know most [illegal aliens] will lose their case, because based on the immigration court data, and they know based on the Homeland Security Lifecycle Report, if [illegal aliens are] not detained, they won’t be removed at all … That’s why they’re releasing them.”

He added, “No one’s talking about this…if the American people knew … I think a lot of people sit at home and say, ‘Well, if [illegal aliens] lose their case they’ll be ordered removed and ICE will be able to remove them.’ No they can’t. Because they won’t find them.”

https://www.zerohedge.com/political/us-border-crisis-national-security-crisis-former-ice-chief-tom-homan

Blackstone’s BREIT Gets $4 Billion California Injection

 Blackstone Inc. is getting a $4 billion cash infusion from the University of California for its massive real estate fund Blackstone Real Estate Income Trust, which is facing heightened pressure from investors pulling cash.

UC Investments will invest the $4 billion in the Class I common shares, according to a statement on Tuesday. The deal will give the $68 billion BREIT a longer-term source of capital. In exchange, the agreement ensures that the University of California nabs a minimum annualized net return of 11.25% over the six-year holding period of its investment thanks to a $1 billion backstop from Blackstone.

BREIT, which was designed for wealthy individual investors, has struggled in recent months and been forced to limit withdrawals, raising concerns about Blackstone’s growing reliance on the mass affluent, who are proving more fickle in volatile markets than the firm’s traditional institutional investor base. The redemption restrictions across the industry have prompted queries from the Securities and Exchange Commission.

The University of California’s investment arm, which oversees $150 billion, reached out to Blackstone after media reports about BREIT’s difficulties.

The deal is “a massive affirmation of the quality of the portfolio we have constructed, of the values of the assets here and the performance outlook,” Jon Gray, Blackstone’s president, said on Bloomberg Television.

The deal could prove to be a major boost to BREIT in one of its first challenging markets. The transaction is a new tool for BREIT in striking a deal with institutional capital, Gray told CNBC in an interview.

The University of California has a long-standing relationship with Blackstone, investing $2 billion in the private equity firm’s funds for more than a decade, the organizations said in the statement.

“Investors can benefit from stable cash-flowing investments that can grow with high global inflation,” Jagdeep Singh Bachher, the University of California’s chief investment officer, said in the statement.

Blackstone Chief Executive Officer Steve Schwarzman said in December that BREIT’s redemptions were spurred by investors needing liquidity, rather than any indication of the fund’s performance.

Last year through November, returns totaled 8.4% for a popular BREIT share class. Blackstone has attributed BREIT’s outperformance to its focus on residential and industrial properties in markets where limited supplies support steady rent increases and high cash flow. BREIT’s net asset value is $68 billion, while its total asset value is about $126 billion.

“This type of large, opportunistic investment effectively leverages the UC’s more than $150 billion portfolio,” said University of California Regent Richard Sherman, Chair of the Investments Committee.

https://finance.yahoo.com/news/blackstone-breit-gets-4-billion-133750550.html

South Korea Says Talks On Nuclear-Sharing With US Underway

 Suddenly US involvement on the Korean peninsula is about to potentially ratchet into uncharted territory, as South Korea confirmed on Tuesday it is in talks with Washington to provide a nuclear deterrent presence at a moment Pyongyang is threatening its own nuclear arsenal expansion.

"South Korea confirmed Tuesday that Seoul and Washington are discussing its involvement in U.S. nuclear weapons management in the face of intensifying North Korean nuclear threats, after President Joe Biden denied that the allies were discussing joint nuclear exercises," The Associated Press reports.

Despite President Joe Biden answering "no" to a reporter's question after being asked if joint nuclear exercises are on the horizon with Seoul, South Korean President Yoon Suk Yeol's top adviser for press affairs, Kim Eun-hye, explained that the two countries "are discussing an intel-sharing, a joint planning and subsequent joint execution plans over the management of US nuclear assets in response to North Korea’s nuclear (threats)."

President Yoon himself had affirmed something similar in an interview published Monday in a local newspaper. While South Korea has no nuclear weapons of its own, the idea could possibly be for some kind of nuclear sharing arrangement similar to NATO's inter-alliance sharing agreement. As it stands, the US provides Korea with a "nuclear umbrella" - though this remains too ambiguous for South Korea's leaders, apparently.

Here's how the AP paraphrased President Yoon's Monday statements:

In the Chosun Ilbo interview, Yoon said that while the U.S. nuclear weapons belong to the U.S., planning, intel-sharing and exercises involving them must be jointly conducted with South Korea. He said he finds it difficult to assure his people of a security guarantee with the current levels of U.S. security commitment.

The report indicates that talks on this sensitive topic, given that mere headlines of nuclear-sharing talks could trigger threat escalation out of Pyongyang, could be taking place via unofficial channels.

All of this comes in response to a New Year directive given by the north's Kim Jong-Un, ordering his forces to embark on an 'exponential' expansion of nuclear forces. 

Kim recently said: "They are now keen on isolating and stifling (North Korea), unprecedented in human history," according to the official Korean Central News Agency. "The prevailing situation calls for making redoubled efforts to overwhelmingly beef up the military muscle."

Kim then at a meeting of top ministers called for "an exponential increase of the country’s nuclear arsenal" - and specifically involving the mass production battlefield tactical nuclear weapons with an eye toward South Korea.

https://www.zerohedge.com/geopolitical/south-korea-says-talks-nuclear-sharing-us-underway

Simple nasal swab can provide early warning of emerging viruses

 As the COVID-19 pandemic showed, potentially dangerous new viruses can begin to spread in the population well before the global public health surveillance system can detect them.

However, Yale researchers have found that testing for the presence of a single immune system molecule on nasal swabs can help detect stealthy viruses not identified in standard tests, they report Jan. 1 in the journal The Lancet Microbe.

"Finding a dangerous new virus is like searching for a needle in a haystack," said Ellen Foxman, associate professor of laboratory medicine and immunobiology and senior author of the study. "We found a way to significantly reduce the size of the haystack."

Public health officials typically look to a few sources for warning signs of emerging disease. They study emerging viruses in animals that may transmit the infection to humans. But determining which of the hundreds—or thousands—of new viral variants represent a true danger is difficult. They also look for outbreaks of unexplained respiratory ailments, which was how SARS-Cov-2, the virus that causes COVID-19, was discovered in China late in 2019.

By the time an outbreak of a novel virus occurs, however, it may be too late to contain its spread.

For the new study, Foxman and her team revisited an observation made in her lab in 2017, which they thought might provide a new way to monitor for unexpected pathogens. Nasal swabs are commonly taken from patients with suspected respiratory infections and are tested to detect specific signatures of 10 to 15 known viruses. Most tests come back negative. But as Foxman's team observed in 2017, in a few cases, the swabs of those who tested negative for the "usual suspect" viruses still exhibited signs that antiviral defenses were activated, indicating the presence of a virus. The telltale sign was a high level of a single antiviral protein made by the cells that line the nasal passages.

Based on that finding, the researchers applied comprehensive genetic sequencing methods to old samples containing the protein, and in one sample, found an unexpected influenza virus called influenza C.

The researchers also used this same strategy of retesting old samples to search for missed cases of COVID-19 during the first two weeks of March 2020. While cases of the virus had surfaced in New York State around that same time, testing was not readily available until weeks later. Hundreds of nasal swab samples collected from patients at Yale-New Haven Hospital during that time had tested negative for standard signature viruses. When tested for the immune system biomarker, the vast majority of those samples showed no trace of activity of the antiviral defense system. But a few did; among those, the team found four cases of COVID-19 that had gone undiagnosed at the time.

The findings reveal that testing for an antiviral protein made by the body, even if the tests for known respiratory viruses are negative, can help pinpoint which nasal swabs are more likely to contain unexpected viruses.

Specifically, screening for the biomarker can allow researchers to narrow down the search for unexpected pathogens, making it feasible to do surveillance for unexpected viruses using swabs collected during routine patient care. Samples found to possess the biomarker can be analyzed using more complex genetic testing methods to identify unexpected or emerging pathogens circulating in the patient population and jumpstart a response from the health care community.

Yale's Nagarjuna R. Cheemarla and Jason Bishai are co-lead authors of the paper, as are former Yale researchers Amelia Hanron and Joseph R.Fauver.

More information: Nagarjuna R Cheemarla et al, Nasal host response-based screening for undiagnosed respiratory viruses: a pathogen surveillance and detection study, The Lancet Microbe (2022). DOI: 10.1016/S2666-5247(22)00296-8

https://medicalxpress.com/news/2023-01-simple-nasal-swab-early-emerging.html

China threatens response to COVID testing requirements for passengers

 Chinese officials have called out other countries for their COVID-19 testing requirements for travelers coming from China, threatening to impose countermeasures in response.

Speaking at a daily briefing on Tuesday, Foreign Ministry spokesperson Mao Ning called the virus testing requirements imposed by other countries “excessive” and “unacceptable” and said they “lack scientific basis.”

Several countries including the U.S., Australia, Canada, the United Kingdom, India and Japan have announced strict COVID-19 measures toward passengers coming from China amid growing concerns of the lack of data on daily infections in the country and the spread of new variants. 

“We believe that the entry restrictions adopted by some countries targeting China lack scientific basis, and some excessive practices are even more unacceptable,” Mao said.

“We are firmly opposed to attempts to manipulate the COVID measures for political purposes and will take countermeasures based on the principle of reciprocity,” Mao added. 

Mao’s remarks come as the Biden administration has plans to implement new COVID-19 restrictions for passengers traveling from China amid the surge of virus cases and the lack of transparency with reporting virus data from the country. 

Starting Thursday, all passengers who are at least 2 years old or older traveling from China, Hong Kong or Macau are required to show a negative COVID-19 test no more than two days before their departure.

U.S. officials noted that the requirement will apply to all air passengers regardless of their nationality and vaccination status.

China, which has downgraded COVID-19 from a Class A infectious disease to Class B and shifted away from its strict COVID measures as well, last month announced it will lift the mandatory COVID-19 quarantine requirement for travelers entering the country.

https://thehill.com/policy/healthcare/3796388-china-threatens-response-to-covid-testing-requirements-for-passengers/

Medicare lost millions in savings due to spotty oversight: federal watchdog

 A federal watchdog has found that Medicare lost out on millions of potential savings due to spotty oversight of the average sales price of medications, impacting how much Medicare Part B beneficiaries pay for coverage.

The Centers for Medicare & Medicaid Services (CMS) requires drug manufacturers to submit the quarterly average sales price (ASP) for medications, which is determined by dividing the amount of sales dollars by the volume of medication sold.

This information, along with additional drug data that must be submitted, affects where Medicare Part B payments are set. If this data in incomplete, then the CMS uses the wholesale acquisition cost for the specific drug, which is the price set by the manufacturer for direct sales without rebates, discounts or other reductions in price.

An online ASP data submission system was created in 2019 to help collect accurate data. This data is then subjected to quality checks each quarter by the CMS.

The Office of Inspector General (OIG) for the Department of Health and Human Services found in two reports released Tuesday that while the CMS has an established procedure to oversee data on the average sales price of medications, the agency lacks a process to review the manual analysis. Invalid or missing ASP data resulted in the CMS being unable to determine payment amounts for 8 percent of products between 2016 and 2020.

A limited number of outpatient drugs are covered under Medicare Part B, including medications that usually require equipment such as injections and those administered through nebulizers. The payment for covered medications is determined after the CMS calculates a drug’s average price per volume, which in turn is seen in Medicare Part B payments.

Due to quarterly changes in sale prices and volume, manufacturers sometimes submit pricing data for a drug that is equal to or less than zero, which can be an error but can also be an appropriate amount in certain situations, such as when the manufacturer had no sales to report for that specific quarter.

According to the OIG, regardless of whether these valueless or negative prices are appropriate, the CMS does not include them in its calculations for Part B payments.

“CMS did not accurately implement all price reductions, which are an important tool to lower prescription drug costs. Gaps in CMS’s oversight processes prevented the program and its enrollees from realizing millions in savings,” the OIG said.

These incorrectly implemented reductions resulted in a loss of $2.8 million in savings, according to the OIG. The agency came to this conclusion after reviewing drug payment data from the first quarter of 2016 to the last quarter of 2020.

Edward Burley, the OIG’s deputy regional inspector general, told The Hill that the $2.8 million lost in savings was the result of the CMS setting Medicare payment amounts at a higher, incorrect number for seven drug codes.

Burley’s office had recommended that these prices be adjusted down, which the CMS did not do.

“By virtue of making that mistake, they lost out on $2.8 million in savings. So that was a specific issue about essentially CMS taking our recommendations and just incorrectly inputting the payment amounts and making an error on that front, which resulted in the lost savings,” said Burley.

The OIG recommended that the CMS develop a strategy of internal controls to ensure the accuracy of Medicare Part B payments.

In its response to the OIG report, the CMS said it identified “legitimate reasons” for not calculating payment amounts for certain drugs and said its current system fell within “statutory requirements.” The agency, however, said it shared in the report’s concerns regarding Part B payments.

“We are proactively looking for ways to strengthen our internal controls and are actively working on enhancements to the current ASP system and internal processes. We will take OIG’s suggestions into considerations as we continue to make enhancements in this area,” the CMS said in its response.

https://thehill.com/policy/healthcare/3796488-medicare-lost-millions-in-savings-due-to-spotty-oversight-federal-watchdog/

Trimethylamine-N-oxide tied to cardiovascular mortality, vascular brain lesions in afib

 

Marco Luciani1,2, 

Daniel Müller3,4, 

Chiara Vanetta5, 

Thamonwan Diteepeng2, 

Arnold von Eckardstein3, 

http://orcid.org/0000-0001-8134-2421Stefanie Aeschbacher6,7, 

Nicolas Rodondi8,9, 

http://orcid.org/0000-0002-4043-8061Giorgio Moschovitis10, 

Tobias Reichlin11, 

Tim Sinnecker12,13, 

Jens Wuerfel13,14, 

Leo H Bonati12,15, 

Seyed Soheil Saeedi Saravi1,2, 

Patricia Chocano-Bedoya8,16, 

Michael Coslovsky7,17, 

Giovanni G Camici2, 

Thomas F Lüscher2,18,19, 

Michael Kuehne6,20, 

Stefan Osswald6,20, 

David Conen21, 

http://orcid.org/0000-0002-7199-0406Jürg Hans Beer1,2

DOI: http://dx.doi.org/10.1136/heartjnl-2022-321300

Abstract

Objective Trimethylamine-N-oxide (TMAO) is a metabolite derived from the microbial processing of dietary phosphatidylcholine and carnitine and the subsequent hepatic oxidation. Due to its prothrombotic and inflammatory mechanisms, we aimed to assess its role in the prediction of adverse events in a susceptible population, namely patients with atrial fibrillation.

Methods Baseline TMAO plasma levels were measured by liquid chromatography-tandem mass spectrometry in 2379 subjects from the ongoing Swiss Atrial Fibrillation cohort. 1722 underwent brain MRI at baseline. Participants were prospectively followed for 4 years (Q1–Q3: 3.0–5.0) and stratified into baseline TMAO tertiles. Cox proportional hazards and linear and logistic mixed effect models were employed adjusting for risk factors.

Results Subjects in the highest TMAO tertile were older (75.4±8.1 vs 70.6±8.5 years, p<0.01), had poorer renal function (median glomerular filtration rate: 49.0 mL/min/1.73 m2 (35.6–62.5) vs 67.3 mL/min/1.73 m2 (57.8–78.9), p<0.01), were more likely to have diabetes (26.9% vs 9.1%, p<0.01) and had a higher prevalence of heart failure (37.9% vs 15.8%, p<0.01) compared with patients in the lowest tertile. Oral anticoagulants were taken by 89.1%, 94.0% and 88.2% of participants, respectively (from high to low tertiles). Cox models, adjusting for baseline covariates, showed increased total mortality (HR 1.65, 95% CI 1.17 to 2.32, p<0.01) as well as cardiovascular mortality (HR 1.86, 95% CI 1.21 to 2.88, p<0.01) in the highest compared with the lowest tertile. When present, subjects in the highest tertile had more voluminous, large, non-cortical and cortical infarcts on MRI (log-transformed volumes; exponentiated estimate 1.89, 95% CI 1.11 to 3.21, p=0.02) and a higher chance of small non-cortical infarcts (OR 1.61, 95% CI 1.16 to 2.22, p<0.01).

Conclusions High levels of TMAO are associated with increased risk of cardiovascular mortality and cerebral infarction in patients with atrial fibrillation.

Trial registration number NCT02105844.

https://heart.bmj.com/content/early/2023/01/01/heartjnl-2022-321300