This study assessed whether China's workday-rescheduling policy is associated with short-term and long-term outcomes in patients with ST-segment elevation myocardial infarction (STEMI), particularly in occupational groups more likely to be affected by rescheduling.

A prospective cohort study was conducted using data from the China Acute Myocardial Infarction registry between January 2013 and September 2014. A total of 15 854 STEMI patients were included. Since individual adherence to workday rescheduling is not directly measured in the registry, occupational category was used as a proxy to define groups more likely versus less likely to be affected by the workday-rescheduling policy. The primary outcome was in-hospital all-cause mortality. Secondary outcomes included in-hospital major adverse cardiovascular and cerebrovascular events (MACCE) and 2 year all-cause mortality. Multivariable logistic and Cox regression models were used for analysis.

Using occupational category as a proxy for the likelihood of exposure to workday rescheduling, we stratified patients into a rescheduling-likely group (n=3141) and a rescheduling-unlikely group (n=12 713). Among patients in the rescheduling-likely occupational group, in-hospital mortality was significantly higher during abnormal workdays than conventional weekdays (7.8% vs 3.44%; adjusted OR=3.01; 95% CI 1.40 to 6.45). Two-year mortality was also higher (adjusted HR=1.99; 95% CI 1.20 to 3.30). Among 12 713 patients in the rescheduling-unlikely occupational group, no significant mortality differences were observed across temporal groups. Within the rescheduling-likely group, baseline characteristics and care quality indicators were generally comparable across the four temporal groups.

Workday-rescheduling-induced abnormal work cycles are associated with higher in-hospital and 2 year adverse events in affected ST-segment elevation myocardial infarction patients. These findings should be interpreted as heterogeneity in the association between abnormal workdays and mortality by occupational likelihood of rescheduling exposure rather than as a direct individual-level causal effect of rescheduling.

A previously healthy surfer apprentice in his late 30s presented to our emergency department with acute paraplegia and loss of sensation in the lower limbs following sudden back pain during his third surfing lesson. The patient reported a hyperextension movement of the back while trying to stand up on the surfboard. On examination, he was classified as grade A on the American Spinal Injury Association (ASIA) Impairment Scale, with a sensory level at T10, hypotonic paraplegia, urinary retention and constipation. T2-weighted MRI revealed hyperintensity in the central spinal cord between T7 and T10 and a T11 focus of restricted diffusion compatible with spinal cord ischaemia. CT angiography of the thoracic and lumbar spine showed stenosis and occlusion of segmental arteries at the T11-T12, T12-L1 and L1-L2 levels. After extensive work-up, a diagnosis of surfer's myelopathy was made. The patient underwent antiplatelet treatment, high-dose methylprednisolone and early rehabilitation, but no major improvement was noted in the first 3 weeks. After 8 weeks of rehabilitation, the patient was able to dorsiflex and plantarflex the feet, as well as flex the legs, but remained unable to walk. Bilateral hypoaesthesia persisted and he had not regained anal or urinary sphincter control. He is now classified as ASIA D, and the MRI demonstrated complete resolution of the signal abnormalities after 8 weeks. Our case describes this non-traumatic entity with angiographic documentation of multiple vascular occlusions, which has rarely been reported in the literature and is thought to be secondary to arterial wall dissection and/or in situ thrombosis due to hyperextension and sudden movement of the back.

Buerger's disease, or thromboangiitis obliterans, is a rare vascular disorder closely linked to smoking. It can cause severe ischemic pain, trophic disorders, and a high risk of amputation. Its management requires a specialized, multidisciplinary, and patient-centered approach. Drawing on the testimony of Nicolas Robin, a patient receiving vascular care, this article highlights the clinical, functional, psychological, and social consequences of this condition, as well as the challenges involved in the care pathway.

Vascular diseases represent a major public health challenge due to their high prevalence and their functional and skin-related complications. Their management relies on a comprehensive approach that combines medication, appropriate physical activity, and lifestyle changes, with diet playing a central role. Tailored nutritional support is therefore a key therapeutic tool for promoting wound healing, preventing complications, and improving patients' quality of life. Nurses play an essential role in identifying at-risk situations, providing nutritional monitoring, and coordinating care throughout the patient's treatment journey.

In sarcoidosis, personalised strategies that consider the various phenotypes and endotypes of the disease have the potential to improve patient care. The 'treatable traits' (TT) approach offers a promising strategy that has already been proposed and implemented in several other chronic pulmonary diseases. In this review, we propose five distinct TT categories for patients with sarcoidosis: aetiological, lifestyle, pulmonary, extrapulmonary (systemic) and comorbidities.Despite the potential of this strategy, several challenges hinder its implementation. In addition, much of the knowledge on the definition and prevalence of TTs comes from single-centre studies. Creating international registries will enhance our understanding and provide more accurate data on these traits.TTs are dynamic and require continuous evaluation to effectively respond to changes caused by disease progression or treatment response. A multidisciplinary management approach is therefore crucial as sarcoidosis can impact multiple organs. Integrating primary care physicians into the management framework will improve overall patient care.Incorporating patient preferences into the TT strategy is vital for improving adherence to treatment. Additionally, using patient-reported outcome measures will provide valuable insights into the impact of treatment.While the TT approach is feasible in developed healthcare systems, challenges exist in resource-limited settings. Advancing patient-centred care towards 5P medicine involves addressing key TTs that meet the unique patient needs.Therefore, randomised controlled trials focused on TTs are needed. Our proposed TT strategy aims to enhance quality of life and outcomes for patients with sarcoidosis while increasing awareness of the importance of TTs among healthcare providers and advocacy groups.

Purulent pericarditis is a rare, but life-threatening condition occurring in roughly 27.7 cases of pericarditis per 100,000 population per year in developed countries. Gram positive cocci are the predominant causative pathogens with Staphylococcus aureus and Streptococcus species being the most common. Early recognition is essential in preventing complications such as cardiac tamponade, constrictive pericarditis, and effusive-constitutive pericarditis. Despite appropriate medical management including both drainage and antibiotics, mortality rates remain elevated and approximately 50% of cases are diagnosed postmortem.

An 84-year-old male with a history of myelodysplastic syndrome, permanent atrial fibrillation and heart failure with preserved ejection fraction presented to the emergency department with sharp, left-sided chest pain radiating to the right shoulder, worsened by inspiration. A computed tomography angiogram performed to evaluate for pulmonary embolisms revealed a large pericardial effusion. Electrocardiogram (EKG) demonstrated low-voltage tachycardia. Transthoracic echocardiography showed a large circumferential pericardial effusion with fibrinous strands. The patient underwent pericardiocentesis with drainage of 450 cc of purulent fluid, followed by placement of a pericardial drain. Fluid analysis revealed a pH of 6.9 and 15,095 nucleated cells/μL with 89% neutrophils. Pericardial fluid and blood cultures were positive for MRSA. The patient was initiated on intravenous vancomycin and transesophageal echocardiography was negative for infective endocarditis. He was subsequently transitioned to daptomycin to complete a four-week course of antibiotics. Repeat blood cultures were negative.

This case illustrates the diagnostic challenges and management considerations for MRSA-associated purulent pericarditis in a frail host. Early echocardiography and pericardiocentesis are critical in management. Despite source control and target antibiotics, mortality remains high in frail hosts.

Despite the proven efficacy of direct oral anticoagulants (DOACs) in preventing thrombus formation in atrial fibrillation (AF), thrombus formation may rarely occur even with appropriate anticoagulation. We report the case of a 70-year-old woman with a history of AF, initially on warfarin, who underwent percutaneous left atrial appendage closure with a Watchman FLX 27 mm device due to recurrent gastrointestinal bleeding. She subsequently developed multiple unprovoked deep venous thromboses, necessitating the reinitiation of rivaroxaban therapy. She presented to the hospital with complaints of lower abdominal pain. Although the CT abdomen and pelvis was not a dedicated cardiac study, the superior slices incidentally captured the inferior and posterior left atrium, revealing a lobulated soft-tissue density suspicious for thrombus. Labs included INR 1.8, APTT of 40, and D-dimer of 0.62. Transthoracic echocardiography could not visualize thrombus. Transesophageal echocardiography revealed a large mobile thrombus in the superior cavity of LA. The watchman device was well seated with no flow noted across the device. A hypercoagulability workup showed low levels of Protein S antigen at 21. She was placed on warfarin. Follow-up TEE in 3 months showed a decrease in the thrombus size. This case highlights the importance of evaluating an underlying hypercoagulable state when thrombus develops despite DOAC therapy. While DOACs prevent thrombus formation in atrial fibrillation, their failure should not be dismissed as incidental. Clinicians should pursue a hypercoagulability workup, especially when thromboembolic events appear disproportionate to the CHA₂DS₂-VASc score. Early identification of inherited or acquired thrombophilies can guide tailored and effective long-term management.

Intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) are the keystones of current treatment for acute ischemic stroke. Most IVT candidates harbor medium or distal arterial occlusions, while EVT targets large artery occlusions. However, both treatments often fail to achieve sustained recanalization, microvascular reperfusion, and optimal clinical outcomes. Supplementing IVT with antithrombotic therapies has not shown consistent benefit, and alternative lytics such as tenecteplase provide, at best, a marginal improvement in outcome compared with alteplase. This review summarizes current evidence on multiple dosing strategies of IVT, including repeat administration of IVT in non-EVT candidates and IVT or intra-arterial thrombolytics in combination with EVT. We discuss the physiologic, pharmacokinetic, and clinical rationale for these approaches, highlight results from key clinical trials, and identify knowledge gaps to guide future research. Emerging data support novel fibrinolytic agents, sequential IVT dosing, and adjunct intra-arterial thrombolysis as promising strategies to enhance reperfusion and functional recovery while maintaining safety.

The engagement of youth in the design of services that promote and increase the uptake of essential services to reduce HIV and other sexually transmitted infections is vital to sustaining these preventive services. The study objective is to identify strategies for sustaining HIV prevention services among Nigerian youth, in partnership with community-based organizations, through a crowdsourced open call and designathon in Nigeria.

From February to March 2024, Nigerian youth (ages 14-24) submitted ideas to an open crowdsourcing call on how community-based organizations in Nigeria might sustain HIV self-testing and youth-friendly preventive services for at-risk youth. The submissions were scored in each domain: relevance, novelty, scalability, replicability, potential for sustainability, and promotion of equity and fairness, with an integer score of 1 (low) to 3 (high)(S1). Ten teams were selected to participate in the 72-hour designathon. Both quantitative and qualitative analysis was conducted. The study used thematic analysis and the PEN 3-Cultural Model to categorize qualitative data into six themes. Descriptive statistics were used to calculate participants' demographic characteristics.

One hundred and seventy-eight participants submitted entries; 161 were online entries, and 17 were received via WhatsApp. The majority of participants were female (57.1%) and aged 19-23 years (55.0%), with a mean age of 21.7 (±4.1). Most participants were from the southwest of Nigeria (53.8%), had secondary education (68.9%), and were students (67.9%). About one-third of teams (31.1%) indicated collaborating with non-governmental organizations as a promising way to sustain preventive services. Six themes emerged: Adapted Intervention Design and Delivery, Youth Engagement and Education, Organization Setting, Socio-cultural and Community Context, Community Leadership Through Training and Financial Resources, and Sustainment Through Community Collaboration.

The crowdsourcing contest open call and designathon engaged youth from diverse backgrounds, and it is a practical way to generate solutions from key stakeholders affected by the community's prevailing health issues. Developing service delivery strategies that engage, educate, and collaborate with youth on HIV prevention could be sustainable. However, this will not be conclusive without implementing them over time to test their feasibility and sustainability.

BACKGROUND Coronary artery embolism (CAE) is an infrequent but clinically significant non-atherosclerotic cause of ST-elevation myocardial infarction (STEMI). It presents unique diagnostic and therapeutic challenges due to its varied etiologies and the frequent absence of significant coronary artery disease. While atrial fibrillation is the most recognized cardiac arrhythmia associated with coronary embolism, atrial flutter as an embolic source remains underreported. This report highlights the complexities of diagnosing and managing CAE manifesting as an atypical STEMI and sudden cardiac arrest in a patient with previously undiagnosed atrial flutter, emphasizing the critical importance of identifying underlying embolic sources, particularly atrial flutter, to guide appropriate therapy. CASE REPORT An 82-year-old woman with non-ischemic cardiomyopathy presented after an out-of-hospital ventricular fibrillation cardiac arrest. Her post-resuscitation electrocardiogram revealed an inferior STEMI. Emergency coronary angiography demonstrated abrupt embolic occlusions in the distal right coronary artery, without evidence of significant underlying atherosclerosis. Percutaneous coronary intervention was performed to restore blood flow. After the procedure, telemetry revealed new-onset atrial flutter, the presumed embolic source. Her hospital course was complicated by severe global hypokinesis out of proportion to the infarct territory and progressive respiratory failure, ultimately leading to a family decision to transition to comfort care. CONCLUSIONS This case underscores the critical need to consider coronary artery embolism in the differential diagnosis for STEMI, particularly in patients lacking significant atherosclerotic disease burden. The presence of arrhythmias, such as atrial flutter, should raise strong clinical suspicion for an embolic etiology. While a good outcome was not achieved in this specific case, early recognition of CAE remains crucial for guiding appropriate revascularization strategies and initiating prompt anticoagulation to prevent recurrent thromboembolic events in surviving patients.