Influenza A(H1N1)pdm09 remains one of the predominant seasonal influenza viruses worldwide and continues to evolve under the combined effects of host immunity, vaccination, and changing epidemiological conditions. However, the long-term impact of the COVID-19 pandemic on its evolutionary dynamics remains poorly understood. We investigated the genetic variability and phylodynamic evolution of the hemagglutinin (HA) and neuraminidase (NA) genes of Italian A(H1N1)pdm09 viruses collected between 2009 and 2026. Time-calibrated phylodynamic analyses, Bayesian Skyline Plots (BSPs), Lineages Through Time (LTT) graphs, principal component analysis (PCA), and codon-based selection analyses were used to characterize long-term evolutionary patterns. Both HA and NA followed continuous evolutionary trajectories, with a marked post-2020 genetic shift associated with the emergence of 6B.1A.5a.2-related clades. HA showed greater evolutionary variability than NA, whereas selection analyses identified only one positively selected site in HA and none in NA, consistent with reduced adaptive diversification in recent strains. Phylodynamic analyses revealed a marked decline in effective population size and lineage accumulation during the COVID-19 pandemic, followed by renewed expansion after 2022. Overall, Italian A(H1N1)pdm09 viruses exhibited reduced genetic diversity, limited evidence of positive selection, and coordinated genomic restructuring following the pandemic. These findings provide new insights into the long-term evolutionary dynamics of A(H1N1)pdm09 in Italy and reinforce the importance of sustained genomic surveillance for anticipating evolutionary changes and informing evidence-based public health strategies.

BACKGROUND Cardiac resynchronization therapy can fail in the presence of anatomical variations, such as persistent left superior vena cava, which can preclude coronary sinus cannulation and left ventricular lead placement. Conduction system pacing, particularly left bundle branch area pacing, has emerged as a physiological alternative for achieving ventricular resynchronization in such anatomically challenging situations and may provide an effective solution when standard cardiac resynchronization therapy (CRT) is not feasible. CASE REPORT We report the case of a 78-year-old man with chronic heart failure (left ventricular ejection fraction 35%) and a history of mitral valve replacement with a bioprosthesis, tricuspid valve repair, and a bilateral Maze procedure. The patient was indicated for cardiac resynchronization therapy pacemaker (CRT-P) implantation due to sick sinus syndrome with tachy-brady arrhythmia and left bundle branch block with a QRS duration of 190 ms. Periprocedural venography revealed a persistent left superior vena cava draining into a markedly dilated coronary sinus without suitable lateral branches, preventing left ventricular lead placement. Following device implantation, the patient experienced progressive heart failure deterioration, with a decline in left ventricular ejection fraction (LVEF) to 25% and an increase in NT-proBNP to 7741 ng/L, subsequently fulfilling criteria for implantable cardioverter-defibrillator implantation. Due to unfavorable venous anatomy, conduction system pacing (CSP) was selected as an alternative strategy. A right-sided implantable cardioverter defibrillator (ICD) system with left bundle branch area pacing (LBBAP) was successfully implanted, resulting in significant QRS narrowing to 120 ms and excellent pacing parameters. At 2-month follow-up, the patient remained clinically stable (NYHA class II) with improvement in LVEF to 30-35%. CONCLUSIONS This case illustrates that LBBAP can provide effective ventricular activation and resynchronization when conventional CS-based CRT is not feasible due to venous anomalies. LBBAP is a safe and effective alternative in patients with PLSVC and unfavorable CS anatomy.

Factors like age, sex, high-energy trauma, and complex fractures are factors for acute compartment syndrome (ACS), but the influence of sociodemographic factors remains unexamined. The goal was to assess whether sociodemographic factors were independently associated with ACS requiring fasciotomy after tibia fracture when accounting for available clinical and injury-related factors.

This is a retrospective study of patients diagnosed with tibia fractures between 2016 and 2021 using the Nationwide Inpatient Sample (NIS), a 20% weighted sample of 95% of the U.S. inpatient population. The primary outcome was the rate of ACS requiring fasciotomy.

A total of 118,769 patients were identified (weighted N = 593,845), with 2.51% (14,880) diagnosed with ACS requiring fasciotomy. There was a non-significant decrease in the rate of ACS from 2016 to 2021 (2.63% vs. 2.29%, p = 0.065). Patients with ACS requiring fasciotomy had higher hospital charges ($242,160 vs. $117,557; p < 0.001), rates of inpatient mortality (2.1% vs. 1.6%; p = 0.012) and longer length of stay (12.8 days vs. 7.03; p < 0.001). Younger age (41.6 vs. 51.4; p < 0.001), male sex (3.59% vs. 1.23%; p < 0.001), non-whites (2.87% vs. 2.31%; p < 0.001), Hispanic ethnicity (2.87% vs. 2.46%; p = 0.005), operative treatment of tibia (5.87% vs. 2.26%; p < 0.001), concurrent fibula fracture (3.19% vs. 2.06%; p < 0.001), private insurance (2.88% vs. 2.32%; p < 0.001) and hospital transfer (3.12% vs. 2.40%; p < 0.001) were associated with higher rates of ACS on bivariate analysis. Multivariate analysis showed that older age (OR = 0.288, p < 0.001) and female gender (OR = 0.430, p < 0.001) decreased risk while surgical treatment (OR = 2.358, p < 0.001) increased the risk for ACS.

While sociodemographic factors have some influence in the development of ACS in patients with tibia fractures, clinical factors-like age, gender and surgical management-have a stronger influence and should primarily guide clinical suspicion and decision-making.

Although carotid endarterectomy (CEA) is the standard treatment for carotid stenosis, the incidence, predictors, and clinical significance of external carotid artery (ECA) occlusion after CEA remain poorly characterized. We assessed these factors and whether exoscope introduction influenced the ECA occlusion rate.

We retrospectively analyzed 75 consecutive CEA cases with a patent preoperative ECA performed between January 2020 and December 2025 (mean age 73.4 years; 60 male). Preoperative ECA diameter was measured on MRA. Intraoperative indocyanine green (ICG) angiography was routinely performed, and postoperative MRA or CTA and diffusion-weighted imaging (DWI) were obtained within one week. An exoscope replaced the microscope in January 2024; periods were compared using Fisher's exact test.

ECA occlusion occurred in 3 cases (4.0%), all asymptomatic and without new DWI lesions. The occlusion group had a significantly smaller preoperative ECA diameter (2.57 vs. 3.92 mm, P = 0.027; ROC AUC 0.880, cutoff 2.10 mm) and more frequent poor intraoperative ICG perfusion (67% vs. 1%, P = 0.003). Occlusion occurred in 2 of 46 microscope cases (4.3%) and 1 of 29 exoscope cases (3.4%; P = 1.000). Insufficient distal ECA endarterectomy was the suspected cause in all cases.

ECA occlusion after CEA was uncommon and asymptomatic. A small preoperative ECA diameter and poor intraoperative ICG perfusion were significant predictors. Because ECA patency matters for future EC-IC bypass and comparable rates are reported after stenting, surgeons should preserve ECA flow through adequate distal endarterectomy and intraoperative ICG assessment.

The ECG "Spiked Helmet Sign," with diffuse concave ST-segment elevation and a J-point spike, typically suggests acute pericarditis. However, after LVAD implantation, it may herald a localized pericardial hematoma and impending tamponade.

A 68-year-old male with end-stage ischemic cardiomyopathy underwent LVAD placement. Hours postoperatively, ECG showed this sign with QTc prolongation (578 ms). Bedside echocardiography revealed a 6-mm localized pericardial/mediastinal hematoma. Troponin I peaked on day 1 and fell. Conservative management was successful.

Recognition of this ECG sign after LVAD surgery should prompt immediate echocardiography to detect pericardial complications.

To evaluate the clinical efficacy of navigated laser photocoagulation (Navilas®) for persistent macular edema (ME) secondary to branch retinal vein occlusion (BRVO), and to determine whether angiographic microaneurysm (MA) morphology, including clustered MAs, telangiectatic capillaries (TelCaps), and MAs within collateral vessels, is associated with successful discontinuation of anti-vascular endothelial growth factor (VEGF) therapy. This retrospective observational study included eyes with persistent BRVO-associated ME treated with Navilas® at Nagoya City University Hospital between June 2014 and February 2022 and followed for at least 3 months. Clinical data and multimodal imaging findings were retrospectively reviewed. Outcomes included changes in best-corrected visual acuity and central subfield thickness, changes in anti-VEGF injection frequency, and successful discontinuation of anti-VEGF therapy. Angiographic MA morphology was assessed using fluorescein angiography and indocyanine green angiography. Logistic regression analysis was performed to identify morphological predictors of treatment discontinuation. Best-corrected visual acuity remained stable throughout follow-up after Navilas®. Approximately 60% of eyes achieved successful discontinuation of anti-VEGF therapy. Discontinuation was achieved in 63% (5 out of 8) of eyes with TelCaps, 33% (2 out of 6) of eyes with MAs within collateral vessels, and 27% (3 out of 11) of eyes with clustered MAs. In eyes that required continued anti-VEGF therapy, the injection frequency was significantly reduced compared with the pretreatment period. Logistic regression analysis demonstrated that the presence of clustered MAs was significantly associated with failure to discontinue anti-VEGF therapy. Navilas® appears to be an effective adjunctive treatment for persistent BRVO-associated ME, maintaining visual function while reducing the burden of anti-VEGF therapy. The presence of clustered MAs may serve as a useful angiographic biomarker of suboptimal response to navigated laser treatment, potentially reflecting severe localized hyperpermeability and extensive capillary nonperfusion. Angiographic assessment of MA morphology may therefore help refine patient selection and guide individualized treatment strategies.

Early-life psychosocial factors may be associated with long-term cardiovascular health. We investigated whether self-reported loneliness during childhood is associated with an increased risk of developing hypertension, heart disease, and stroke in later life. We focused on low-educated, middle-aged, and older women, a potentially vulnerable population. This study was conducted and reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement for cohort studies. We conducted a prospective cohort study using data from the China Health and Retirement Longitudinal Study (CHARLS), including 4341 women aged ≥45 years with low educational attainment (primary school or less) at baseline (2011) and followed through 2020. Childhood loneliness was assessed retrospectively using 2 questions on the frequency of loneliness due to having no friends and the presence of a close friend during childhood. Participants reporting frequent loneliness and no close friend were classified as exposed. Incident hypertension, heart disease, and stroke were defined by new physician diagnoses or blood pressure measurements/medication use. Cox proportional hazards models estimated hazard ratios (HRs) adjusted for demographic, behavioral, and clinical covariates. Mean baseline age was 61.21 ± 9.63 years. Over a median 9.0-year follow-up, 2245 women developed hypertension (52.44%), 1343 developed heart disease (31.37%), and 474 had a stroke (10.92%). Childhood loneliness was reported by 5.25% of participants. In fully adjusted models, childhood loneliness was associated with a 31% higher hazard of hypertension (HR 1.31, 95% confidence interval [CI]: 1.01-1.70) and a 41% higher hazard of heart disease (HR 1.41, 95% CI: 1.06-1.89). The association with stroke was elevated but not statistically significant (HR 1.47, 95% CI: 0.97-2.21). Childhood loneliness is associated with increased risks of hypertension and heart disease in later life among Chinese women with low education. This highlights the importance of early psychosocial experiences for cardiovascular health.

This retrospective observational study evaluated the incidence, subtypes, and risk factors for hemorrhagic transformation (HT) after tenecteplase-tissue plasminogen activator (TNK-tPA) therapy in patients with acute ischemic stroke. Adults with acute ischemic stroke who received intravenous TNK-tPA between June 2022 and June 2025 and had complete baseline data and follow-up neuroimaging were included. All patients underwent routine follow-up computed tomography or magnetic resonance imaging at 24 ± 6 hours after thrombolysis, with additional earlier imaging when neurological deterioration occurred. Demographic characteristics, vascular risk factors, baseline neurological severity assessed by the National Institutes of Health Stroke Scale, blood pressure, pre-stroke antiplatelet use, onset-to-needle time, Alberta Stroke Program Early CT Score, and admission laboratory parameters - including white blood cell count, hemoglobin, platelet count, international normalized ratio, fibrinogen, and D-dimer (mg/L fibrinogen-equivalent units) - were collected. HT was classified as hemorrhagic infarction (HI-1, HI-2) or parenchymal hematoma (PH-1, PH-2) according to European Cooperative Acute Stroke Study criteria. Among 181 TNK-tPA-treated patients, 28 (15.5%) developed HT, including 17 cases of HI and 11 of PH. In an exploratory multivariable logistic regression model, older age, higher baseline National Institutes of Health Stroke Scale, lower Alberta Stroke Program Early CT Score, higher systolic blood pressure, and increased international normalized ratio and D-dimer levels were associated with HT. The model showed acceptable apparent calibration and discrimination (area under the receiver operating characteristic curve = 0.86); however, 14 candidate variables were evaluated for only 28 events (approximately 2 events per variable), creating a substantial risk of overfitting. These findings are hypothesis-generating and require validation in larger independent cohorts.

Ischemic heart disease (IHD) remains a leading global health burden influenced by demographic transitions, socioeconomic disparities, and modifiable risk factors. Comprehensive analyses of global patterns are crucial to inform public health interventions. Using data from the Global Burden of Disease study 2021, we assessed global, regional, and national trends in IHD burden (1990-2021). Age-standardized rates of incidence, prevalence, mortality, and disability-adjusted life-years were evaluated. Trends were analyzed using estimated annual percentage change, age-period-cohort models, Bayesian forecasts, risk-factor attribution, decomposition analyses, health inequality, and frontier efficiency analyses. From 1990 to 2021, global IHD prevalence nearly doubled despite stable age-standardized rates, driven by population aging and growth. Eastern Europe exhibited consistently high disease burdens compared to sub-Saharan Africa. Significant gender disparities persisted, with higher burdens among males. High blood pressure, low-density lipoprotein cholesterol, and dietary risks dominated globally. Although age-standardized incidence and mortality declined, especially in high-sociodemographic index countries, absolute numbers increased due to demographic momentum. Forecasts suggest continued increases in absolute cases and deaths through 2035 despite declining standardized rates.Despite reductions in age-standardized IHD burden, substantial disparities persist. Future strategies should address demographic drivers, expand preventive efforts in lower-sociodemographic index regions, and enhance health system efficiency.

Mitral annular calcification (MAC) is a common degenerative process in older adults that can impair mitral valve compliance, elevate transmitral gradients, and increase left ventricular filling pressure. However, the extent to which increasing MAC severity parallels invasive hemodynamic evidence of heart failure with preserved ejection fraction (HFpEF) and established diagnostic algorithms remains uncertain. This was a single-center cross-sectional study. We evaluated 160 patients referred for HFpEF assessment who underwent comprehensive echocardiography. MAC severity was graded from 1 to 4 (n = 40 per group). HFpEF was defined invasively as a pulmonary capillary wedge pressure of ≥15 mm Hg at rest or ≥18 mm Hg after a standardized fluid challenge. Multivariable regression models tested the independent association between MAC grade (per 1-category increase) and invasive HFpEF diagnosis, as well as continuous H2FPEF (Heavy, Hypertensive, Atrial fibrillation, Pulmonary hypertension, Elder, Filling pressure score) and HFA-PEFF (Heart Failure Association Pretest Assessment, Echocardiography and Natriuretic Peptide, Functional Testing, Final Etiology) scores, adjusting for natriuretic peptide levels and key echocardiographic diastolic parameters. Participants were older (mean age, 76 years) and two-thirds were female, with preserved left ventricular ejection fraction (~59%). Higher MAC severity was associated with progressive elevations in pulmonary capillary wedge pressure (13.0-18.0 mm Hg at rest; 16.0-24.5 mm Hg after fluid challenge; P < .001) and, among catheterized participants, with a higher proportion meeting invasive HFpEF criteria (28.1%, 30.0%, 60.0%, and 85.0% across grades 1-4, respectively; P < .001). MAC grade was independently associated with invasively defined HFpEF (odds ratio, 1.78; 95% confidence interval, 1.22-2.38; P = .03), H2FPEF (β, 0.31; P = .03), and HFA-PEFF (β, 0.42; P = .004) scores. N-terminal pro-B-type natriuretic peptide was correlated with all outcomes. MAC severity showed a graded relationship with diastolic burden, invasive HFpEF confirmation, and diagnostic scores, suggesting that advanced MAC is associated with a hemodynamic profile consistent with HFpEF.