We report the case of a 15-year-old female presenting with exertional syncope and a history of refractory respiratory symptoms. Comprehensive preoperative multimodality imaging-including echocardiography, multi-detector computed tomography (MDCT) with three-dimensional reconstruction, and bronchoscopy-revealed a rare complex of congenital anomalies: a type 2 A bridging bronchus (BB), a pulmonary artery sling (PAS), and an atrial septal defect (ASD). Crucially, imaging confirmed the absence of significant tracheal stenosis, thereby obviating the need for tracheoplasty. The patient successfully underwent surgical repair via median sternotomy on cardiopulmonary bypass, which included reimplantation of the left pulmonary artery and patch closure of the ASD. Postoperative MDCT confirmed patency of the reconstructed pulmonary artery and the patient's symptoms resolved. This case underscores the indispensable role of advanced imaging in the diagnosis and surgical planning of complex congenital cardiopulmonary anomalies, particularly for guiding a tailored surgical approach in the setting of rare associations like BB and PAS.

The management of a snakebite is often challenging due to limited experience, limited access to intensive care, delays in presentation and high variability in venom composition and specific antivenom availability. Classified within the genus Eristicophis, the MacMahon viper is a venomous snake species for which only two detailed case reports exist. Its venom has predominantly haemotoxic properties while neurotoxic and cytotoxic effects are less pronounced. This case illustrates the effects of Eristicophis macmahonii venom on both haemostasis and cardiovascular stability, in addition to a significant local envenomation reaction that required intervention. Laboratory analysis revealed a rapid onset of thrombocytopenia and impaired haemostatic function expressed in rotational thromboelastometry (ROTEM) analysis. The first 6 hours represented an acute phase with significant hypotension and associated syncope. In the absence of clinical signs of bleeding, transfusion of blood products or administration of coagulation factors was not initiated. Thrombocytopenia resolved spontaneously within 8 days.

Nonspecific electrocardiographic (ECG) abnormalities are common in patients presenting with syncope, but their presence does not necessarily establish the mechanism of transient loss of consciousness. The frontal QRS-T angle has recently been proposed as a marker for identifying cardiac syncope in the emergency department. However, it may reflect structural and electrical abnormalities and coexist with syncope without being mechanistically related to the event. In the reported cohort, most patients classified as having cardiac syncope had structural cardiac conditions, while only a minority were assigned an arrhythmic etiology; among the latter, atrial fibrillation with rapid ventricular response predominated, with no ventricular tachyarrhythmias reported. These findings highlight a broader limitation in the interpretation of nonspecific ECG abnormalities in syncope: association with cardiac disease or cardiovascular risk does not establish causation of the syncopal event. Distinguishing ECG findings that are incidental to the event from those that identify a plausible mechanism of transient cerebral hypoperfusion is essential for etiological diagnosis of syncope.

State Ceremonial and Public Duties (SCPD) expose soldiers to extreme physiological stressors, predisposing to syncope. Despite a high incidence of syncope in military personnel, physiological responses during SCPD are unknown. Data were collected across three ceremonial parades (n = 41; 3 female, age = 24 ± 1 years, duration = 2.5 h). Parades had alternating phases of motionless standing and marching. Pre-parades, baseline cardiovascular parameters (systolic arterial pressure [SAP] and heart rate [HR]), anthropometric measures, urinary sodium, anxiety and parade perspectives were collected. Salivary steroid analyses were performed pre- and post-parade. In thirty participants (n = 10/parade; 2 female) continuous SAP, HR, respiration, postural sway and skin temperature were collected using discrete wearable technology (Astroskin) worn underneath the traditional uniform. During parades, HR and minute ventilation were elevated, with maximum HR reflecting 71 ± 1.5% of age-predicted max. Parade SAPmin was 107 ± 1.8 mmHg (range 88-125 mmHg). During prolonged motionless standing (Stand 2; 63 ± 1mins), 50% of participants experienced reduced SAP that exceeded clinical criteria for orthostatic hypotension. Lower Stand 2 SAPmin was associated with larger leg mass (r = 0.484, p = 0.012), and lower percent body fat (r = 0.523, p = 0.006). Post-parade, salivary cortisol decreased (p < 0.001) while aldosterone increased (p < 0.001). Maximum estimated core temperature was 38.6 ± 0.03 °C, indicating considerable thermal stress, with a "high" physiological stress index of 7.2 ± 0.2. Participants did not fear repercussions for fainting during SCPD, but associated it with profound stigma. This work highlights the utility of wearables in field environments. SCPD represent considerable physiological stress, with marked cardiovascular instability, and substantial thermal, orthostatic, and exercise stress. Use of evidence-based prevention measures could improve syncope outcomes during SCPD.

Vagal-mediated cardiovascular responses can occur following carbon dioxide pneumoperitoneum during laparoscopic surgery. In rare cases, an exaggerated vagal reflex may result in profound bradycardia or asystole. We report the case of a 44-year-old woman (American Society of Anesthesiologists physical status II) who developed abrupt bradycardia progressing to asystolic cardiac arrest immediately after abdominal insufflation during an elective minimally invasive gynecologic procedure. The planned operation included hysteroscopy with MyoSure (Hologic, Inc., Marlborough, MA, US) resection, NovaSure (Hologic) endometrial ablation, Acessa (Hologic) radiofrequency fibroid ablation, diagnostic laparoscopy, and salpingectomy for symptomatic uterine fibroids refractory to conservative management. Her past medical history was notable only for uterine fibroids and recently diagnosed hypertension. Preoperative laboratory testing and vital signs were within normal limits, and electrocardiography demonstrated normal sinus rhythm without clinically significant rhythm abnormalities. Immediately following the bradycardia, one milligram of atropine was administered intravenously. The patient then became asystolic, pneumoperitoneum was evacuated, and cardiopulmonary resuscitation was initiated. Return of spontaneous circulation was achieved after a single round of compressions, with restoration of normal sinus rhythm. The intra-abdominal portion of the procedure was subsequently aborted, and the patient remained hemodynamically stable postoperatively. At cardiology follow-up nine days postoperatively, the patient reported prior vasovagal-type episodes, including syncope following influenza vaccination and near-syncope during magnetic resonance imaging with intravenous contrast. This case highlights the importance of rapid recognition and management of vagally mediated cardiac events in the operating room. It also raises the question of whether targeted preoperative assessment for prior syncope or vasovagal episodes may help identify patients at increased risk for exaggerated vagal responses during procedures involving pneumoperitoneum, a potential area for future investigation.

This article summarizes the top 20 research studies of 2025 identified as POEMs (patient-oriented evidence that matters). Treating male sex partners of female patients with oral and topical medication reduces recurrence of bacterial vaginosis. Anti-influenza drugs do not reduce hospitalizations or mortality. COVID-19 vaccines still improve mortality and reduce hospitalizations. Influenza vaccines are safe in pregnancy. Vaginal estrogen appears to be safe in breast cancer survivors. Women with normal bone density given zoledronic acid every 5 years have fewer fractures. Early post-partum insertion of a long-acting reversible contraceptive is associated with fewer pregnancies vs delayed insertion. Early medication abortion before pregnancy confirmation is safe and effective. After stent placement in patients with atherosclerotic coronary vascular disease who are taking an anticoagulant, adding aspirin worsens outcomes. After catheter ablation for atrial fibrillation, discontinuing anticoagulants after 1 year is safe if atrial arrhythmia does not recur, whereas left atrial appendage closure is superior to oral anticoagulation. For patients with provoked venous thromboembolism and at least one ongoing risk factor, 12 months of apixaban is better than 3 months. Clopidogrel is slightly more effective than aspirin for the secondary prevention of myocardial infarction and stroke over 3 years. Intensive blood pressure lowering decreases cardiovascular events but increases rates of hypotension and syncope, and there are concerns about the applicability of the data to the United States. Duloxetine, milnacipran, and pregabalin provide meaningful pain reduction in adults with fibromyalgia. Amyloid-directed monoclonal antibodies do not provide clinically meaningful cognitive benefits and may cause harms. Bright light therapy is effective for nonseasonal depression. Water exposure 6 hours after cutaneous surgery does not increase the risk of complications. A meta-analysis of platelet-rich plasma injections for knee osteoarthritis concluded that high-quality studies found no meaningful pain improvement. Using an oral challenge to rule out sulfonamide allergy is safe when used with a risk assessment tool.

Aortic stenosis is the most common valvular heart disease in the United States, and it affects up to 3.7% of the general population. Atherosclerosis results in progressive calcification of the aortic valve, leading to valve narrowing. Aortic stenosis is more common in older adults and men and in those with bicuspid aortic valves or cardiovascular risk factors. Classic symptoms of aortic stenosis include exertional angina, dyspnea, syncope, presyncope, and symptoms of heart failure. Patients may present with atypical symptoms (eg, fatigue, exercise intolerance), which may be mistaken for other cardiopulmonary conditions or attributed to aging. Transthoracic echocardiography is the preferred test for diagnosis because it can classify the severity of aortic stenosis. Asymptomatic patients with aortic stenosis may be monitored with echocardiography every 3 to 5 years for mild stenosis, 1 to 2 years for moderate stenosis, and 6 to 12 months for severe stenosis. No specific treatment prevents the need for aortic valve replacement or reverses aortic stenosis. Aortic valve replacement is indicated in patients with symptomatic severe aortic stenosis and in a subset of those with asymptomatic severe stenosis. There is no difference in mortality between transcatheter aortic valve replacement and surgical valve replacement.

Superior vena cava (SVC) injury during pacemaker implantation is rare, with most cases reported during lead extraction rather than placement. In adults with congenital heart disease (ACHD), unexpected resistance during lead advancement requires immediate reassessment because technical or device-related factors can cause venous injury even when pre-procedural imaging does not show hostile venous anatomy. Evidence on the management of venous injury during implantation is limited.