A 40-year-old woman was referred for cardiac assessment following a syncopal event. Echocardiography showed a dilated right ventricle and subsequent cross-sectional imaging suggested partial anomalous pulmonary venous connection (PAPVC) and a sinus venosus defect (SVD). She reported exertional dyspnoea, fatigue, paroxysmal nocturnal dyspnoea, longstanding palpitations, and documented runs of atrial tachycardia. Transoesophageal echocardiography demonstrated a dilated right ventricle and pulmonary arteries, mild tricuspid regurgitation, anomalous connection of the right upper and right middle pulmonary veins to the right superior vena cava (SVC), and a persistent left SVC draining to a dilated coronary sinus. Unusually, the interatrial communication consisted of only a small, restrictive fenestration between the SVC and the left atrium. Invasive haemodynamics confirmed a large left-to-right shunt (Qp:Qs 3.3:1) with normal pulmonary artery pressure (mean 19 mmHg). Balloon interrogation demonstrated a restrictive communication and prolapse of the compliant balloon into the pulmonary veins with apparent obstruction, indicating unsuitability for transcatheter correction; the patient underwent surgical repair. We report a previously undescribed SVD in which the interatrial communication is restrictive despite a large shunt carried by the anomalous venous connection and discuss its implications for transcatheter versus surgical decision-making.

Tetrandrine, a bisbenzylisoquinoline alkaloid extracted from Stephania tetrandra S. Moore, is clinically used in the treatment of silicosis and rheumatoid arthritis. Despite its demonstrated efficacy, systematic safety evaluations remain limited. This study represents the first effort to identify adverse event (AE) signals associated with tetrandrine meglumine using the World Health Organization VigiAccess database. Global AE reports for tetrandrine were extracted up to July 6, 2025. The collected data included demographic variables such as age group and gender, as well as regional distribution. Additionally, data on adverse drug reaction-related disease systems and symptoms were compiled from adverse drug reaction annual reports and reports submitted to the World Health Organization. Disproportionality analyses were conducted using the reporting odds ratio (ROR) and the Bayesian confidence propagation neural network. A total of 265 reports were included, documenting 448 AEs. The most commonly affected systems were gastrointestinal disorders (38.39%), skin and subcutaneous tissue disorders (16.96%), and nervous system disorders (16.07%). Frequently reported adverse reactions included nausea, dizziness, pruritus, vomiting, rash, abdominal pain, diarrhea, and abnormal hepatic function. Strong association signals were observed for oral anesthesia (ROR 241.19, 95% confidence interval [CI] 79.74-729.58), abnormal hepatic function (ROR 20.31, 95% CI 12.27-33.63), hypoaesthesia (ROR 10.47, 95% CI 4.66-23.54), pollakiuria (ROR 9.53, 95% CI 3.04-29.83), and abdominal pain (ROR 8.94, 95% CI 5.96-13.41). Additionally, potential adverse reactions not listed in the product labeling, including pruritus, rash, abnormal hepatic function, chest pain, palpitations, hypoaesthesia, edema, pyrexia, insomnia, pollakiuria, and dyspnea, were identified. This study comprehensively characterized the AE profile of tetrandrine and identified novel adverse effects. These findings underscore the importance of ongoing drug safety monitoring and patient management, and highlight the need for clinicians to use this medication more appropriately, tailoring treatment regimens based on the identified adverse effect profiles.

Background/Objectives: Jangwon-hwan (JH), known as Zhuangyuan-wan in Chinese medicine, has traditionally been used for forgetfulness and poor memory, often accompanied by palpitations and insomnia. However, the pharmacological mechanisms underlying its traditional use for memory-related symptoms remain unclear. This study aimed to evaluate the effects of JH on memory function and to elucidate the underlying mechanisms, thereby providing scientific evidence for its use. Methods: JH (30 or 100 mg/kg) was orally administered for 28 days in normal mice and for 14 days in scopolamine-induced memory-impaired mice. Memory performance was assessed behaviorally, with molecular and histological analyses of brain tissue. Results: JH improved passive avoidance memory and increased hippocampal synaptophysin and postsynaptic density protein 95 in normal mice. JH also enhanced medial septal cholinergic neuronal activation and increased hippocampal acetylcholine levels. It further increased muscarinic acetylcholine receptor M1 and metabotropic glutamate receptor 5 expression, upregulated synaptic plasticity-related genes, and enhanced hippocampal neuronal activation. Consistent with its effects on cholinergic signaling, JH attenuated scopolamine-induced memory impairment and preserved hippocampal phosphorylation of calcium/calmodulin-dependent protein kinase II, extracellular signal-regulated kinase, and cAMP response element-binding protein. Conclusions: Collectively, these findings indicate that the memory-enhancing effects of JH are associated with enhanced cholinergic signaling, synaptic plasticity, and hippocampal neuronal activation, providing molecular evidence supporting its traditional use for forgetfulness and poor memory.

Background/Objectives: Ephedrae Herba (EH) is widely used in traditional East Asian medicine, but safety concerns regarding its adverse events remain. This study aimed to investigate EH-associated adverse events using clinical pharmacovigilance data and to perform exploratory in silico analyses to propose potential molecular mechanisms underlying these adverse events. Methods: A disproportionality analysis was performed using individual case safety reports from the Korea Adverse Event Reporting System database. EH-containing products were compared with other herbal medicine products using reporting odds ratios (RORs), proportional reporting ratios, and information components. Network pharmacology identified adverse event-related genes and pathways, and protein-protein interaction networks were constructed. Molecular docking predicted direct adverse event-associated targets of ephedrine and compared mechanisms with control compounds (aconitine and spinosin). Results: Four adverse-event signals were detected in the primary analysis: sleep disorder, dry mouth, insomnia, and palpitations. Sensitivity analysis identified four signals, with three (dry mouth, insomnia, and palpitations) consistent across both analyses; constipation emerged only in the sensitivity analysis. Conclusions: Adverse event-associated network analysis predicted key pathways: Neuroactive ligand-receptor interaction, Pathways of neurodegeneration, and Dopaminergic synapse. Molecular docking predicted that ephedrine may act on downstream signaling mechanisms shared by neurotransmitter systems, including the dopaminergic system, distinct from control compounds.

Background and Objectives: Pediatric chest pain is usually benign, but identifying children who require admission or have a cardiac diagnosis remains challenging. We aimed to identify factors associated with these outcomes, with a focus on recurrent presentation and the combined value of C-reactive protein (CRP) and predefined red-flag findings. Materials and Methods: This retrospective cohort included children aged 0-18 years presenting with chest pain to a tertiary pediatric emergency department between January 2021 and January 2026; visits with insufficient documentation were excluded. Red-flag findings were predefined as effort-related chest pain, syncope, palpitations, dyspnea, fever, or a family history of sudden cardiac death. Independent predictors were assessed using multivariable Firth logistic regression, and cluster-robust standard errors were used in a sensitivity analysis to account for recurrent visits. Results: Of 1703 visits (1435 patients), 452 (26.5%) were recurrent presentations. Admission occurred in 64 visits (3.8%), and 91 (5.3%) had a cardiac diagnosis. Red-flag findings (OR, 5.15), abnormal ECG (OR, 4.00), CRP > 5 mg/L (OR, 3.71), male sex (OR, 2.13), and recurrent presentation (OR, 2.51) were independently associated with admission (all p ≤ 0.009). Recurrent presentation was not associated with a cardiac or psychogenic diagnosis. Admission and cardiac diagnosis rates increased from 1.4%/2.2% in children with neither elevated CRP nor red-flag findings to 22.2%/24.8% in those with both. Routine ECG, troponin, and chest radiography had low diagnostic yields (2.1-6.0%), whereas echocardiography performed selectively yielded abnormal findings in 79.7%. Conclusions: Red-flag findings, abnormal ECG, elevated CRP, and recurrence were associated with admission, whereas recurrence was not associated with diagnosis. Combining CRP with red flags may improve risk stratification, though prospective validation is needed.

Background: Pheochromocytoma is a rare tumor of the adrenal medulla, often associated with hypertension, headache, diaphoresis, and palpitations, but presentations vary; some are silent until incidentally found or when complications develop. One rare complication is spontaneous adrenal hemorrhage, previously mainly found at autopsy, which can extend into the retroperitoneum, causing acute pain and mimicking emergencies. Imaging modalities like computed tomography are vital for detection, especially in acute cases, while magnetic resonance imaging provides greater tissue detail to identify tumors such as pheochromocytomas. If a functional adrenal tumor is suspected, biochemical tests for catecholamine excess are crucial for diagnosis and management. In this report, we present a case of pheochromocytoma that initially manifested with spontaneous adrenal hemorrhage without hypertension, thereby complicating and prolonging the diagnostic process. Case presentation: A previously healthy 34-year-old man presented with sudden, severe right-sided abdominal and flank pain, nausea, vomiting, and headache. He was normotensive but anemic and required a red blood cell transfusion. Initial computed tomography revealed a large hemorrhagic lesion in the right retroperitoneal space. The hematoma was managed conservatively. Magnetic resonance imaging confirmed subacute hematoma. Follow-up computed tomography showed gradual regression of the hematoma but persistence of an enhancing right adrenal lesion. Elevated plasma metanephrine and normetanephrine levels, together with positive iodine-123 metaiodobenzylguanidine imaging and preoperative computed tomography, supported the diagnosis of pheochromocytoma. After preoperative alpha-adrenergic blockade, laparoscopic right adrenalectomy was performed without complications. Histopathology confirmed a pheochromocytoma classified as moderately differentiated (GAPP), with a Ki-67index of 1-3%. Genetic testing showed no pathogenic variants in the analyzed genes associated with hereditary pheochromocytoma or paraganglioma syndromes. Conclusions: Spontaneous adrenal hemorrhage may be the first sign of pheochromocytoma, even in normotensive patients. Acute bleeding can obscure the tumor. Persistent adrenal lesions after hematoma regression should be monitored with computed tomography or magnetic resonance imaging, along with biochemical and functional evaluation, to avoid serious complications or death.

Medical clearance is still required for many people living with long-term conditions before participating in organised physical activity (PA) despite international guidance suggesting it is usually unnecessary. Existing physical activity readiness tools often direct people towards medical review, creating avoidable barriers. This study aimed to co-create digital, patient-facing guidance to support informed, autonomous decision-making about physical activity without routine medical clearance. This three-phase study used the Knowledge-to-Action framework to develop patient-facing information. Phase 1: Literature review, audit of industry adverse events and stakeholder surveys. Phase 2: Cross-sector workshops with healthcare professionals (HCPs), patient advocates and industry representatives. Phase 3: Creation of consensus statements through patient focus groups, multidisciplinary HCP panel, secondary patient consultation and implementation partner consultation with final consensus validation. Consensus development followed ACcurate COnsensus Reporting Document (ACCORD) principles and Appraisal of Guidelines for Research and Evaluation (AGREE II) criteria. There was cross-sector agreement that current processes are not fit for purpose. Clinicians reported low confidence in providing medical clearance, industry stakeholders identified governance and implementation challenges, and patients expressed concern about worsening symptoms and requested clear, supportive guidance. Through iterative consensus, four headline safety statements and seven symptom-specific statements were developed, addressing musculoskeletal pain, fatigue, shortness of breath, cardiac chest pain, palpitations, diabetes and falls, including practical self-management advice and indicators for seeking medical review. These patient-centred, evidence-based statements offer a credible alternative to routine medical clearance and may reduce barriers to engagement with organised physical activity opportunities for patients and industry providers. Future work will evaluate feasibility, acceptability and safety in real-world settings.

Cervical carcinosarcoma (CCS), also known as malignant mixed Müllerian tumor (MMMT) of the cervix, is an exceptionally rare and aggressive biphasic neoplasm composed of both epithelial and mesenchymal malignant components. Due to its rarity, optimal management strategies are not well established, particularly in low-resource settings. Most reported cases present at an advanced stage and are associated with poor prognosis. To our knowledge, this represents the first reported metastatic case of CCS from Sub-Saharan Africa. We report a case of advanced CCS in a 33-year-old woman who presented to a tertiary referral center in Northern Tanzania with a five-month history of heavy and prolonged vaginal bleeding, lower abdominal pain, headaches, palpitations, and generalized weakness. Clinical examination revealed a large vaginal mass with restricted uterine mobility and rectal involvement. Imaging demonstrated a heterogeneously enhancing cervical mass measuring 10 × 9 × 14 cm with parametrial invasion, recto-sigmoid infiltration, bilateral ovarian enlargement, peritoneal dissemination, lymphadenopathy, and ascites, consistent with FIGO stage IVB disease. Exploratory laparotomy revealed omental caking, bilateral ovarian masses, liver surface nodules, and extensive pelvic adhesions. A total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO) was performed. Histopathological examination demonstrated a biphasic malignant tumor composed of carcinomatous elements arranged in nests and cords and sarcomatous pleomorphic spindle cells. Immunohistochemistry showed epithelial differentiation with p16 positivity and mesenchymal differentiation highlighted by desmin. Intraoperative findings and imaging confirmed ovarian and peritoneal metastases, consistent with advanced disease. Multidisciplinary review recommended systemic chemotherapy with carboplatin and paclitaxel followed by radiotherapy. Treatment was not initiated, however, due to financial constraints. The patient was subsequently lost to follow-up.

Sleep disruption is a common hallmark of posttraumatic stress disorder (PTSD), causing significant distress and often persisting after remission of other symptoms. Autonomic dysregulation is commonly comorbid and has been implicated in the underlying pathophysiology of both wake- and sleep-related symptoms following trauma. However, existing self-report tools for nightmares and trauma-related sleep disruption place relatively little emphasis on autonomic symptoms such as palpitations and sweating, limiting our ability to gauge these features quantitatively, assess their impact on sleep, and track their response to treatment. Here, we describe the initial validation of a novel exploratory 11-item self-report measure, the Seattle Trauma and Autonomic Related Sleep Symptoms (STARSS) Scale, developed to assess trauma-related sleep disruption including nightmares and autonomic hyperarousal symptoms. Psychometric validation of the STARSS was assessed in a sample of 830 healthcare workers and first responders working during the COVID-19 pandemic. The full scale (STARSS-11) positively correlated with self-report measures of symptom domains often associated with nightmares and commonly elevated following trauma exposure including PTSD (PCL-5; r = 0.76), anxiety (GAD7; r = 0.65), depression (PHQ9; r = 0.63), and insomnia (ISI; r = 0.56), and displayed strong internal consistency (α = 0.89; ω = 0.93). The STARSS-11 is well-fit by a 4-factor model: hyperarousal upon waking, trauma dream intensity, and self- and partner-reported excessive physical activity during sleep. An item-reduced STARSS-9 with 3 factors is also described. These outcomes suggest STARSS is a promising tool for the assessment of sleep disturbance related to trauma and dysautonomia in research settings.

(1) Background: In routine clinical practice, CHDs are occasionally diagnosed in adulthood, mostly relatively minor defects that become symptomatic later in life. Less frequently, adults may present with complex CHDs that, due to anatomical variations, remain undiagnosed until adulthood. Another important group comprises patients with previously unrecognized CHDs, particularly those from socioeconomically disadvantaged settings with limited access to healthcare. (2) Body: In adulthood, CHDs often present with nonspecific symptoms suggestive of other cardiovascular conditions (cardiomyopathy or coronary artery disease), including dyspnea, chest discomfort, signs of HF, syncope, palpitations, and paradoxical embolism. The initial manifestation may also be a malignant arrhythmia or sudden cardiac death; therefore, early recognition and diagnosis are crucial. TTE represents the first-line diagnostic modality. Reduced LVEF in young patients, particularly when accompanied by left atrial and right-sided cardiac chamber dilatation, should raise suspicion of an underlying CHD. The diagnostic evaluation may be supplemented by TEE, CMR imaging, and right heart catheterization. Familial forms of CHD and the risk of transmission to offspring have been extensively investigated, particularly for conditions with a strong genetic component, such as BAV. (3) Conclusions: In adult patients with newly diagnosed CHD, accurate recognition of clinical symptoms and completion of an appropriate diagnostic workup are essential for establishing the diagnosis and initiating timely treatment. Furthermore, identification of families at increased genetic risk is important to facilitate targeted genetic panel screening. Future research should focus on developing and validating appropriate screening strategies for the early detection of CHDs in resource-limited regions.

Bicuspid aortic valve (AV) is the most common congenital cardiac valvular anomaly and often progresses to severe calcific aortic stenosis (AS). Although surgical AV replacement has been the conventional treatment, transcatheter AV implantation (TAVI) is emerging as a viable alternative, especially in patients with high surgical risk or complex anatomy. This case report demonstrates the crucial role of echocardiography in the management of TAVI in a patient with bicuspid AS. A 66-year-old male with a 3-year history of palpitations and recurrent presyncope underwent a comprehensive evaluation for suspected AV disease. Transthoracic echocardiography (TTE) revealed severe bicuspid AS with preserved left ventricular function. Coronary angiography and computed tomography angiography were performed for anatomical and procedural assessment, confirming suitability for TAVI. The procedure was conducted through a transfemoral approach using a 24-mm self-expanding bioprosthetic valve under echocardiographic guidance. TEE provided real-time imaging during valve deployment, while serial TTE was used for postprocedural and follow-up evaluations at 1 and 6 months to assess valve function and complications. This case underscores the central role of echocardiography in the comprehensive management of TAVI for bicuspid AS, from patient selection and intraprocedural guidance to postimplantation monitoring, ultimately optimizing clinical outcomes.

Mediastinal masses are an uncommon finding in the emergency department and cause a variety of symptoms and presentations. Cardiac arrhythmias represent a rare complication that may reveal these tumors, particularly through cardiac compression. We report the case of a 40-year-old patient with a past medical history of a primary mediastinal hepatoid adenocarcinoma treated with chemotherapy. The patient was admitted to the emergency department with palpitations occurring with changes of position. Upon further investigation and initial treatment with an oral beta-blocker, the patient had an enormous anterior and middle mediastinal mass extending vertically across all three anatomical levels, with significant mass effect on cardiac structures explaining his dysrhythmia occurring at the change of position. Given the size of the mass and its close relationship to surrounding structures, the patient was started on chemotherapy while continuing beta-blocker therapy. Palpitations are most often a symptom of a benign underlying condition; however, they can also be a sign of potentially serious and life-threatening diseases, and hence a thorough investigation is important.

Entrapment of an undeflated angioplasty balloon with subsequent shaft disruption is a rare, life-threatening complication of percutaneous coronary intervention (PCI). When percutaneous retrieval fails, emergency surgical extraction with concomitant revascularization may be the only lifesaving option. Shaft disruption of a non-deflating angioplasty balloon represents an exceptionally rare subset of PCI device entrapment, with only isolated cases reported in the literature. A 76-year-old hypertensive and diabetic woman presented with a 5-day history of exertional dyspnea, palpitations, and generalized fatigue. Diagnostic coronary angiography revealed triple-vessel coronary artery disease involving distal left main, proximal left anterior descending artery (LAD), ramus, left circumflex (LCx), and right coronary artery (RCA). She underwent multivessel PCI. LCx and ramus were stented uneventfully. During attempted LAD lesion preparation, the dilatation balloon failed to deflate; the distal tip collapsed while the proximal segment remained inflated; a stent was therefore never deployed in the LAD. Attempts to withdraw the balloon led to shaft fracture, with the partially inflated balloon retained in the LAD and guidewire fragment prolapsing into the aorta. Multiple retrieval maneuvers with fresh guidewires failed and hemodynamics deteriorated despite intra-aortic balloon pump (IABP) and dual inotropic support. Emergency surgery revealed hemorrhagic pericardial effusion and a hematoma along the proximal LAD. Under cardiopulmonary bypass (CPB), an oblique aortotomy exposed the guidewire exiting the left coronary ostium. The retained wire (≈25 cm) and inflated 2-cm balloon were extracted en bloc. Two reversed saphenous vein grafts (rSVGs) were placed to mid-LAD and posterior descending artery (PDA). The patient was weaned off bypass uneventfully and discharged on postoperative day 6. Entrapment of an undeflatable balloon during LAD PCI with shaft disruption is exceedingly rare. Early recognition, prompt surgical conversion, and complete revascularization are crucial for survival in this high-risk complication.

Hypercalcaemia is a recognised complication of thyrotoxicosis usually related to increased bone resorption. However, coexistent hyperphosphataemia is uncommon and may create diagnostic uncertainty. It is postulated that serum calcium and phosphate levels rise due to high bone turnover and increased renal reabsorption of phosphate in response to excess thyroxine. Hypercalcaemia may also alter the clinical presentation of thyrotoxicosis, making both diagnosis and management challenging. We report two patients with this unusual biochemical presentation. The first patient was a 69-year-old woman who presented with body aches, lethargy, low mood, constipation, polyuria, and proximal muscle weakness for 2 months. The second was a 56-year-old woman who presented with palpitations, anxiety, tremulousness, dyspnoea, dysphagia, and headache for 4 months. Both had multinodular goitres (MNGs) without eye disease. Their TSH levels were undetectably low with extremely high free T4 levels. Serum calcium and phosphate levels were high in both patients. ALP levels were mildly elevated, vitamin D levels were deficient or insufficient, and parathyroid hormone (PTH) levels were low-normal. DXA scans revealed severe osteoporosis. Both patients improved clinically and biochemically with adequate intravenous hydration, frusemide, carbimazole, propranolol, and bisphosphonates. The second patient underwent a successful left thyroid lobectomy, while the first patient remained well on medical treatment. Unexplained hypercalcaemia and hyperphosphataemia should alert the clinicians to the possibility of underlying thyrotoxicosis. Prompt recognition and management is essential to prevent bone loss, correct metabolic abnormalities, and avoid complications. Clinicians should also consider the possibility of hypercalcaemia associated with thyroid dysfunction in patients presenting with nonspecific symptoms such as fatigue, constipation, proximal weakness, polyuria, or mood changes.