Studies of Taiwanese mammals reveal varied patterns of population divergence. Low-mobility species such as mole-shrews and Formosan wood mice exhibit strong north–south splits. Surprisingly, similar patterns also occur in mobile taxa like Formosan serow and sambar deer. In contrast, other mobile species, including flying squirrels, and Reeves’s muntjac, show weak or no population structure. This recurring north–south divergence across taxa with diverse ecologies suggests that shared environmental and geographic gradients, in addition to historical isolation, may underlie these patterns. If so, species occupying similar habitats may exhibit comparable genetic breaks regardless of life history traits. Prior studies based solely on mitochondrial DNA may have missed fine-scale structure in species like muntjac; high-resolution SNP data now offer improved resolution. Here, we analyzed genome-wide SNPs from 71 Taiwanese Reeves’s muntjac and comparative Chinese samples. We detected deep divergence from Chinese muntjac (~0.24 MYA), and further north–south subdivision within Taiwan (~0.06 MYA). Demographic modeling revealed a complex history involving glacial isolation and asymmetric gene flow, mainly from north to south. Within Taiwan, genetic differentiation was shaped by both geography and climate, especially temperature annual range (Bio7), with niche models showing environmental separation. Selection scans identified PLA2-associated genes, potentially linked to thermal adaptation. This is the first study to demonstrate that both geographic and environmental heterogeneity jointly contribute to mammalian divergence in Taiwan. The repeated north–south split across ecologically diverse species highlights shared climatic and topographic factors driving parallel population structure in Taiwan’s montane ecosystems.

Introduction: Co-production of evidence syntheses has the potential to facilitate translation of research findings into policy and practice. However, few studies have explored the process of implementing co-produced evidence. This gap limits our understanding of how, and to what extent, co-production promotes knowledge translation. In this study, we used an implementation science lens to explore the factors that would motivate and shape interest-holders (including policymakers, health service representatives and consumers) to participate in implementing the Best Practice Principles in partnering with consumers (BPP) in hospitals in Melbourne, Australia. The BPP were developed as part of a co-produced Cochrane qualitative evidence synthesis exploring consumers’ and health providers’ experiences and perceptions of partnering. Methods: This exploratory, qualitative study was informed by cooperative inquiry and normalisation process theory (NPT). A six-member panel, including researchers, policy makers and consumers, guided data collection and analysis. Data collection involved semi-structured interviews with eleven participants (including consumer engagement leads, consumer representatives and a policymaker) about how to implement the BPP in hospitals in Melbourne, Australia. Interviews were analysed using framework analysis. Results: Interview participants reported the BPP were relevant to practice, consumer-centred, practical and flexible. There were several additional factors that could impact their uptake into practice. These included integration of the BPP into government policies and guidelines, evidence of the cost/benefit of BPP implementation, endorsement from health service leadership, involvement of consumers throughout the implementation process, a structured implementation and flexible measurement of implementation success. Conclusion: This exploratory study suggested that the BPP, a tool developed through a co-produced Cochrane qualitative evidence synthesis, promoted knowledge translation. Other factors at the macro- (political and economic), meso- (systems and organisations) and micro- (individual) levels could influence the implementation’s success. Implications for Cochrane authors aiming to optimise the knowledge translation of their review results are discussed.

The critical zone (CZ), extending from the vegetation canopy to unweathered bedrock, hosts coupled hydrologic, geochemical, and biological interactions that regulate soil health, water resources, and ecosystem sustainability. The subsurface CZ can extend tens of meters below the surface and is largely inaccessible, except in happenstance exposure from quarries or road cuts through mountain hillsides. Drilling and subsequent borehole sampling, monitoring and imaging reveal the importance of the deep subsurface for CZ evolution and function. However, drilling can be labor-intensive, require expensive, specialized equipment, and can only be done where the equipment can be deployed, limiting the number and placement of boreholes. To empower the next generation of critical zone scientists to employ drilling and downhole techniques, this review synthesizes emerging research objectives and methods commonly used during CZ drilling campaigns over the last 30 years. We focus on three CZ research themes: (1) physical and chemical weathering, (2) subsurface water storage and flow, and (3) solute, microbial, and gas dynamics. For each theme, we evaluate drilling techniques, sampling strategies, downhole logging approaches, long-term monitoring, and analytical methods that collectively enable diverse hypothesis-testing. We conclude by providing a vision for the future of drilling within the CZ, with a focus on novel drilling techniques aimed at recovering saprolitic material as well as borehole designs that can monitor and sample the vadose zone. Additionally, we emphasize that near-surface geophysics and data-model integration efforts are needed to expand borehole observations to the larger scales that are necessary to advance CZ science and inform ecosystem and water resource management.

Abstract Background: Pulsed field ablation (PFA) has rapidly emerged as a promising alternative to conventional thermal ablation for atrial fibrillation (AF), offering tissue selectivity and procedural efficiency. However, recent evidence has raised concerns about its cerebral safety profile, particularly regarding silent cerebral lesions (SCLs) and microembolic signals (MES) detected by transcranial Doppler. Content: In light of the study “Comparison of cerebral micro-embolization detected by transcranial doppler examination between radiofrequency ablation and pulsed field ablation for atrial fibrillation,” this editorial discusses the unexpectedly high burden of cerebral MES observed with PFA—especially with certain catheter designs—compared with high-power short-duration radiofrequency ablation. Potential mechanisms include gas microbubble formation, microthrombus generation, and device- or technique-related air entrainment. These findings challenge the assumption that PFA is intrinsically safer with respect to cerebral embolization. Conclusion: While PFA represents a major technological advance in AF ablation, the emerging evidence underscores that not all PFA systems are equal regarding embolic safety. Device engineering, procedural optimization, and systematic neurological monitoring are essential to ensure that the benefits of this novel energy source are not offset by an “invisible” cerebral cost. Vigilance and continued innovation will be critical to secure both efficacy and neurological safety in the next generation of ablation technologies.

As the wild progenitor population of cultivated apricots, Xinjiang wild apricots hold irreplaceable significance in maintaining ecosystem functions and conserving germplasm resources. This study employed a combined approach utilising chloroplast DNA fragments (rpl32-trnL and ndhC-trnV) and a single-copy nuclear gene (DXH) to conduct a systematic phylogeographic analysis of wild apricot resources within the Ili wild fruit forests of Xinjiang. Results indicate significant divergence between genetic structures revealed by chloroplast DNA and nuclear genes, reflecting complex evolutionary processes driven by natural selection, genetic drift, and gene flow across distinct genetic systems. Genetic variation predominantly resided within populations, with weak differentiation between them. Neutrality tests and mismatch analysis indicated that wild apricot maternal lineages had not undergone significant historical expansions, suggesting a possible shared population contraction (bottleneck effect). Conversely, nuclear gene data supported recent expansion, with the Yining County population exhibiting the most pronounced expansion signal, indicating effective recording of this event by the nuclear genome. Niche modelling using the MaxEnt approach indicates that key environmental factors influencing wild apricot distribution include precipitation during the wettest season (100~135 mm), precipitation during the warmest season (90~120 mm), and soil sand content (6%~38%). The current suitable habitat is primarily concentrated in the Ili Kazakh Autonomous Prefecture, while projections under future climate scenarios indicate an expansion trend in its suitable range. This study systematically elucidates the genetic diversity characteristics and phylogeographic patterns of Xinjiang wild apricot, clarifying its population history dynamics and future distribution potential. It provides theoretical foundations and practical guidance for the scientific conservation and sustainable utilisation of germplasm resources for this species.

Caragana, a dominant leguminous plant in the barren semi-fixed deserts of northern China, forms critical symbiotic nitrogen-fixing associations with Mesorhizobium, which are vital for ecosystem functioning globally. However, the genetic adaptation of Caragana-associated Mesorhizobium symbionts driven by membrane transporters and nucleotide repair genes remained poorly illustrated. Recognizing the pivotal roles of membrane transporters (cysW, exoY, idhA) and nucleotide repair genes (mutS, uvrC) in microbial environmental resilience, this study investigated the adaptive dynamics of 68 representative Mesorhizobium strains isolated from Caragana across five geographically distant areas (A–E) in this desert belt. Phylogenetic analyses based on the five target genes revealed that strains clustered primarily by genospecies rather than geographic origin, with high topological congruence between membrane transporter, nucleotide repair and core gene trees. Genetic differentiation and frequent interspecific gene flow were predominantly driven by recombination (over mutation), indicative of active horizontal gene transfer (HGT) as a key evolutionary force. Notably, despite geographic separation, strains from the same genospecies exhibited extensive sequence homology in both gene sets, suggesting shared adaptive traits disseminated through HGT. Collectively, our results demonstrated that Caragana-associated Mesorhizobium have evolved primarily through adaptive processes shaped by homogeneous harsh desert environments, rather than geographic isolation. The membrane transporters likely facilitated rapid acquisition of nutrient uptake and stress-tolerance traits via recombination, while nucleotide repair genes maintained genomic integrity under extreme conditions. This dual genetic strategy underscores how HGT and purifying selection synergistically drive ecological adaptation in desert microbiomes.

Title: Spotlight Commentary: Deprescribing in long-term care facilities – Towards Safer and Smarter Medication Use in Older AdultsAuthors: Nataša Skočibušić 1,2,3, Igor Rubinić1,2, Vera Vlahović-Palčevski 1,2Department of Clinical Pharmacology, Clinical Hospital Centre Rijeka, Krešimirova 42, 51000Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, CroatiaDepartment of Health Ecology, Teaching Institute of Public Health of Primorsko-goranska, County, Krešimirova 52a, 51000 Rijeka, CroatiaCorresponding author : Nataša SkočibušićWord count : 1060References : 10 (BJCP: 6)Potentially inappropriate medication (PIM) use remains highly prevalent among older adults in long-term care facilities (LTCF), despite its well-documented risks for adverse clinical, functional, and economic outcomes. Numerous strategies have been explored to optimize pharmacotherapy in this vulnerable population, yet identifying interventions that reliably improve prescribing quality and resident outcomes remains an ongoing challenge. Evidence supporting broad, system-level interventions to enhance prescribing practice in long-term care is still limited, despite smaller-scale studies demonstrating meaningful benefits for residents’ health and well-being.The British Journal of Clinical Pharmacology has published several key contributions addressing these concerns, including research on PIMs, deprescribing initiatives, and pharmacist-led interventions to improve medication management in older adults. These studies underscore the complexity of medication optimization in aged care, highlighting the need for adaptable, evidence-based strategies that consider clinical context, patient-specific factors, and healthcare system variability.The global population of older adults is expanding at an unprecedented rate, with projections indicating that by 2050, approximately 17% of the world’s population, around 1.6 billion people, will be aged 65 and older 1. As life expectancy rises, the prevalence of polypharmacy, the concurrent use of multiple medications, has increased significantly. Polypharmacy increases the likelihood of exposure to PIMs, encompassing suboptimal prescribing practices such as overprescribing, underprescribing, and misprescribing, which are strongly linked to negative outcomes including reduced quality of life, hospitalizations, adverse drug reactions (ADRs), falls, disability, and mortality 2. Older adults often face multimorbidity, frailty, cognitive decline, and social deprivation, factors that not only complicate pharmacotherapy but also challenge the delivery of integrated care within predominantly disease-centered medical systems.A particularly vulnerable subgroup comprises older adults in LTCF, where adverse outcomes from inappropriate medication use are highly prevalent. Roller-Wirnsberger et al. highlighted that multimorbidity, defined as the coexistence of multiple chronic diseases without a single dominant condition, affects over 60% of individuals aged 65 years and older and increases with advancing age 3. Managing such patients often extends beyond standard clinical protocols, requiring more personalized and holistic models of care.A recent systematic review by Gutteridge et al. reinforced the critical importance of effective medication management in nursing homes and other long-term care settings 4. The authors identified medication-related harm as a global health priority, particularly in aged care services, where polypharmacy and complex treatment regimens are common. Their review underscored the need for comprehensive medication management systems, continuous quality monitoring, and multidisciplinary engagement. Pharmacist-led medication reviews, deprescribing initiatives, and ongoing staff education, emerge as key components in improving medication safety and optimizing therapeutic outcomes.Certain medication classes, such as benzodiazepines, Z-drugs, antidepressants, antithrombotic agents, opioids, antipsychotics, diuretics, insulin, and anticonvulsants, are particularly associated with ADRs in this population 5. These are frequently associated with adverse effects such as falls, haemorrhagic events, constipation, delirium, and hypoglycaemia – common causes of emergency department visits and hospitalizations 5. Despite recognition of these issues, PIM prescribing remains widespread in LTCF, posing ongoing clinical, economic, and ethical challenges.A study by Roberts et al., involving 52 nursing homes, demonstrated that pharmacist-led interventions implemented in collaboration with nursing and medical staff significantly improved medication appropriateness and reduced psychoactive and unnecessary drug use among nursing home residents 6. Subsequently, Cool et al. confirmed the benefits of multidisciplinary strategy, demonstrating that a general geriatric intervention, centred on staff education and support, reduced PIM use 7. Structural and organizational factors, including special care units and access to psychiatric services, also shaped prescribing patterns. Although reductions in high-risk medications, such as long half-life benzodiazepines, were modest, the findings reinforced the value of a coordinated, team-based approaches to medication optimisation.Building on these multidisciplinary and educational strategies, deprescribing has emerged as a central approach to reducing medication-related harm in older adults. Deprescribing refers to the systematic, supervised discontinuation of medications that are no longer necessary or may cause harm. It is particularly relevant in frail older adults who are more susceptible to ADRs due to age-related pharmacokinetics and pharmacodynamics changes, multimorbidity, and functional decline. The goal extends beyond simply reducing medication burden and involves aligning therapy with current clinical needs, life expectancy, and patient preferences. Effective deprescribing involves comprehensive medication review, careful evaluation of risks and benefits, shared decision-making with patients and caregivers, and close monitoring for withdrawal effects or symptom recurrence8,9.Evidence from nursing home populations demonstrates that such interventions, led by pharmacists working alongside physicians and nurses, can reduce PIM prevalence in nursing homes by up to 59%, while simultaneously lowering all-cause mortality by 26% and falls by 24%, without increasing hospitalizations or withdrawal-related adverse events8. Key elements of success include prioritization of high-risk drug classes, patient and caregiver education, ongoing monitoring, and using validated tools such as the Beers Criteria or STOPP/START to guide medication review. Shared decision-making enhances patient satisfaction and adherence, although its direct impact on clinical endpoints remains less clear 8.A systematic review by Page et al. confirmed that deprescribing interventions are generally safe and feasible 9. While randomized trials showed no significant change in mortality, non-randomized studies suggested potential survival benefits, particularly in those aged 65–80 years. Outcomes varied by medication type, e.g. discontinuing bisphosphonates was typically safe due to their prolonged effects, whereas withdrawal of antihypertensives produced modest blood pressure increases requiring individualized management. These findings affirm that selected medications can often be safely withdrawn without compromising health outcomes or quality of life.While most attention was focused on prescribed medications, the contribution of over-the-counter (OTC) drugs represent an often-overlooked source of medication-related harm in older adults. Commonly used agents such as non-opioid analgesics, antacids, laxatives, and cough or cold preparations are frequently self-administered, often perceived as harmless, and rarely disclosed to clinicians. However, they can contribute to therapy duplication, drug-drug interactions, and ADRs10. Incorporating OTC medication use into comprehensive medication reviews is therefore essential for safe prescribing practices.In conclusion, polypharmacy and inappropriate prescribing remain critical challenges in the care of older adults, particularly those in long-term care settings. Deprescribing offers a pragmatic, evidence-based strategy to optimize medication use, reduce harm, and improve clinical outcomes. Its success depends on structured, multidisciplinary, patient-centred approaches that employ validated assessment tools and shared decision-making. Continued research is needed to improve deprescribing processes, clarify long-term impact, and develop scalable models adaptable across diverse healthcare settings. By advancing ad disseminating such evidence, BJCP continues to play an important role in promoting safe, rational, person-centred pharmacotherapy for the world’s growing older population.

A document by Jose Marino. Click on the document to view its contents.

Therapy-related acute myeloid leukemia following plasma cell leukemia: a case report and literature review

Background: Immunoglobulin products are widely used for the treatment of immunodeficiency and autoimmune disorders. Although clinical trials have demonstrated their efficacy and tolerability, data describing their postmarketing safety profile in pediatric populations remain limited, particularly regarding rare and serious adverse events. This study aimed to characterize adverse event reports associated with immunoglobulin use in children during the postmarketing period. Methods: Pediatric adverse event reports (<18 years) submitted to the U.S. Food and Drug Administration Adverse Event Reporting System between 1 January 2001 and 31 December 2023 were analyzed. Descriptive statistics were used to summarize reported adverse events, and selected events and deaths were reviewed individually. Results: In total, 2,997 pediatric adverse events reports were identified, of which 1,855 (61.9%) were classified as serious. The most frequently reported adverse events were headache (n=394), pyrexia (n=294), urticaria (n=231), vomiting (n=229), nausea (n=182), off-label use (n=154), and infusion-related reaction (n=151). Clinically significant adverse events were infrequent, including hemolytic disorder (n=82), aseptic meningitis (n=80), anaphylaxis (n=34), thromboembolic event (n=34), renal impairment (n=22), and transfusion-related acute lung injury (n=7). Adverse event patterns were similar between intravenous and subcutaneous formulations, except for higher rates of systemic infusion reactions with intravenous administration and injection-site reactions with subcutaneous administration. Among 110 deaths, leading causes were unspecified (n=37), nervous system disorders (n=20), and infections (n=16). Conclusion: The postmarketing safety profile of immunoglobulin in pediatric patients was consistent with clinical data observed in prelicensure studies and described in the package insert, with no new safety concerns identified.

A document by Abhisek Jha. Click on the document to view its contents.

The variable and unpredictable output from distributed generation (DG) like wind and solar creates new reliability concerns for distribution networks. Integrating DG on a large scale can unbalance the power supply and compromise quality, making accurate reliability assessment essential. This paper puts forward a new assessment method using a Transformer network. The method first utilizes an improved minimum path algorithm designed for grids with DG. This algorithm models the scenario where a section of the grid, if cut off from the main supply, can form an operational island, using its local DG to power essential loads. Secondly, the Transformer network is innovatively applied to classify reliability indices into specific intervals, transforming a difficult prediction challenge into a more manageable classification task. This overcomes the problem of non-smoothness in reliability data. We demonstrate the method’s effectiveness on Feeder 4 of the IEEE RBTS 6-node test system. The proposed framework enables dynamic monitoring and proactive warnings against operational risks in the grid.

High-entropy oxides (HEOs) with five or more metal components in a single oxide phase, hold attractive potential to enhance the lithium polysulfides (LiPSs) adsorption-catalysis ability in Li-S batteries due to the noteworthy synergistic effect of the multiple metal sites. Herein, we have synthesized a RuO2-based HEO, i.e. (RuIrFeCoNi)O2 via a simple molten salt method for Li-S batteries. Our results prove that the introduction of multiple metal components endows HEO with moderate adsorption of LiPSs and promising bidirectional catalysis on the liquid-solid conversion between soluble LiPSs and insoluble Li2S. Particularly, compared with the quaternary (RuFeCoNi)O2 catalyst, the inferior kinetics enhancement of the LiPSs generation, but the superior promotion of Li2S deposition for HEO greatly favors the inhibition of shuttle effect. Such an asymmetric catalysis behavior induces remarkable electrochemical performance of Li-S batteries assembled with HEO-modified separator. High specific capacities of 1641.1 mAh g-1 at 0.1 C and 812.5 mAh g-1 at 2 C are achieved. Remarkably, superior cycle stability is realized with a low capacity decay rate of only 0.060% per cycle within 1000 cycles at 1 C rate. This study unveils the catalytic mechanism of HEO in promoting polysulfide conversion and offers a robust foundation for designing efficient catalysts for Li-S batteries.

Forest composition and structural diversity play a key role in shaping habitat availability and biodiversity, particularly influencing the occurrence of saproxylic species associated with tree-related microhabitats (TreMs). TreMs and deadwood are essential features of forest ecosystems, offering critical habitats for saproxylic arthropods that contribute to decomposition, nutrient cycling, and overall forest resilience. Understanding the complex interactions between forest structures, TreMs, and arthropod communities is crucial for biodiversity conservation and sustainable forest management. This study explores how forest composition, deadwood, and TreMs together influence arthropod diversity and community composition in temperate forests, using a large-scale eDNA metabarcoding approach. We assessed arthropod communities across 135 forest plots in the Black Forest, Germany with varying degrees of retention. Our findings reveal that specific TreMs, such as cavities, mosses, and insect galleries, significantly contribute to arthropod richness, particularly for Collembola, Coleoptera, and Arachnida. Canopy closure, deadwood volume, and snag availability emerged as key determinants of community composition, while low degrees of retention negatively impacted terrestrial arthropods biodiversity by reducing habitat complexity. These findings reveal that species richness and community composition are driven by different ecological factors, highlighting the complexity of forest ecosystems. They underscore the need for forest management strategies that preserve deadwood and TreMs, enhance structural heterogeneity, and consider broader indicators of forest naturalness to effectively support arthropod biodiversity.

Breeding systems can impact population dynamics and genetic diversity, especially when a population is small or isolated. Here, we used a long-term dataset of demographic data combined with 1,745 single nucleotide polymorphisms to investigate mating patterns within a population of the eastern quoll (Dasyurus viverrinus) reintroduced to a conservation-fenced reserve. Pedigree reconstruction revealed that 47.62% of eastern quoll litters exhibited multiple paternity, containing up to three sires. Trait-based generalised linear mixed-modelling showed reproductive success was significantly correlated with bodyweight, age, and colour-morph. A cross-species comparison within the Dasyuridae (which includes the eastern quoll) showed that shorter lifespan increased the rate of multiple paternity, but the degree of sexual size-dimorphism or intersex aggression does not. Our study indicated that individual traits can predict reproductive success, but the likelihood of multiple paternity can depend on the evolutionary/life history of the species (e.g., lifespan). Further research should focus whether the interaction between breeding system and life history may predict patterns of multiple paternity within a species.

Mountain catchments are key freshwater suppliers to lowland urban populations, sustaining key ecosystem services, particularly in seasonally semiarid environments where potential evapotranspiration (PET) exceeds precipitation (P) for most of the year. However, the biophysical controls that enable snow-free mountains to maintain year-round positive water yields remain poorly understood. In this study, we analyze the water yield of 25 mountain catchments along a climatic gradient of central Argentina, where monsoonal precipitation ranges from 350 to 850 mm/year. We combine long-term hydrometric records with catchment biophysical descriptors of climate, topography, land cover, morphometry and lithology to identify the main drivers of water yield and related hydrologic signatures. Observed water yields varied widely across catchments (7 to 674 mm/year) and often surpassed estimates from extensively used theoretical and empirical hydrological models (i.e. 1974 Budyko´s envelope and 2001 Zhang´s watershed synthesis, respectively), highlighting the key role of local biophysical mountain features, beyond climate, generating flow. Generalized linear models identified mean annual precipitation and the fraction of exposed rock as the strongest positive predictors of water yield, while the aridity index (PET/P), woody vegetation cover, and drainage density were negatively associated with water yield. Hydrologic signatures offered further insight into underlying processes with altitude range and herbaceous vegetation appearing to support higher baseflows. Catchments with higher aridity and woody vegetation cover showed greater dry-season water yield fractions, highlighting the importance of low flows in these systems. By contrast, in more subhumid catchments, topographic attributes such as steep slopes and valley extent emerged as dominant drivers of runoff generation, in clear contrast to the fraction of flatlands. Comparisons with adjacent lowland systems evidenced that the topography, rocky outcrops, and vegetation of the studied mountain landscapes promote the generation of significant water yields, underscoring their critical hydrological and ecological role in the region.

A 60-year-old man was diagnosed with non–ST-segment elevation acute coronary syndrome (ACS) (Figure A). Coronary angiography (CAG) showed collateral flow from the left to right coronary artery (RCA) without occlusion (Figure B, C). Intravascular ultrasound (IVUS) revealed plaque-rich stenosis (Figure D), treated with drug-eluting stent (DES) placement.One month later, he was brought to our hospital due to ventricular fibrillation, requiring Veno-arterial extracorporeal membrane oxygenation (VA-ECMO). CAG showed mid-RCA stenosis refractory to 1 mg intracoronary isosorbide dinitrate (ISDN) (Figure E). OCT demonstrated fibrous cap disruption in the mid RCA, with otherwise normal adjacent segments. (Figure F-H). Although definitive plaque rupture was not evident, the lesion was considered potentially responsible for ACS, and PCI with DES implantation was performed. Continuous intravenous ISDN was administered post-PCI. After neurological recovery under targeted temperature management (TTM), VA-ECMO was weaned on day 3, with no significant ECG changes during TTM.Three hours later, ST elevation (Figure I, J) and pulseless electrical activity required VA-ECMO reinstitution. CAG showed distal RCA occlusion relieved after 15 mg ISDN (Figure K, L). OCT revealed microthrombus, multiple intimal injuries, and vessel shrinkage (Figure M–P). He died on day 4 from non-occlusive mesenteric ischemia despite intensive care.This patient experienced three ACS episodes in a short period, two at rest in the early morning. In the first event, the collateral flow suggests transient occlusion, possibly due to resolved thrombus or severe spasm. Intimal rupture has been documented in vasospastic angina; however, the extensive and multiple lesions identified in our case on final-event OCT may represent a more severe phenotype that has not been well characterized in previous literature.1 These findings underscore the potential of spasm to trigger cardiac arrest and the diagnostic utility of OCT.Figure Legends(A) Initial ECG. (B) Stenosis. (C) Collateral flow. (D) Plaque-rich stenosis. (E) Mid-stenosis. (F) Fibrous cap rupture. (G, H) Normal segments. (I, J) ECGs around recurrent arrest. (K) Occlusion. (L) Restored flow. (M, arrow) Thrombus. (N–P, arrow) Intimal injuries and vessel shrinkage.

Spontaneous Thoracic Spinal Epidural Hematoma: A Case Report and Literature Review