Objectives: Literature has shown a high prevalence of poor inhaler technique among COPD patients throughout the past several decades. We aim to study patient perspectives on inhaler use to understand how inhaler therapy can be better approached. Methods: COPD patients who were regularly using pressurized metered-dose inhaler(s) (pMDI) with or without spacers were recruited to complete a survey regarding their perception of inhaler use. Each patient’s inhaler technique was assessed using the American Thoracic Society (ATS)’s recommended steps on using pMDIs. Results: One hundred and one patients participated in the study. 91 (90.1%) reported that they use their inhaler correctly and 80 (79.2%) indicated that using their inhaler is easy, however 47 (46.5%) demonstrated inhaler misuse. 35 (34.7%) indicated that they prefer to consolidate all of their inhalers into one. When asked about previous training, 25 (24.8%) reported that they have not been shown how to use inhalers before. Conclusions: Despite the high prevalence of poor inhaler use, the majority of COPD patients are confident in their inhaler technique and find them easy to use. Increasing patient awareness of poor inhaler technique and providing more frequent coaching on how to correctly use pMDI’s may be beneficial in improving overall COPD management.

Objective: Infertility is recognized as a public health issue worldwide where the total fertility rate is decreasing in most countries. Hence, this study assesses the use of folic acid supplementation prior to pregnancy in the Lebanese population. Method: It was a cross-sectional study that took place between December 2019 and February 2020 using a representative sample of community patients. Of 1000 participants who were approached, 980 were completed and collected back. The sample was drawn from the districts of all Lebanese governorates (Beirut, Mount Lebanon, North Lebanon, South Lebanon, and Bekaa). Results: Conclusion: The findings of this study about the assessment of the use of folic acid prior to pregnancy may be the first step towards the development of efficient health promotion programs oriented for the adequate utilization of folic acid use among Lebanese population

Somatostatin (SST) receptors are well known to regulate exocrine secretions, neurotransmission and inhibit cell proliferation. SSTR subtypes exhibit heterodimerization with unique signaling characteristics. In the present study, using western blot and co-immunoprecipitation, FACS analysis, immunofluorescence, we investigated the differential interaction between MRAP1 and SSTRs and the role of MRAP1 on mouse SSTR2/SSTR3 and SSTR2/SSTR5 heterodimerization in HEK293 cells. The interaction binding sites of SSTR2/SSTR3 or SSTR2/SSTR5 with MRAP1 depend on SSTR3 and SSTR5 but not SSTR2. MRAP1 binding sites on SSTR3 are extensive, while the binding sites on SSTR5 are concentrated on TM6 and TM7. We also determined that MRAP1 enhanced agonist-mediated cAMP inhibition by inhibiting SSTR2/SSTR3 and SSTR2/SSTR5 heterodimerization. Up-regulation of ERK1/2 phosphorylation, p27Kip1 and increased cell growth inhibition when co-expressing SSTR2/SSTR3 or SSTR2/SSTR5 with MRAP1, suggested an effect of MRAP1 on anti-proliferative response of two SSTR heterodimers. Taken together, these results provide new insights for binding protein MRAP1 in the maintenance and regulation of mouse SSTR dimers which might be helpful to better understand the molecular mechanism involving SSTRs in tumor biology.

BACKGROUND AND PURPOSE A recently discovered multi-target opioid/neuropeptide FF (NPFF) receptor agonist, DN-9, exhibited peripherally acting analgesia. To improve its metabolic stability and blood-brain barrier penetration, we designed and synthesized a novel cyclic disulfide analogue of DN-9, OFP011, and examined its bioactivity using in vitro cAMP and in vivo behavioral experiments. EXPERIMENTAL APPROACH OFP011 was pharmacologically characterized using the in vitro cAMP assays at opioid and NPFF receptors. The blood-brain barrier (BBB) transport property of OFP011 was investigated using pharmacokinetic and pharmacological experiments. Antinociceptive properties of OFP011 were investigated in acute, inflammatory and neuropathic pain. Its adverse effects on locomotor coordination, gastrointestinal transit, antinociceptive tolerance, addiction, reward, and respiration were further assessed. KEY RESULTS OFP011 exhibited multifunctional agonistic efficacies at mu-, delta-, kappa-opioid, NPFF1 and NPFF2 receptors in vitro. The pharmacokinetic and pharmacological experiments demonstrated its BBB permeability after systemic administration. In addition, subcutaneous OFP011 produced potent and long-lasting antinociception via central opioid receptors in various pain models. At the highest analgesic doses, subcutaneous OFP011 induced reduced adverse effects, including tolerance, gastrointestinal transit, motor function, addiction, reward, and respiration depression. Notably, OFP011 achieved oral antinociceptive activity in different pain models. CONCLUSION AND IMPLICATIONS OFP011 exhibited potent and sustained analgesia without opioid-like side effects. Collectively, the results imply that the multifunctional opioid/NPFF receptor agonists with improved BBB penetration may be a promising strategy to treatment of moderate to severe nociceptive and pathological pain with fewer side effects.

Background: Liver transplant (LT) recipients with COVID-19 have been reported as a high-risk population for severe disease through the COVID-19 pandemic. Studies have shown that liver transplantation did not significantly increase the risk of death and severe disease in patients with SARS-CoV-2 infection. Methods: From September 2020- March 2021, we collected data and serum anti-SARS-CoV-2 IgM +IgG results for 91 liver transplant recipients. Study enrolment was performed when patients presented for scheduled routine follow-up. All participants with serum anti-SARS-CoV-2 IgM+IgG completed a questionnaire querying information including clinical symptoms in the last six months. We further collected 91 patients with anti-SARS-CoV-2 IgM + IgG results. Seven patients had a known history of symptomatic COVID-19 during the previous six months. Of the 84 participants included in the study, 21 (25 %) had positive anti-SARS-Cov-2 IgM + IgG results. In addition, we applied the COVID-19 PCR test to all 21 patients, and all of them were negative. Overall, only seven patients declared flu-like upper respiratory tract infection symptoms or diarrhea in detailed inquiry. Conclusion: We documented past SARS-CoV-2 infection in 25 % of our outpatient LT recipients, and the majority were asymptomatic. There was no significant relationship between symptoms and seropositivity for SARS-COV-2.

The world is under the threat of COVID-19 pandemic caused by SARS-COV2 since January 2020. And this pandemic has caused millions of deaths still it is affecting the lives of many people affected by this viral disease. The unavailability of definite treatment is a main focus to ponder because symptomatic treatment like use of antibiotics, steroids and oxygen therapy is also a cause of many opportunistic infections like oral candidiasis caused by Candida Albicans and the main reasons of this infection are the excessive use of medications which may cause drug reaction, the continuous use of oxygen therapy and co-morbidities and poor oral hygeine etc. which increase the length of hospital stay of patient and also affect the quality of life of patient as patients become dysphagic as unable to take orally due to the severity of this opportunistic infection. This case study was done to check the prevalence of oral candidiasis in inpatients of COVID-19 and their possible management was done with the use of both topical as well as systemic antifungals and this condition resolved in 5 to 7 days with the proper management and proper maintenance of oral hygiene. Keywords: Pandemic, opportunistic, infection, topical, systemic, hygiene

Atrial fibrillation patients with heart failure often have the worst prognosis. Pacing combined with atrioventricular node ablation (AVNA) is often the last resort in patients with atrial fibrillation (AF) and heart failure (HF) who are refractory to medication therapy or AF catheter ablation, especially in those with other arrhythmias that need pacemaker therapy. His bundle pacing is a physiologic pacing option for patients undergoing AVNA, which prevents the adverse consequences of right ventricular pacing and enhances the response rate compared with biventricular pacing (BVP). Several studies have proven the clinical benefits, feasibility and efficacy of His bundle pacing combined with atrioventricular node ablation in patients with AF and HF. However, this must be confirmed in large randomized clinical trials. Due to HBP limitations of difficulty in implantation, lower success rates in patients with QRS prolongation, and high and unstable pacing capture threshold, the concept of left bundle branch pacing has been proposed in recent years. In this review, we discussed the epidemiology of atrial fibrillation and heart failure, their interrelations, current treatment for patients with AF and HF and focus on the role and current evidence for His bundle pacing combined with atrioventricular node ablation in patients with AF and HF.

In 2018, there was an outbreak of African swine fever (ASF) in China, which spread to other provinces in the following three years, severely damaging China’s pig industry. ASF is caused by the African swine fever virus (ASFV). Given that the genome of the African swine fever virus is very complex and whole genome information is currently inadequate, it is important to efficiently obtain virus genome sequences for genomic and epidemiological studies. The prevalent ASFV strains have low genetic variability; therefore, whole genome sequencing analysis provides a basis for the study of ASFV. We provide a method for the efficient sequencing of whole genomes, requiring only a small number of tissues. The pig spleen were crushed and homogenized, and the tissue and cell fragments were removed by low-speed centrifugation. The virus-like particles (VLPs) in the solution were purified and concentrated by filtration and over-speed centrifugation. After obtaining the relatively pure VLP sample, nucleic acids were extracted simultaneously by co-extraction of viral DNA (dsDNA, ssDNA) and RNA (ssRNA, dsRNA). Then, the database construction method was selected according to the genomic types of ASFV, and the whole ASFV genome was obtained through data filtering, host sequence removal, virus classification, data assembly, virus sequence identification, statistical analysis, gene prediction, and functional analysis. Our proposed method will facilitate ASFV genome sequencing and novel virus discovery.

Current increases in not only the intensity and frequency but also the duration of drought events could affect the growth, physiology, and mortality of trees. We experimentally studied the effects of drought duration in combination with fertilization on leaf water potential, gas exchange, growth, tissue levels of non-structural carbohydrates (NSCs), tissue NSC consumption over winter, and recovery after drought release in oak (Quercus petraea) and beech (Fagus sylvatica) saplings. Long drought duration (> 1 month) decreased leaf water potential, photosynthesis, and NSC concentrations in both oak and beech saplings. Nitrogen fertilization did not mitigate the negative drought effects on both species. The photosynthesis and relative height increment recovered in the following rewetting year. Height growth in the rewetting year was significantly positively correlated with both pre- and post-winter root NSC levels. Root carbon reserve is critical for tree growth and survival under long-lasting drought. Our results indicate that beech is more sensitive to drought and fertilization than oak. The present study, in a physiological perspective, experimentally confirmed the view of Ellenberg (2009) that the European beech, compared to oak, may be more strongly affected by future environmental changes.

Objectives We aimed to evaluate the awareness and perspectives of acromegaly patients in the diagnosis and treatment processes, as well as to evaluate basic clinical and demographic features. Methods A cross-sectional study was conducted at the Endocrinology Department of Yildirim Beyazit University between March 2019-April 2020. Fifty-eight acromegalic patients were enrolled. All patients were identified from our database and called for a clinical visit and fill the questionnaire forms. Results Fifty-eight patients were included in this study (41.4% female). The mean age of the patients was 52 ± 10.8. Median years from symptom to diagnosis (min-max) was 2 (1-12). 55.2% of the patients did not graduate from high school. Thirty of fifty-eight (51.7%) patients had knowledge about the etiology of their disease.While 12 patients (20.7%) noticed their initial symptoms themselves, 75% of the patients reported their symptoms during the clinical history taken by a health care professional. The majority of patients were diagnosed by an endocrinologist (69%). Acromegaly didn’t affect social life but affected work life and caused early retirement. Transsphenoidal surgery was performed as primary treatment in 96.6% of the patients (n=56). 46 patients (79.3%) received medical treatment with somatostatin receptor ligands (SSRL) (octreotide or lanreotide LAR) with or without cabergoline. Overall disease control was achieved in 38 patients (65.5%). Conclusions Acromegaly is usually detected incidentally by clinicians. The diagnosis of acromegaly is delayed in most patients and disease-related complications have already developed at the time of diagnosis. We think that increasing the awareness of the society and health care professionals will reduce both disease-related comorbidities and the economic burden on the health system.

Objective: To observe the relationship between fluid balance and the short-term outcomes of aged patients after gastrectomy for gastric cancer. Methods: The clinical data of patients with gastrectomy for gastric cancer from January 2016 to December 2018 were retrospectively analyzed. 691 patients were analyzed and classified into three fluid administration groups representing incremental quartiles of the primary exposure variable. Preoperative characteristics used for statistical adjustment included gender, age, weight, admission type, ASA degree. Operative factors included procedure duration, estimated blood loss, urine output, and so on. The primary outcomes included acute kidney injury (AKI)，and postoperative respiratory complications (PRCs) Exploratory outcomes included length of stay, postoperative length of stay and total cost of hospitalization. The association between perioperative factors and AKI/PRCs in hospital was tested with multivariable logistic regression analyses. Results: 16 cases were diagnosed as AKI and 23 cases PRCs. The association between intraoperative fluid balance and the incidence of AKI/ PRCs remained U-shaped but the difference was not statistically significant. After adjustment, lower urine output (P=0.017, OR=0.997,95%CI=0.994-0.999) and coronary heart disease (P=0.032, OR=4.867,95%CI=1.142-20.75) were independent predictor of AKI in aged patients. Coronary heart disease (OR=3.371,95%CI=1.021-11.129, P=0.049) and intestinal obstruction (OR=12.501,95%CI=3.058-51.107, P <0.0005) were independent predictor of PRCs in aged patients. Conclusion: There were no significant association between the incidence of AKI or any other complications and intraoperative fluid balance during radical gastrectomy in aged patients. Lower urine output and coronary heart disease were independent predictors of AKI. Coronary heart disease and intestinal obstruction were independent predictors of PRCs in aged patients after radical gastrectomy. Trial registration: This study was approved by the Affiliated Drum Tower Hospital of Nanjing University (Registration number: 2018-162-01).

Developing a good therapeutic drug for SARS-CoV-2 infection responsible for the ongoing coronavirus disease 2019 (COVID-19) pandemic is highly essential. Thus, identifying the key host molecular pathway targeted by SARS-CoV-2 during infection is of topmost importance. Subsequent screening of old or new drugs as well as medicinal plants targeting the identified pathways will prove useful and hasten the discovery of a potent COVID-19 drug. The information and data on COVID-19 were collated from various resources and literature databases such as PubMed, Science Direct, Wiley, Springer, Taylor and Francis, Scopus, Inflibnet, Google, and Google Scholar. The keywords and corresponding Relevant Medical Subject Headings (MeSH) terms used for searching databases include COVID-19; Herbal Medicine; Molecular Pathways; Pathophysiology, Phytotherapy, SARS-CoV-2. The study reviewed the existing literature on molecular action pathways of SARS-CoV-2 infection. We also discussed the ongoing SARS-CoV-2 drugs. The review also critically analyzes the molecular signaling and prospective therapeutic targets, cellular infection, incubation and proliferation strategy, clinical signs, symptoms of COVID-19 infection, the current global infection, mortality statistics, current medical management, and the prospect of therapeutic development. Plant-derived natural compounds could be evaluated and developed into antiviral drugs for the inhibition of coronavirus enzymes. Some herbal medicines have also been used and found to be therapeutically effective as secondary interventions for the prevention and treatment of COVID-19.

We describe a novel use of endoscopic balloon sinuplasty to treat isolated frontal sinusitis in a patient with a large burden of intranasal telangiectasia with a history of hereditary haemorrhagic telangiectasia

1. Enforced change due to COVID 19 has led to positive changes in practice. 2. Early senior triaging and review led to a reduction in emergency clinic attendances. 3. Emergency clinics could be further supported through protocols, departmental guidance and permanent changes to senior cover. 4. Increased senior presence could improve teaching and training of junior colleagues. 5. The integration of telemedicine is a useful tool in both the elective and emergency settings.

A document by Manoj Sharma. Click on the document to view its contents.

Background. A subset of individuals with allergic asthma develops a late phase response (LPR) to inhaled allergens, which is characterized by a prolonged airway obstruction, airway inflammation and airway hyperresponsiveness. The aim of this study was to identify changes in the plasma proteome and circulating hematopoietic progenitor cells associated with the LPR following an inhaled allergen challenge. Methods. Serial plasma samples from asthmatics undergoing inhaled allergen challenge were analyzed by mass spectrometry and immunosorbent assays. Peripheral blood mononuclear cells were analyzed by flow cytometry. Mass spectrometry data was analyzed using a linear regression to model the relationship between airway obstruction during the LPR and plasma proteome changes. Data from immunosorbent assays was analyzed using linear mixed models. Results. Out of 396 proteins quantified in plasma, 150 showed a statistically significant change 23 h post allergen challenge. Among the most upregulated were three protease inhibitors: alpha-1-antitrypsin, alpha-1-antichymotrypsin and plasma serine protease inhibitor. Altered levels of 13 proteins were associated with the LPR, including increased factor XIII A and a decreased von Willebrand factor. No relationship was found between the LPR and changes in the proportions of classical, intermediate, and non-classical monocytes. Conclusions. Allergic reactions to inhaled allergens in asthmatic subjects was associated with changes in a large proportion of the measured plasma proteome, whereof protease inhibitors showed the largest changes, likely to influence the inflammatory response. Many of the proteins altered in relation to the LPR are associated with coagulation, highlighting potential mechanistic targets for future treatments of type-2 asthma.

Background Asthma is characterized by an aggravated immune response to respiratory viral infections: This phenomenon is a clinically well-recognized driver of acute exacerbations, but how different phenotypes of asthma respond immunologically to virus is unclear. Objectives To describe the association between different phenotypes and severity of asthma and bronchial epithelial immune responses to viral stimulation. Methods In the Immunoreact study, healthy subjects (n=10) and 50 patients with asthma were included; 30 (60%) were atopic, and 34 (68%) were eosinophilic; 15 (25%) had severe asthma. All participants underwent bronchoscopy with collection of bronchial brushings. Bronchial epithelial cells (BECs) were expanded and stimulated with the viral replication mimic poly (I:C) (TLR3 agonist) in vitro. The expression of TLR3-induced pro-inflammatory and anti-viral responses of BECs were analyzed using RT-qPCR and multiplex ELISA and compared across asthma phenotypes and severity of disease. Results Patients with atopic asthma had increased production of IL-4, IFN-β, IL-6, TNF-α, and IL-1β after poly (I:C) stimulation compared to non-atopic patients, whereas patients with eosinophilic asthma and non-eosinophilic asthma did not differ in the response to poly (I:C). Patients with severe asthma displayed a decreased antiviral IFN-β, and increased expression of IL-8, most pronounced in atopic and eosinophilic asthmatics. Interestingly, release of IL-33 and TSLP in response to poly (I:C) was increased in severe eosinophilic asthma, but not in severe atopic asthma. Conclusions The bronchial epithelial immune response to a viral mimic stimulation differs between asthma phenotypes and severities, which may be important to consider when targeting novel asthma treatments.

Introduction: Typhoid fever is an acute, generalized infection of the reticuloendothelial system, which is caused by Salmonella typhi and causes substantial and hepatic complications and biochemical changes. Currently, the diagnostic test is isolation of bacteria from blood, stool and occasionally urine, but serologic tests are still commonly used, and there is still a necessity for the rapid and reliable diagnostic test for typhoid fever. The objective of this study was to determine the hematological changes in adult typhoid patients as compared to healthy control. Methodology: A total of 50 patients and 50 healthy individuals were enrolled in this research, and variations in hematological factors were studied. Results: Hematological parameters were found deranged in typhoid fever including hemoglobin (low, 10.97±0.88), hematocrit (low, 37.72±1.40), ESR (high 45.08±13.42), platelet count (high 588840±97185), WBCs count (high 38267±22279), neutrophil percentage (high, 73.56±9.96), lymphocyte percentage (low, 21.24±10.08), and NLCR (high, 5.14±4.00) as compared to healthy control group. Conclusion: This differentiating pattern is easy to obtain by minimal invasive procedure and can be used for typhoid infection diagnosis.

Background: Coronavirus disease-2019 (COVID-19) can cause asymptomatic, mild upper respiratory tract symptoms, pneumonia in young persons. How the disease will progress in each patient is still unknown. Therefore, we aimed to investigate the prognostic markers of the development of pneumonia and the clinical characteristics of patients under 65 years with COVID-19 confirmed by a positive reverse transcriptase polymerase chain reaction (RT-PCR) test. Method: In this retrospective study, a total of 271 patients admitted in our unit were included. The patients were divided into two groups, those who did or did not develop pneumonia. Their clinical features, treatment protocols and laboratory parameters were recorded retrospectively. Results: Pneumonia developed in 67.9% (n = 184) of the cases. Age in the pneumonia group was higher than in the non-pneumonia group (p < 0.001). In the logistic regression analysis, when symptom and comorbidity status were examined according to the presence of pneumonia; HT (OR: 4,525 95% CL: 1,494–13,708) were the most important risk factor for pneumonia. When age and laboratory values were examined according to the presence of pneumonia, advanced age (OR: 1.042 95% CL: 1.01–1.073), low albumin (OR: 0.917 95% CL: 0.854–0.986) and high troponin (OR: 1.291 95% CL: 1.044–1.596) were identified as risk factors for pneumonia. Conclusion: HT, older age, low albumin, high troponin were important factors for predicting COVID-19 pneumonia in patients under 65 years of age. Young patients with these predictive factors should be more carefully evaluated by further diagnostic procedures, such as thoracic CT. Key Words: COVID-19, pneumonia, young adults

Introduction: This study is planned to determine the knowledge of personal protective equipment use of senior paramedic students before graduation during COVID-19 pandemic. Methods: The research is a descriptive study. The universe of the study consisted of 180 senior paramedic students studying at three universities in İzmir. When evaluating the study data, descriptive findings were expressed as percentage, mean, standard deviation and median. Results: 38.1% of the students are between 18-20 years old, 50.0% are between 21-23 years old and 11.9% are 23 years old and above. 58.3% of the students participating in the study are females and 41.7% are males. In the study, 74.4% of paramedic students stated that healthcare personnel working in ambulance or patient transport vehicles should use medical masks, gowns, gloves and eye protection while transporting suspected COVID-19- (SARS-CoV-2) patients to the health institution. 78.5% of the students answered that an N95/FFP2 mask should be used while intervening and taking samples in a patient suspected of having COVID-19. Discussion: As a result, it was found that during the COVID-19 pandemic period, the knowledge of personal protective equipment use of senior paramedic students before graduation is sufficient in some cases and not clear and sufficient in some cases. It is recommended that students should be given effective training on the use of PPE during the intervention of the patient with COVID-19 before graduation.

Background: The social stigma associated with a disease represents an important issue for health policymakers at the local, national, and international levels. This study aimed to survay and analyze the experience of stigma among patients with coronavirus disease 2019 (COVID-19) in Iran. Methods and Materials: This qualitative study was conducted from September to December 2020 in the Fars, Khorasan, and Yazd provinces of Iran. Sampling was done via the snowball method; based on data saturation criteria, 24 adults over 18 years of age who had experienced affliction with COVID-19 were recruited. Semi-structured telephone interviews were conducted with each patient. Data were analyzed following the conventional content analysis method described by Erlingsson and Brysiewicz. Results: The results showed that during their affliction with COVID-19, the participants experienced difficult, anxious times, with rejection and alienation from their first-degree relatives taking them by surprise. The three main themes extracted from this study were (i) fear and rejection, (ii) discrimination, and (iii) loneliness. These experiences have changed the attitudes of the participants toward life and themselves. Conclusion: Based on our results, it can be said that paying attention to social stigma among patients during pandemics is an important social necessity and health policy. It is recommended to have psychological counseling sessions for those afflicted and to provide education and training to the public regarding the proper treatment of patients with COVID-19. Quantitative studies in this field are highly recommended.

Monocyte subsets, including classical, intermediate and non-classical monocytes, are involved in the pathogenesis of inflammatory or autoimmune diseases. The pathogenic role of monocytes in the peripheral blood mononuclear cells (PBMCs) of patients with rosacea remains unclear. This study aimed to assess frequencies of monocyte subsets in PBMCs from rosacea patients before and after clinical treatment. We applied flow cytometry to examine frequencies of monocyte subsets in 116 patients with rosacea，while patients with 26 systemic lupus erythematosus (SLE), 28 acne and 42 normal healthy subjects without skin problems (HC) were recruited as controls. Expression of CCR2 on monocytes and plasma levels of CCL2, HMGB-1, IL-1β and TNF-α were measured in HC and rosacea patients before and after treatment. The frequency of classical monocytes, but not intermediate or non-classical monocytes, was higher in rosacea as compared with HC, which decreased after treatment. Frequencies of monocyte subsets showed no gender difference, while increased with age in patients but not in HC. Frequencies of classical monocytes in patients with erythromatotelangiectatic rosacea (ETR) and ETR-papulopaustula rosacea (PPR) overlap were significantly higher than HC or patients with only PPR or phytomatous rosacea (PhR). There was a significant higher expression of CCR2 in classical monocytes, with higher plasma levels of CCL2, HMGB-1, IL-1β and TNF-α in patients than in HC, which all significantly decreased after treatment. Our data indicated a possible association between abnormal classical monocytes frequencies and rosacea.

In social animals, when conspecific individuals use limited resources differently jealousy will occur. To address whether jealousy is an environmental variable underlying negative evolutionary responses to superior phenotypes, we investigated jealous behaviours in the azure-winged magpie, Cyanopica cyanus, under natural and experimental conditions. Within a triad composed of a feeder, a target and three differently-ranked third-party individuals, the target was fed exclusively to experimentally imitate a scene of uneven resource distribution. Three jealousy-type behaviours were exhibited by the third-party (i.e., raiding and assaulting the target, ingratiating themselves with the feeder) and target (expelling and flaunting the worm to third-party, ingratiating itself with the feeder), respectively, that were significantly affected by their social ranks. It suggests that uneven distribution of limited resources should account for the occurrence of jealous behaviours, and that jealousy may function as a reverse evolutionary force to neutralize the potentially too quick diffusion of superior phenotypic traits.

An Isoproterenol Dependent Broad QRS Tachycardia: What is the Mechanism?Weizhuo Liu MD1, Nanqing Xiong MD2*, Wentao Gu MD21. Department of Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiaotong University, 241 West Huaihai Road, Shanghai 200030, China2. Department of Cardiology, Huashan Hospital Fudan University, 12 Wulumuqizhong Road, Shanghai 200040, China*Corresponding author: Nanqing Xiong MD, Department of Cardiology, Huashan Hospital Fudan University, 12 Wulumuqizhong Road, Shanghai 200040, China. E-mail: huashancardio@163.comKey words: wide QRS complex tachycardia, intermittent preexcitation, Wolff-Parkinson-White syndrome, antidromic AV reentrant tachycardia, AV-nodal-refractory atrial extrastimulusThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.A 27-year-old female presenting with recurrent palpitation during exercise was referred for electrophysiology study. Electrocardiogram (ECG) during symptom was not documented. Her baseline ECG was sinus rhythm with normal PR interval. Ventricular pacing and programmed extrastimulus showed retrograde conduction via AV node. A-H interval was progressively prolonged during atrial extrastimuli without preexcitation (Figure 1). No tachycardia was inducible until isoproterenol infusion, after which a wide QRS tachycardia was initiated by ventricular burst pacing. Figure 2 showed 2 intracardiac recordings during tachycardia. What can be learned from the tracings?Figure 2A showed a wide QRS complex tachycardia with left bundle branch block morphology, left-inferior frontal axis and 1:1 VA relationship, the cycle length of which was about 365ms. There was no His electrogram preceding each QRS, instead, a putative retrograde His could be observed after local ventricular electrogram on His catheter with an H-A interval around 100ms. Differential diagnosis included ventricular tachycardia (VT) from right ventricular outflow tract and different types of preexcited tachycardia. A sensed atrial extrastimulus was delivered when AV node was refractory, indicated by the unchanged timing of atrial signal on His catheter, which advanced the next QRS with identical morphology to tachycardia. This phenomenon suggested the presence of an anterograde conducting accessory pathway. Measurement of A-A interval indicated the tachycardia was reset, providing the evidence that the AP was participating in the reentry [1]. VT can be ruled out by the unchanged QRS morphology during sensed atrial extrastimulus and entrainment from atrium, while preexcited AV nodal reentry and nodoventricular tachycardia was precluded by the resetting of tachycardia with AV-nodal-refractory atrial extrastimulus. The fact that atrial extrastimulus with earlier prematurity terminated the tachycardia without conduction to the ventricle (Supplemental Figure) also argued against AVNRT with innocent bypass tract, which in this setting would require the timing of the extrastimulus to exactly encounter the refractory period of the pathway when terminating AV nodal reentry. Furthermore, the tachycardia could also terminate spontaneously with an atrial signal, making preexcited atrial tachycardia highly unlikely (Figure 2B). Therefore, the diagnosis of antidromic atrioventricular reentrant tachycardia (AVRT) was made based on all the evidence above.But how could the patient have antidromic AVRT whose preexcitation was absent at baseline, during atrial extrastimuli, and pacing from both atria (not shown)? If we look into the sinus QRS configuration after tachycardia cessation in Figure 2B, prominent delta waves could be observed, which emerged only during isoproterenol infusion in this case. In Wolff-Parkinson-White syndrome, intermittent anterograde pathway conduction dependent on isoproterenol, although not common, has been reported [2]. The pathway conduction was unsustainable when isoproterenol was discontinued, proving the unidirectional conducting accessory pathway was highly isoproterenol-sensitive, which served as the anterograde limb of the antidromic AVRT. On the other hand, isoproterenol also facilitated the retrograde conduction of AV node, which played the role of the retrograde limb. The pathway was then ablated near 12 o’clock site of tricuspid annulus, after which no delta wave was present with isoproterenol infusion, and the tachycardia was therefore not inducible.