A 65 year-old with history of prior ablations for regular narrow QRS short- RP tachycardia presented with recurrence of palpitations. An electrophysiological study showed long VA tachycardia with concentric atrial activation with a left ventricular origin extrastimulus delivered during His refractoriness, advancing the next ‘A’. A HRVPB can only reset an ORT if it ‘pulls in’ the local V at the ventricular insertion of an accessory pathway. As showcased in this case, erudite analysis of the pattern of perturbation of local ventricular electrograms is of paramount significance when interpreting responses to this maneuver. This concept when fortified with a heightened index of clinical suspicion for mitral annular block, anatomical knowledge of the pattern of LA-CS muscular connections, and pathway orientation, led to accurate electrophysiological diagnosis and management.

Early life exposure to antibiotics and laxatives in relation to infantile atopic eczemaSarah El-Heis 1 DMSarah R Crozier1,2 PhDNicholas C Harvey1,3 PhDEugene Healy4 PhDKeith M Godfrey1,3,5 FMedSci1 Medical Research Council Lifecourse Epidemiology Centre, University of Southampton,Southampton, UK2 NIHR Applied Research Collaboration Wessex, Southampton Science Park, Innovation Centre, Southampton, UK3 NIHR Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK4 Dermatopharmacology, Faculty of Medicine, University of Southampton, Southampton, UK5 Developmental Sciences, University of Southampton, Southampton, UK

Avian diet can be affected by site-specific variables, such as habitat, as well as intrinsic factors such as sex. This can lead to dietary niche separation, which reduces competition between individuals, as well as impacting how well avian species can adapt to environmental variation. Estimating dietary niche separation is challenging, due largely to difficulties in accurately identifying food taxa consumed. Consequently, there is limited knowledge of the diets of woodland bird species, many of which are undergoing serious population declines. Here, we show the effectiveness of multi-marker faecal metabarcoding to provide in-depth dietary analysis of a declining passerine, the Hawfinch (Coccothraustes coccothraustes). We collected faecal samples from (n=262) UK Hawfinches prior to, and during the breeding seasons in 2016-2019. We detected 49 and 90 plant and invertebrate taxa, respectively. We found Hawfinch diet varied spatially, as well as between sexes, indicating broad dietary plasticity and the ability of Hawfinches to utilise multiple resources within their foraging environments.

Background: Ototoxicity is a common disabling side effect of platinum-based chemotherapy. This study aimed to systematically assess the evidence on the management of platinum-induced ototoxicity in adult cancer patients. Methods: Three databases were searched up to November 1, 2022. Original studies were included if they reported on a pharmacologic or non-pharmacologic intervention to prevent or treat platinum ototoxicity in adults. The articles’ quality was assessed with two grading scales. Results: Eighteen randomized controlled trials and five quasi-experimental studies with 1673 patients were analyzed. Eleven interventions were identified, nine pharmacological and two non-pharmacological. Six of the interventions (sodium thiosulfate, corticoids, sertraline, statins, multivitamins, and D-methionine) showed mild benefit preventing cisplatin-induced ototoxicity. The data must be carefully analyzed due to the low quality and underreporting of side effects. Conclusions: Current interventions have mild benefits preventing cisplatin-induced ototoxicity in adult cancer patients. High-quality research is required to clarify the significance of these findings.

The limited land is under unprecedented pressure from production, living and ecology. In order to evaluate the land pressure in the Yangtze River Delta region in 1995, 2000, 2005, 2010, 2015, and 2020 from the perspective of production, living, and ecology. This study builds a land pressure evaluation index system based on a fuzzy comprehensive evaluation model using multi-source and multi-scale data. In order to investigate trade-offs and synergies among production, living, and ecology pressures, we use the mechanical equilibrium model in physics. We then analyze land pressure model reliability and uncertainty using Monte Carlo simulations. The results show that (1) Our model can effectively reveal the level of land pressure and reflect the land pressure geographical pattern of “high in the east and low in the west, high in the south and low in the north” that characterizes the Yangtze River Delta region. (2) While living and ecology pressures are tending to rise, production pressures are tending to decrease. (3) Except for Shanghai, the trade-off areas are primarily concentrated in economically successful regions with high production and living pressure and low ecology pressure. The coordinated areas are primarily found in northern Jiangsu Province and northern Anhui Province.

This article aims to analyze the influence of high cycle fatigue damage on the mechanical properties and low cycle fatigue performance of Q690D. Monotonic tensile and cyclic loading tests were performed on Q690D specimens with different degrees of high cycle fatigue damage. Degradation models were established to describe the declining trending of mechanical properties with the increase of pre-fatigue damage. Manson-Coffin models for Q690D steels of different pre-damage levels were established. Besides, a comparison was presented between Q690D and Q355B. The research work in this article provides a fundamental reference for the appropriate assessment of the mechanical performance of Q690D high-strength steel structures after long-term alternating loading.

A 69-year-old man was diagnosed with fulminant myocarditis with circulatory collapse. His cardiac rhythm deteriorated to asystole on the second day; however circulatory status was maintained through extracorporeal membrane oxygenation and intra-aortic balloon pumping. After 38h-lasting asystole, heart resumed beating. He was discharged without neurological deficits on day 25.

Letter to the editor

Primary Ewing’s sarcoma (EWS) of non-sacral spine is extremely rare, especially in middle-age. Therapeutic strategy aims: to large tumor resection, to provide spine stability and to avoid recurrence through chemo and radiotherapy. We report a case of thoracic spine EWS in an adult treated by combined approach en bloc vertebrectomy.

The respiratory tract antimicrobial defense system is a multilayered defense mechanism that relies upon mucociliary clearance and components of both the innate and adaptive immune systems to protect the lungs from inhaled or aspirated microorganisms. One of these potential pathogens, non-typeable Haemophilus influenzae ( NTHi), adopts several, multifaceted redundant strategies to successfully colonize the lower airways and establish a persistent infection. NTHi can impair mucociliary clearance, express multiple multi-functional adhesins for various cell types within the respiratory tract and evade host defenses by surviving within and between cells, forming biofilms, increasing antigenic drift, secreting proteases and antioxidants, and by host-pathogen cross-talk, impair macrophage and neutrophil function. NTHi is recognized as an important pathogen in several chronic lower respiratory disorders, such as protracted bacterial bronchitis, bronchiectasis, cystic fibrosis and primary ciliary dyskinesia. The persistence of NTHi in human airways, including its capacity to form biofilms, results in chronic infection and inflammation, which can ultimately injure airway wall structures. The complex nature of the molecular pathogenetic mechanisms employed by NTHi is incompletely understood but improved understanding of its pathobiology will be important for developing effective therapies and vaccines, especially given the marked genetic heterogeneity of NTHi and its possession of phase-variable genes. Currently, no vaccine candidates are ready for large phase III clinical trials.

A 5-month-old male baby was brought to the emergency room with a one-day history of respiratory distress, wheezing, vomiting, and high fever. Wheezing had been present since birth but had recently become more frequent and intense, occurring even at rest. The baby was born full-term by cesarean delivery and had a medical history of gallbladder agenesis, secundum atrial septal defect (ASD), and cryptorchidism.

We described a 17-year-old male with a large pulmonary hydatid cyst with a spontaneous rupture. He developed acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. He was treated with albendazole, broad-spectrum antibiotics, and corticosteroids. He underwent surgery after discharge. ARDS after rupture of hydatid cyst was rarely reported.

Headwater streams can constitute up to 80% of river channel length and are vulnerable to anthropogenic pressures due to their high connectivity to adjacent land, large relative catchment size and low dilution capacity. In these environments unrestricted cattle access is a potential significant cause of water quality deterioration, resulting from increases in stream bank erosion, riparian damage and sediment deposition among others. Several studies have reported improvements in physico-chemical and hydromorphological conditions of streams following elimination of cattle access; few, however, have focussed on the ecological impacts of such management practices. Here, such impacts are assessed. We look at the short-term effects by comparing habitat condition, sediment deposition, and instream macroinvertebrate communities upstream and downstream of cattle access points prior to, and one year following exclusion via fencing. The long-term effects are also measured by reassessing a small stream catchment entirely fenced off from cattle access in 2008 under a concerted management effort. In the short term, cattle exclusion led to reduction in deposited sediment downstream of cattle access points and a related homogenisation of macroinvertebrate community structure between upstream and downstream sampling points. Increased abundances of specific indicator taxa ( Ancylus fluviatilis, Glossosomatidae and Elmidae) in the fenced catchment following 9 years of exclusion highlight the long-term ecological benefits of such mitigation practices. These findings highlight the importance of incentivised agri-environment schemes in reducing the negative impacts of cattle access to these vulnerable ecosystems.

Functional connectivity (FC) during sleep has been shown to break down as non-rapid eye movement (NREM) sleep deepens before returning to a state closer to wakefulness during REM sleep. However, the specific spatial and temporal signatures of these fluctuations in connectivity patterns remain poorly understood. The goal of this study was to investigate how frequency-dependent network-level FC fluctuates during nocturnal sleep in healthy young adults using high-density electroencephalography (hdEEG). Specifically, we examined source-localized FC in resting-state networks during NREM2, NREM3, and REM sleep in the first three sleep cycles of 29 participants. Our results showed that FC within and between all resting-state networks decreased from NREM2 to NREM3 sleep in multiple frequency bands and in all sleep cycles. The data also highlighted a complex modulation of connectivity patterns during the transition to REM sleep whereby delta and sigma bands hosted a persistence of the connectivity breakdown in all networks, whereas a reconnection was observed in the default mode (DMN) and the attentional networks in frequency bands characterizing their organization during wake (i.e., alpha and beta bands, respectively). Finally, all network pairs (except the visual network) showed higher gamma-band FC during REM sleep in cycle three compared to earlier cycles during the night. Altogether, our results unravel the spatial and temporal characteristics of the well-known breakdown in connectivity observed as NREM sleep deepens. They also shed light on a complex pattern of connectivity during REM sleep that is consistent with both breakdown and reconnection processes that are network- and frequency-specific.

In this issue of the Journal, Kushnir, et al. provide a report of temporal trends in first time ablation at a large academic medical center over a 10 year period. This editorial provides commentary on the report.

Introduction: Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) is a rare inherited disorder usually affecting the right ventricle (RV), characterized by fibro-fatty tissue replacement of the healthy ventricular myocardium. It often predisposes young patients to ventricular tachycardia, heart failure, and / or sudden cardiac death. However, recent studies have suggested predominantly left ventricle (LV) involvement with variable and / or atypical manifestations. Cardiac Magnetic Resonance (CMR) imaging has emerged as the non-invasive gold standard for the diagnosis of ARVC. Case summary: A 21-year-old athletic male with a family history of unknown ventricular arrhythmias, presented with near syncope, chest pain and exertional palpitations. He had an initial work-up that was grossly unremarkable including, electrocardiography (ECG), echocardiography and CMR imaging. Six months later, he presented again with recurrent symptoms during exercise and his ECG demonstrating a new epsilon wave. He had markedly elevated cardiac biomarkers, (troponin I >100 ng/dl, normal value < 0.04 ng/dl). A subsequent coronary angiogram was performed, which was normal. Holter monitoring further showed subsequent episodes of ventricular tachycardia with a right bundle branch morphology. An endomyocardial biopsy was performed, which was negative. A follow-up CMR demonstrated the new development and prominent left ventricular epicardial scar in the lateral wall. The patient underwent familial genetic testing, which confirmed the presence of an isolated JUP gene mutation and showed multiple genes consistent with ARVC in his mother. Thus, he manifested a partial transmission of only one abnormal gene for ARVC and exhibited a markedly different expression in his disease without evidence of typical right-sided heart pathology. A third CMR study was performed, which showed partial improvement in myocardial fibrosis after exercise cessation. Conclusion: We present a case of a young male with a newly diagnosed isolated JUP gene mutation and a genetically diagnosed family history of ARVC. During his course, he demonstrated the progression of a characteristic epsilon wave on ECG and the presence of new, atypical, left ventricular fibrosis on repeat CMR imaging. This case demonstrates a complex interplay between variable genetic penetrance, phenotypical heterogeneity, and lifestyle factors including exercise, in his disease expression and provides insight on the natural course of an isolated JUP mutation. Although rare, clinicians should have a high threshold for the suspicion of ARVC or variants of this disorder even in the absence of classic right sided pathologies and /or an initially normal work-up.

A document by Nagham Ailabouni. Click on the document to view its contents.

A 34-year-old woman with breast cancer and the BRCA2: p.Gln3047Ter was treated with olaparib. After tumor progression, cancer genomic profiling testing revealed the BRCA2 p.Gln3047Ter and p.Gln3047Tyr, with 48.9% and 0.37% allele frequency, respectively. These findings shed light on reversion mutation as a resistance mechanism to olaparib in breast cancer.