Several brain areas modulate pain transmission through direct projections to the spinal cord. The descending modulation is exerted by neurotransmitters acting both at spinally projecting neurons and at interneurons that target the projection neurons. We analyzed the expression of mu-opioid (MOR), gamma-aminobutyric acid GABA(B), and NK1 receptors in spinally projecting neurons of major medullary pain control areas of the rat: rostroventromedial medulla (RVM), dorsal reticular nucleus (DRt), nucleus of the solitary tract, ventral reticular nucleus, and lateralmost part of the caudal ventrolateral medulla. The retrograde tracer cholera toxin subunit B (CTb) was injected into the spinal dorsal horn, and medullary sections were processed by double immunocytochemistry for CTb and each receptor. The RVM contained the majority of double-labeled neurons followed by the DRt. In general, high percentages of MOR- and NK1-expressing neurons were retrogradely labeled, whereas GABA(B) receptors were mainly expressed in neurons that were not labeled from the cord. The results suggest that MOR and NK1 receptors play an important role in direct and indirect control of descending modulation. The co-localization of MOR and GABA(B) in DRt neurons also demonstrated by the present study suggests that the pronociceptive effects of this nucleus may be controlled by local opoidergic and GABAergic inhibition of the pronociception increased during chronic pain.

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Purpose The purpose of this paper is to assess differences between employees of family and non-family firms regarding their perceptions of employer branding and psychological contract levels. Moreover, focusing on family firms, the authors assess the relation between the employees’ perceptions of employer branding and the psychological contract levels. Design/methodology/approach The empirical evidence is provided by a sample of 165 Portuguese employees, 76 employees of family firms and 89 non-family firms’ employees, who responded to a questionnaire that included employer branding and psychological contract measures. All respondents study in small and medium-sized private companies. Findings The results confirmed the research hypotheses, suggesting that employees of family companies show higher perceptions of employer branding and psychological contract levels than employees of non-family companies. Results also reveal that the perceptions of employer branding are positively related to the psychological contract levels of the family firm’s employees. Originality/value This paper aims to contribute to the literature by addressing two contemporary organizational aspects yet under-addressed in the comparison between family and non-family firms while pursuing to offer insights on the relationship between the perceptions of employer branding and levels of the psychological contract of employees working in family firms.

Takotsubo syndrome (TS) is an acute and reversible clinical syndrome characterized by transient hypokinesis of the left ventricular (LV) apex. Variant forms of LV dysfunction have been reported, including inverted Takotsubo syndrome (ITS), which represents only 5% of cases and has previously been linked to excessive use of inhaled adrenergic beta-2 agonists. The authors describe the case of a 60-year-old female patient who was diagnosed with ITS after the excessive use of inhaled adrenergic beta-2 agonists. This case highlights an uncommon variant of this syndrome that may not be obvious and must be suspected in this particular context. LEARNING POINTS• Takotsubo syndrome (TS) was initially described with a classic pattern of LV apical akinesis and accounts for around 75-80% of cases.Variants including inverted Takotsubo (also known as basal variant) can affect other areas of the myocardium.• Several physiopathological mechanisms have been implicated. Catecholamine-induced cardiotoxicity is one of the most supported theories, while other triggers, including excessive use of inhaled beta-2 agonists, have also been described. • Treatment of TS is mainly symptomatic and conservative and frequently leads to rapid resolution and LV function recovery. KEYWORDS Takotsubo syndrome, catecholamines, adrenergic beta-2 agonists CASE REPORT We report the case of a 60-year-old woman with a history of chronic obstructive pulmonary disease (COPD), hypereosinophilic syndrome, hypothyroidism, rheumatoid arthritis, depression and arterial hypertension, whose treatment included fluticasone/salmeterol 50 μg/250 μg two puffs twice a day. The patient presented to the emergency room (ER) with a depressed level of consciousness after experiencing dyspnoea, cough and fever for 2 days at home. At home the patient had already overused her bronchodilator, but at the ER she received continuous nebulized salbutamol, furosemide and intravenous hydrocortisone, with no clinical improvement and a worsening of respiratory acidosis. The patient was promptly transferred to the ICU for intubation and mechanical ventilation under ketamine sedation, due to severe bronchospasm. Blood tests revealed an elevated CRP (13.17 mg/dl) and elevated NT-proBNP (11695 pg/ml), while the initial set of cardiac

Squamous cell carcinoma (SCC) of the conjunctiva is a rare malignancy that is part of the spectrum of ocular surface squamous neoplasia (OSSN). Numerous non-modifiable and modifiable risk factors, such as male sex, age, cigarette smoking, and immunosuppression, have been identified. Any lesion of the conjunctiva requires a differential diagnosis between benign and malignant diseases, and all suspicious lesions should be biopsied.We present a case of SCC of the conjunctiva in a former smoker with multiple risk factors, including a previous SCC of the lower lip. Metastatic tumors rarely occur in the conjunctiva, but due to our patient's medical history, the exclusion of metastasis from the previous primary tumor was performed through whole-body imaging restaging.The patient underwent a no-touch wide resection, followed by adjuvant topical chemotherapy with 5fluorouracil (5-FU). After finishing treatment, the patient continues to attend regular ophthalmology and oncology appointments.Increasing population awareness of modifiable risk factors for OSSN is essential. Misdiagnosis can lead to a loss of time in treatment and progression of the disease.

Objective To analyze and compare COVID-19 patient characteristics, clinical management and outcomes between the peak and plateau periods of the first pandemic wave in Portugal. Methods This was a multicentric ambispective cohort study including consecutive severe COVID-19 patients between March and August 2020 from 16 Portuguese intensive care units. The peak and plateau periods, respectively, weeks 10 - 16 and 17 - 34, were defined. Results Five hundred forty-one adult patients with a median age of 65 [57 - 74] years, mostly male (71.2%), were included. There were no significant differences in median age (p = 0.3), Simplified Acute Physiology Score II (40 versus 39; p = 0.8), partial arterial oxygen pressure/fraction of inspired oxygen ratio (139 versus 136; p = 0.6), antibiotic therapy (57% versus 64%; p = 0.2) at admission, or 28-day mortality (24.4% versus 22.8%; p = 0.7) between the peak and plateau periods. During the peak period, patients had fewer comorbidities (1 [0 - 3] versus 2 [0 - 5]; p = 0.002) and presented a higher use of vasopressors (47% versus 36%; p < 0.001) and invasive mechanical ventilation (58.1 versus 49.2%; p < 0.001) at admission, prone positioning (45% versus 36%; p = 0.04), and hydroxychloroquine (59% versus 10%; p < 0.001) and lopinavir/ritonavir (41% versus 10%; p < 0.001) prescriptions. However, a greater use of high-flow nasal cannulas (5% versus 16%, p < 0.001) on admission, remdesivir (0.3% versus 15%; p < 0.001) and corticosteroid (29% versus 52%, p < 0.001) therapy, and a shorter ICU length of stay (12 days versus 8, p < 0.001) were observed during the plateau. Conclusion There were significant changes in patient comorbidities, intensive care unit therapies and length of stay between the peak and plateau periods of the first COVID-19 wave.