N = 232) treating COVID-19 patients in the hospitals of Pakistan through well-established adopted questionnaires. The discriminant and convergent validity of the data was tested through confirmatory factor analysis by using AMOS statistical package. The mediation and moderation hypotheses were tested by using PROCESS Macro by Hayes. The results showed that safety specific transformational leadership enhances psychological well-being among healthcare workers, and COVID-19 perceived risk mediates this relationship. Moderation results also confirmed that safety conscientiousness moderates the relationship between safety specific transformational leadership and COVID-19 perceived risk. This study offers implications for both researchers and practitioners.Occupational health researchers have begun to realize that the psychological well-being of healthcare workers who are providing treatment against COVID-19 is deteriorating. However, there is minimal research conducted on it, particularly in the context of leadership. The current study aims to fill this important gap by identifying critical factors that can enhance the psychological well-being of healthcare workers. We proposed that safety specific transformational leadership enhances psychological well-being among healthcare workers, and COVID-19 perceived risk mediates this relationship. Furthermore, the safety conscientiousness of healthcare workers was proposed to be a boundary condition that enhances the negative relationship between safety-specific transformational leadership and COVID-19 perceived risk. Data were collected from healthcare workers ( The world is facing one of the worst pandemics in the history of mankind . Researchers widely use the rule of thumb to find the sample size  for this purpose. A Post hoc analysis was done by setting predictors to three while keeping other parameters to default settings . The 232 sample size generate a high power of 0.99, which confirmed that the collected sample is adequate for testing the proposed model  by Witte  to measuSafety consciousness was measured by using a scale developed by Barling et al. . The sca2 = 878, χ2/df = 1.26, IFI = 0.96, TLI =0.95, CFI = 0.96, RMR = 0.06, and RMSEA = 0.03 than one-factor model by loading all items on single factors i.e., χ2 = 2,325, χ2/df = 3.31, IFI = 0.61, TLI =0.58, CFI = 0.60, RMR = 0.12, and RMSEA = 0.10. The fit indices for the four-factor are in line with recommended model fitness criteria , COVID-19 perceived risk , and psychological well-being . Age also showed non-significant association with safety consciousness , COVID-19 perceived risk , and psychological well-being . The relationship between education and all study variables namely safety consciousness , COVID-19 perceived risk , and psychological well-being  was also non-significant. Experience also showed non-significant relationship with safety consciousness , COVID-19 perceived risk , and psychological well-being . Lastly, designation was also shown to have non-significant relationship with safety consciousness , COVID-19 perceived risk , and psychological well-being . These results show that none of the demographic variables shares a significant relationship with study variables. Hence, these variables were not controlled while conducting further analysis.The current study collected data for age, gender, education, designation, and job experience in addition to study variables. We conducted an analysis of variance (ANOVA) test to identify those demographic variables which have a significant relationship with the study variables. Gender showed non-significant relationship with safety consciousness  and significantly positively related to psychological well-being , and safety consciousness . COVID-19 perceived risk showed a significant and negative correlation with psychological well-being  and safety consciousness . Psychological well-being showed a positive and significant relationship with safety consciousness .p < 0.01), which led to the acceptance of hypothesis 1. The relationship between safety specific transformational leadership and COVID-19 perceived risk was also negatively significant , whereas COVID-19 perceived risk also showed a negative and significant relationship with psychological well-being . The Bootstrap 5000 results of the indirect effect of safety specific transformational leadership on psychological well-being through COVID-19 perceived risk were also significant at 95% confidence interval . The upper and lower limits 95% confidence intervals contain no zero. Hence, hypothesis 2 is also supported.p < 0.01). The R square change was also significant for the interactive effect . The slope test results further confirmed that the negative relationship between safety specific transformational leadership and COVID-19 perceived risk strengthens at high values of safety consciousness . Hence, hypothesis 3 is also accepted. We used model 1 of Process Macro by Hayes to test the moderating role of self-consciousness between safety specific transformational leadership and COVID-19 perceived risk. The rationale for using Process Macro for moderation is that it also gives results for the slope test by showing the variance in the relationship between independent and dependent variables at high, medium and low values of moderator. Keeping in view the recommendations of Aiken et al. , safety After more than a year, the number of COVID-19 cases is still rising  and Second Victim Experience Support Tool (SVEST) help reduce stress caused due to work and non-work related issues Scott, . On a moThe results of the current study should be viewed in light of its limitations. The current study only investigates the psychological outcome of safety specific transformational leadership. Future studies have investigated its performance-related or behavioral outcomes. Another limitation of this study is that it has taken employee perception as an underlying mechanism between safety specific transformational leadership and employee psychological well-being. Future researchers may test the mediating role of employee attitudes and emotions between safety specific transformational leadership and employee psychological well-being. This study has not taken any personality disposition as the boundary condition. Future studies can extend this study by investigating the moderating role of different personality traits and situational factors. The current study followed a time-lagged research design which offers benefits against cross-sectional research design but fails to catch variance among study variables over time. Future studies may replicate the findings of this study by collecting longitudinal data to test the change in variance among proposed variables across time. Lastly, the results of this study are only limited to healthcare workers. Future researchers may conduct studies on employees working in other sectors in which employees are required to remain physically present at the workplace during COVID-19, such as banks.Healthcare workers have become frontline soldiers against COVID-19. However, they are under immense stress due to frequent exposure to infected patients. The current study has identified safety specific transformational leadership as a suitable leadership style that combines with employee safety consciousness and dampens the COVID-19 perceived risk among healthcare workers. This reduction in perceived risk improves psychological well-being among healthcare workers.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by The National University of Modern Languages (NUML) constitutes the departmental Ethics Approval Committee. The Faculty of Management Sciences, NUML Research Ethics Board, reviewed The Combined Effect of Safety Specific Transformational Leadership and Safety Consciousness on Psychological Well-being of Healthcare Workers research proposal and considers the procedures, as described by the applicant, to conform to the University's ethical standards and university guidelines. Moreover, the participation in the survey was voluntary, and study participants were first explained about the details of the project. It was assured to them that their responses will be kept in strict anonymity and will be reported as aggregate results. The patients/participants provided their written informed consent to participate in this study.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


After myocardial infarction (MI), a strong inflammatory response takes place in the heart to remove the dead tissue resulting from ischemic injury. A growing body of evidence suggests that timely resolution of this inflammatory process may aid in the prevention of adverse cardiac remodeling and heart failure post-MI. The present challenge is to find a way to stimulate this process without interfering with the reparative role of the immune system. Extracellular vesicles (EVs) are natural membrane particles that are released by cells and carry different macromolecules, including proteins and non-coding RNAs. In recent years, EVs derived from various stem and progenitor cells have been demonstrated to possess regenerative properties. They can provide cardioprotection via several mechanisms of action, including immunomodulation. In this review, we summarize the role of the innate immune system in post-MI healing. We then discuss the mechanisms by which EVs modulate cardiac inflammation in preclinical models of myocardial injury through regulation of monocyte influx and macrophage function. Finally, we provide suggestions for further optimization of EV-based therapy to improve its potential for the treatment of MI. Despite decades of research, cardiac repair upon myocardial infarction (MI) injury remains a challenge and ischemic heart disease continues to be one of the leading causes of death worldwide . The immA growing body of evidence suggests that timely resolution of the inflammatory process may aid in the prevention of adverse cardiac remodeling and heart failure . In factTransplantation of stem cells or their derivates into the damaged heart has been studied over the last two decades expecting these cells to regenerate cardiac cells in the ischemic area . InitialEvidence supported the hypothesis that cell-based therapy may act via paracrine signaling as a conditioned medium derived from these cells increased cardiomyocyte survival in both in vitro co-culture system and in vivo ,19,20. VTogether with the paracrine hypotheses where EVs play a role, it is thought that the injected cells in the heart can modify cardiac inflammation . AccordiIn this review, we highlight the role of the innate immune system in post-MI healing, focusing on the function of monocytes and macrophages during cardiac ischemic injury and repair. Next, we summarize and discuss the mechanisms by which the EVs studied as therapy in myocardial repair can modulate monocyte and macrophage function and, thus, cardiac inflammation. Finally, we propose how EV-based treatment can be optimized to increase its immunomodulatory properties in an MI setting.The hostile environment of the infarcted area gives rise to necrotic and stressed cells that trigger sterile inflammation by exposing damage-associated molecular patterns (DAMPs). DAMPs include damaged or modified extracellular matrix components and intracellular constituents such as ATP, alarmins, or mitochondrial elements and have been extensively studied as therapeutic targets to prevent ischemic injury in the preclinical setting . PatternNeutrophils, monocytes, and macrophages are primarily responsible for the phagocytosis of cell debris ,33. In a+, lymphocyte antigen 6C (LY6C)high monocytes arrive at the injured region 30 min after MI thanks to the high concentration of CCL2 in the infarcted area. This pro-inflammatory monocytic population secretes IL-1β, IL-6, and TNFα, thereby contributing to continued cardiac inflammation and scavenge dead cells. Next to this initial wave of pro-inflammatory monocytes, there is a less intensive wave of pro-reparative CCR2-LY6Clow, CX3C chemokine receptor 1(CX3CR1)high monocytes due to the presence of chemokine fractalkine (CX3CL1) between day 5 and 16 after MI [high and LY6Clow) have been studied in mice [+CD16low and non-classical CD14+CD16high monocytes in humans [Monocytes and macrophages follow a biphasic response to ischemic injury in the heart  37]. In. In37]. after MI . During after MI . Althoug in mice , they arn humans . Clinican humans ,41. Neven humans .Macrophages initiate the resolution of the inflammatory phase through the engulfment of damaged cells, which induces phenotypic changes in macrophages through the upregulation of the signaling pathways such as kinase AMPK ,42. On tLeft ventricular (LV) dysfunction can occur in case of dysregulation of this inflammatory response due to chronic low-grade inflammation, contributing to heart failure development . A betteEVs are endogenous carriers of biological material and can be classified into two major categories according to their origin in the cell: exosomes, also called small EVs (30–100 nm in diameter), and microvesicles . Exosomes are generated within the endosomal compartment, whereas microvesicles are formed via the budding of the plasma membrane . Given tThe therapeutic potential of EVs, derived mainly from stem and progenitor cells, has been explored in the context of myocardial repair after MI ,51,52,53A meta-analysis revealed that EVs derived from the previously mentioned cells showed an ability to reduce infarct size and improved the ejection fraction of the treated infarcted hearts in both small and large animal models . The mecPreclinical research has shown the potential of targeting the CCR2-CCL2 signaling axis and, thus, pro-inflammatory monocyte infiltration in ischemic heart failure . Likewis+ neutrophils and MAC-3+ macrophages in the hearts was observed at day 1 and 3 post-MI as well as a decrease in circulating white blood cells at the same time points. Similar to MSC-EVs, CPC-EVs significantly decreased Ly6G+ neutrophils and Ly6Chigh monocytes in the mouse cardiac tissue of a permanent ligation MI model when injected into the heart at both acute (2 days after ligation) and chronic phases (3 weeks after ligation) of ischemic heart failure [The first study providing evidence that MSC-EVs can decrease cardiac inflammation was performed in a mouse model of myocardial ischemia/reperfusion injury, where the EVs were injected intravenously before reperfusion . Here, a failure . There iThe therapeutic role of EVs has been mostly attributed to the delivery of functional cargo to recipient cells. EVs can carry different biomolecules, including proteins and non-coding RNAs, in particular microRNAs (miRNAs) . miRNAs high monocyte infiltration in the murine heart on day 3 post-MI [+ macrophages in the peri-infarct zone one week after MI and were enriched in miR-24-3p [miR-24 has been described to limit vascular inflammation by regulating macrophage behavior in atherosclerosis and abdominal aortic aneurysm mouse model ,65. Cons post-MI . Here, m post-MI . SimilariR-24-3p . CollectBesides miR-24-3p, miR-146a-5p and miR-181b were also described to be enriched in EVs reducing the monocyte influx in the injured heart. Rats treated with CPC-EVs, administrated via the tail vein at different days after doxorubicin/trastuzumab-induced cardiac toxicity, demonstrated a reduction in the number of infiltrated monocytes one month after cardiac damage . These E+ macrophages in the treated rats one month after EV injection [high monocytes at day 3 and increased anti-inflammatory CD206+ macrophages at day 7 post-MI [Although most studies refer to miRNAs as being responsible for the therapeutic role of EVs, proteins have been reported to contribute as well. For instance, CPC-EVs administrated in the heart 1 h after ligation reduced CD68njection . Pregnannjection . IGF-1 f post-MI ,75,76.In short, these studies indicate that EVs secreted from different progenitor and differentiated cells can inhibit the monocyte influx into the injured region via different mechanisms and, thus, are potentially attractive therapeutic agents to fight cardiac inflammation .Macrophages are the most abundant immune cells present in the heart after MI . MacrophInterestingly, there is a difference in the capacity of stem- and progenitor-derived EVs to modulate macrophage polarization after MI as described in the literature so far . In geneESC-EVs induced M2 macrophage polarization by decreasing nitric oxide synthase (iNOS) expression and increasing CD206 levels in the cardiac tissue of a doxorubicin-induced cardiomyopathy mouse model two weeks after multiple intraperitoneal injections on different days . In addiEVs secreted by bone marrow and adipose tissue-derived MSCs showed an anti-inflammatory effect in vivo in MI and dilated cardiomyopathy models. Groups treated with MSC-EVs shown a decrease in pro-inflammatory cytokines, such as IL-1β, IL-6, and TNFα, which contrasted with a rise of anti-inflammatory cytokines, namely IL-10 ,85,86,87Human CDC-EVs, injected intramyocardially after reperfusion, modulated macrophage polarization in treated rats and pigs . Here, cMSC- and CDC-EVs modulated macrophage polarization in a dose-dependent manner in vitro ,85,88. OIt appears that the functional transfer of multiple miRNAs is involved in the mechanism of action by which EVs modulated macrophage polarization . MiR-182EVs hold several advantages that make them an exciting therapeutic alternative over cell therapy due to their intrinsic properties. For example, they can survive in the extracellular space, bypass biological barriers and deliver active biological cargo to recipient cells . NeverthIn the future, bioengineering of EVs may be used to improve the therapeutic properties of EVs . For insEVs can transmit information to recipient cells without delivering their content but by acting at the cell surface of the targeted cell . For insEVs comprise various proteins as well as coding and non-coding RNAs as cargoes in their lumen . The abuMost research focused on EV-derived miRNAs when considering the therapeutic potential of EV cargo, however, it is speculated that one would need, on average, over 100 EVs to detect a single copy of an abundant miRNA . BearingThe chemokine CCL2-CCR2 signaling axis has been investigated over the last years as a potential target to decrease monocyte recruitment ,105. InfAlternatively, cardiac macrophages, either tissue-resident or monocyte-derived, could be pushed toward an anti-inflammatory phenotype by manipulating their gene expression . NuclearAn EV must bind to its recipient cells to exert its biological function. It is known that EVs are capable of binding to specific target cells and that protein and lipid composition of their surface influence their targeting behavior. For instance, CD47 has been reported to inhibit EV uptake by macrophages  while phSurface engineering of EVs offers an exciting opportunity to optimize EV performance in vivo . There aMembrane fusion has also been used in nanomedicine to obtain biosynthetic hybrid vectors. This approach can also be applied to EVs by fusing them with, for example, functionalized liposomes, improving their cellular delivery . LikewisAnother essential point is to choose a selective feature of the cell of interest when considering EV targeting optimization. Nevertheless, the characterization of monocyte and macrophage populations in cardiac ischemic is still in its infancy. Single-cell transcriptomics analysis will improve our understanding of which monocyte and macrophage population should be targeted and when . This adIt is generally accepted that EVs need to be internalized to exert their function on the recipient cells, however, it is unclear whether this is a requisite in monocytes and macrophages. This process is likely to depend on the mechanism of action by which EVs interact with recipient cells and whether it is due to the biological cargo or a moiety on their surface. If EV uptake is required, strategies to increase their internalization and endolysosomal escape, such as EV modification with cationic lipids, should be considered . NeverthIt has become evident over the last decade that monocytes and macrophages play a central role in cardiac repair following MI, which makes them attractive therapeutic targets. EVs have been investigated due to their regenerative properties in cardiovascular settings. Here, the described research collectively shows that immunomodulation provided by stem and progenitor cell-derived EVs can be one of the mechanisms of action by which EVs offer cardioprotection post-MI. Further research addressing the challenges in the EV field will be key to fine-tune EV therapy in the future. These include characterization of therapeutic content of EVs and improvement of its cell targeting as well as what is the best administration route and its time window. Although there is still a long way to pursue before translation into clinics is possible, there is an exciting avenue for immunomodulatory therapy in MI provided by EVs.


Due to the microvascular effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), head and neck reconstructive surgeries utilizing free tissue transfers may be profoundly affected by SARS-CoV-2 infection in the immediate postoperative period. Our objective is to describe two adult patients who developed SARS-CoV-2 after undergoing relatively uncomplicated segmental mandibulectomies. In both cases, the patients were initially negative for SARS-CoV-2, underwent relatively uncomplicated segmental mandibulectomies with fibula free flap reconstructions, and were later discharged in stable conditions. Both patients subsequently experienced significant infectious sequelae at the donor and recipient sites with near-total split-thickness skin graft loss in the donor sites in the setting of postoperative SARS-CoV-2 infection. The first patient developed sepsis and gangrenous changes to his fibula donor site requiring four operative debridements and partial amputation with subsequent osteomyelitis of the remaining fibula. The second patient experienced dehiscence of the oral fibula free flap as well as a 22 cm phlegmon at the fibula donor site that required surgical debridement. In consideration of these cases, SARS-CoV-2 infection during the immediate postoperative period of head and neck reconstruction procedures may elevate the risk of major wound complications. Special consideration must be taken when performing free tissue transfers during the COVID-19 pandemic. Our clinical understanding of the coronavirus disease 2019 (COVID-19) pandemic is rapidly evolving. The causative virus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been shown to cause endothelial cell inflammation and vasculitis with microvascular dysfunction and thrombosis .The effects of SARS-CoV-2 on the microcirculatory system are of particular concern in reconstructive surgery. In otolaryngology, skin grafts, tissue rearrangements, and microsurgical tissue transfer procedures are frequently utilized to address head and neck tissue defects -5. SucceIn consideration of these factors, SARS-CoV-2 infection during the perioperative period of head and neck reconstruction procedures may elevate the risk of major wound complications. Here, we present a case series of two patients profoundly affected by the deleterious effects of SARS-CoV-2 in the immediate postoperative period after free tissue transfer at a tertiary academic medical center from June to July 2020. Of note, these two cases were performed prior to SARS-CoV-2 vaccinations being publically available.Case report 12 but displayed mildly low albumin levels of 3.0 g/dL indicating possible malnutrition. Three days prior to surgery, he tested negative for SARS-CoV-2 on a nasopharyngeal swab using PCR. The patient underwent a left segmental mandibulectomy with modified left neck dissection in addition to tracheostomy and gastrostomy tube placement. His mandible defect was reconstructed with a right-sided fibula free flap. A split-thickness skin graft (STSG) from his left lateral thigh was used to close the free flap donor site. There were no intraoperative complications. Final pathology revealed a T4aN3bM0 SCC with multiple high-grade features, including positive extranodal extension, perineural invasion, and lymphovascular invasion. The patient’s postoperative course was complicated by a 1 cm area of dehiscence in the neck on postoperative day (POD) 6, which was managed with local wound care. On POD7, he was decannulated from his tracheostomy and the cast over the fibula site was removed. There was complete STSG adherence without loss of any portion of the graft. He was discharged the same day. At the time of his discharge, he displayed no COVID symptoms. At his first follow-up on POD13, the area of dehiscence in the neck was noted to be improving though there was a minor retraction of the STSG from the edges of the fibula donor site. On POD20, the patient presented to the emergency room with complete STSG dehiscence and dry, gangrenous changes of the fibula free flap donor site. He was newly SARS-CoV-2 positive on repeat testing via the Simplexa COVID-19 Direct RT-PCR assay  using a nasopharyngeal swab but was asymptomatic. Blood tests and chemistries were notable for leukocytosis though he had no systemic infectious symptoms. The patient was afebrile with stable vital signs.The first patient was a 55-year-old man who presented with a pathologic mandible fracture. He was subsequently found to have a soft tissue mass in his gingivobuccal sulcus extending to his retromolar trigone with erosion extending from the mid-body of his left mandible to the ramus on computerized tomography. The patient also had significant ipsilateral lymphadenopathy involving neck levels 1B through 3 with the largest node measuring 21 mm. Biopsy of the erosive mass was positive for squamous cell carcinoma (SCC). The patient is a former smoker (an approximately 40 pack-year history) with a history of type 2 diabetes mellitus and hypertension. He had an appropriate body mass index (BMI) of 27.29 kg/mKlebsiella aerogenes, Enterobacter cloacae, and Peptostreptococcus. Bone biopsies were also positive for Klebsiella and E. cloacae. He remained hospitalized under the careful co-management of infectious disease specialists. No additional medications were given for SARS-CoV-2, as the patient did not demonstrate any respiratory sequelae at that time.The patient was started on ceftriaxone and vancomycin and received four operative debridements with V.A.C. VeraFlo wound vacuum placement . Initially, the necrotic wound tracked down to the lateral malleolus and ankle. Areas of purulence surrounded his gastrocnemius muscles. Tissue cultures showed On POD40, the patient redeveloped left-sided cervical lymphadenopathy and another left-sided mandible mass. Needle biopsy confirmed the diagnosis of recurrent SCC. Repeat head and neck imaging showed extensive metastatic lymphadenopathy in the bilateral submental and submandibular space in addition to a large heterogeneously enhancing mass in the left mandible measuring up to 5.7 cm. Due to the aggressive nature of his cancer, immediate initiation of chemotherapy and radiation was recommended. His prior fibula donor site did not respond well to operative debridement, systemic antibiotics, and local wound care with the VeraFlo wound vacuum. On POD51, the patient underwent a partial amputation of his right lower extremity and an awake tracheostomy. He was discharged home soon after with a plan for immediate outpatient adjuvant therapy.Before being able to initiate his treatments, the patient was readmitted on POD56 with signs and symptoms of sepsis. Admission labs showed leukocytosis of 43.7K white blood cells and lactate of 4.4 mmol/L. He was hypotensive, febrile, and tachypenic. Lower extremity scans revealed osteomyelitis of the remaining fibula with a new soft tissue abscess. Blood cultures had no positive growth. Repeat head and neck imaging showed dramatic progression in the patient’s cervical lymphadenopathy and left mandible mass, which had nearly tripled in size (15.3 cm from 5.7 cm on POD40). The tumor was non-resectable and too large for radiation. The patient elected against chemotherapy and was discharged to home hospice on POD63.Case report 22. He received a segmental mandibulectomy with left fibula free flap reconstruction in September 2020. Three days prior to surgery, he had a negative nasopharyngeal swab test for SARS-CoV-2. After the resection, the patient was staged as recurrent T4aN0. Following the surgery, the patient’s postoperative course was complicated by a small area of dehiscence along the central neck incision, which was managed with local wound care. On POD6, the cast over the fibula site was removed and the STSG was adherent without loss of any portion of the graft. On POD9, the patient was seen in the clinic with all surgical sites in the appropriate stages of healing.The second patient is a 64-year-old gentleman who initially presented with pT2N1MX (Stage III) SCC of the oral tongue in 2017. He underwent a partial glossectomy, right modified radical neck dissection, and tracheostomy. The tongue was reconstructed with a left radial forearm free flap with lateral left thigh STSG coverage of the arm defect. His postoperative course was uncomplicated, and he completed adjuvant radiation in 2018. In March 2020, he had local recurrence at the interface of the native tongue and radial forearm free flap. At this time, left partial glossectomy, marginal mandibulectomy, left modified radical neck dissection, and repeat tracheostomy were performed. The oral defect was repaired with a right radial forearm free flap with an ipsilateral thigh STSG. The patient’s perioperative course was again uncomplicated without wound breakdown. Given his clear margins of resection, negative lymph nodes, and prior history of radiation treatment, no adjuvant therapy was pursued at that time. In August 2020, a second recurrence of his cancer occurred with the involvement of the mandible. There was no pathologic cervical lymphadenopathy. The patient was a former smoker (an approximately 25 pack-year history) who quit in 2018. The patient had no other past medical history and was reasonably well-nourished with albumin of 4.3 g/dL and a BMI of 23.2 kg/mOn POD16, the patient presented to the emergency department with a two-day history of chills and fevers with increased pain at the fibula donor site. Admission vitals and labs were unremarkable. Upon presentation to the emergency room, the patient was noted to have partial loss of the skin graft on his left leg with surrounding erythema. Though the intra-oral fibula flap was viable, the sutures holding it in place were dehiscent and plating hardware was exposed. He tested positive for SARS-CoV-2 through the Simplexa COVID-19 Direct RT-PCR assay nasopharyngeal swab.Enterococcus faecalis, Enterobacteriaceae, methicillin-susceptible Staphylococcus aureus, and Streptococcus agalactiae. Antibiotic coverage was expanded to include vancomycin, cefepime, and metronidazole. The VeraFlo wound vacuum was exchanged for a traditional model five days after placement. A healthy wound bed was seen with new granulation tissue. The patient was discharged on POD30 with the wound vacuum in place, daily oral wound care, and a plan for long-term antibiotics.The patient was admitted for intravenous ciprofloxacin based on early lower extremity cultures. The area of intraoral dehiscence was explored and managed with local wound care. Lower extremity imaging was positive for a 22 cm phlegmon. He was taken to the operating room for wide local debridement and wound washout. Purulence was tracking to the posterior calf along previously dissected surgical planes. The non-viable STSG was gently debrided. The VeraFlo wound vacuum was placed. The wound cultures taken in the operating room showed polymicrobial growth with Microsurgical flap procedures in head and neck surgery rely on the establishment of proper revascularization for success and include multiple wound sites. Combining this with the predilection of SARS-CoV-2 to cause microvascular pathology suggests that free-flap reconstructions may face unique challenges with concurrent SARS-CoV-2 infection. Several case studies have described remarkable surgical site complications in the setting of SARS-CoV-2 infection -15. BenmThe microcirculatory effects of SARS-CoV-2, as well as the necessity of proper neovascularization, are particularly critical factors in the two cases of free tissue transfers presented here. Both patients tested negative for SARS-CoV-2 three days prior to surgery, underwent uncomplicated fibula free-flap reconstructions after segmental mandibulectomies, and were discharged home in stable conditions. These patients subsequently developed significant donor site infections and skin graft loss associated with SARS-CoV-2 infection during the recovery period, and the degree of flap dehiscence and donor site infection was severe in both cases. The first patient also developed severe sepsis and required a partial lower extremity amputation. However, the patient was at a higher risk of wound complications due to his medical comorbidities and initial nutritional status.In the second case, although found to be well-healing for two weeks after surgery, dehiscence of the oral fibula free flap occurred suddenly 16 days after surgery. This is an uncommon timeline for microvascular tissue transfer failures . NotablyGrafts and free tissue transfers are integrated through imbibition, inosculation, and revascularization. At one week after surgery, neither of these patients showed signs of imminent donor or recipient site morbidities. The initial stages of imbibition and inosculation were completed during the first week when they were hospitalized and not in contact with SARS-CoV-2. Neovascularization was likely impeded by infection with SARS-CoV-2 approximately two weeks after surgery in both these cases.At the time of this publication, research is beginning to illuminate how SARS-CoV-2 mediates microvascular changes through the production of angiotensin II (Ang II). The angiotensin-converting enzyme 2 (ACE2) is the functional receptor of SARS-CoV-2 -17. ACE2Special consideration must be taken when performing tissue transfer procedures during the COVID-19 pandemic. Providers should utilize preventative measures to reduce the risk of SARS-CoV-2 infection in the perioperative period. Patients and their families should also be educated on the possible deleterious side-effects of SARS-CoV-2 on flap and wound healing, and emphasis should be placed on preventing at-home exposure to SARS-CoV-2 after discharge. Additionally, patients at home should be isolated from other members of the household when possible, and screening family members for SARS-CoV-2 should be considered. We recommend more frequent wound examinations and early detection through careful monitoring for the development of symptoms associated with SARS-CoV-2 infection during all patient interactions.


Cox regression analysis, after propensity score matching, showed that therapies, including remdesivir-containing therapy, were not statistically associated with 30-day survival or mortality. The Kaplan–Meier curves of 30-day survival in patients treated with remdesivir or not before (p = 0.24) and after (p = 0.88) propensity score matching showed no differences between the two study groups. Finally, patients treated with remdesivir or not showed the same need for HFNC/NIV or mechanical ventilation. Conclusions: This real-life experience of remdesivir use in hospitalized patients with COVID-19 was not associated with significant increases in rates of survival or reduced use of HFNC/NIV or mechanical ventilation compared with patients treated with other therapies not including remdesivir.Objectives: Remdesivir is currently approved for the treatment of COVID-19. The recommendation for using remdesivir in patients with COVID-19 was based on the in vitro and in vivo activity of this drug against SARS-CoV-2. Methods: This was a prospective observational study conducted on a population of patients hospitalized for COVID-19. The primary endpoint of this study was the impact of remdesivir-containing therapy on 30-day mortality; the secondary endpoint was the impact of remdesivir-containing therapy on the need for high-flow oxygen therapy (HFNC), non-invasive ventilation (NIV), or mechanical ventilation. The data were analyzed after propensity score matching. Results: A total of 407 patients with SARS-CoV-2 pneumonia were consecutively enrolled. Out of these, 294 (72.2%) were treated with remdesivir and 113 (27.8%) were not. Overall, 61 patients (14.9%) were treated during hospitalization with HFNC, NIV, or mechanical ventilation, while 30-day mortality was observed in 21 patients (5.2%). Univariate analysis of patients treated with remdesivir or not showed no differences in 30-day mortality (4% vs. 6%,  Corticosteroids, particularly dexamethasone, have been the standard of care in patients with severe coronavirus disease COVID-19) since the publication of the results of the RECOVERY trial 9 since t. Other aRemdesivir is an inhibitor of viral RNA polymerase that was initially studied on Ebola virus . RemdesiReal-world data on the efficacy of remdesivir in the treatment of hospitalized patients with COVID-19 are needed. Therefore, we performed this prospective observational study aiming to investigate the impact of remdesivir on 30-day mortality and the need for invasive and non-invasive ventilation in a large Italian institution.This prospective observational study included patients admitted to Policlinico Umberto I of the University Hospital of Rome, Italy, from October 2020 to February 2021. Inclusion criteria were (1) positive SARS-CoV-2 real-time polymerase chain reaction test or antigenic test on nasopharyngeal swab, (2) pneumonia diagnosed either by thorax CT or chest x-ray, and (3) need for hospitalization. Patients who required high-flow oxygen therapy (HFNC) or non-invasive ventilation (NIV) or mechanical ventilation at the time of hospitalization were excluded from this analysis.All patients were evaluated in a dedicated emergency department by dedicated infectious diseases specialists who identified patients with SARS-CoV-2 pneumonia, followed the patients during hospitalization, and collected all data prospectively without interfering with patient management. This observational study was conducted according to the principles stated in the Declaration of Helsinki, and it conforms to standards currently applied in our country. This study was approved by the local EC. Informed consent was obtained from the patients.2/FiO2 ratio of less than 200 mmHg according to the Berlin definition ) were not available for all study population. Third, this analysis evaluated consecutively hospitalized patients independently from COVID-19 severity, as demonstrated by the low mortality rate (6% of remdesivir group vs. 4% of those not treated with remdesivir). Finally, the analysis of the beneficial effects of treatments should be interpreted cautiously because it was not conducted with randomized groups and might therefore be affected by several measured and unmeasured confounding factors. However, the comparison of patients treated and not treated with remdesivir was based on a robust statistical methodology appropriate for non-randomized cohort studies about therapy.In conclusion, in this real-life experience, the use of remdesivir in hospitalized patients with COVID-19 was not associated with significantly increased rates of survival or reduced use of HFNC/NIV or mechanical ventilation compared to treatment with other therapies not including remdesivir. These results suggest the need to conduct other RCTs to evaluate the impact of remdesivir in hospitalized COVID-19 patients at different stages of the disease or in combination with other drugs . However


Background: Massive vaccination campaigns have been undertaken globally to combat the spread of the Coronavirus Disease 2019 (COVID-19). While most COVID-19 vaccines have shown excellent efficacy and safety profiles in clinical studies, real-world monitoring of vaccine safety is still important. In this study, we aimed to investigate the early side effects of Pfizer-BioNTech (BNT162b2) mRNA vaccine in children between 12–18 years old in Saudi Arabia. Method: To investigate the side effects in children in this age range following the administration of either one or two doses of Pfizer-BioNTech (BNT162b2) mRNA vaccine, we conducted a retrospective, cross-sectional study using a self-administered online survey. General and demographic data were collected, and vaccine-associated side effects following vaccination were evaluated. Results: The study recruited a total of 965 eligible participants. Overall, 571 (60%) of the study participants reported at least one side effect following Pfizer-BioNTech (BNT162b2) mRNA vaccination. The most frequently reported side effects were pain or redness at the site of injection (90%), fatigue (67%), fever (59%), headache (55%), nausea or vomiting (21%), and chest pain and shortness of breath (20%). Joint or bone pain were reported less frequently among our participants (2%). Our data showed that more female participants reported side effects compared to male participants, with 52% and 48%, respectively. Side effects were more common after the second dose compared to the first dose in our study cohort. Conclusions: While 60% of the children (12–18 years old) who received Pfizer-BioNTech (BNT162b2) mRNA vaccine reported side effects, our data showed that these side effects were not different from those that were reported in the clinical trials which lasted only for a few days. Side effects were more common after the second dose. Larger epidemiological and molecular studies are needed to evaluate the safety and the effectiveness of COVID-19 vaccine in protection of children against SARS-CoV-2 reinfections. Coronavirus Disease 2019 (COVID-19) is an ongoing global pandemic that is caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) . NotablyVaccination is a crucial public health intervention method to control the spread of infectious diseases, including the ongoing COVID-19 pandemic . CurrentCurrently, substantial mass vaccination campaigns are underway worldwide to combat this ongoing pandemic. Globally, almost 5.5 billion doses of COVID-19 vaccines have been administered to date, with a rate of 33.54 million doses given on a daily basis . Saudi AThe Pfizer-BioNTech vaccine (BNT162b2) is based on mRNA technology to express the SARS-CoV-2 spike (S) gene . The tecA retrospective, cross-sectional study was conducted using a self-administered online survey to report side effects in children aged 12–18 years-old following Pfizer-BioNTech (BNT162b2) vaccination in Saudi Arabia. The survey was designed to have a dual language (Arabic and English) questionnaire, using Google Forms, which was delivered to participants via social media between 1st August to 24th August of 2021. This study included participants who received both single and double doses of the Pfizer-BioNTech (BNT162b2) vaccine. The survey was developed after an intensive literature search that included PubMed, Medline, Google Scholar, and other databases, aiming to identify potential and common short-term side effects post-Pfizer-BioNTech (BNT162b2) vaccine. The questionnaire was designed to have multiple sections. The first section has an introductory part about the purpose of the study, contact details for the study investigators to facilitate communication between study investigators and participants as well as a consent section for agreeing to participate in the study. The second section was designed to collect general information about the study participants including gender, age, chronic diseases such as hemoglobinopathies, type 1 diabetes, asthma, and others, as well as previous infection history with SARS-CoV-2 infection. The third section was formulated to focus mainly on the COVID-19 vaccine-related data such as number of doses received, side effects experienced following COVID-19 vaccine, timing, and duration of the side effects. Participants were also allowed to report no symptoms by leaving the box unchecked. We have included a subsection for side effects where we listed the most frequent side effects reported by other studies ,30,31,32Ethical approval for conducting this study was obtained from the standing ethical approval committee at Jazan University . Consent was obtained from all participants or their tutors prior to participation in the study. The study excluded responses that did not contain the informed consents, participants who provided incomplete responses, those outside the age group of 12–18 years old, and those who received a COVID-19 vaccine other than the Pfizer-BioNTech (BNT162b2) vaccine.p = 0.05 value.The sample size was calculated using raosoft.com. As there were no statistics available for the number of children in this age group among the total Saudi population, we used the whole country population (around 30 million) as our population size. The sample size was calculated based on a 5% margin of error, a 50% response rate, and a 95% confidence interval, for a population of 30 million inhabitants. Consequently, a sample size of 385 responses was determined to be sufficient for this study. However, to reduce sampling bias in our method as this study was based on an online questionnaire distributed via social media, we increased the sample size to include 965 participants, which is more than 2-folds of the required size. Descriptive statistics were reported for the collected data. Further descriptive analysis using t-test and chi-square test were performed for statistical purposes for all participants, and those who are presented with side effects versus those without side effects. Then, further descriptive analysis using t-test and chi-square test were done for those who received single dose versus two doses. The data were statistically analyzed using SPSS v.23  with a significance level of p = 0.003) . The median age for the study participants was 16 years old with almost 48% of the participants being male. Only 29% of the study participants reported that they had been previously diagnosed with COVID-19. A total of 10% of our study participants reported that they have current health conditions such as type 1 diabetes, sickle cell anemia, and asthma, while 44% of the participants reported that they had received two doses of the vaccines. Overall, almost 60% of the study participants experienced side effects. These data are also summarized in = 0.003) . Further= 0.003) .In the present study, 571 of the study participants reported side effects following vaccination, representing 60% of the total study subjects . The mosWe further categorized the participants who reported side effects following vaccination into 2 groups, i.e., participants who received single doses and participants who received two doses of Pfizer-BioNTech (BNT162b2) vaccine. These two groups were compared against each other using several parameters, including previous history of infection with SARS-CoV-2, presence of chronic health conditions, gender, time and duration of side effects, and the types of side effects experienced following vaccination . Our datVaccines have been proven to play critical roles in eliminating and controlling infectious diseases’ epidemics. The rapid development and availability of COVID-19 vaccines have brought a glimmer of hope to the world, and it is believed that widespread vaccination seems to be the most effective method of controlling the ongoing COVID-19 pandemic. However, vaccine acceptance and uptake could influence the efforts to control the spread of the COVID-19 pandemic. Given the rapid development and emergency authorization of COVID-19 vaccines, more trepidation about receiving COVID-19 vaccines were noticed among some populations worldwide. Furthermore, the recent reports of some rare cases of serious side effects such as thrombosis  and myocn = 208) [Saudi Arabia is one of first countries that approved COVID-19 vaccines in children 12 years old and older immediately following the release of sufficient data on vaccine safety and efficacy in this age group ,16. In an = 208) . More sin = 208) ,38. Thisn = 208) . Pain/ren = 208) ,22,23,24n = 208) . We alsoPublished literature showed that side effects were more prevalent in females than in males and in people aged 55 years or younger than in those older than 55 years ,23,24. STo the best of our knowledge, this is the first study to investigate the adverse effects of the Pfizer-BioNTech vaccine in children aged 12–18 years old in Saudi Arabia. We have shown that the current study participants reported only common side effects which were previously reported in several other studies. Notably, we have provided our study participants with a choice to report any other side effects which were not listed in the survey. However, no other adverse effects were reported by any of the study participants, indicating that our data is in strong agreement with the type of adverse effects that were reported from phase 3 clinical study.The data from our study showed that side effects were more frequently reported after the second doses and among individuals with a history of previous exposure to SARS-CoV-2. Results from our study may contribute to increasing the public confidence in the safety profile of COVID-19 Pfizer/BioNTech vaccines, which may contribute to accelerating the process of vaccination coverage. Our study still bears some limitations. First, the study used self-reported data, which may introduce information bias, such as inconsistency in participants’ reports, i.e., some participants might be more likely to report adverse effects than others. Additionally, the distribution of this survey was dependent on the authors’ networks. A community-based survey would be more appropriate for this kind of study. However, since social distancing is still strongly recommended, we preferred to conduct this study as a web-based study to ensure the safety of all our study participants. Another limitation of the current study is that it monitored the vaccine’s short-term side effects (immediately after injection). The medium and long-term effects of the vaccine are still unknown in our study cohort. It would be of importance for future study to assess other rare events following COVID-19 vaccination such as thromboembolic profiles and myocarditis .In conclusion, the side effects following the COVID-19 Pfizer-BioNTech vaccine in children aged 12–18 years are common side effects which were previously reported in several other studies and do not persist for long. The adverse effects were more frequently reported among those who previously had COVID-19 and following the second doses. Data from our study may contribute to increasing public confidence regarding side effects associated with COVID-19 Pfizer/BioNTech vaccines, which may contribute to accelerating the process of vaccination coverage. A follow-up study on a larger population to evaluate the long-term side effects as well the effectiveness of the COVID-19 vaccines in children is warranted.


Outcome measures were alcohol craving and use over a follow-up period of one year. Analysis was performed by means of repeated measures multivariate analysis of variance. (3) Results: The results showed a main group-by-time interaction effect on craving  = 2.654, p = 0.032) and an effect of group on alcohol use  = 4.9, p = 0.002), with lower alcohol craving and use in the group with active rTMS compared to the control group. Differences in craving between groups were most prominent three months after treatment. At 12 months follow-up, there was no effect of rTMS on craving or abstinence. (4) Conclusions: This small-scale randomized controlled trial showed the efficacy of high-frequency rTMS over the right dlPFC diminished alcohol craving and use in recently detoxified patients with AUD during the first months after detoxification. These findings suggest that rTMS might be an effective add-on in treating patients with AUD and warrant replication in future large-scale studies.(1) Background: Current evidence-based treatments for alcohol use disorder (AUD) are moderately effective. Studies testing repetitive transcranial magnetic stimulation (rTMS) in AUD commonly apply a limited number of rTMS sessions with different rTMS settings, showing inconsistent effects on craving for alcohol. This study tested the efficacy of a robust rTMS protocol on craving and alcohol use. (2) Methods: In a single-blind randomized controlled trial in recently detoxified patients with AUD, ten days of high-frequency rTMS over the right dorsolateral prefrontal cortex on top of treatment as usual ( Alcohol use disorder (AUD) is a chronic relapsing disorder characterized by an impaired ability to control alcohol use, leading to clinically significant impairment or distress . A core Psychosocial  and pharmacological treatments  show low to moderate effect sizes ,7. With Noninvasive brain stimulation may offer a promising new treatment strategy targeting AUD via a different mechanism than existing treatments . RepetitMeta-analyses of neuromodulation studies in patients with various addictive disorders showed a moderate to a large effect size of rTMS in decreasing craving for drugs of abuse ,13,14,15Two recently published sham-controlled rTMS studies testing robust, high-frequency rTMS in patients with AUD, however, did not find any effects of rTMS compared to placebo. One study applied deep rTMS on the insula  but failThe current study aimed to test the efficacy of a robust high-frequency rTMS protocol, stimulating the right dlPFC, with clinical outcome measures alcohol craving and use, and a follow-up period of one year. Specifically, we tested the hypotheses that compared to sham rTMS, rTMS over the right dlPFC, added to treatment as usual (TAU), would lead to reduced (1) alcohol craving (primary outcome) and (2) alcohol use (secondary outcome).In a single blind randomized controlled trial efficacy of rTMS was investigated. The research protocol was approved by the Medical Ethical Committee of the Radboud University Medical Centre  and registered in a trial Register .Eligible patients with AUD were recruited between 2015 and 2019 at two addiction care centers (IrisZorg and Novadic-Kentron) and Radboud University Medical Centre in The Netherlands. In total, 37 individuals were screened for eligibility, wherefrom 34 were included and randomized . After baseline measurements, four individuals withdrew their consent to participate.Inclusion criteria were: (1) meeting DSM-5 criteria for AUD as their primary diagnosis using the structured clinical interview for DSM-5 disorders—clinician version (SCID-5-CV)   , years oVisual Analog Scale (VAS). The VAS is commonly used in studies to assess the severity of craving in patients with substance use disorder . A totalAlcohol Urge Questionnaire (AUQ). The AUQ is a validated instrument . It measures momentary alcohol craving in patients with AUD ,33. It cObsessive-Compulsive Drinking Scale—short version (OCDS-5). The OCDS-5 is a shortened version of the original OCDS  (CronbacAlcohol craving (primary outcome) was measured at five timepoints: at baseline (day one of the rTMS treatment), at the end of the rTMS treatment (10th day), and at follow-up: one, three, and 12 months after finishing rTMS treatment. Three instruments were used at all timepoints to measure alcohol craving:At baseline (day 1 of the rTMS treatment) and at the start of each rTMS treatment session (2nd–10th day), participants were asked about their alcohol use since the last treatment.At follow-up 1, 3, and 12 months after rTMS treatment, alcohol use was assessed using the TimeLine Follow-Back (TLFB) method over the previous period of 1 month. The TLFB is a validated instrument to systematically estimate alcohol use over a specified timeframe (Spearman’s ρ = 0.93) ,38. PartIndices of alcohol use were measured using different instruments at different timepoints: With these data, sampled over four periods of time, which spanned a total of 12 months, six alcohol use indices were calculated: (1) percentage abstinence at endpoint; (2) total amount of alcohol consumption during measured time periods; (3) mean alcohol consumption per day during measured time periods; (4) time to relapse in days, as defined by relapse in a heavy drinking day (HDD)  before the start of the data collection.After allocation to one of the two groups, (baseline) sample characteristics, stimulus location, and rTMS intensity were determined. Next, participants received ten active or sham rTMS sessions over ten consecutive days. Though some patients interrupted rTMS treatment over the weekend, leading to a variation of 10–14 days of the total treatment period. After one, three, and 12 months following the last rTMS session, participants were visited at home or visited a treatment facility to assess relapse rates and craving. For a schematic overview of this procedure, see p-values < 0.05 were considered significant.The Statistical Package for Social Sciences (SPSS) version 27 was used to analyze the data . The mett-test was used for continuous variables in case normality was met (Kolmogorov Smirnov test); otherwise, the non-parametric Mann–Whitney-U test was applied. Baseline sample characteristics were summarized using descriptive statistics and compared between groups. For categorical variables, comparisons were performed with a Chi-square test, while Fisher’s exact tests were used in case the expected counts were less than 5. A two-sample To analyze the effect of rTMS on craving, after calculating correlations , a multivariate one-way repeated measures MANOVA was used, with VAS, OCDS-5, and AUQ total scores as continuous dependent variables, time as a within-subject factor (4 levels), and rTMS treatment as a between-subject factor (2 levels). In case of significant results, post-hoc contrast analyses were performed using linear discriminant analysis and ANOVA’s to identify which craving outcome measures at which specific timepoints contributed to the significant findings. In case of unequal distribution of baseline characteristics, sensitivity analyses were performed.To analyze the effect of rTMS on alcohol use, after calculating correlations , a multivariate one-way measure MANOVA was used, with our predefined six indices , time to relapse, total amount abstinent days, and total amount of HDD-days) as dependent variables, and rTMS treatment  as between-subject factor. In case of significant results, post-hoc contrast analyses were performed using linear discriminant analysis and T-tests to identify which outcome measures contributed to the significant findings. Thirty participants started the treatment, and all had six or more DSM-5 AUD criteria (severe AUD). All participants’ follow-up data were available , except 2(1) = 9.299, p = 0.002), with more comorbid PTSD in the sham group , group  = 6.156, p = 0.003), and an group-by-time interaction effect  = 2.654, p = 0.032), indicating increased craving over time for all participants but less increased craving over time in the rTMS group versus sham. Kendall tau-b was below 0.7. Univariate ANOVA showed interaction effects of time x group for all outcome measures, except the OCDS-5  = 5.575, DS-5 see . TestingDS-5 see . SensitiDS-5 see . Althougp < 0.01), we combined these measures in analysis. The one-way MANOVA on alcohol use showed an effect of group  = 5.6, p = 0.001), indicating decreased alcohol use in the rTMS group, compared to sham. Post-hoc analysis showed that the rTMS group consumed less alcohol (factor 1.86), had less DD (average difference: 40 DD), and had less HDD (average difference: 21 HDD). The percentage abstinence at the endpoint did not differ between groups . HoweveThe current findings with a higher dose of pulses applied throughout the treatment course suggest persisting effects of rTMS on alcohol craving and use for at least three months. This is in line with the limited studies about rTMS in patients with AUD  and withThe decrease of statistical group differences at one year might suggest fading effectiveness of rTMS over time. Indeed, in the depression literature, persisting effects beyond three months have mainly been observed in studies using even more intensive treatment procedures (daily sessions for 6 weeks) or applying booster sessions after an initial treatment episode . HoweverIn the current study, the only craving measure that did not show an effect of rTMS was the OCDS-5. The lack of findings on the OCDS-5 might be explained by its seemingly lesser validity when used in a population of heavy drinking subjects, such as in this study . Since tSimilarly, the observed absolute difference in abstinence at the endpoint failed to reach significance, potentially due to too small a sample size to detect differences in a dichotomous outcome measure. Yet, again this might also indicate that the effects of 10 rTMS sessions did not persist for a year, as outlined above. It might also be that rTMS does reduce the level of alcohol consumption but does not facilitate full abstinence. Indeed, several studies have shown differential effects of evidence-based AUD treatments on alcohol consumption, HDD, and full abstinence ,53,54. TIn addition, other forms of TMS (like Theta Burst Stimulation) and other neuromodulation techniques  should be more extensively evaluated in the field of addiction since studies have revealed potential benefit over conventional rTMS or similar effect sizes, respectively ,56. FinaIn the current study, rTMS was targeted at the right DLPFC. This is in contrast with the majority of depression literature, where the left DLPFC is considered the primary brain target for high-frequency rTMS. However, AUD studies targeting rTMS to the left DLPFC have largely yielded negative findings . StudiesOne study showed that stimulating rTMS on the right dlPFC strengthened connectivity between frontoparietal regions and the striatum in healthy individuals, whereas rTMS on the left dlPFC weakened these connections . The strn = 30) is substantially larger than the mean sample size for clinical studies in this field (n = 22.2) [This study has to be evaluated in light of some strengths and limitations. Major strengths of the current study include the robust rTMS stimulation protocol of ten sessions and 30.000 pulses in total, and a long follow-up period of a year, with no drop-out in either treatment group. This provides insight into the potential time-dependent effect of rTMS. Though the sample size in the current study ( = 22.2) , it is s = 22.2) . Though Medication use at baseline did not differ between groups. However, the current study did not account for benzodiazepine and antipsychotic use in follow-up. Though benzodiazepines were generally fully tapered off during detoxification, any persisting effect of benzodiazepine use on rTMS effectiveness cannot be ruled out. Similarly, antipsychotics were frequently prescribed (32%). Since it is known that benzodiazepines and antipsychotics may attenuate rTMS effects, the current findings might underestimate the effectiveness of rTMS in AUD . HoweverThe rTMS methods to determine MT and position the coil applied here are in line with FDA guidance for rTMS procedures . HoweverFinally, the sham condition applied here (two wing 90-degree tilting of the coil) might be discernable by patients from real rTMS because it does not induce sensations on the scalp. This might have diminished the placebo effect in the control group. However, because major effects were found at three months follow up, confounding is unlikely because of this potentially reduced placebo effect. Future studies should ask patients about the expected group membership  and/or apply other forms of sham rTMS; however, sham TMS approaches are inherently insufficient ,78.This small-scale randomized trial shows the potential efficacy of high-frequency rTMS applied over the right DLPFC on top of TAU in recently detoxified AUD patients on both alcohol craving and consumption. Given the observed effects were most prominent at three months follow-up, future studies should explore whether prolonged rTMS treatment or the use of booster sessions can induce more prolonged effects. Furthermore, future studies should explore potential working mechanisms and replicate these findings in substantially large clinical samples.


Resistant hypertension (R-HTN) implies a higher mortality and morbidity compared to non-R-HTN due to increased cardiovascular risk and associated adverse outcomes—greater risk of developing chronic kidney disease, heart failure, stroke and myocardial infarction. R-HTN is considered when failing to lower blood pressure below 140/90 mmHg despite adequate lifestyle measures and optimal treatment with at least three medications, including a diuretic, and usually a blocker of the renin-angiotensin system and a calcium channel blocker, at maximally tolerated doses. Hereby, we discuss the diagnostic and therapeutic approach to a better management of R-HTN. Excluding pseudoresistance, secondary hypertension, white-coat hypertension and medication non-adherence is an important step when diagnosing R-HTN. Most recently different phenotypes associated to R-HTN have been described, specifically refractory and controlled R-HTN and masked uncontrolled hypertension. Optimizing the three-drug regimen, including the diuretic treatment, adding a mineralocorticoid receptor antagonist as the fourth drug, a β-blocker as the fifth drug and an α1-blocker or a peripheral vasodilator as a final option when failing to achieve target blood pressure values are current recommendations regarding the correct management of R-HTN. Arterial hypertension (HTN), defined as office systolic blood pressure (BP) values ≥ 140 mmHg and/or diastolic BP values ≥ 90 mmHg, is known as the most important risk factor for cardiovascular (CV) diseases. Nowadays, the prevalence of HTN amounts to 1.13 billion people, or around 30–45% of the global population . The WorResistant hypertension (R-HTN), a severe form of HTN, has been intensively studied since the early 1960s, when it was first defined. R-HTN is considered when failing to lower BP below 140/90 mmHg despite adequate lifestyle measures and optimal treatment with at least three antihypertensive medications of different classes, including a diuretic, typically a blocker of the renin-angiotensin system (angiotensin converting enzyme inhibitor or angiotensin receptor blocker) and a long-acting calcium channel blocker (CCB), at maximum or maximally tolerated daily doses administered at the appropriate dosing interval [The 2018 European Society of Hypertension and European Society of Cardiology (ESH/ESC) Guidelines’ definition for R-HTN requires inadequate control of BP to be confirmed by ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) and adherence to therapy to be validated . After eDifferent R-HTN-associated phenotypes have been described. The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline introduced two new concepts: controlled R-HTN and refractory R-HTN . ControlMost recently, a new R-HTN-associated phenotype was described—masked uncontrolled HTN, referring to patients receiving four or more antihypertensive medications and achieving an adequate office BP control, but with elevated out-of-office BP . Hence, Various physiological mechanisms are involved in maintaining normal BP values; hence, their dysfunction may lead to the development of HTN. R-HTN is broadly attributed to two underlying processes: the renin-angiotensin-aldosterone system and sympathetic nervous system activation.Aldosterone is the most important mineralocorticoid hormone produced in the zona glomerulosa of the adrenal cortex as a response to angiotensin II, increased levels of extracellular potassium and corticotropin activity. Aldosterone regulates the sodium and potassium balance by binding and activating the mineralocorticoid receptor in the distal tubule and collecting duct of the kidney. Increased aldosterone production induces salt retention and, consequently, fluid retention, thus promoting elevated BP values. The detrimental actions of aldosterone include endothelial dysfunction, sympathetic activation and oxidative stress. In vascular smooth muscle cells, aldosterone displays several extrarenal effects by activating the expression of genes involved in inflammation, calcification and fibrosis ,11,12. AEssential HTN is characterized by both impaired parasympathetic tone and increased sympathetic activation. Increased levels of the adrenergic neurotransmitters norepinephrine and epinephrine have also been found in normotensive patients with a family history of HTN . The symActivation of the adrenergic nervous system is involved in the development of vascular remodeling, endothelial dysfunction and arterial stiffness in hypertensive state . For a sIn recent years, new methodologies have been developed making it possible to employ genome-wide association studies (GWAS) for testing the correlation between thousands of common gene variants and common characteristics in samples from different populations. GWAS assume genetic expression and epigenetic analysis in different tissues, and this way, thousands of genes and pathways with potential biological relevance may be discovered. However, the results for BP phenotypes are scarce as the gene variants explain only 2.2% of BP variation and are, thus, not applicable for clinical implementation . MoreoveThe classification of R-HTN has become much easier after the new definition of R-HTN was published in the 2018 ESH/ECS guideline . When asWhite-coat uncontrolled HTN—in patients with office BP above goal, but out-of-office BP measured by ABPM or HBPM are below target values;Masked uncontrolled HTN—in patients with adequate office BP control, but with elevated out-of-office BP measured by either ABPM or HBPM;Sustained uncontrolled HTN—in patients whose BP values are elevated at both office and out-of-office measurements.According to the definition, elevated values of office BP are not sufficient for establishing the diagnosis of R-HTN, and the inadequate control of BP needs to be confirmed by ABPM and, if not available, HBPM in patients whose adherence to therapy has been confirmed . These tUncontrolled R-HTN—in patients with office BP ≥ 140/90 mmHg and/or 24-h ambulatory BP ≥ 130/80 mmHg, taking three or more antihypertensive medications of different classes, including a diuretic, and usually a long-acting calcium channel blocker and a blocker of the renin-angiotensin system blocker at maximal or maximally tolerated doses;Controlled R-HTN—in patients with office BP < 140/90 mmHg and/or 24-h ambulatory BP < 130/80 mmHg, taking at least four antihypertensive medications of different classes.Another HTN classification based on BP control and number of antihypertensive medications is the following  and non-prescription drugs  . HoweverAfter excluding pseudoresistance and drug-related HTN, screening for secondary causes of HTN is essential. Screening for this type of HTN should be guided by clinical findings as, in most situations, curative treatment of secondary HTN does not imply the normalization of BP values, especially if the disease had evolved for a long period of time and, thus, led to possible vascular or organ damage.Once a patient was diagnosed with R-HTN, a set of nonpharmacological, pharmacological and, if needed, device-based strategies can be applied in order to obtain optimal control of BP.Nonpharmacological measures are commonly recommended as they are the cornerstone for both preventing and treating HTN. We will discuss below several lifestyle factors that influence BP values.Obesity is, undeniably, one of the most evident and yet neglected problems of public health. The number of obese adults was estimated at 500 million in 2016, with an alarming increasing trend among children. It is estimated that by 2030, the epidemic of “globesity” will amount to approximately 1.5 billion people .Even if the pathophysiological mechanisms that link obesity to BP are complex, the key element might be the distribution of body fat. Vague was the first to raise this issue back in 1956, when finding the correlation between metabolic and CV complications and the phenotype of obesity—android or gynoid . Since t2 and 4.5 cm waist circumference in men and 1.3 kg/m2 and 2.5 cm in waist circumference in women, the systolic BP increases with 1 mmHg [Studies also demonstrated that there is an almost linear correlation between body mass index and BP values. With every 1.7 kg/mh 1 mmHg .2 doubles the risk of true R-HTN [2. Even if the BP-lowering effect appears in early stages of weight loss, the long-term effects being more attenuated, persevering in weight loss is extremely important [The National Health and Nutrition Examination Survey (NHANES) and the Spanish ABPM Registry demonstrated that a body mass index above 30 kg/mmportant . HoweverOne of the most important measures in reducing BP values is, undeniably, sodium restriction, given the fact that hydro-saline retention is involved in the pathophysiology of HTN. The 2018 ESH/ECS Guidelines recommend a daily sodium intake limited to 5 g per day . In contThe Dietary Approaches to Stop Hypertension (DASH) diet was designed as a 11-week program in 459 individuals with mild and untreated HTN who were randomly assigned to one of three types of diet. The first one—the DASH diet—was based on fruits, vegetables and low-fat dairy products with reduced saturated and total fat, the second was based on fruits and vegetables rich in potassium and fiber, while the third one was based on a typical American diet (the control diet). Each diet accounted a total sodium intake of about 3 g per day. The DASH diet lowered BP by 6/3 mmHg, while the fruits and vegetables diet lowered BP by 3/1 mmHg . In addiPhysical activity has been consistently studied and shown to reduce both systolic and diastolic BP, being beneficial for preventing and treating HTN as well as lowering CV risk and mortality. There are multiple types of physical activities, such as dynamic or aerobic exercises  and isometric or resistance exercises , and each of these showed BP-lowering properties. When hypertensive patients perform 90 to 150 min of aerobic exercise per week, they can register a reduction of BP values by 5–8 mmHg, whereas when performing an isometric resistance exercise over the course of 8–10 weeks, the systolic BP can be reduced by 4–5 mmHg . The benOther lifestyle measures that are found to be helpful in reducing BP values are: limiting alcohol consumption to less than 14 units per week in men and less than 8 units per week in women, avoiding binge drinking, avoiding excessive caffeine, smoking cessation and having a healthy sleep pattern with at least six hours of sleep per night .Beyond lifestyle measures, the psychosocial factors play an important role in treating HTN, mainly because they may influence adherence and/or persistence to therapy. Psychosocial stress, anger, anxiety and especially depression are common in adults and are frequently associated with the development of HTN, hence affecting the individual health and the quality of life . A meta-All hypertensive patients require drug therapy in addition to lifestyle measures to achieve an adequate BP control. We will discuss below the pharmacological strategies that should be applied in a stepwise manner in order to achieve therapeutic success in R-HTN .When treating R-HTN assuring that the diagnostic criteria have been fulfilled alongside with optimal nonpharmacological measures is essential. Therefore, the treatment of R-HTN includes at least three antihypertensive medication of different classes, including a diuretic, and usually a blocker of the renin-angiotensin system and a CCB, at maximum or maximally tolerated daily doses and at the appropriate dosing interval. Note that when HTN is associated with atrial fibrillation or heart failure, the initial triple therapy may be different. Additionally, adherence to treatment must be improved  .Thiazide-like diuretics  are considered the first-line diuretics in R-HTN having a longer half-life when compared to thiazide diuretics (hydrochlorothiazide), which translates into a better control of BP .2, it is advisable to use thiazide or thiazide-like diuretics, whereas in patients with eGFR below 30 mL/min/1.73 m2, loop diuretics  are preferred. Even though hydrochlorothiazide is the most prescribed thiazide diuretic, switching to chlorthalidone might be a better choice due to its longer acting effect , its higher efficiency and superiority in preventing CV events and left ventricle hypertrophy [When choosing the appropriate diuretic, one must take into account the estimated glomerular filtration rate (eGFR). In patients with eGFR higher than 30 mL/min/1.73 mertrophy ,42. Elecertrophy .When target BP values cannot be obtained with the three-drug regimen, a fourth medication needs to be added. Therefore, given the fact that mineralocorticoid receptor blockade is extremely important in hypertensive patients, mineralocorticoid receptor antagonists are one of the front-runner medication classes for treating R-HTN ,5.The PATHWAY-2 study (Prevention and Treatment of Hypertension with Algorithm Based Therapy) included patients with uncontrolled R-HTN taking optimal treatment with at least three antihypertensive medication of different classes who were randomized to a double-blinded, four-way cross-over comparison of 3 months each of placebo, spironolactone (25 or 50 mg), bisoprolol (5 or 10 mg) and doxazosin modified release (4–8 mg) . Spirono2, as it may lead to deterioration of renal function and hyperkalemia. Studies show that potassium binders such as patiromer are extremely efficient in patients with R-HTN and chronic kidney disease by enabling patients to continue the treatment with spironolactone with a lower risk of hyperkalemia [Even though spironolactone is very useful in treating R-HTN, it has certain limitations and contraindications. It should not be used in patients with eGFR lower than 45 mL/min/1.73 mPATHWAY-2 included several sub-studies aimed to explore the underlying causes of R-HTN, including the role of aldosterone and excess fluid retention as important mediator of treatment resistance. The first sub-study demonstrated the relation between the baseline aldosterone-renin ratio and baseline renin level and the BP response to spironolactone . The secThe fourth therapeutic option consists of adding a cardio-selective β-blocker or a combined α- and β-blocker, especially if the basal heart frequency is above 70 beats per minute, and in case they are not already part of the treatment for a different pathology such as heart failure with reduced ejection fraction, atrial fibrillation, or coronary artery disease. The 2018 ESH/ECS guideline favors the use of bisoprolol as it was shown in the PATHWAY-2 study ,46. HoweIn case β-blockers are ineffective, contraindicated or not tolerated, central α-2 agonists such as clonidine, rilmenidine or moxonidine can be considered. A patch form of clonidine is preferred because of a lower risk of rebound after discontinuation or non-adherence . More reRarely, if there is a specific contraindication to β-blockers, a non-dihydropyridine calcium channel blocker can be added .The fifth therapeutic option consists of adding a new therapeutic class with a more potent antihypertensive effect, but also with greater side effects.The first option would be α1-blockers such as doxazosin. The starting dose for doxazosin is 1 mg per day, preferably in the evening in order to minimize the risk of orthostatic hypotension and/or syncope, especially in older adults. The dose can increase every one or two weeks until a maximum dose of 16 mg per day, although many patients only need 4 to 8 mg per day in order to obtain adequate control of BP. The α1-blockers may be considered in patients with concomitant benign prostatic hyperplasia [α-methyldopa is frequently used in pregnancy HTN, but it can also be useful in R-HTN. The starting dose is 250 mg, once daily, preferably in the evening for one or two weeks to minimizing the effect of sedation and to monitor tolerance. Then, the doses can be slowly increased until a maximum dose of 2 g per day .If BP is still uncontrolled with the aforementioned medications, hydralazine can be another option. Doses less than 150 mg per day decrease the risk of developing drug-induced lupus-like syndromes. Another major disadvantage of hydralazine is that the direct arterial vasodilation determines the activation of the sympathetic nervous system with subsequent tachycardia and hydro-saline retention . Thus, hSince the activation of the sympathetic nervous system is one of the key mechanisms for the development and progression for both essential HTN and R-HTN, there has been an emerging need to create a series of device-based therapies to disrupt this mechanism and, thus, control BP.The purpose of renal sympathetic denervation is to ablate the sympathetic nerves that are localized close to the renal arteries by radiofrequency or ultrasound waves emitted by an endovascular catheter and, therefore, interrupt the sympathetic activation. This therapy was evaluated in patients with R-HTN taking 4–5 antihypertensive drugs by three studies called SYMPLICITY . It was first used in a human feasibility trial (SYMPLICITY HTN-1) and then in a larger randomized prospective study (SYMPLICITY HTN-2) and showed a reduction in office BP and a good safety profile when using this device ,55. HoweSince then, the Renal Denervation for Hypertension (DENER-HTN) Trial showed a statistically significant reduction in daytime ambulatory systolic BP (–5.9 mmHg) in hypertensive patients on a three-drug regimen randomized to renal sympathetic denervation, when compared to patients taking four antihypertensive medications without renal denervation .Recently, catheters have been re-designed to allow complete circumferential renal nerve ablation. SPYRAL-OFF MED Pivotal trial is a prospective, sham-controlled, randomized trial that uses this type of catheter and evaluates renal sympathetic denervation independently of antihypertensive drugs. This trial showed significant BP reduction (–4.7 mmHg in 24-h ambulatory BP and –6.6 mmHg in office BP) after 3 months of follow-up . AlthougRadiofrequency from renal sympathetic denervation can be replaced with ultrasound, as new research demonstrated—Paradise Renal Denervation System, ReCor Medical. This technique also showed a reduction of BP in its own proof-of-concept trial .The carotid baroreceptor activation reflex is triggered by a rapid pressure within the carotid body, which leads to a reduction of sympathetic signals to the vessels, heart and kidneys, and hence, to the reduction of BP. There are two types of devices that evaluate baroreceptor activation therapy: an implantable pulse generator (Rheos and BAROSTIM NEO systems) and an endovascular device (MobiusHD).The Rheos system consists of a battery-powered implantable pulse generator that electrically activates the carotid baroreflex. Although the Rheos Pivotal Trial showed no superiority of baroreceptor activation therapy for reducing BP compared to medical therapy after a six-months follow-up, more than half achieved a systolic BP less than 140 mmHg .The central arteriovenous anastomosis assumes unloading the arterial vascular bed into the venous system. The ROX Coupler utilizes a stent-like nitinol device that is placed through the anastomosis that has been created between the femoral artery and vein and demonstrated efficacy in lowering BP . HoweverThe identification of new molecules to lower BP and CV risk is a continuous concern of the pharmaceutical industry. Notwithstanding a large spectrum of new therapeutic agents used in HTN, it seems difficult to create efficient and competitive molecules that go beyond the clinical phases of studies.Several studies evaluated the antihypertensive effect of the association between angiotensin-converting enzyme inhibitors and neutral endopeptidase inhibitors. The first class of drugs inhibit the angiotensin-converting enzyme leading to a decrease of angiotensin-II, thus improving vasoconstriction and reducing sodium retention. The second class of drugs prevents the degradation of natriuretic peptides into metabolites and promotes vasodilation, increases sodium excretion and displays antihypertrophic and antifibrotic properties. Their effect on BP is synergic and the protection of organ damage is superior. The biggest problem when combining these two classes is the growing number of patients with angioedema because both angiotensin-converting enzyme inhibitors and the neutral endopeptidase inhibitors are involved in the degradation of bradykinin. The Omapatrilat Cardiovascular Treatment vs. Enalapril (OCTAVE) trial compared the antihypertensive effect of omapatrilat versus enalapril and although the antihypertensive effect was superior, angioedema appeared more frequently with the first (2.17% versus 0.68%) . These oAs discussed before, the mineralocorticoid receptor antagonists have proved their efficiency in controlling BP. At this moment, among the novel nonsteroidal mineralocorticoid receptor antagonists, dihydronaphthyridine finerenone BAY94-8662) has accumulated the most evidence. Finerenone is distributed in both cardiac and renal tissues, and it was initially developed for the treatment of heart failure with reduced ejection fraction and mild to moderate chronic kidney disease . Fineren2 has accA functional renin-angiotensin system exists inside the brain and controls the cardiac functions and the body fluid homeostasis . AminopePatients with R-HTN present a higher mortality rate compared to non-R-HTN patients due to increased CV risk and its associated adverse outcomes—greater risk of developing chronic kidney disease, heart failure, stroke or myocardial infarction. Excluding pseudoresistance, secondary and white-coat hypertension is crucial when diagnosing R-HTN. Ensuring adherence to lifestyle measures and drug regimen is an important factor in achieving adequate BP control and avoiding unnecessary intensification of treatment. Optimizing the three-drug regimen, switching to a more potent diuretic, adding a mineralocorticoid receptor antagonist as the fourth drug, a β-blocker or combined α- and β-blocker as the fifth drug and an α1-blocker or a peripheral vasodilator as a final option when failing to achieve target BP values, are current recommendations that regard the correct management of R-HTN. Until the approval of new medications, we must optimize the usage of the existing ones by combining them more rationally and in optimal doses, in order to improve adherence to treatment and, thus, control BP. Device-based therapies such as renal sympathetic denervation and carotid baroreceptor activation therapy show promising results but need further studies to confirm their efficacy and safety in clinical practice.