The transition from high school to college can exacerbate mental health problems in young adults yet barriers prevent seamless mental health care. Existing digital support tools show promise but are not yet designed to optimize engagement or implementation.The goal of the research was to test acceptability and effects of an automated digital Mobile Support Tool for Mental Health (MoST-MH) for young adults transitioning to college.Youths aged 18 years and older with a current mental health diagnosis preparing to transition to college  were recruited from a primary care (n=31) and a mental health clinic (n=21). Participants were randomized 2:1 to either receive MoST-MH (n=34) or enhanced Usual Care . MoST-MH included periodic text message and web-based check-ins of emotional health, stressors, negative impacts, and self-efficacy that informed tailored self-care support messages. Both eUC and MoST-MH participants received links to a library of psychoeducational videos and were asked to complete web-based versions of the Mental Health Self-Efficacy Scale (MHSES), College Counseling Center Assessment of Psychological Symptoms (CCAPS), and Client Service Receipt Inventory for Mental Health (C-SRI) monthly for 3 months and the Post-Study System Usability Scale (PSSUQ) at 3-months.MoST-MH participants were sent a median of 5 (range 3 to 10) text message check-in prompts over the 3-month study period and 100% were completed; participants were sent a median of 2 (range 1 to 8) web-based check-in prompts among which 78% (43/55) were completed. PSSUQ scores indicate high usability (mean score 2.0). Results from the completer analysis demonstrated reductions in mental health symptoms over time and significant between-group effects of MoST-MH compared to eUC on depressive symptom severity . No significant differences in mental health self-efficacy or mental health health care use were observed.In this pilot trial, we found preliminary evidence that MoST-MH was engaged with at high rates and found to be highly usable and reduced depression symptoms relative to eUC among youth with mental health disorders transitioning to college. Findings were measured during the COVID-19 pandemic, and the study was not powered to detect differences in outcomes between groups; therefore, further testing is needed.ClinicalTrials.gov NCT04560075; https://clinicaltrials.gov/ct2/show/NCT04560075 Mental health disorders are common among young adults. Internationally, 20% of college students meet criteria for a mental health diagnosis, and 83% of these individuals have onset prior to college matriculation . NationaThe transition from high school to college is a critical period where mental health support is lacking yet urgently needed. New stresses related to academics, finances, and relationships are heightened upon college initiation . These sDigital technology could assist young adults who are transitioning to college by providing rapid and efficient access to mental health support. In a systematic review of 19 studies  of digital mental health interventions for college students, findings suggest that they can be effective for improving depression, anxiety, and psychological well-being . AnotherTo address these barriers, we developed an automated Mobile Support Tool for Mental Health (MoST-MH). MoST-MH was iteratively designed and refined by a multidisciplinary team with expertise in psychology, psychiatry, primary care, and digital interventions with integral feedback from a college student ambassador. MoST-MH was intended to provide support independent of mental health diagnosis type  and designed to minimize the burden of intensive digital interactions using a stepwise algorithm which adapts frequency of interaction to the needs of the youth. MoST-MH is an ecological momentary intervention  in that In this paper, we present pilot randomized trial findings of MoST-MH where we examined intervention engagement, acceptability, and estimates of effects of MoST-MH compared to enhanced usual care (eUC). We hypothesized that youth would engage with MoST-MH at high rates over the first 3 months of college and that they would report high levels of usability. We also hypothesized that youth who received MoST-MH, as compared with youth who receive eUC, would report greater mental health self-efficacy, lower symptom severity, and higher rates of follow-through with mental health care at 3 months.We conducted a pilot randomized trial among youth with a current mental health disorder or recent mental health care preparing to transition to college. Design and a priori hypotheses were registered at ClinicalTrials.gov (NCT04560075). As this was a pilot study, we were not powered to detect significant differences in mental health outcomes between groups. All participants completed written informed consent. Study investigators and outcome assessors were blinded to allocation to treatment arms. All procedures were approved by the institutional review board at the University of Pittsburgh.Participants were recruited from one primary care (n=31) and one mental health clinic (n=21) in Pittsburgh, PA, from August to October 2020. We chose to recruit from health care sites because we view the ultimate implementation to be initiated by care providers who are able to identify individuals with mental health needs prior to leaving for college. The youth’s care providers identified potentially eligible youth and asked the youth about interest in participating in the study; interested youth were texted or emailed a web link that provided information about the study. If they were interested, they contacted the research team via telephone, where enrollment criteria were confirmed. Inclusion criteria included age 18 years or older, current mental health diagnosis documented in their electronic medical record or received mental health services within 3 months per self-, parent-, or clinician-report, graduated high school, plan to attend college or higher education within 6 weeks, and own a personal mobile phone with text messaging. We excluded non-English–speaking individuals given that intervention materials were in English only.We used block randomization whereby two-thirds of participants were randomly assigned to receive MoST-MH and one-third to receive eUC. Blocks balanced the groups based on recruitment site. Random assignment allocation occurred following completion of baseline assessments.MoST-MH aimed to enhance an individual’s mental health by raising awareness of current symptoms, stressors, and impact of stressors and boosting self-efficacy by prompting evidence-based strategies taken from positive psychology, cognitive behavioral therapy, and dialectical behavioral therapy. MoST-MH used text messaging as the primary communication modality given its ubiquity and preferential role for communication among youth  as well Upon allocation, MoST-MH participants were prompted to text a unique keyword to a study phone number to initiate the program. Once program was initiated, participants received a series of welcome messages describing what to expect over the intervention period and ways to reduce breach of privacy . Participants were instructed that they could drop out of the MoST-MH program at any time by texting Quit.Starting on the day of enrollment, MoST-MH participants received mental health check-ins via text message: “How would you rate your emotional health this past week?” If they replied excellent, very good or good, they received a positive feedback text message and link to video library. The brief 2-minute videos were created by the study team and included psychoeducation about mental health self-care during college. If they replied fair or poor, they were sent a link to complete a web-based check-in. When the web link opened, a page displayed a checklist of common stressors  and negaIf they reported low self-efficacy , they received a text message from a skills library and the link to the videos and were asked if it was ok to check in next week. On subsequent MoST-MH check-ins, their reports of stressors and negative effects were compared to the prior assessment and feedback incorporated relative improvement or unresolved stressors/effects. If the ability to self-manage stressors or negative effects was still reported as suboptimal, the individual was prompted to consider making an appointment for seeking mental health care: “Your doctor or another health professional can help. Would you be willing to reach out to them to set up an appointment?” If they were willing, they were provided with a link to resources to assist. Throughout all program queries, missing responses were reprompted once only. To ensure safety, if an individual reported poor mental health and low self-efficacy 2 weeks in a row, they were prompted to seek formal mental health care. The eUC participants received a web link to a library of the same psychoeducational videos provided to the MoST-MH group. eUC received no text message or web-based mental health check-ins.MoST-MH engagement was assessed using text messaging and web-based responses. Mental health symptom severity and health care use were assessed using self-report measures collected monthly for 3 months. Each monthly assessment battery was estimated to take 15 minutes to complete and were completed on a smartphone, laptop, tablet, or desktop. Participants in both groups were sent text message reminders every 3 days up to 3 times prompting them to complete their web-based follow-up assessment batteries. Participants were eligible to receive a total of $100 for participation in the study, including $20 for completing each monthly assessment battery. Participants were not compensated for completing text messages nor web-based assessments.MoST-MH usability was measured via the Post-Study System Usability Scale (PSSUQ)  at 3 monMental health self-efficacy was measured using the 6-item self-report Mental Health Self-Efficacy Scale (MHSES) , which aSymptom severity was measured using the College Counseling Center Assessment of Psychological Symptoms (CCAPS)  which haMental health treatment use was measured using the brief self-report Client Service Receipt Inventory for Mental Health (C-SRI)  includint tests were conducted on continuous baseline variables , and chi-square analyses were conducted on categorical or nominal variables . We tested the hypothesis that youth would engage with MoST-MH at high rates (>80% response rate) by calculating text message and web check-in completions within and between individuals. We tested the hypothesis that youth would report high levels of usability with MoST-MH (mean PSSUQ rating ≤2) by computing PSSUQ ratings at 3-month follow-up. We explored the effect of MoST-MH as compared with eUC on mental health self-efficacy (MHSES), symptom severity (CCAPS), and mental health care services use (C-SRI) using mixed effect  models. Mixed effects models using GEE are recommended for analysis of repeated-measures data and can properly account for missing data [To determine whether any significant differences between groups existed at baseline, independent ing data . To undeParticipants were sent a median of 5 (range 3-10) text message check-ins over the study period (depending on their risk level), and 100% of the text message queries were completed. The 21 participants who reported poor MH via text message at least once over the study period received a median of 2 (range 1 to 8) web-based check-ins. Of the 55 times when a web check-in was prompted, 43 (78%) were completed. We did not find that sex, race, or college living plans were significantly associated with web check-ins. No MoST-MH participants dropped out .The median number of stressors reported per check-in was 2 (range 0 to 5); the median number of negative effects reported per check-in was 3 (range 0 to 8). There were higher mean stressors reported in female compared to male participants . The most common stressors were related to school and finances; the most common negative effects were feeling worn out and low motivation. Using the PSSUQ completed at the 3-month follow-up, overall mean usability score was 2.0 (SD 1.6). For subscale rating, mean score for system usefulness was 1.9 (SD 1.7), information quality was 2.2 (SD 1.5), and interface quality was 1.9 (SD 1.7). We did not find that patient factors  or baseline mental health scores were significantly associated with usability.Using the MHSES, there were no significant improvements in either treatment arm over time for mental health self-efficacy as measured. In GEE analysis, there were no significant time by treatment effects of MoST-MH compared to eUC. We did not find that patient factors  or baseline mental health scores were significantly associated with self-efficacy.Using the CCAPS, in the MoST-MH arm, mental health symptom severity was reduced from baseline to 3 months in all subscales save substance abuse. In eUCs, reduced symptoms over 3 months occurred for general anxiety, family distress, and hostility only. In the month prior to enrollment, 56% of MoST-MH and 67% of eUC participants had received any mental health care. Over the first 3 months of enrollment, 52% of MoST-MH and 65% of eUC participants received any mental health care. In this pilot trial, we found evidence that, for young adults with mental health diagnoses transitioning to college, the MoST-MH intervention was engaged with at high rates, had high usability ratings, and may have reduced depression symptoms over time relative to the eUC group. Together, these findings provide initial support for an automated digital intervention incorporating periodic text message mental health check-ins that trigger web-based check-ins to understand stressors, negative effects, and self-efficacy and then provide self-efficacy support strategies.Compared to other mental health digital interventions, we found good engagement:100% of text message check-ins and 78% of web-based check-ins were completed over 3 months, and no participant dropped out . In contrast, among 28 digital mental health interventions for college students included in a prior systematic review , the aveWe speculate that the high engagement and usability findings for MoST-MH can be attributed to several key design features. First, the study was introduced by a care provider, increasing trust in the intervention. Second, we designed MoST-MH with key input from a college student ambassador. Third, using text messaging to conduct most communication limited the amount of extra steps traditionally involved with apps or web pages, thus increasing ease of interaction. Fourth, the MoST-MH intervention adapted over time so that if an individual was not in need of support, the check-ins were stepped down , reducing the burden on individuals who seemed to not need help at that time.The finding of reduced mental health symptoms in MoST-MH compared with eUC suggests that the intervention may successfully support self-management of mental health symptoms and that mood regulation may be a key mechanism. This is encouraging given the simplicity of the intervention and lack of any intensive cognitive behavioral treatment components. However, despite an intended aim of MoST-MH to enhance an individual’s self-efficacy, we did not find evidence to support this as a mechanism of action. Future studies of MoST-MH will be necessary to identify mechanisms of effects.The use of mental health care decreased slightly in both treatment arms over time, yet it was still occurring in approximately half of all participants any given month. Also, there were no apparent signals of either increased or decreased mental health care use in the MoST-MH arm compared to eUC. On one hand, this is discouraging given that the MoST-MH intervention prompted many participants to reach out for mental health care when they reported low self-efficacy 2 weeks in a row. On the other hand, it may be that the MoST-MH intervention promoted confidence in self-management not reflected in the self-efficacy scales. Future studies are needed to identify how MoST-MH may modify cognitions around mental health care seeking.Several limitations should be discussed. First, we recruited mostly female White youths, therefore findings may not be valid in men or racial or ethnic minorities. Second, we did not follow participants for more than 3 months, limiting understanding of durability and prolonged engagement. Third, our cohort was recruited entirely during the COVID-19 pandemic. As such, the experience and stresses related to the transition to college and the college experience were atypical. Fourth, our sample is transdiagnostic, and we did not assess for specific mental health diagnoses or collect measures on type and other current treatments being received for mental health diagnoses, which may have been key moderators of effectiveness.We note several strengths of our study and intervention design. First, we recruited individuals with any mental health diagnosis, thus rendering our intervention and findings broadly relevant to young adults transitioning to college (transdiagnostic). Second, we compared the MoST-MH intervention to eUC instead of a waitlist control, isolating effects of the digital interactions from those of attention and the psychoeducational videos. Third, we achieved high follow-up rates (86% at 3 months), reducing the likelihood of biased outcome analyses. Fourth, we measured and reported engagement through detailed analysis of reports through both text messages and web check-ins, notably absent in much prior digital MH intervention research . Fifth, We found preliminary evidence in support of an automated digital mental health intervention using periodic check-ins to tailor self-management support for youth with mental health disorders transitioning to college. This study is timely, as there is an urgent need for evidence-based mental health support programs for youth in transition to college that are used longitudinally and can be scaled easily. A program like MOST-MH, if found to be effective at reducing mental health symptoms and improving psychological functioning in a larger trial, could fill a needed gap in supporting youth in their mental health.


Pre-clinical and clinical evidences support that simultaneous blockade of programmed death-1 (PD-1) and vascular endothelial growth factor receptor (VEGFR) can enhance antigen-specific T-cell migration, and show tolerable toxicity with favorable antitumor activity in patients. In this study, we aimed to assess the safety and efficacy of anlotinib, a novel multitarget tyrosine kinase inhibitor for VEGFR, platelet-derived growth receptor (PDGFR), and the stem cell-factor receptor (c-Kit), combined with anti-PD-1 treatment in patients with advanced NSCLC.Sixty-seven patients with previously treated advanced NSCLC receiving anti-PD-1 agents concomitant with anlotinib were retrospectively enrolled in an IRB approved study. Anti-PD-1 agents including pembrolizumab, nivolumab, camrelizumab, toripalimab, sintilimab, and tislelizumab were administered every two or three weeks until disease progression or unacceptable toxicity was reached. Anlotinib was administered orally once daily on days 1–14 of a 21-day cycle. The safety and tolerability of the combination treatment were assessed by the incidence of adverse events. The efficacy of the treatment was assessed by the tumor response and survival.With a median follow-up period of 8.7 months, treatment-related adverse events occurred in 85% (57/67) of patients and grade 3–4 adverse events were observed in 27 patients (40%). No unexpected adverse events or significantly increased toxicities were observed. Complete response was not observed, 19 patients had partial response (28.4%), 39 had stable disease (58.2%) and 9 had progressive disease (13.4%). The overall response (ORR) and disease control rates (DCR) were 28.4% and 86.6%, respectively. The median progression-free survival (PFS) was 6.9 months  and overall survival (OS) was 14.5 months . The benefit of anti-PD-1 plus anlotinib was also observed in patients with EGFR mutation positive, liver metastases and brain metastases.Anti-PD-1 treatment concomitant with anlotinib has tolerable toxicity and favorable antitumor activity in patients with previously treated advanced NSCLC. Our results add to the growing evidence that supports the benefits of combining immunotherapy with antiangiogenic drugs. This combination could be further evaluated with or without chemotherapy, since no additional toxicity was observed in the combination treatment. Tumors can evade immune-mediated killing through the interaction between PD-L1 mainly expressed by themselves and PD-1, the inhibitory receptor primarily located on tumor infiltrating T cells, which leads to T cell exhaustion. Immune checkpoint inhibitors (ICIs) targeting the PD-L1–PD-1 axis have shown superior survival outcomes compared with cytotoxic chemotherapies in patients with advanced non–small cell lung cancer (NSCLC) . SeveralAbnormal tumor vasculature might be one of the mechanisms of resistance to immunotherapy. It can exert immunosuppressive effects including the inhibition the maturation of dendritic cells (DCs), the prevention of T cells infiltration into tumors, and the induction of regulating cells (Tregs) and Myeloid-Derived Suppressor Cells (MDSCs) , 11. SubClinical Trials.gov: NCT01878448), medullary thyroid cancer , and renal cell cancer . According to the results, anlotinib received its first approval as a third-line treatment for advanced NSCLC and its second approval as a second-line treatment for advanced soft-tissue sarcoma in the People’s Republic of China. At present, although preclinical trials have shown that the combined antiangiogenic and anti-PD-1 therapy has a positive application prospect, the safety and efficacy of anlotinib combined with anti-PD-1 are still unknown.Anlotinib AL3818) hydrochloride is a novel small-molecule inhibitor targeting multiple receptor tyrosine kinases involved in tumor angiogenesis, proliferative signaling and tumor microenvironment  hydrochl. AnlotinThis study is intended to evaluate the antitumor activity and safety of anti-PD-1 plus anlotinib in advanced NSCLC. We also explored the clinical efficacy of the combination treatments in key subgroups of patients, including patients with EGFR mutations and patients with baseline liver metastases.We retrospectively enrolled patients with histologically confirmed advanced NSCLC who experienced disease progression after ≥1 systemic treatment. An Eastern Cooperative Oncology Group (ECOG) performance status of 0–2 and measurable disease based on Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 were also required.Patients received one of the following anti-PD-1 agents until disease progression, clinical deterioration, or unacceptable toxicity: sintilimab , toripalimab (Shangha Merck & Co.), camrelizumab , nivolumab , pembrolizumab , or tislelizumab . Anlotinib  was administered orally, once daily  on days 1–14 of a 21-day cycle.The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Research Ethics Board of Shandong Cancer Hospital, and individual consent for this retrospective analysis was waived.Safety and tolerability was evaluated throughout the study using the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0. Measurable disease was assessed and documented before initiating treatment and at least one imaging follow-up had been scheduled for each patient. Radiological assessments of target and non-target lesions were performed every six weeks during the treatment phase until confirmation of disease progression was made. Tumor response was evaluated using RECIST 1.1. Objective tumor responses included complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD). Progression-free survival (PFS) denoted the time between the first anti-PD-1 dosing day and the documented progression or mortality from any cause. Overall survival (OS) denoted the time between the first anti-PD-1 dosing day and mortality or the last follow-up.Survival analyses were performed using the Kaplan-Meier method and the comparison of survival times was performed using the log-rank test. Univariate and multivariate analyses were conducted using the Cox proportional hazards model to analyze factors associated with treatment response and survival. Covariates with p values <0.1 on univariate analyses were incorporated in the multivariate model, which was constructed using the enter method. All other statistical analyses were performed using SPSS 24.0 , and a p-value of <0.05 was considered statistically significant.A total of 67 consecutive patients were enrolled between August, 2018 and September, 2020. Baseline demographic and clinical characteristics are listed in The overall incidence of adverse events was 85% (57 of 56), and most of these observed adverse events were grade 1–2 (The median follow-up period was 8.7 months (range: 1.5 to 23.6 months). As shown in the waterfall plot   as monotherapy has shown poor outcome in patients with EGFR mutations , 23. Dat+ T cells, and increasing the presence of MDSCs and Treg  was only descriptive due to the small sample size. However, our study’s findings may still be deemed as meaningful due to the limited number of similar prospective clinical studies in the literature.Although the combination of antiangiogenic therapy and immunotherapy has been proved to be a very promising treatment in many solid tumors, some issues must be addressed prior to clinical practice application. It is important to identify the optimal dosing and timing to make the combination therapy more effective. Moreover, the exploration of predictive biomarkers is helpful in screening which cancer types and stages would benefit more from this treatment.Our findings show that the combination of anlotinib and anti-PD-1 drugs has promising efficacy and manageable toxic effects as a second- or further-line treatment for patients with previously treated advanced NSCLC. The results further demonstrate the clinical applicability of dual inhibition of the VEGF-VEGFR2 and PD-1-/PD-L1 pathways. Given these findings, prospective investigation is warranted to explored with or without chemotherapy, particularly for patients with tumors for which immune checkpoint inhibitor monotherapy was not superior to chemotherapy.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.The study was approved by the Research Ethics Board of Shandong Cancer Hospital, and individual consent for this retrospective analysis was waived.Conception and design: PW, FT, and JY. Provision of study materials or patients: PW. Collection and assembly of data: PW, XF, TY, and HT. Data analysis and interpretation: PW and FT. Manuscript writing and final approval of manuscript: all authors. All authors contributed to the article and approved the submitted version.This work was supported by grants from the National Natural Science Foundation of China (NSFC 81803066) and the Innovation Project of Shandong Academy of Medical Sciences (2019-04 to JY), and the Academic Promotion Program of Shandong First Medical University (2019ZL002 to JY).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.


Objective: Primary graft dysfunction (PGD) is the leading cause of early death after heart transplantation. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary mechanical circulatory support and time for functional recovery of the transplanted heart. The purpose of this study was to analyze the timing and prognoses of VA-ECMO in patients with severe PGD after heart transplantation.Methods: A total of 130 patients underwent heart transplantation at the Zhongshan Hospital Affiliated with Fudan University between January 2014 and December 2020. All patients received basiliximab immunoinduction and a classic double vena cava anastomosis orthotopic heart transplantation. Among them, 29 patients (22.3%) developed severe PGD in the early postoperative period. VA-ECMO was performed in patients with difficulty weaning from cardiopulmonary bypass (CPB) or postoperative refractory cardiogenic shock. Patients were divided into two groups according to whether or not they were successfully weaned from VA-ECMO (patients who survived for 48 h after weaning and did not need VA-ECMO assistance again). The perioperative clinical data were recorded, and all patients were followed up until discharge. Early outcomes were compared between groups.Results: A total of 29 patients with VA-ECMO support after heart transplantation were included in this study. The proportion of patients receiving VA-ECMO was 22.3% (29/130). Nineteen patients (65.5%) needed VA-ECMO due to difficulty with weaning from CPB, and 10 patients required VA-ECMO for postoperative cardiogenic shock. Nineteen patients (65.5%) were successfully weaned from VA-ECMO. Overall, in-hospital mortality of VA-ECMO support patients was 55.2%. The main causes of death were ventricular fibrillation (four cases), major bleeding (three cases), infection (four cases), and graft failure (five cases).Conclusion: Despite advances in heart transplantation, severe PGD remains a lethal complication after heart transplantation. At present, the treatment for severe PGD after heart transplantation is a challenge. VA-ECMO provides an effective treatment for severe PGD after heart transplantation, which can promote graft function recovery. At present, orthotopic heart transplantation is the most effective treatment for patients with end-stage heart disease. According to the 36th Annual Adult Heart Transplantation Registry report published by the International Society of Heart and Lung Transplantation (ISHLT) registry in 2019, a total of 1,31,249 adult heart transplants were completed by June 30, 2018, although >90% of the ISHLT data came from North America and Europe (Early primary graft dysfunction (PGD) after heart transplantation, especially right heart failure, is an important factor leading to perioperative death, affecting 7.4–36% of heart transplant recipients . The 30-Veno-arterial extracorporeal membrane oxygenation is a temporary cardiopulmonary support technology that can provide effective circulation for critically ill patients with heart failure caused by a variety of reasons . In hearThis retrospective single-center study reviewed the records of 130 adult patients who underwent orthotopic heart transplantation at Zhongshan Hospital, Fudan University  between January 2014 and December 2020. According to the ISHLT criteria, patients with severe PGD who received VA-ECMO support within 24 h after heart transplantation surgery were included in this study. Exclusion criteria included age of <18 years and/or pregnancy. The study was approved by the Ethics Committee of Zhongshan Hospital. Patients were divided into two groups according to whether successful weaning from VA-ECMO occurred (patients were defined as successfully weaned from VA-ECMO if they survived for longer than 48 h after VA-ECMO explantation) , 10. BasAfter successful anesthesia, median sternotomy was performed to establish cardiopulmonary bypass (CPB). The superior vena cava (SVC), inferior vena cava (IVC), and ascending artery were blocked. The main trunk of the aorta and pulmonary artery, SVC, and IVC was cut off. The donor heart was pruned, and the posterior wall of the left atrium between the donor heart and the recipient heart was sutured continuously. The donor heart and recipient aorta were also sutured continuously, followed by aortic crossclamp removal to regain rhythmic contractions in the graft. The anastomosis with IVC, pulmonary artery, and SVC was accomplished in the beating heart to reduce the ischemia time of donor hearts.The specific diagnostic criteria were based on the 2013 ISHLT consensus .Continuous data were expressed as median (IQR). Categorical variables were expressed as percentages (%). Quantitative variables were analyzed using the Mann–Whitney U test. Categorical variables were analyzed by the chi-squared test or Fisher's exact methods as appropriate. Log-rank testing and Kaplan–Meier survival curves were used for survival analysis. Statistical significance was defined as n = 19) and failed (n = 10) weaning groups are summarized in p < 0.01) compared to those in the failure group.A total of 130 patients underwent an orthotopic heart transplantation procedure between January 2014 and December 2020. Twenty-nine patients who were supported with VA-ECMO following heart transplantation surgery were enrolled in the study . None ofp > 0.05). Postoperative peak alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels were both significantly higher in patients who failed to wean from VA-ECMO. Nineteen patients received VA-ECMO support in the operating room due to difficulty with weaning from CPB. Ten patients had VA-ECMO initiated in the cardiac surgery ICU because of refractory postoperative cardiogenic shock. The median time from the end of the operation until VA-ECMO implantation was 8.6 h in the ICU group.Perioperative details of the 29 patients who were supported with VA-ECMO are shown in After a median support period of 5 days, 19 patients (66%) were successfully weaned from VA-ECMO support, whereas six patients died in the hospital despite successful weaning from VA-ECMO. Thirteen patients (45%) survived until hospital discharge. No patient developed leg ischemia or leg fasciotomy due to femoral arterial cannulation. The Kaplan–Meier survival curves for patients with severe PGD who required perioperative VA-ECMO support are shown in Additionally, six of the patients who were successfully weaned from VA-ECMO died, including four patients died of infection or sepsis , one patient died of ventricular arrhythmia (31 days after weaning), and one patient died of neurological complications (19 days after weaning). No patient was lost to follow-up during this period. In addition, VA-ECMO treatment of severe PGD had no adverse effect on graft function among survivors. Details for VA-ECMO implementation and outcomes in this patient are outlined in In this single-center study, 29 out of 130 heart transplant recipients received VA-ECMO and achieved relatively satisfactory results. Because LVADs and RVADs were not available in our center, VA-ECMO was the only effective treatment for patients with severe PGD after heart transplantation. To the best of our knowledge, this study is the first to apply the new ISHLT criteria to Chinese patients to investigate outcomes of severe PGD at high-volume transplantation centers.Over the last several decades, orthotopic heart transplantation has become the standard treatment for select patients with advanced and refractory heart failure. However, severe PGD remains a major cause of perioperative death after heart transplantation. Several studies have investigated the incidence of severe PGD using the ISHLT consensus statement criteria and found that the incidence rate was 7–23% with in-hospital mortality of 19–65% –21. VA-EThe timing of VA-ECMO implantation is an important factor influencing patient outcomes. A previous study has shown that prompt implementation of VA-ECMO allows for adequate organ perfusion and promotes the recovery of graft function, while avoiding multiple organ dysfunction and complications caused by large doses of inotropic or vasoactive agents . This stIt has been reported that successful weaning from VA-ECMO does not mean patient survival. Several studies have assessed the predictors of death after VA-ECMO weaning in postcardiotomy shock patients. VA-ECMO implantation time, poor renal and liver function, high lactate levels, and high SOFA scores were reported to be predictors of death after weaning –26, whicComplications during VA-ECMO support may directly lead to recipient's death or forced weaning from VA-ECMO. The leading causes of death in this study were surgical bleeding, graft failure, and septic shock. The causes of major postoperative bleeding are multifactorial –33. ExceThere were several limitations in this study. First, this was a single-center retrospective study. Second, although the analyses were based on the experience over the past 7 years, the sample size was too small and the follow-up time was relatively short, which meant that detailed risk factor analysis was not possible. Third, due to privacy protection, we are unable to obtain donor information. In the future, multicenter studies with large patient populations are needed to optimize management strategies and to improve outcomes in this rare but complex cardiac emergency.In conclusion, the application of VA-ECMO in the perioperative period of heart transplantation provided a “bridge to recovery” in patients with severe PGD. Further research is needed to determine the optimal time for VA-ECMO use and how to prevent complications to improve patient prognosis.The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by the Ethics Committee of Zhongshan Hospital affiliated to Fudan University (No. B2020-169). The patients/participants provided their written informed consent to participate in this study.J-yH, G-wT, and ZL contributed to study design. XL, Y-jZ, J-lZ, and J-fM contributed to participant enrollment. K-fG and S-gY contributed to study management and data collection. J-yH and S-gY contributed to manuscript writing. G-wT and ZL contributed to data analyses and manuscript revision. All authors have read and approved the final manuscript.This study was supported by grants from the Natural Science Foundation of Shanghai , the Science and Technology Commission of Shanghai Municipality (20DZ2261200 to ZL), the National Natural Science Foundation of China (82070085 to G-wT), the Construction Program of Key but Weak Disciplines of Shanghai Health Commission (2019ZB0105 to ZL), the Clinical Research Project of Zhongshan Hospital , the Smart Medical Care of Zhongshan Hospital (2020ZHZS01 to ZL), the Project for Elite Backbone of Zhongshan Hospital (2021ZSGG06 to G-wT), and the Foundation for Young Researchers of Zhongshan Hospital .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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Introduction: Myocardial infarction with ST-segment elevation (STEMI) is the coronary artery disease associated with the highest risk of morbimortality; however, this risk is heterogeneous, usually being evaluated by clinical scores. Risk assessment is a key factor in personalized clinical management of patients with this disease. Aim: The aim of this study was to assess whether some new cardiac biomarkers considered alone, combined in a multibiomarker model or in association with clinical variables, improve the short- and long-term risk stratification of STEMI patients. Materials and Methods: This was a retrospective observational study of 253 patients with STEMI. Blood samples were obtained before or during the angiography. The assessed biomarkers were C-terminal fragment of insulin-like growth factor binding protein-4 (CT-IGFBP4), high sensitive cardiac troponin T (hs-cTnT), N-terminal fragment of probrain natriuretic peptide (NT-proBNP), and growth differentiation factor 15 (GDF-15); they reflect different cardiovascular (CV) physiopathological pathways and underlying pathologies. We registered in-hospital and follow-up mortalities and their causes  and major adverse cardiac events (MACE) during a two year follow-up. Discrimination, survival analysis, model calibration, and reclassification of the biomarkers were comprehensively evaluated. Results and Discussion: In total, 55 patients (21.7%) died, 33 in-hospital and 22 during the follow-up, most of them (69.1%) from CV causes; 37 MACE occurred during follow-up. Biomarkers showed good prognostic ability to predict mortality, alone and combined with the multibiomarker model. A predictive clinical model based on age, Killip–Kimball class, estimated glomerular filtration rate (eGFR), and heart rate was derived by multivariate analysis. GDF-15 and NT-proBNP significantly improved risk assessment of the clinical model, as shown by discrimination, calibration, and reclassification of all the end-points except for all-cause mortality. The combination of NT-proBNP and hs-cTnT improved CV mortality prediction. Conclusions: GDF-15 and NT-proBNP added value to the usual risk assessment of STEMI patients. Cardiovascular diseases are the leading cause of death globally, causing around one-third of all registered deaths . AtherosThis retrospective observational study included patients with STEMI, older than 18 years and recruited between January 2013 and November 2014, as a sub-study of a national registry (Red de Investigación Cardiovascular (RIC)) of ACS at one university hospital. Patients referred from other hospitals where they had undergone PCI and those without coronary occlusion in the angiography were excluded. Demographic and anthropometric variables, severity scores, and infarction-related characteristics were registered. Patients were followed up for 2 years after discharge by appointments or phone calls, or through electronic health records. The assessed outcomes were death from all or cardiovascular causes, both in-hospital and in follow-up, and major adverse cardiac events (MACE) defined as the composite of the need of additional PCI or coronary artery bypass graft (CABG), reinfarction, or cardiovascular death. Cardiovascular death included death by cardiogenic shock, heart failure, arrhythmic storm, or myocardial rupture.g), plasma aliquots were frozen at −80 °C until analysis. Long-term stability of the study biomarkers at −80 °C have shown negligible or minimum decreases in their immunoreactivity, otherwise not affecting their clinical meaning [All blood samples were obtained within the first 30 min after the patient’s arrival at the hospital (in the emergency department or in the catheterization laboratory). Most samples were obtained before the catheterization, but depending on the clinical workout , some samples were obtained from peripheral veins a few minutes after the cardiologists had begun the catheterization. After centrifugation  curves; the univariate areas under the curve (AUC) were compared with a multibiomarker model, including the four biomarkers by DeLong’s method. The best prognostic cutoff values obtained in the ROC analysis were used in Kaplan–Meier survival analysis, and incidence distributions in patients with and without the outcomes were compared using the log-rank test. Survival analyses were also performed using Cox proportional hazards models. A model integrating biomarkers and clinical variables to assess patients’ risk was derived by lineal regression. The power of the biomarkers to increase outcome prediction was evaluated by calibration , and Akaike Information Criterion (AIC)), discrimination (Integrated Discrimination Index (IDI)), and reclassification analyses. Category-free net reclassification index (NRI) was calculated as the sum of the “event NRI” (NRIe) and the “nonevent NRI” (NRIne); upwards movements in patients meeting an outcome implied improved classification, whereas downward movements implied worse reclassification. Statistical analysis was performed with the statistical packages SPSS 24.0  and R (www.R-project.org).The evaluation of the different biomarkers was performed following the most up to date recommendations ,35. Contp < 0.01). No other relevant differences were observed between genders. Characteristics of the patients and patient’s infarction and the results of laboratory variables are summarized in The study included 253 STEMI patients, 66 (26.1%) of whom were women who were older than the men  of deaths were due to cardiovascular causes. After the two-year follow-up, we registered 75 MACE . Patients who died during hospitalization presented more frequently high-risk criteria such as higher Killip class—93.3% of patients with Killip class IV died during the study—and GRACE 2.0 score, lower LVEF, hypotension, multivessel disease, and cardiac arrest at presentation (data not shown). Regarding laboratory variables, patients who died in-hospital had significantly higher concentrations of glucose and creatinine, higher AST and ALT activities, and more leukocytosis. Median concentrations of the studied biomarkers are shown in When comparing the variables between the patients with and without the outcome, we found that patients with outcomes were older than those without, except for MACE. Higher Killip–Kimball class and GRACE 2.0 score values, higher number of affected vessels and revascularization success, higher glycemia, worse renal function, and increased concentrations of CV biomarkers were significantly more frequent in patients with outcomes in all outcome subgroups .The discrimination ability of the CV biomarkers to predict outcomes was assessed for each single biomarker by the AUC of the ROC curve and compared against a multibiomarker model including all the biomarkers . The mulThe best prognostic cutoff values to predict outcomes were calculated by ROC analysis. We found that a concentration of 63.0 µg/L for CT-IGFBP-4, 988 ng/L for hs-cTnT, and 1454 ng/L for NT-proBNP were predictive of all outcomes, except mortality in the follow-up that was predicted by a slightly lower value. GDF-15 cutoff values ranged between 2724 and 3124 ng/L, depending on the outcome . These cp < 0.05) for the different outcomes  for in-hospital mortality, NT-proBNP+hs-cTnT (5.58%) for cardiovascular mortality, and hs-cTnT (2.02%) for MACE; all-cause and follow-up mortality discrimination was not improved by any biomarker used alone or in combination.e 39.4% and 45.45%, respectively); the model including GDF-15 also improved all-cause mortality prediction . For cardiovascular mortality, the addition of NT-proBNP, hs-cTnT, or both also allowed us to reclassify patients . Finally, only the combined clinical and multibiomarker model produced a significant reclassification (NRI 43.8%), again with a predominance of event reclassification (NRIe 30.2%) in patients with MACE . Regarding cardiovascular mortality, the biomarker that individually best predicted the outcome was NT-proBNP . For MACE prediction, the four assessed biomarkers presented a similar predictive capacity, but were clearly lower (AUC between 0.608 and 0.661) than those found for any type of mortality. Evaluation of association and discrimination capacity is helpful for the evaluation of new biomarkers prior to their use in clinics, but it is not enough. Biomarker values and clinical scores should be combined with calibration and reclassification studies to improve their clinical potential. A typical example of such combination is the GRACE 2.0 score, validated for risk assessment in many clinical conditions including STEMI . HoweverDeviation between observed and predicted risk was assessed using different calibration methods. When biomarkers were added to the clinical model, we observed that GDF-15 and the combination of hs-cTnT and NT-proBNP significantly improved the prediction of in-hospital and cardiovascular mortality of the clinical model, respectively, whereas MACE prediction was ameliorated by NT-proBNP. Biomarkers did not improve prediction of follow-up and all-cause mortality compared to the clinical model. Given the predominance of cardiovascular deaths in our population, the ability of biomarkers to predict all-cause mortality and MACE could be decreased by the low number of noncardiovascular outcomes. If we analyze the capacity of biomarkers to improve prognosis by the increase they promote on the AUC of the clinical model, any of them improve its discrimination for any outcome. The fact that the predictive capacity of the clinical model was so high prevented biomarkers from improving their discrimination . However−The STEMI patient group was enriched with critical patients and comorbid patients compared to other studies. This circumstance provides great support to the biomarkers’ prognostic value and could be highlighted as a strength of the study.−A determination of GDF-15 on admission improved the prognostic capacity of in-hospital mortality compared to a model based only on clinical variables. It could help to grade the treatment required by patients.−The combination of NT-proBNP and hs-cTnT improved the ability of a powerful clinical model to predict cardiovascular mortality.−CT-IGFBP-4, proposed as a biomarker of unstable atheroma plaques implicated in STEMI, was not associated with a significant improvement of the risk models with clinical variables and other biomarkers.In a population of STEMI patients treated according to recommendations and through measuring for the first time a combination of four biomarkers  with more recent and automated technology available, we found that:Given the composition of the study group, enriched with older and critical patients compared to other groups, our results should be corroborated in different STEMI populations. Some blood samples from our study were obtained a few minutes after the cardiologist had begun the catheterization. Reflow of the obstructed coronary artery leads to an abrupt release of biomarkers into the circulation; this fact may represent a confounding factor compared to studies that obtained the samples prior to PCI. However, previous publications have demonstrated that biomarkers obtained after PCI are as useful for risk assessment as those measured in prePCI samples ,50,51,52


Among vascular closure devices (VCDs), the novel collagen plug-based MANTA VCD is the first designed for large bore percutaneous access. We aimed to assess the features and predictors of access-site vascular complications in an unselected trans-femoral transcatheter aortic valve replacement (TF-TAVR) population.Patients undergoing large bore arteriotomy closure with 18F MANTA VCD following TF-TAVR at a large tertiary care center from September 2019 to January 2021 were prospectively analyzed. Primary Outcome was the MANTA VCD access-site-related complications according to Valve Academic Research Consortium-3 (VARC) definitions. Its incidence and predictors were evaluated.p = 0.04), minimum common femoral artery diameter (CFA) (p < 0.01), sheath-to-femoral-artery ratio (SFAR) (p < 0.01), and a lower puncture height (p = 0.03). A CFA diameter <7.1 mm with a SFAR threshold of 1.01 were associated with VCD failure.Eighty-eight patients  undergoing TF-TAVR were included, mostly (63%) treated with a self-expandable device and with outer diameter sizes varied from 18F to 24-F. MANTA VCD technical success rate was 98%, while 10 patients (11%) experienced MANTA VCD access-site vascular complications which included 8% of minor complications and only to 2% of major events resulting in VARC type ≥2 bleeding. Vessel occlusion/stenosis (60%), perforation (20%), and pseudoaneurysm/dissection/hematoma (20%) occurred, but all were managed without surgical treatment. Independent predictors of failure were age (In a more comers TF-TAVR population, MANTA VCD was associated with reassuring rates of technical success and major access-site vascular complications. Avoiding lower vessel size and less puncture site distance to CFA bifurcation might further improve outcomes. Catheter-based treatment strategies for complex cardiovascular disease requiring large bore femoral vascular access, such as trans-femoral transcatheter aortic valve replacement (TF-TAVR), markedly increased over the last decades . NeverthThe ongoing Padua University REVALVing Experience (PUREVALVE) registry has prospectively collected data on all patients undergoing TAVR in this large tertiary care center since June 2007. For the purpose of this analysis, all consecutive patients undergoing large bore arteriotomy closure with MANTA VCD following TF-TAVR from September 2019 to January 2021 were included. No selection process for using or excluding the MANTA device was applied, identifying a so-called “more comers” population. Indications for TAVR, approach, and prosthesis choice were based on the Heart Team decision. Nonetheless, the Heart Team discussion did not influence the decision-making process on MANTA or other VCD. All subjects gave their informed consent for both TAVR and clinical data collection. Baseline and periprocedural characteristic and clinical outcomes data were collected up to 30-days follow-up and inserted in a dedicated dataset. The study was conducted according to the principles of the Declaration of Helsinki and Good Clinical Practice.According to renal function, all patients underwent vascular ultrasound, multidetector computed tomography (MDCT), and/or angiography evaluation prior to TAVR to determine any significant vascular pathology in the planned femoral access site. Chronic anticoagulation therapy was interrupted at least 24 h prior to interventions. Procedures were performed by three different operators (none of them having prior MANTA deployment experience) and the implanted valves included both balloon and self-expandable bioprosthesis. The analysis also included the roll-in-cases, defined as the first ten consecutive cases per operator . Only anPre-procedural MCDT and intra-procedural angiography analysis were performed in order to evaluate the following: the common femoral artery (CFA) and superficial femoral artery calibers, presence, site  and extension  of calcifications of the iliofemoral axis and of the puncture site (PS), and puncture height which is defined as the distance between the PS relative to the CFA bifurcation at the angiographic evaluation. Maximum sheath diameter, arteriotomy depth measured by the dedicated MANTA locator, and the sheath-to-femoral artery ratio  were also collected. All measurements were performed by two experienced structural interventional cardiologists (GM and LDA) who were unaware of patient clinical data.The MANTA VCD technical success was defined as the achievement of target arteriotomy closure without the use of bailout surgery or endovascular procedures , adapted from the Valve Academic Research Consortium-3 consensus document (VARC-2) for TAVR . The prit-test (parametric test) or the Kruskal-Wallis test and Wilcoxon rank-sum test (non-parametric test) between three and two groups, respectively. Normal distribution was evaluated with the Shapiro-Wilk test. Categorical variables (as frequencies or percentage) were compared with the χ2 test or the Fisher exact test, as appropriate. Logistic regression analysis was used to estimate possible MANTA-access vascular adverse events. All the covariates significantly associated with the outcome of interest at univariate analysis (p < 0.05 for model inclusion and p > 0.10 for exclusion) and those considered clinically relevant  were included. Results were reported as odds ratios (OR) and 95% confidence intervals (CI). For all analyses, a two-sided p < 0.05 was considered to be significant.For the purpose of this analysis, we compared patients with vs. without MANTA-access vascular complications. Baseline and procedural characteristics are described with mean ± standard deviation (SD) or medians and 1st and 3rd interquartile ranges (IQRs) for continuous variables and percentages for discrete variables. Continuous variables were compared with one-way ANOVA and Student's unpaired Taking into account all the independent predictors, Youden's index was used to identify the threshold of those variables to best forecast MANTA-access complications. The receiver-operating characteristics curve (ROC) and the related area under the curve (AUC) were reported for the identified thresholds. The analyses were performed using R software (version 4.0.2) with the rms and pROC packages –16.p < 0.01] and the maximum  diameter , the puncture height, and the grading of calcification .A total of 88 consecutive patients undergoing TF-TAVR treated with 18F MANTA large bore arteriotomy closure were included in our analysis . Baselindiameter , and a sThe MANTA VCD was deployed successfully in all but two patients with a technical success rate of 98%.Clinical outcomes according to VARC-3 definitions were listed in No death, myocardial infarction, AKI, sepsis, and femoral target side local infection rates up to 30-days follow-up occurred. One patient had a hemorrhagic stroke.p = 0.04], the roll-in case performance , the minimum femoral artery diameter both at TS and PS , SFAR , and a lower puncture height relative to the femoral bifurcation . The identified threshold of the minimum CFA diameter to best predict vascular adverse events was 7.1 mm with a SFAR threshold of 1.01. Using this cut-off point for the ROC, both are identified as intermediate to high accurate discriminant of device failure (respectively with an AUC of.91 and 0.81). Otherwise, a puncture <1 mm or below the CFA bifurcation resulted in a less powerful discriminant of MANTA-access vascular complications.Logistic regression analysis for predictors of MANTA-access vascular complications is presented in This is a prospective single-center analysis on the use of the 18F MANTA VCD for large bore arteriotomy closure in a more comers population treated by TF-TAVR that focus on the features and predictors of access-site vascular complications. The main findings are: (1) the use of MANTA device was associated with favorable technical success and major primary access site vascular complications rates; (2) the most frequently encountered vascular complication with MANTA VCD was target vessel occlusion/stenosis; and (3) independent predictors of the primary access complications were age, small femoral artery diameter, larger SFAR, and a lower puncture height.Vascular complications at the puncture site after TAVR negatively affect clinical outcomes , 13. DesThe dedicated collagen plug-based MANTA VCD is a novel method for large caliber arteriotomy closure, with promising safety and efficacy profile in highly selected patients with major and minor vascular complication rates ranging between 2–5% and 0–8%, respectively –10. In lIn our analysis focused on intermediate/low risk TAVR-treated patients, we confirmed a high arteriotomy closure success rate 98%) by the use of MANTA device, extending these results to patients also excluded in early studies as those with obesity, excessive calcifications, and/or tortuosity of the ileo-femoral artery –10. The % by the To note, the main observed reason of MANTA-access adverse vascular events was CFA occlusion secondary to the toggle misplacement in femoral arteries with smaller caliber. Different from previous reports, we failed to find a significant increase in significant bleeding and pseudoaneurysm formation due to incomplete apposition of the collagen-based plug , 23, 26.Related to the predictors of vascular complications, by our multivariate analysis, we found that in pre-procedural planning, it is important to accurately assess the size of the CFA with the expected SFAR for the chosen TAVR prosthesis. In particular, a minimum CFA of 7.1 mm and SFAR of 1.01 is essential to envisage an uneventful 18F MANTA implantation. During TAVR procedure, the other major predictor of the primary-access vascular complications is the height of implantation related to the CFA bifurcation. To note, when the minimum reference CFA caliber is met, the severity and location of vessel calcification do not seem to play a major role in device failure as shown by others , 10.Finally, the inclusion of the roll-in-cases in our series negatively impact the occurrence of vascular adverse events, confirming the importance of the learning curve of an operator, which had previously been reported with suture-based but not collagen-based VCD , 23, 25.For a thorough understanding of our results, we should acknowledge several limitations. This was a single-center registry including a relatively small number of patients with a non-randomized design. Moreover, the clinical outcomes were not adjudicated by an independent committee. Therefore, our results may be influenced by unknown confounding variables and be underpowered to distinguish other predictors of MANTA-access adverse vascular events. Nevertheless, our sample size is comparable to previous reports, and we added additional insights on a broader population treated by highly experienced TAVR operators.Moreover, similar to previous analysis , 12, 25,Access technique  may have affected clinical outcomes. Furthermore, the lack of systematic post-procedural US assessment of TAVR access may have led to underreporting of vascular complications as pseudoaneurysms. Larger multi-center studies are warranted to accurately assess the impact of MANTA VCD usage, device failure, and clinical outcomes.This more comers experience with MANTA VCD during TF-TAVR procedure showed reassuring rates of technical success and major access-site vascular complications, with a non-negligible rate of minor vascular events. Avoiding lower vessel size, less PS distance to CFA bifurcation and performing a systematic ipsilateral ilio-femoral angiography before vessel puncture and after MANTA VCD deployment might further increase the rates of successful arteriotomy closure.The data that support the findings of this study are available from the corresponding author, Giuseppe Tarantini, upon reasonable request.The studies involving human participants were reviewed and approved by the local ethical committee of Padua University Hospital. The patients/participants provided their written informed consent to participate in this study.In particular, GT, GM, GL, and LD'A participated to the conception, design, analysis, and interpretation of data. All authors contributed to the drafting of the manuscript, its critical revision for important intellectual content, the final approval of the submitted text, agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved, and have contributed significantly to the submitted work.GT reports honoraria for lectures/consulting from Medtronic, Edwards Lifesciences, Boston Scientific, GADA, and Abbott. The remaining 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Euglycemic diabetic ketoacidosis (eu-DKA) is an uncommon and serious adverse event associated with the use of sodium-glucose cotransporter (SGLT-2) inhibitors. It is a state of increased anion gap metabolic acidosis with ketosis but in the setting of normal serum glucose levels. Diagnosis of this serious entity could easily be missed given the non-specific symptoms and the normal glucose measurements.This ketogenic state can be triggered by various stressors including infection, surgery, myocardial infarctions, omission of insulin dosage, as well as low carbohydrate diet. In this report, we present a case of eu-DKA in a 68-year-old woman with type 2 diabetes that occurred in the postoperative period of glaucoma surgery. She was started shortly before surgery on SGLT-2 inhibitor (ertugliflozin). While the diagnosis was initially missed, it was subsequently confirmed when she presented with reduced appetite, generalized fatigue, and constipation. Ertugliflozin was discontinued, and she was successfully treated with conservative management and without insulin drip.This case highlights the need to consider the diagnosis of eu-DKA in patients treated with SGLT-2 inhibitors since the diagnosis could easily be missed especially in the postoperative period with the non-characteristic symptomatology and normoglycemia. Sodium-glucose cotransporter SGLT-2) inhibitors that are a relatively newer class of antidiabetic medications have emerged as important therapeutic agents that reduce cardiovascular events, hospitalization from heart failure, as well as the progression of chronic kidney disease (CKD) in both diabetic and non-diabetic populations. The therapeutic indications for these agents are rapidly changing the guidelines of the American Diabetes Association (ADA), American College of Cardiology (ACC), as well as other major national and international organizations -6. This  inhibitoIn this report, we present a case of a 68-year-old woman with type 2 diabetes who developed eu-DKA after initiation of ertugliflozin therapy and was precipitated by recent eye surgery. Of importance, the diagnosis was missed during the initial visit given the non-specific nature of the symptoms and the normal glucose values obtained during the post-operative period. This patient was treated conservatively without insulin drip, indicating that she has insulin secretory capacity and corollary to the management of alcoholic ketoacidosis, which is another sub-type of euglycemic ketoacidosis. We also provide a literature review on the diagnosis and preventive measures of this potentially serious adverse effect of SGLT-2 inhibitors.Initial admissionThe patient is a 68-year-old woman with hypertension, type 2 diabetes, and recent right eye surgery for glaucoma two days prior to admission when she presented with a right-sided headache with blurry vision and slowed speech lasting for a few hours. The symptoms spontaneously resolved during the initial emergency room interview. There was no weakness, incontinence, syncopal episodes, or trauma. Physical exam showed a fixed dilated pupil with decreased visual acuity likely secondary to surgery with no focal neurological deficits. She was admitted for workup of transient ischemic attack.Of note, she was initiated on ertugliflozin right before the surgery. Initial labs Table  showed aRepeat admissionThe patient presented eight days later with decreased appetite, generalized malaise, and constipation. The physical exam was unremarkable. However, labs Table  showed aManagementThe diagnosis of mild eu-DKA secondary to the SGLT-2 inhibitor was made. An endocrinology consult was sought and was advised to stop ertugliflozin and continue supportive management with intravenous fluids and insulin aspart coverage. The patient was also administered 2 liters of Ringer’s lactate solution and was continued on 100 mL/hour continuous infusion. Diet was re-initiated as tolerated. Soon after ertugliflozin was held, the patient's appetite and bowel movements improved. She was observed for symptomatic improvement and on Day 2 of hospitalization, AG improved to 19 and HCO3- to 21. Blood glucose during the hospital course remained <140 mg/dL and did not require any additional insulin. On the last day of hospitalization, the patient noted having the ‘best meal’ in two weeks as opposed to her reduced appetite previously. Upon discharge, ertugliflozin was held; she was initiated on sitagliptin and discharged home with endocrinology follow-up.SGLT-2 receptors are located in the early S1 segment of the proximal renal tubules as opposed to the SGLT-1 receptors that are located in the S2, S3 segment. Under normal physiology, 80%-90% of the glucose reaching the proximal tubules is absorbed by the SGLT-2 receptors, and 10-20% is absorbed by the SGLT-1 receptors [In nondiabetic individuals, the renal threshold for glucosuria is 180 mg/dL, with most of the glucose being reabsorbed in the proximal renal tubules . But in Diabetic ketoacidosis (DKA) includes hyperglycemia (serum glucose >250 mg/dL), acidosis  and ketosis (ketonuria or ketonemia) [The incidence of DKA associated with SGLT-2 inhibitors has been ≤0.3% in the trials involving empagliflozin, dapagliflozin, and ertugliflozin -8. A metMost patients developing euglycemic DKA may have a precipitating event. The commonly reported factors include surgery, infections including COVID-19, pericarditis, concurrent ketogenic/low carbohydrate diets, a recent change of diabetic regimen with reduction or omission of insulin dosages, nausea and vomiting, gastroparesis, pregnancy, and acute pancreatitis -19. DiagThe pathogenesis of eu-DKA is not entirely certain. But, it has been hypothesized that SGLT-2 inhibitors lead to increased glycosuria and reduced serum blood glucose levels, with a shift in metabolism towards the utilization of gluconeogenesis and lipolysis. As there is persistently normal glucose, insulin secretion is reduced to a minimum . This phPatients on SGLT-2 inhibitors have reduced glycogen stores and any inciting event can precipitate eu-DKA. Physiologic stressors like surgery and infection can increase stress hormones like cortisol, adrenaline causing further insulin resistance and protein catabolism from alpha and beta receptor stimulation ,20. FurtTypically, from most of the reported cases, eu-DKA has been managed similar to hyperglycemic DKA with intravenous insulin, fluids, and frequent monitoring of serum electrolytes until anion gap acidosis resolution -19. But,Important learning points1) The diagnosis of eu-DKA in patients on SGLT-2 inhibitors can be easily missed or delayed, given the non-specific symptomatology together with normal blood glucose. Therefore, keeping this diagnostic entity in mind is quite critical for early diagnosis and management of this potentially serious adverse event.2) Higher dose of ertugliflozin is probably more prone to eu-DKA development.3) Insulin drip is not required in all cases, particularly in type 2 diabetes with partially preserved insulin secretory capacity. Patients can initially be conservatively managed with fluids and initiation of dietary management.4) With rapidly increasing indications for the use of SGLT-2 inhibitors and increasing usage in heart failure populations, potential acidosis should be considered as it poses a particularly high risk of increased mortality in acute heart failure patients.There has been a growing indication for SGLT-2 inhibitors given the evidence from major clinical trials of reduction of cardiovascular events, hospitalization for heart failure, as well as the progression of CKD in both diabetic and nondiabetic populations. Although the incidence of eu-DKA is relatively low, it should be considered especially in patients with risk factors that could precipitate eu-DKA, including those with infection, myocardial infarction, trauma, as well as postoperatively as in our case presentation.


Background: Testing of possibly infected individuals remains cornerstone of containing the spread of SARS-CoV-2. Detection dogs could contribute to mass screening. Previous research demonstrated canines' ability to detect SARS-CoV-2-infections but has not investigated if dogs can differentiate between COVID-19 and other virus infections.Methods: Twelve dogs were trained to detect SARS-CoV-2 positive samples. Three test scenarios were performed to evaluate their ability to discriminate SARS-CoV-2-infections from viral infections of a different aetiology. Naso- and oropharyngeal swab samples from individuals and samples from cell culture both infected with one of 15 viruses that may cause COVID-19-like symptoms were presented as distractors in a randomised, double-blind study. Dogs were either trained with SARS-CoV-2 positive saliva samples (test scenario I and II) or with supernatant from cell cultures (test scenario III).Results: When using swab samples from individuals infected with viruses other than SARS-CoV-2 as distractors (test scenario I), dogs detected swab samples from SARS-CoV-2-infected individuals with a mean diagnostic sensitivity of 73.8% (95% CI: 66.0–81.7%) and a specificity of 95.1% (95% CI: 92.6–97.7%). In test scenario II and III cell culture supernatant from cells infected with SARS-CoV-2, cells infected with other coronaviruses and non-infected cells were presented. Dogs achieved mean diagnostic sensitivities of 61.2%  and 75.8% , respectively. The diagnostic specificities were 90.9%  and 90.2% , respectively.Conclusion: In all three test scenarios the mean specificities were above 90% which indicates that dogs can distinguish SARS-CoV-2-infections from other viral infections. However, compared to earlier studies our scent dogs achieved lower diagnostic sensitivities. To deploy COVID-19 detection dogs as a reliable screening method it is therefore mandatory to include a variety of samples from different viral respiratory tract infections in dog training to ensure a successful discrimination process. Clostridium difficile (Staphylococcus aureus (The ongoing coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) still affects the life of people all over the world and highlights the need of rapid point-of-care screening tests as a key tool to contain viral spread. The real-time quantitative reverse transcription polymerase chain reaction (rtRT-PCR) is considered the gold standard for diagnosing SARS-CoV-2 infections with high diagnostic accuracy . For exaifficile , Staphyls aureus , and oths aureus . ConsequIn the first published pilot study, dogs were able to detect saliva samples from COVID-19 patients with a diagnostic sensitivity of 83% and specificity of 96% , which hA pathogen-specific odour is thought to be detected by dogs being composed of unique volatile organic compounds (VOCs). Laboratory identification of the specific VOC pattern is, however, still in its infancy and there is little published data on the creation of different odours by viral infections. Angle et al. trained dogs to detect cell cultures infected with bovine viral diarrhoea virus (BVDV) . After tInactivated saliva samples from SARS-CoV-2-infected and healthy individuals as negative controls were used for training. The saliva samples were acquired and prepared as described in previous studies . In addiClinical swab samples used in this study were obtained from routine diagnostics at the Robert Koch Institute . For pooled SARS-CoV-2 samples, a mix of 20 naso- and oropharyngeal swabs from PCR confirmed SARS-CoV-2 patients were used, similar Ct values (<1.0 difference) were matched. A 1:3 dilution was performed using swab samples from healthy individuals in phosphate buffered saline (PBS) as a negative matrix. As sample medium, PBS was used for all samples. Furthermore, pooled samples from individuals infected with four different coronaviruses and nine other viruses causing respiratory infections in humans like influenza viruses and parainfluenza viruses were included . All sam2 and 90% humidity for HCoV-OC43 and -NL63 and at 37°C for the other coronaviruses. Supernatant of the cell cultures was harvested when infection of the monolayers reached 90–100% [assessed either by cytopathic effect or immunofluorescence signal against viral protein (data not shown)]. Supernatants were cleared from cellular debris by centrifugation at 5,000 xg for 10 min in an Eppendorf 5804 centrifuge. Cleared supernatants were inactivated as described in our first study . Six different human coronaviruses were cultured in a human hepatocyte derived carcinoma cell line , Malinois (n = 4), German Shepherd (n = 2) and Cocker Spaniel (n = 1)  were included in our studies. All dogs completed obedience training before the study, and some had a history of scent detection or protection work. Ages ranged between 1 and 5 years. Included dog breeds were Labrador Retriever ( (n = 1) .As described in our previous studies , 17 a deEvery nose dip into the DDTS' slots was evaluated with four possible options:True positive (TP): the dog correctly indicates a SARS-CoV-2 positive sampleFalse negative (FN): the dog sniffs shortly at a SARS-CoV-2 positive sample but does not indicate itTrue negative (TN): the dog sniffs shortly at a negative/distractor sample and correctly does not indicate itFalse positive (FP): the dog incorrectly indicates a negative/distractor sampleFor indicating a sample, the dogs rested with their snout in the respective device test slot (“freezing”). The indication time was recorded by the DDTS and after indicating the target sample the device automatically responded with a reward, i.e., food. Afterwards, the DDTS changed the positions of the presented samples without letting the dog or dog handler know the new positions of negative, distractor or positive samples. This allowed a double-blind sample presentation. In addition, all staff involved was positioned to prevent any interaction or influencing of the animals during the study.P ≤ 0.05 was considered significant. All calculations were done with the Prism 9 software from GraphPad .The diagnostic sensitivity as well as diagnostic specificity, positive predictive values (PPV), and negative predictive values (NPV) were calculated according to Trevethan . PPV is This study was carried out in accordance with the ethical requirements established by the Declaration of Helsinki. The study obtained ethical approval by the Berlin Chamber of Physicians (Eth 20/40) and was approved by the local Ethics Committee of Hannover Medical School (MHH) and Hamburg Medical Association for the University Medical-Center Hamburg-Eppendorf (UKE) . Written informed consent from all participants was obtained before sample collection. Animal work according to the study protocol and design was approved by the German Armed Forces.Three test scenarios were performed to address the aim of the study. In the first test scenario (scenario I), dogs who were trained with saliva samples discriminated between SARS-CoV-2 swab samples and swab samples from patients infected by other respiratory tract infection viruses . The dogOverall, a total of 2,054 sample presentations were performed in three different test scenarios. During the presentation of swab samples (test scenario I), 139 correct indications and 50 false rejections of SARS-CoV-2 positive swab samples were recorded, while 919 correct rejections and only 46 false indications of swab samples from the other 13 viruses were made. When the supernatants of the different cell cultures were presented to the dogs trained with saliva (test scenario II), they indicated 67 SARS-CoV-2 sample presentations correctly and rejected 43 positive samples incorrectly. They made 45 false positive responses to any one of three other coronaviruses or one non-infected control and 443 correct rejections. In comparison, dogs trained with cell cultures for 3 days (test scenario III) correctly identified 45 SARS-CoV-2 supernatants correctly but incorrectly rejected 16 positive samples, whereas 220 correctly negative and 26 false positive responses to the other seven cell culture samples (six different coronaviruses and one non-infected control) were made .Rapid detection of SARS-CoV-2 infections remains one of the main strategies to control the current global pandemic. Several studies have shown that trained scent detection dogs can discriminate SARS-CoV-2-infected individuals from healthy individuals with high diagnostic accuracies. However, to use medical detection dogs, as a reliable diagnostic test, it is important to ensure their capability to distinguish between samples from SARS-CoV-2-infected people and other viral infections causing similar symptoms. In the current study, dogs were able to discriminate samples from SARS-CoV-2 infected individuals and cell cultures from those infected with one of 15 other common acute respiratory viruses as distractors.During 964 presentations of swab samples from patients with different viral infections other than SARS-CoV-2 (test scenario I), the scent dogs alerted falsely to 46 samples, which led to a mean specificity of 95.1%. This specificity is comparable to our first pilot study by Jendrny et al. in which we only used samples from healthy, SARS-CoV-2 negative individuals without any respiratory symptoms as control samples and obtained a specificity of 96.35% . When usWhen presenting cell culture samples to dogs trained by saliva, the mean sensitivity was 61.2%, which is lower compared to sensitivities ranging from 82% to 95% in our previous studies , 17. TheThe prevalence in our study was 17.5%. The high prevalence is a result of the fact that we presented one SARS-CoV-2 positive sample next to several samples from different viruses. In a pandemic, prevalences will vary and are usually significantly lower. When the prevalence falls below a certain threshold the dogs might get frustrated and stop searching for a positive sample. To ensure that scent dogs keep their diagnostic accuracies in case of a low prevalence and to have an internal control it is important to reward dogs during a test run not only for finding positive samples but also for not indicating wrongly negative samples. Furthermore, one has to ensure that the training entails an increasing number of empty runs (presentation of only negative samples). Dogs' frustrations levels should then be recorded and considered when working in the field, ensuring dogs will receive a sufficient number of rewards to keep them positively engaged in the field. A further limitation can be the dog handler. Not only the dog but also the dog's handler has an individual character, an individual training level and therefore require different training requirements. The DDTS can overcome some of these limitations, as dogs can be trained to work independently [The prevalence of an infectious diseases is dynamic in a pandemic. As aforementioned the prevalence in our test paradigm was higher than in the current pandemic situation, which is further subject to change with an ever-increasing number of people getting vaccinated. The real positive predictive values would be with the current prevalence lower when sensitivity and specificity of dogs remain unchanged and the dogs would be deployed without a rewarding system. However, as in our test setting, a lower prevalence does not impact the performance of the dogs necessarily, as the frequency of getting rewarded is above the prevalence of the disease.in vitro  Hannover Medical School 9042_BO_K_2020 University Medical-Center Hamburg-Eppendorf PV7298. The patients/participants provided their written informed consent to participate in this study. The animal study was reviewed and approved by German Armed Forces.NH participated in the planning of the study, carried out the main practical work, data analyses, and helped draught the manuscript. FT, SM, PJ, and HV designed and coordinated the study, drafted the manuscript (FT), conducted and coordinated (FT) the sample acquisition, and were responsible for data analyses (SM). MK-B, CS, and AO participated in the planning of the laboratory part of the study and were in charge for the legal permission for sample processing. CS, RE, KZ, and RW carried out the laboratory work at the Research Center for Emerging Infections and Zoonoses (CS) and Bundeswehr Institute of Microbiology  including sample preparation, virus inactivation, and RtRT-PCR. HE programmed the DDTS software and supported the dog training. IP, TW, MM, AF, and MA were in charge for the ethical approval, patient recruitment and sample collection (IP and AF) at Hannover Medical School , and University Medical-Center Hamburg-Eppendorf (AF and MA). ANi and AP coordinated the sample acquisition at the Robert Koch Institute. AP, JM, and EK performed the sample preparation including rtRT-PCR at the Robert Koch Institute. ANa and EP were responsible for coordinating the acquisition and data of samples as part of the support provided by the German armed forces. CE was responsible for the special research proposal of the German Armed Forces as project manager on the part of the German Armed Forces. ME coordinated the cooperation with the University of Veterinary Medicine Hannover. AB participated in the planning of the cultivation of the different coronaviruses and provided the HuH7.5 cells. ES was responsible for the dog training and helped with data analyses. ME and ES were also involved in designing and coordinating the study. All authors have read and approved the final manuscript.The project was funded as a special research project of the German Armed Forces Medical Service (02Z9-S-852121) and supported by the COVID-19 Research Network of the State of Lower Saxony (COFONI) through funding from the Ministry of Science and Culture of Lower Saxony in Germany (14-76403-184).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. The handling editor is currently organizing a Research Topic with one of the authors HV.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.