Platelet-rich plasma (PRP) preparations have recently become widely available in sports medicine, facilitating their use in regenerative therapy for ligament and tendon affections. Quality-oriented regulatory constraints for PRP manufacturing and available clinical experiences have underlined the critical importance of process-based standardization, a pre-requisite for sound and homogeneous clinical efficacy evaluation. This retrospective study (2013–2020) considered the standardized GMP manufacturing and sports medicine-related clinical use of autologous PRP for tendinopathies at the Lausanne University Hospital . This study included 48 patients , and the related PRP manufacturing records indicated a platelet concentration factor most frequently in the range of 2.0–2.5. The clinical follow-up showed that 61% of the patients reported favorable efficacy outcomes  following a single ultrasound-guided autologous PRP injection, whereas 36% of the patients required two PRP injections. No significant relationship was found between platelet concentration factor values in PRP preparations and clinical efficacy endpoints of the intervention. The results were in line with published reports on tendinopathy management in sports medicine, wherein the efficacy of low-concentration orthobiologic interventions appears to be unrelated to sport activity levels or to patient age and gender. Overall, this study confirmed the effectiveness of standardized autologous PRP preparations for tendinopathies in sports medicine. The results were discussed in light of the critical importance of protocol standardization for both PRP manufacturing and clinical administration to reduce biological material variability (platelet concentrations) and to enhance the robustness of clinical interventions (comparability of efficacy/patient improvement). Tendinopathies are debilitating and painful affections, which often have severe consequences on the daily activities  of patients and on healthcare systems ,2,3,4. FIf the tendon tissue’s extracellular matrix (ECM) structure is damaged, physiological repair processes may result in the synthesis of disorganized matrix, potentially leading to fibrin strand breakage  . The resAutologous PRP therapy for tendon affections requires a local ultrasound-guided injection of a processed blood extract, which has been obtained by minimal manipulation  from patients’ blood. Such extracts are composed of concentrated platelets in autologous plasma following the removal of erythrocytes and lymphocytes ,29,30. SImportantly, highly contradictory reports and analyses of PRP clinical efficacy are available in current scientific literature sources, when considering all therapeutic indications and manufacturing methods ,40,44,45This retrospective study  investigated the standardized GMP manufacturing and sports medicine-related clinical use of autologous PRP for tendinopathies at the Lausanne University Hospital . The primary objective of the study was to evaluate PRP injection efficacy in patients treated at the Sports Medicine Unit for tendon-related affections based on the clinical files and GMP manufacturing records of PRP preparations. As previously reported, the in-house GMP manufacturing of PRP preparations at CHUV has enabled rapid clinical management of tendinopathies, cutaneous burns, and arthrosis lesions in multiple institutional departments . From a (i)Discriminate the success rate according to the age of the patients at the time of the PRP treatment.(ii)Highlight whether PRP could help in resuming physical activity faster in younger versus older patients.(iii)Determine how many PRP injections were necessary on average.(iv)Highlight the nature and volume of the resumed physical activity in the studied patient population.The present retrospective study was reviewed and approved by the Vaud State Ethics Committee  and was conducted following the principles of the Declaration of Helsinki and applicable Swiss laws . In this(i)Number of PRP applications required for healing.(ii)Ratio of platelet concentration in the PRP injection to platelet concentration in native blood  for each patient.(iii)Possible relationship between the number of PRP injections required and the platelet concentration factor.(iv)Potential treatment-related adverse events as detected.(v)Patient clinical evolution following the PRP treatment.In order to obtain appropriate data and information within the scope of this retrospective study, the specific elements of the request submitted to the local ethics committee comprised the following: Given the exploratory nature of this retrospective study, the sample size calculation was not based on formal statistical methods. The sample size was evaluated according to an internal feasibility study, which showed that 75 patients with diagnosed tendinopathies were treated with autologous PRP injections since the implementation of the procedure in 2013 at the CHUV and would be eligible for the retrospective study.Patient clinical files were investigated at a preliminary level for cases of tendinopathy treatment by autologous PRP injection at the Sports Medicine Unit, since the implementation of the procedure at the CHUV in 2013 and until December 2020. The inclusion criteria restricted the search to the adult patient population  that received a PRP injection treatment for tendinopathy. The exclusion criteria disqualified pediatric patients  and patients who refused to be included in any research or have their data anonymously analyzed. Overall, 75 patients were initially included in the study. Further investigations led to the exclusion of several cases based on the absence or refusal of consent provision or on the presence of documented epicondylalgia. Finally, a total of 48 patients were retained for an in-depth analysis within this retrospective study.Demographic, radiological, biological, and clinical data were collected and analyzed from computerized patient records . The patient data notably included clinical and anamnestic histories, clinical and health observations, ultrasound image reports, choice of treatment, application of treatment, and ambulatory follow-up. In order to investigate the potential relationship between platelet concentration factors and PRP treatment efficacy, the patients were classified according to the qualitative assessment of their clinical state and the ultrasound appearance of their tendon tissular lesion.All patients included in the present retrospective study received final autologous PRP products prepared by an in-house GMP platform, following a standardized CHUV-UTR protocol . The in-The use of autologous blood for PRP preparations significantly reduces the risk of cross-contamination compared to the use of third-party blood. This approach was, therefore, retained by the attending physicians at the Sports Medicine Unit in the CHUV. During patient anamnesis and diagnostic investigation, an ultrasound scan was performed on all the patients included in this study. The purpose of the ultrasound was to determine the precise site of the tissular injury and to qualify the type of tendon injury. Notably, several patients did not present any ultrasound-detectable lesions. Then, a native blood sample was drawn and was sent to the GMP production unit, along with a medical prescription for an autologous PRP preparation. Following the manufacture, the final PRP products were returned to the attending physicians within 2 h of blood collection.The attending physicians excluded the presence of contra-indications for PRP treatment  for each patient. For outpatient PRP local administration by injection, ultrasound guidance was chosen to ensure accurate positioning of the needle on the tendon tissue lesion. Ultrasound guidance  of the needle also ensured that sensitive tissues, such as nerves, vessels, and healthy tendons, were avoided. For the few patients who did not present any ultrasound-detectable tendon lesions, the available clinical information was used to determine the PRP injection site. For the administration of the PRP injection, the patients lied on an examination table in the dorsal, lateral, or ventral position depending on the area to be treated. Particularly, the most comfortable position for the patients was sought in order to avoid any movement during the procedure. The injection area was then locally disinfected using topical chlorhexidine, and the PRP preparation was injected. Standard antalgics were prescribed, and follow-up visits were specified as appropriate.Quantitative variables that followed a Gaussian/normal distribution were analyzed and visualized using means and standard deviations. Categorical  variables were represented by percentages and frequencies. The statistical calculations and/or data presentation were performed using Microsoft Excel and Microsoft PowerPoint .The methodological overview of the present retrospective study is presented in For all patients included in this retrospective study , with 75% of the patients leading active lives . An examThe diagnosis-related information gathered from the clinical files confirmed that all 48 patients presented severe tendon tissular alterations or a functional disorder. Regarding the follow-up of the patients after their PRP treatment and the evaluation of intervention efficacy, a positive evolution was defined as a complete recovery of physical condition, with complete disappearance of pain. An analysis of the patient follow-up data revealed that 61% of the patients who reported a positive evolution received a single autologous PRP injection A.A total of 36% of the patients who reported a positive evolution required a second autologous PRP injection to maintain this positive evolution, and 3% of the patients who reported a positive evolution required three or more PRP injections to fully recover A. OveralThe analysis of PRP manufacturing records for the patients included in this retrospective study revealed that the average native blood samples drawn from the patients for autologous PRP preparation were characterized as having a volume of 20 mL. The platelet concentration factors of the final autologous PRP products for clinical use were 2.79 on average, whereas the most frequent platelet concentration factor interval was of 2.0–2.5 in value .p < 0.05) difference in mean patient age values between the two groups, it was concluded that patient age was not a predictive criterion for autologous PRP treatment efficacy in the studied patient population.Overall, no significant relationship was found between the final PRP product attributes  and efficacy-related outcomes in the analyzed dataset. On average, the patients who reported a positive evolution were younger than those who reported a non-positive evolution . HoweverAn analysis of patient gender in relation to autologous PRP treatment efficacy revealed that males reported a positive evolution more often than females  and two overweight patients . There were also two sports teachers, a sedentary 41-year-old patient, two athletes aged 21 and 32, a patient who was applying for disability insurance benefits, and a patient for whom no further information was available. It should be noted that five patients within the non-positive evolution group presented a significant discrepancy between anamnestic complaints and ultrasound findings.When considering the distribution of platelet concentration factors for the 48 included patients, relatively low values were most frequent . In detail, the mean platelet concentration factor was determined for every patient, where applicable. Then, a gap analysis was performed for each patient to study the difference between the individual values of platelet concentration factor and the mean value of platelet concentration factor for the specified patient . The resThe relatively low average results of the gap analysis presented in The clinical use of autologous PRP has expanded rapidly in recent years despite the absence of a clear consensus on product preparation and characterization methodologies ,33,44,51(i)Training and qualification of personnel.(ii)Validation of premises, equipment, testing procedures, and computerized systems.(iii)Traceability assurance .(iv)Storage and distribution of final products.(v)Performance of self-inspections/audits for any complaints, recalls, and notifications to hemovigilance, along with implementation of appropriate corrective and preventive actions.In the case of Switzerland, the applicable legal bases for PRP preparation and use are highly similar to European frameworks. Therein, PRP is considered as a “non-standard medicinal product”, meaning that good manufacturing practice (GMP) standards must be applied . SpecifiThe purpose of the above-mentioned legal and regulatory procedures is to protect patients and to ensure that appropriate responsibility is assumed by clinicians for the assurance of the safety, quality, and efficacy of the administered autologous PRP treatments ,49,50. OThe validation of the GMP production platform and the qualification of the equipment and personnel contribute to guarantee the reproducibility of the quality of autologous PRP products, contrasting with extemporaneous preparation in a physician’s office using a kit. Importantly, the use of sub-optimal preparation and administration protocols can potentially jeopardize the clinical efficacy of PRP intervention and incur elevated morbidity and healthcare costs. Based on the sensitive nature of blood products and on the invasiveness of the PRP administration route , maximal safety and quality of the final product are ensured by the use of an appropriate GMP production platform .The demographic data of the included patient sample in the present retrospective study show high diversity in patients affected by tendinopathies , Table 1It is important to mention that general or specific patient-related factors  can potentially impact platelet activity and negatively influence autologous PRP treatment efficacy. Furthermore, the technical specifications of the PRP manufacturing process  are known to affect platelet reactivity and platelet yields in the finished PRP preparation, which can also potentially affect the therapeutic efficacy of the intervention ,24,25. WFrom a manufacturing and control point-of-view, further autologous PRP product standardization could be performed, notably by normalizing the platelet concentration in the final PRP product; however, several factors argue against such steps. Firstly, the low dispersion of recorded platelet concentration factor values and the documented high process robustness in this retrospective study indicated that limited technical gains could be procured by such an endpoint normalization , Table 4An alternative technical approach to PRP final product standardization would be individual growth factor or cytokine content-based standardization, which presents both advantages and disadvantages ,44. On tOverall, the presented results confirmed the interest of using a standardized PRP manufacturing workflow, especially for patient cohorts presenting high demographic variability. Parallelly, it may be concluded that detailed investigation into patient demographic and diagnostic parameters is of prime importance for the appropriate demonstration of PRP intervention efficacy. By extension, the performance of large-scale retrospective studies on the therapeutic uses of PRP, taking into account all relevant demographic factors, could potentially enable the identification of predictive factors of standardized PRP intervention efficacy. This would, in turn, enable researchers to better define the applicable or optimal clinical pathway and treatment regimen using autologous PRP, thereby facilitating enhanced clinical success and rationalization of overall healthcare resources.The overall prevalence of osteoarthritis, tendinopathy, and ligament injuries generally increases with age. Notably, rotator cuff tendinitis, rhizarthrosis, and carpal tunnel increase in women during perimenopause, without any direct link to physical activity or trauma ,2,3,5,61(i)Overuse of tendons implicating ECM degradation  ,3.(ii)Formation of neo-vessels related to exogenous stresses and stimuli  ,64.(iii)Tissue aging related to endogenous factors  ,61,63.With regard to age-related variations in tendon tissue healing, the decline of the vascular bed can also contribute to the progression toward less efficient tissular repair, as well as to the emergence of clinically perceivable pain for minor lesions. Inflammation and vasculature in tendinopathy have been poorly studied as neo-vessels seem to be very different from the normal vasculature formed during tissue growth and are not fully functional ,64. OverMany biological parameters and lifestyle choices are involved in chronic tendinopathies, leading to multifactorial etiologies and alterations. Among the possible alterations to normal tissular functions are perturbations of nerve function and vascularization, cell density and phenotypes changes, cell–cell interactions, cell–matrix interactions, cytokine balance, and overall tendon matrix alterations  5,64]. ,64. 5,64Within autologous PRP treatments, high patient-related innate variability exists for the quantity and quality of platelets. A variety of reasons related to overall patient health, diet, genetics, and environmental factors may play a role in the efficacy obtained following the administration of autologous PRP ,70,71. PTaking all the abovementioned patient-related factors into account, it would seem logical to obtain poorer results in elderly and overweight patients with little or no physical activity and low androgen levels ,62. SuchThe present retrospective study sets forth the use of a fully GMP-compliant and accredited manufacturing platform for the preparation of finished autologous PRP products for clinical use. Although such practices should be applied in most cases according to the applicable legal bases in Europe and in Switzerland, very few clinical centers currently apply this level of quality and traceability for the preparation of autologous PRP. This is due to the well-known high variability in the content and application of the legal bases for PRP, as best shown within the European patchwork of laws, rules, and directives ,51,52.The first main study limitation consisted in the small size of the included patient sample . This was mainly due to the limited number of patients treated for tendinopathies by PRP in Lausanne when compared to larger centers . However, this aspect is considered to be counterbalanced by the availability of high-quality original data pertaining to patient treatment and follow-up, as well as GMP manufacturing records for all the administered autologous PRP preparations. Notably, it is difficult to directly compare the present study to other published reports mainly due to the autologous PRP manufacturing method . However, similar trends were observed in the analyzed original data, such as the use of relatively low platelet concentration factors  for tendinopathy management and the absence of significant differences in efficacy related to final platelet concentrations.Secondly, an accuracy issue was identified within the described GMP manufacturing process of autologous PRP with regard to the determination of platelet counts in whole blood and in the finished PRP preparations. Specifically, the mean platelet counts determined in whole blood were 73 ± 29 G/L for the samples included in the study, and 192 ± 96 G/L for the corresponding autologous PRP preparations. These values were found to be low with regard to normal whole blood platelet counts in the general population  ,75,76. IImportantly, as the present study focused on the attributes of the final autologous PRP products and specifically on the platelet concentration factors characterizing the obtained PRP, the aforementioned systematic accuracy issues within platelet enumeration bear virtually no consequences  and have not resulted in any kind of systematic clinical failures. However, this important element constitutes a prime real-world and experience-based example of the current need for additional standardization of manufacturing and control activities for PRP products ,78,79,80This retrospective study considered the standardized GMP manufacturing and sports medicine-related clinical use of autologous PRP for tendinopathy management in 48 patients. Importantly, the results of this study have demonstrated the effectiveness of standardized autologous PRP preparations for tendinopathies in sports medicine. As shown in the presented results and related data interpretations, manufacturing process standardization and holistic integration of patient-related factors are necessary for an appropriate evaluation of autologous PRP administration efficacy. Notably, the available GMP manufacturing records have shown that relatively low platelet concentration factors  are sufficient to obtain a positive evolution in most of the treated clinical cases. The statistical discussions of the available data enable us to outline the manufacturing process repeatability and robustness, which are critical factors to ensure the continuous provision of high-quality orthobiologic care to each patient. Furthermore, a detailed analysis of the demographic factors of the patients who reported a non-positive evolution following PRP treatment provides some insights into how to further perform clinical pathway optimization in complex cases. Overall, the presented results confirm the central importance of process and protocol standardization for autologous PRP manufacturing/control and clinical administration. These elements are considered as prerequisites for the reduction of inter-individual variability and for the sound assessment of therapeutic intervention efficacy. Finally, the analyses of process-based and patient-related elements in the present study may be useful in the establishment of enhanced clinical workflows for autologous PRP therapies, aiming to reduce tendinopathy-related morbidity and costs and ensure long-term patient remission. To further enhance the orthobiologic treatment’s clinical efficiency for tendinopathies in sports medicine, relevant insights may be gained from best practices in transfusion medicine to ensure safe and appropriate PRP clinical use.


People tend to belong to multiple social circles, which construct and reflect a person’s social identity. Group affiliation is embodied and may be expressed by personal adornment. Personal adornment in general has multiple functions in human societies, among them the assimilation and transmission of different aspects of personal and collective, social and cultural identity. Beads in general, including shell beads, often constitute parcels of composite adornment, and as such are used in different configurations to portray these messages. The shared use of similar bead types by different individuals and communities indicates the mutual affiliation of the sharing parties to the same cultural circles and reflects social ties and relationships. The Pre-Pottery Neolithic B (PPNB) period in the Levant is a time of pivotal changes to human lifeways necessitating profound adjustments in all aspects of life, including social relations and networks. Here we use the shell bead assemblage from the cultic-mortuary aggregation site of Kfar HaHoresh, in comparison to shell bead assemblages from multiple other sites in the Levant, as a proxy for the exploration of local and regional networks and connections between PPNB communities. Multivariate analyses of shell bead type distribution patterns across the Levant demonstrate that some types were widely shared among different communities, characterising different geographic regions, while others were rare or unique, highlighting relationships between sites and regions, which are occasionally independent of geographic proximity. Specific occurrences of shared shell bead types between Kfar HaHoresh and compared sites further illuminate the web of connections between PPNB communities in the Levant and the varying breadths of sharing-patterns reflect the hierarchical nature of the underlying social circles. Outlining these widening social affiliations sheds light on the complex structure of Neolithic social identity. Humans strive for a sense of social belonging as an innate feature of human nature. We identify ourselves with certain social groups  and disassociate ourselves from others, assuming the different roles these associations entail. Different theories in social psychology, such as Social Identity and Social Categorization –4 examinPersonal adornment, in our case, involves the wearing on the body of different artefacts, imbued with social and cultural meaning. The use of personal adornment constitutes an embodiment of identity; an introverted bodily construction of identity, on the one hand, and its extroverted communication, on the other –17. On aFrom an archaeological perspective, items of adornment found in archaeological sites, used to ornament humans, as well as animals or associated equipment , reflecShells of marine molluscs have been one of the earliest materials and artefacts chosen to be used for adornment in human history. Early uses of shells as beads seem to be associated with the emergence of modern humans, appearing in Middle Palaeolithic and Middle Stone Age sites, dating between 140–70,000 years ago, in South Africa, North Africa and the Levant –36. In tth millennium calBC . Here we use a different aspect of material culture–shell beads–to refine our ability to interpret such connections. In this paper we examine and define the variety of shell bead types found in different sites in the Levant, trace the geographic spread of the different types, and emphasize the scale and patterns of their distribution. Based on theories of social identity and the social roles of personal adornment, we hypothesize that the use of the same bead types by different communities represents expressions of social affiliation. Through multivariate analysis of the distribution patterns of different shell bead types we illuminate complex networks and community relationships. The results indicate that different shell bead types have different distributional scales, from pan-Levantine, through regional, to individual occurrences of unique types. These distribution patterns suggest that social relationships and identities were influenced by cultural affinities and not exclusively based on geographic proximity. We show, for example, that the communities using KHH had connections with the distant (>90km away) community of Jericho, as based on their shared use of special bead types and other shell related practices, unique only to them. The specific patterns of distribution of different bead types, and particularly their varying breadths, outline the hierarchically tiered structure of the Levantine Neolithic social identity.Shell beads from KHH and 23 additional sites were selected for comparison . Sites wThe sites selected for this analysis are not evenly dispersed across the study area and extensive regions in both the Mediterranean and the desert zones are not represented. This is due to multiple factors, such as research biases or limited shell publications, as well as possible true absences of PPNB sites or shell assemblages in some regions  is designed to represent ranked differences between data points, based on a distance matrix, by producing a gradient ordination of points , 114. FoClustering analyses are designed to group objects into clusters based on varying degrees of dissimilarities between objects , 114. NeNMDS and Neighbour-joining analysis may be used to analyse binary data (presence/absence) with the mediation of designated distance matrices , 114. WeOne-Way ANOSIM is a non-parametric test of significance, examining the difference between groups as expressed by distance matrices. The test is based on comparing dissimilarities within-groups with dissimilarities between-groups , 114. ItEventually, after examining the broad perspective through multivariate analyses, we concentrate on specific examples of common shell bead types and the distribution of their rarer variants, as they appear at KHH and other sites. This descriptive approach is used to demonstrate specific cross-regional connections within the pan-Levantine interaction sphere.Neverita, Polinices, Mammilla, and Natica/Notocochlis); or with Columbella, Pisania, Engina, and Euplica shells , as well as Melanopsis which is a somewhat similar looking freshwater shell  with removed dorsa, Nerita shells perforated on the bulging side of the last whorl opposite the aperture (8NSW), complete Conus shells perforated through the apex and spire (5CASN), or Scaphopods (13SCAPH). An additional large group is shared by all regions except the Desert-south (shown to the right in Glycymeris (1GNU) and Cardiidae shells (1CNU) or ground Cardiidae (1CGU). An additional group characterizes the Desert-south and centre regions (shown to the left in Clanculus (9CBWGH) or Polinices (9PBWGH) beads. Smaller groups of shell bead types, represented on both edges of the seriation plot, typify only the Mediterranean-north and centre regions (on the far right), such as Glycymeris shells with a gouged hole in the umbo (1GGHBU), Unionidae shells double perforated in the hinge area (12MPV2), or cowrie columellar lips with knobs shaped at both ends (2CDRLK2), or only the desert-south region (on the far left), such as Notocochlis (previously Natica) beads (9MBWP) and Nerita aperture rings (8NAR). Some shell bead types are occasionally found beyond the limits of the region they typify  is statistically significant (P = 0.0001), yet only slightly more dissimilar between zones than within each zone (R = 0.3616). A comparison between the landscape units displays a comparable overall dissimilarity . A pairwise contingency table, showing both  regions , indicatThe study of shell assemblages from 24 PPNB sites across the Levant, and the examination of the distribution patterns of 133 shell bead types forming these assemblages, reveal variable levels of connections between different components of the regional population. The examination of this complex network of relations enhances our interpretation of Neolithic society and identity across the Levant.The distribution of items of personal adornment has been previously used to demonstrate populations’ social structure and identity, including social affiliation or disassociation, with particular reference to shell beads among other types of adornment , 30. FolShell beads are usually attributed to composite forms of adornment. They constitute elements, or building blocks, used to create a wider visual effect , 117. ThStemming from this, the leading premise in the definition of shell bead types here, is that they were designed to have a recognizable and distinguishable look, either on their own or as part of composite adornment. Therefore, any aspect of a shell bead affecting its overall individual appearance should be taken into consideration. The identification and definition of the distinct shell bead types used in this analysis , Fig 2 wIn the studied assemblages, artificially perforated and shaped shells were used alongside naturally perforated shells. Shells may become naturally perforated due to attrition of the empty shell by surf abrasion on the beach or sea-bottom, by trauma to the shell body, or different types of predation –120. NatIn other cases, artificial manufacturing of the shell beads was clearly apparent. Shells were turned into beads using various technologies, including gouging, hammering, grinding, and sawing  Fig 2)..Fig 2). Theodoxus shells found in several Mediterranean sites (8TSW), were used to imitate imported exotic beads such as the Red Sea Nerita common bead type (8NSW)  may have served different needs of the local society [When turned into beads, shells may have been simply perforated, retaining their natural form, or manipulated into various shapes. The degree of manipulation exerted on the shell beads expresses a varying range of investment. When turned into beads, shells may have been simply perforated, retaining their natural form, or manipulated into various shapes. The degree of manipulation exerted on the shell beads expresses a varying range of investment, as seen for example, in the similar treatment of Naticidae shells or Buccinoidea shells (e (8NSW)  fi-fiii. society .Despite having suggested instances of material substitution and imitation above, we are well aware of the possibility that Neolithic people did not perceive similarities between shell or bead types in the same way we do. Differences in perception were identified, for example, in the deviations between aboriginal Australian Gidjingali and Linnaean shell taxonomy [Other shells that were extensively manipulated, were sometimes fashioned into geometric forms, resembling beads made of various other materials during the same period. Beads made of minerals and stone , 130–132Finally, after a shell bead has been produced, it was presumably used for adornment. The different uses and stringing modes of shell beads add multiple factors influencing their overall visuality. The location of the perforation on the shell allowed for different stringing directions, exposing different sides of the shell, or positioning it at different angles, and the number and size of perforations also influenced the specific hanging mode and display , 139. AnPrevious studies have demonstrated patterns and relationships of Neolithic life. Based on lithic studies of bidirectional blade industries, Barzilai  defined Our findings complement and expand upon these earlier suggestions. The seriation analysis demonstrates that there is a geographic orientation to the distribution of shell bead types across the Levant, with considerable overlap in the areas in which the bead types appear. Some bead types epitomize a region, or several regions, while others are widely shared throughout the study area. Shell bead types that were found to characterize a region represent the local adornment preferences and local social circles, while shell bead types that characterize several regions attest to the expansion of these ties. The appearance of multiple shell bead types in sites across the study area, as well as the occasional appearance of several geographically restricted shell bead types in sites far from their typical region/s, reflect the maintenance of long-distance networks and social relationships enabling widespread sharing of cultural markers throughout the Levant.The seriation analysis has shown that sites that are related to one another, as based on the composition of their shell bead type assemblage, are not necessarily geographically adjacent. Sites in the Mediterranean-centre and south and the Desert-north regions are particularly intermixed, as is similarly expressed in the results of the Neighbour-Joining cluster analysis. While the bead type composition of Ramad (in the Damascus basin) resembles those of Shakrat Msaied and Basta  more than that of nearby Aswad , as a rule, sites from the Mediterranean-north and the Desert-south regions remain more stable in their position at the ends of the seriation continuum.The results of NMDS indicate that the different regions are fairly distinct, especially the Mediterranean-north region, and display separable shell bead type compositions. However, a considerable degree of overlap is apparent, particularly among the sites in the Mediterranean-centre and south regions, including parts of the Desert-north and centre regions. This fits well with the results of the one-way ANOSIM that found that the regions at the margins of the study area, namely the Desert-south and Mediterranean-north regions, display the most dissimilarity and contribute most to the significance of these differences, while the Mediterranean-centre and south and the Desert-north regions are the most alike. These results also correspond well with the results of the unconstrained seriation analysis presented above, together reflecting gradient levels of shell bead type sharing throughout the Levantine interaction sphere. The distinction of shell bead assemblages from the margins of the study area reflects the existence of local adornment preferences, as well as proximity to the shell sources that are common within each region and generally not inter-regionally shared. The overlapping or intermixing of assemblages from the centre of the study area reflect more shell bead type sharing that reflect intensive interactions among these sites and regions.In several instances, identified in both the NMDS and Neighbour-joining, as well as in the seriation analyses, assemblages from remote sites were found to be more similar than those of nearby sites or from other sites in the same region. This highlights the intra-regional variability in shell bead choices and indicates that adornment preferences were not strictly limited to geography. The observed similarities between remote sites represent the establishment of relationships and affiliations between communities , unrelated to their geographic proximity.Geographic proximity has been regarded in the past as the basis for social identification. De Swaan , for exaDifferences in environmental conditions between the Mediterranean and desert zones were also bridged, especially in bordering regions. The most obvious case is that of Jericho, which according to the results of all analyses, displays a Mediterranean-style shell bead assemblage, rather than a desert one. Despite being situated in a desert environment, characterized by year-round hot and extremely dry climatic conditions caused by the rain shadow effect and a barren petrous desert landscape , 145, coThe statistical analyses used to examine the distribution patterns of shell bead types indicate that not all social circles and affiliations are based on geographic proximity and may be related to various systems and networks operating in the greater region. As fractions of the population were continuously moving across the landscape, even after the wide-scale adoption of sedentary life, and regularly interacting on different levels , 59, 65,For example, different systems of resource exploitation may drive interactions between geographically distinct groups. The cyclical movement between environmental zones driven by the seasonal availability of resources , may genObsidian exchange networks, active in the region from as early as the Epipalaeolithic Natufian period , facilitFurthermore, marriage arrangements and genealogical ties likely connected between remote communities. Familial and biological relationships among individuals buried at KHH were investigated based on indicative tooth morphologies , showingAs mentioned above, some of the shell bead types that appear in many of the PPNB sites in the Levant are widely shared among communities on a large scale and represent the pan-Levantine cultural interaction sphere. Cowries with a removed dorsum (2CDR)  are one In situ finds at Tell Halula, where such cowrie beads were found still arranged in rows or chains, placed around pelvises and heads of interred individuals [This shell bead type may be used and strung in different ways. Use-indentations on the extremities of the dorsum removal-line are indications of stringing or sewing through either one or both ends of the aperture and are repeatedly found on specimens from KHH, Yiftahel , Aswad : fig. 9,Additional bead types were made on cowrie shells, yet these appear in fewer sites. For example, a different cowrie bead type was made of only the inner lip of a cowrie with a removed dorsum, featuring a circular groove at each end, creating knobs presumably designed to facilitate suspension by tying (2CDRLK2). Of all the sites in our sample, this bead type was only found at Tell Halula : fig. 2jSemicassis shells, used to create concave crescent pendants [This technological and stylistic idea is further found on ’cassid-lips’. ’Cassid-lips’ are the naturally detached outer lips of pendants . ’CassidA different variant of cowrie beads has a complete dorsum and a ground hole in the centre of the ventral face of the inner lip (2DCLG) . Such beThis outlined web of connections between communities , reflectAdditional connections between communities in the Galilee and the Judean desert are also found in other aspects of shell use, for example, in relation to plastered skulls. Skull removal practices are known from as early as the Epipaleolithic Natufian period in the region, and during the PPNB are found across the Levant and beyond : Fig 1. People associate themselves to multiple social and cultural circles, creating affiliations that constitute fundamental aspects of personal and social identity. The use of personal adornment plays a part in both the embodiment and the construction of these aspects of identity, as well as in their external demonstration and communication.In order to effectively communicate the desired messages, items of personal adornment must create a specific, deliberate, and recognizable visual effect. The shape, appearance, mode of manipulation, manner of use, posture, and more, of every item of personal adornment used, has crucial roles in the creation of the desired look , 25, 116The study of different aspects of social identity and social connections through the use of items of personal adornment must thus include a clear definition of types and systematic recording of the distribution of such items. The combination of detailed descriptions of individual micro-relations, along with the use of advanced statistical tools such as multivariate analysis that provide a broad macro-overview, enables a holistic perspective on the subject.In this analysis we examined shell beads, as representative items of personal adornment, from PPNB sites across the Levant. The PPNB period in the Levant is a time of fundamental shifts in human lifeways, revolving around heightened sedentism and the adoption of agricultural practices, yet involving multifaceted reconfigurations in all aspects of life. Social connections, alliances, and networks were essential factors in these evolving adaptations, shaping the emerging Neolithic identities. Here we considered the various shell bead appearances as a basis for the definition of shell bead types and examined the distribution of these types across the Levant. We referred to the shared use of different shell bead types among communities from various sites as indications of shared cultural markers and thus reflections of mutual affiliation and the existence of social connections. Through the examination of different shell bead type distribution patterns, we suggest that Neolithic communities maintained different levels of connections with other communities, creating widening social networks. Some relationships were based on geographic proximity, creating local adornment styles. Our results, from across the Levant, reaffirm previous suggestions for the existence of cultural territories , or ‘triShell beads found at the cultic-mortuary aggregation site of KHH reveal multiple connections between the communities using the site and other communities in the Levant. As seen in the multivariate analyses, they are first and foremost linked to the general Mediterranean “style”, and particularly to the central and southern areas of the Mediterranean environmental zone. However, shared innovations in stringing-mode design (‘knobs’) and particular manners of shell bead position while stringing (location of use-indentations), reflect connections to communities living far to the north of the Galilee. At the same time, shared unique bead types (specific cowrie and cassid-lip variants) and other shell related practices (the use of shells in the eyes of plastered skulls) indicate particularly close relations between some communities in the Galilee and those in the northern Judean desert, specifically at Jericho. It is thus apparent that local, regional, and pan-regional social networks were at play in the lives and identities of the Neolithic inhabitants of the Levant.To conclude, within the huge cultural and social ’supra-group’ constituting the ’PPNB interaction sphere’, people presumably affiliated themselves with multiple narrower social circles, each contributing to the constitution of the individual’s social identity and feelings of social assimilation and differentiation . These aS1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


Copper is a metal historically used to prevent infections. One of the most relevant challenges in modern society are infectious disease outbreaks, where copper-based technologies can play a significant role. Currently, copper nanoparticles and surfaces are the most common antimicrobial copper-based technologies. Despite the widespread use of copper on nanoparticles and surfaces, the toxicity mechanism(s) explaining their unique antimicrobial properties are not entirely known. In general, toxicity effects described in bacteria and fungi involve the rupture of membranes, accumulation of ions inside the cell, protein inactivation, and DNA damage. A few studies have associated Cu-toxicity with ROS production and genetic material degradation in viruses. Therefore, understanding the mechanisms of the toxicity of copper nanoparticles and surfaces will contribute to developing and implementing efficient antimicrobial technologies to combat old and new infectious agents that can lead to disease outbreaks such as COVID-19. This review summarizes the current knowledge regarding the microbial toxicity of copper nanoparticles and surfaces and the gaps in this knowledge. In addition, we discuss potential applications derived from discovering new elements of copper toxicity, such as using different molecules or modifications to potentiate toxicity or antimicrobial specificity. Copper is a heavy metal with three oxidation states: metallic copper, cuprous ion, and cupric ion; the last two being stable . This elEscherichia coli-mediated mastitis . Th. Th2O, CCu2O NPs  [87,88,80 nanoparticles. ROS production mediated by the Cu ions released from the nanostructure is the main cause of the cellular effects of CuS NPs , microorganisms cannot grow on the surface and the inactivation time is short: minutes to hours in the case of “wet” conditions and minutes in “dry” conditions. Finally, the key steps that influence contact killing in microorganisms are the dissolution of copper on surfaces, the bacteria–metal contact, the surface structure, and the nobility of the metal alloys ,122,123.Considering the current knowledge regarding copper surface toxicity and their increasing applications that impact millions of humans daily in public environments, it is necessary to understand the effect of copper surfaces on microbial communities, to determine the microorganisms most capable of surviving on them, and to elucidate if these surfaces generate a selection pressure favoring microorganisms of health interest. Santo et al. (2010) isolated microorganisms present in European copper-composite currencies . The autViruses are highly susceptible to copper-mediated toxicity because viruses lack a metal response or repair mechanisms such as those that exist in microorganisms ,58. Tabl2O, Cu0, CuS, and CuI—against viruses have been reported to date. Many articles evaluating the effect of different Cu-NPs—CuO, Cu2O) over coated and uncoated viruses. Tavakoli and Hashemzadeh (2020) described that the mechanisms associated with the antiviral activity of CuO nanoparticles against Herpes Simplex Virus (HSV-1) involve the interaction with the virus surface  determined that the antiviral mechanism of copper(i) iodide (CuI) particles against influenza H5N1 virus involves the generation of hydroxyl radicals. This radical could degrade functional viral proteins, such as hemagglutinin (HA) and neuraminidase (NA). Furthermore, the oxidation of lipids from the virus coating was also reported .In general, the toxicity mechanisms of copper-based NPs on viruses have been associated with damage to the viral genome, inhibition of replication, protein synthesis, and the assembly and release of virions ,128,129.In viruses, the toxicity mechanism is not associated with metabolic processes. In this regard, surface mechanisms could be associated with virus immobilization and genetic material inactivation. It has also been related to blocking or destroying the viral receptors for host cells . The antThe mechanism of virus inactivation on copper surfaces is shown in In the current COVID-19 pandemic caused by the SARS-CoV-2 virus, using copper surfaces and nanoparticles has become an alternative approach to prevent the spread of the virus. SARS-CoV-2 infection is spread by drops exhaled from the nose or mouth of people infected with the virus. These droplets can be in the air or reach commonly used surfaces . The usePreviously, Warnes et al. (2015) evaluated the effect of copper surfaces on the human coronaviruses causing severe acute respiratory syndrome (SARS) and the Middle East Respiratory Syndrome (MERS). The authors assessed the human coronavirus 229E on five joint-touch surfaces, including copper and copper alloy surfaces. Rapid inactivation of the coronavirus on copper surfaces depends on the composition of the surface. Inactivation was associated with copper ions released from the surface, ROS generation, and viral genome fragmentation . AboubakAs has been seen throughout this review, the use of copper surfaces and nanomaterials as antimicrobials has strongly increased during the last few decades. Since these metallic materials are potential tools for combating future microbial agents, it is crucial to thoroughly explore the pathways involved in their toxicity. The toxic effects of copper are mainly associated with the dissolution of ions from the surface or the destabilization of nanoparticles. These ions cause the rupture and depolarization of the plasma membrane, the production of ROS, the inhibition of essential metabolic enzymes, genotoxicity, and cell death. Considering the literature, there are still many unanswered questions associated with the copper toxicity mechanism, a situation that represents an enormous challenge for the scientific community.Regarding limitations, Bisht et al. (2022) suggest that one of the main problems limiting the development of new copper applications is that most trials are conducted using in vitro studies ; howeverIn addition, it is necessary to understand how the use of copper surfaces and NPs affects microbial communities. For example, the effect of masks or clothing with copper fibers or the effect of NPs on the skin microbiota should be determined. On the other hand, due to their use in hospitals, it is relevant to determine what changes are produced by copper surfaces among the abundance of pathogens associated with HAIs. This point is appropriate considering that this metal could generate selection pressure among the organisms present in the surface community. In turn, it will be necessary to find elements that could enhance the antimicrobial effects of copper to make it more effective and specific to defined microbial genera/species, especially in the future, when new antimicrobial agents will be required in the face of multidrug-resistant organisms.Another relevant point to consider is the effect of copper on human health and the environment. Copper NPs can be toxic in different organisms when used in inappropriate concentrations, causing inflammation in the pulmonary epithelium and accumulating in organs such as liver and kidney ,156,157.After analyzing the literature regarding Cu-based NPs, one limitation is observed that is related to the composition of the nanoparticles used in many studies. Fifty percent of the articles cited in In conclusion, despite the enormous advance of the last few decades in understanding the effect of Cu surfaces and NPs on microorganisms, many unanswered questions about their antimicrobial effect remain. A total understanding of this process is essential, particularly considering the wide use of copper as an antimicrobial in different applications and the urgent necessity for developing new alternatives to deal with multidrug-resistant microorganisms.


Compared to in vivo methods, in vitro simulated GI digestion models have some advantages, such as short in duration, less expensive, and less labor and resource intensive, and also not being burdened with the same ethical restrictions. They are widely employed to study the structural changes, digestibility, and release of food components in the GI tract.The worldwide increase in diet-related diseases has promoted research during the past few decades on the mechanisms of food digestion in the gastrointestinal (GI) tract. Food digestion is a complex process that consists of the oral, gastric, and intestinal phases, in which numerous mechanical, chemical, and enzymatic processes are involved. Several types of digestion models including the in vitro GI models, and to understand the health effects of their digests.Apart from environmental sustainability and animal welfare considerations, Plant-based foods with several nutritional and health benefits have drawn much interest recently. But their nutritional and health benefits will depend on several factors such as the degree of food processing, the quantity consumed, and one of the most important of these, the amount of nutrients or bioactive compounds finally released and absorbed during GI digestion. Therefore, the key objective of this Research Topic is to elucidate the digestibility and bioaccessibility of dietary ingredients in plant-based foods through application of Yang et al. investigated the effect of heat treatment on in vitro digestion of quinoa albumin. It is obvious that heat treatment decreased the degree of hydrolysis of quinoa albumin and total amino acid content during in vitro digestion. Furthermore, the in vitro digestion decreased gradually with the increase in treating temperature. Therefore, nonthermal processing technologies including ultrasonication, ultrahigh pressure, and pulsed electric field technologies have been widely used to improve functional, structural properties and digestibility of food protein . Compared with ME, the instant powder obtained with IE showed lower starch digestibility, lower starch digestion rate constants for the fast step (Kf), lower estimated glycemic index, higher resistant starch content, and higher α-glucosidase inhibitory activity, indicating that the Tartary buckwheat/adzuki bean instant powder produced by IE could serve as an ideal anti-diabetic food resource.Starch is a major energy source of the human diet, starch digestion is closely related to human health, especially in regulating blood sugar . To deveGuice et al. investigate the efficacy of a food-grade, microbial inulinase preparation with companion invertase activity on several dietary fructan-rich substrates in the static INFOGEST in vitro digestion simulation. The in vitro digestion data suggested that the use of microbial inulinase as an exogenous enzyme could reduce dietary fructan-type FODMAP exposure.Numerous epidemiological and interventional studies have demonstrated that dietary fibers have important associations with the development and management of various diseases, such as reduce risk of cardiovascular disease, diabetes, and some cancers . Howeverin vitro simulated GI digestion models were applied to characteristic the properties of digestibility, function and structures of protein, phenolic compounds, starch and dietary fiber from plants. To better simulate the real gastrointestinal digestion of the nutrients or bioactive compounds from plant-based foods, more work is needed to improve or develop in vitro GI models. Moreover, the health benefits of the digestive products of plant-based foods should be further studied in the future.To conclude, the present Research Topic provides several examples which All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.


Endothelial cells (ECs) form a simple squamous epithelium, the endothelium, which lines the lumen of all blood vessels and the heart. The endothelial layer, along with its underneath basal lamina, covered by a subendothelial connective tissue coating, forms the tunica intima, or interna, of all blood vessels. A thicker middle tunica media, mainly composed of varying amounts of elastic fibers and smooth muscle, and an outer tunica adventitia (or externa) of loose connective tissue account for the remaining covering structures of the vessel wall of the largest blood vessels  Figure A. In conIn addition to forming a semi-permeable barrier that regulates exchanges of solutes between blood and the surrounding tissues across the blood vessel wall, healthy vascular ECs are dynamic and multifunctional cells that have countless functions in multiorgan health and homeostasis. These include the maintenance of vascular homeostasis , the forIn cancer, the presence of a largely disorganized blood vessel network corroborates the importance of the vascular endothelium as a major therapeutic target to counteract tumor development and progression. In this regard, while anti-angiogenic therapy, which aims to block Vascular Endothelial Growth Factor (VEGF) signaling, has received considerable attention in the field of oncology, it has proved to be inefficient in the treatment of certain cancers. This condition, which mainly results from the establishment of tumor resistance to treatment, and the activation of adaptive compensatory mechanisms ,12,13 haCancers, dedicated to the “Role of Endothelial Cell Metabolism in Normal and Tumor Vasculature”, resulted in a total of six published articles, including one original research article and five review articles. In their research article, Tsai and collaborators investigated the role of bile acid signaling in pleural angiogenesis [Cancers will be of interest to both scientists and physicians.This Special Issue of ogenesis . This stogenesis  recapituogenesis  present ogenesis  discuss ogenesis . The autogenesis  and coll


Dietary Management in Children with Immune Related Diseases hosts scientific articles that enrich scientific knowledge about the role of nutrition in modulating and enhancing immune function to prevent chronic inflammatory diseases. The role of diet in the achievement and maintenance of a healthy status is well recognized, and in recent years, evidence has been presented of a link between a well-functioning immune system and good health overall. The immune system has a central role, not only in fighting infection, but also in regulating many acute and chronic disorders.This special issue of Frontiers in Nutrition entitled Mbugi et al. conducted a cross-sectional study in three African districts with the highest prevalence of malaria and potential micronutrient deficiencies, exploring the effect of micronutrients, and in particular zinc, on the profiles of IgG subclasses in Tanzanian children aged ≤5 years. The potential for production of antibodies is influenced by micronutrient status, and the profile of both cytophilic and non-cytophilic IgG subclasses was reported to be variably influenced by the zinc status, with IgG3 being critically affected across all the groups in the age range studied. The administration of precise amounts of zinc boosts the production of protective IgG subclasses, and should be considered in malaria interventional programs for children in endemic areas.This collection of four articles highlights the fundamental role of balanced nutrition in certain immune related conditions in childhood. In the first, Feketea et al. of four clinical cases proposes the term FPIPLE for a food-protein induced protein-losing enteropathy. FPIPLE is a mixed IgE and non-IgE food allergy in young infants, along with eosinophilic gastrointestinal diseases (EGID). The cases presented showed the same clinical pattern: poor weight gain, edema due to hypoproteinemia/hypoalbuminemia from enteral loss of proteins, anemia, eosinophilia, raised levels of fecal α1-antitrypsin and specific-IgE, and allergy skin prick test positive for offending foods, establishing a distinct clinical entity. Protein-losing enteropathy associated with gastrointestinal allergy has been described in adults, but data on clear diagnostic criteria in infancy have been limited  with the maternal diet during pregnancy and breastfeeding in Greek infants. FPIAP is a transient benign condition causing colitis in infants, often presenting in the first month of life. It is a non-IgE mediated immune response to one or more foods, with inflammation in the distal colon, eosinophilic infiltration of the rectal mucosa, and blood in the feces  in childhood. Malnutrition of a complex and multifactorial nature is documented to affect 10–50% of children undergoing HSCT, and although it significantly affects outcomes, it continues to be largely unrecognized. The review concludes that nutritional support could be a risk- and cost-effective way of improving allo-HSCT outcomes in children.In the fourth paper, Despite the large current body of literature related to dietary management in children with immune-related diseases, the papers in this special issue show that many areas remain unexplored regarding the correlation of dietary factors with immune status and health. Firstly, the effects of single nutrients on immune function are difficult to study, but well-designed intervention studies to investigate the effects of overall dietary patterns on the immune system represent real life conditions, and would be more feasible, and their results more reliable. Secondly, the prevalence of FPIPLE in primary care and pediatric allergy and gastroenterology practice is unknown, and better characterization of this mixed IgE and non-IgE mediated food allergy is needed. Thirdly, intervention studies during pregnancy and lactation might provide more robust evidence on the appropriate dietary interventions for mothers to prevent FPIAP in their infants. Finally, in-depth nutritional assessment is required, with evaluation of the appropriate dietary intervention to improve allo-HSCT outcomes in children.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.


Climate change is a critical issue that mandates every person's participation. Various devastating impacts secondary to global warming have been reported, affecting millions of people globally. Although the physical health impact of climate change is prominent, psychological effects have also been observed. A large-scale study in the US reported an increased likelihood of negatively impacting mental health, when the maximum temperature was elevated to certain levels, and women and low-income groups had a higher probability of being affected Moreover, an increased prominence of psychological effects can be observed during natural disasters, with global warming causing more frequent and more climate change-related events. The psychological impact is often evident due to more severe exposure during natural disasters. One of the significant events with a substantial impact on millions of people was Hurricane Katrina which hit many parts of the US in August 2005, resulting in the increased risk of mental illness by 4% in the exposed group In 2015, the urgency to address the climate emergency was apparent. One-hundred-and-ninety-six countries came together in a display of solidarity for climate action, signing a legally binding international treaty known as 'The Paris Agreement' Additionally, one of the outcomes of the negotiations was the promotion of the COP26 Health Programme. The primary focus of this initiative was health professional advocacy, the establishment of a climate-resilient and sustainable health system, and promoting health adaptation research through the Adaptation Research Alliance Mental health management should not be limited to healthcare management, but must be viewed from a broader perspective. The Mayor of Utrecht, Sharon Dijksma, emphasized the importance of city planning to transform the area into a more sustainable environment, resulting in more active lifestyles and better wellbeing. According to World Bank, 56.2% of the global population reside in urban areas, indicating the importance of catering to the health of wellbeing of urban populations In conclusion, mental health is equally important to physical health, and incorporating mental health elements is crucial in any plan related to net-zero. The governments, stakeholders, policymakers, professionals, and communities must work together to implement holistic action towards achieving net-zero goals.


The most performed percutaneous valve replacement procedure is for the aortic valve. In recent years, there have been developments in percutaneous valve replacement methods for other valves, including the pulmonary valve. Computed tomography plays a crucial role in various stages of procedure planning and provides essential information regarding potential complications after the procedure. We present images documenting step by step how to evaluate cardiac computed tomography in the qualification procedure for transcatheter pulmonary valve implantation in patients with dysfunctional native right ventricular outflow tract. In cases of pathological heart valve conditions, the standard treatment method is valve replacement. Valve replacement can be performed surgically or through a less invasive percutaneous approach. The most commonly performed percutaneous valve replacement procedure is for the aortic valve. In recent years, there have been developments in percutaneous valve replacement methods for other valves, including the pulmonary valve .The primary indication for transcatheter pulmonary valve implantation (TPVI) is to treat dysfunction of the right ventricular outflow tract (RVOT) in patients who have undergone surgery for congenital heart defects, with the goal of preventing irreversible damage to the right ventricle (RV). Initially, TPVI was an alternative to surgery and was primarily used in patients with dysfunctional conduits connecting the right ventricle to the pulmonary artery (RV-PA conduit). However, it is now also used in patients with dysfunctional native RVOT, which has expanded the pool of eligible cases ,3. CompuBefore TPVI, CT imaging helps in patient selection, identifying contraindications to the procedure, and choosing the appropriate device. CT images are used to assess the morphology of the RVOT and the anatomy of the main pulmonary artery (MPA) ,5.To reduce artifacts and optimize image quality, a three-phase administration of contrast medium is used. Three-phase contrast agent administration involves the administration of: contrast agent alone, a mixture of contrast agent and physiological saline, and physiological saline only. Optimization of the ionizing radiation dose in this type of examination is particularly important. The methods that reduce the dose of ionizing radiation include CT tube voltage reduction, ECG-monitored radiation modulation (tube current), iterative image reconstruction, deep learning-based image reconstruction and deep learning-based image denoising, reduction in the scan range (scan length), modulation of the current intensity depends on the attenuation of the radiation, heart rate control, multi-slice, and dual-source and wide-field tomography. Retrospective ECG-gated CT facilitates dynamic assessment of the RVOT and pulmonary valve in all phases of the cardiac cycle, as well as quantitative evaluation of heart chamber volumes .The first piece of information obtained from CT images is the shape of the RVOT, which can take five different forms. Type I  is pyramidal or aneurysmal , type IIDue to the high isotropic spatial resolution in all phases and planes of the heart, CT is the most suitable method for measuring the native RVOT. Images from double-oblique reconstructions of the RVOT and PA are used for this purpose. Implantation in the native RVOT is more challenging than in the RV-PA conduit due to its larger, variable, and dynamic geometry, as well as its unpredictable compliance. Therefore, a comprehensive assessment of the native RVOT is required to determine the appropriate valve bioprosthesis. Measurements of surface areas, circumferences, and diameters at six different levels from the RVOT to the PA bifurcation are needed ,6 Figur. DependiThese measurements can change by up to 50% during the cardiac cycle, so it is essential to perform measurements in the end-systolic phase when the RVOT and MPA are largest, atrioventricular valves are closed, and heart chamber volumes are smallest, as well as in the end-diastolic phase when the RVOT and MPA are smallest, and heart chamber volumes are largest ,6 Figur.Additionally, three measurements of distances between the RVOT, pulmonary valve, and MPA bifurcation are performed  Figure .Potential complication associated with TPVI is the compression of the coronary artery. The risk of coronary artery compression is assessed during the heart catheterization procedure by inflating a balloon in the RVOT. However, CT imaging before the procedure can also help estimate the risk of coronary artery compression. The assessment involves measuring the distance between the coronary arteries and the RVOT or conduit. A distance of less than 2 mm between the coronary arteries and the RVOT is considered to increase the risk of coronary artery compression after TPVI ,5,6 Fig.CT examination also provides an information about vascular access and potential non-cardiac contraindications to the procedure.