Background: Hearing impairments are associated with reduced walking performance under Dual-task (DT) conditions. Little is known about the neural representation of DT performance while walking in this target group compared to healthy controls or younger adults. Therefore, utilizing the Mobile Brain/Body Imaging approach (MoBI), we aim at gaining deeper insights into the brain dynamics underlying the interaction of cognitive and motor processes during different DT conditions  controlling for age and the potential performance decrements of older adults with hearing impairments.Methods: The cross-sectional study integrates a multifactorial mixed-measure design. Between-subject factors grouping the sample will be age (younger vs. older adults) and hearing impairment (mild vs. not hearing impaired). The within-subject factors will be the task complexity (single- vs. DT) and cognitive task modality . Stimuli of the cognitive task will vary according to the stimulus modality , presentation side (left vs. right), and presentation-response compatibility . Analyses of DT costs and underlying neuronal correlates focus either on gait or cognitive performance. Based on an a priori sample size calculation 96  community-dwelling older adults (50–70 years) and 48 younger adults (20–30 years) will be recruited. Gait parameters of speed and rhythm will be captured. EEG activity will be recorded using 64 active electrodes.Discussion: The study evaluates cognitive-motor interference (CMI) in groups of young and older adults as well as older adults with hearing impairment. The underlying processes of the interaction between motor and cognitive tasks will be identified at a behavioral and neurophysiological level comparing an auditory or a visual secondary task. We assume that performance differences are linked to different cognitive-motor processes, i.e., stimulus input, resource allocation, and movement execution. Moreover, for the different DT conditions  we assume performance decrements within the auditory condition, especially for older, hearing-impaired adults. Findings will provide evidence of general mechanisms of CMI  as well as task-specific effects in dual-task performance while over ground walking. Age-related decline in hearing is one of the most common chronic conditions in older adults, affecting nearly half of people over the age of 65 . In receLongitudinal studies have shown that hearing impairment is independently associated with poorer cognitive performance even when controlling for age and sex . SeveralAge-related changes in the auditory system can include both, higher pure-tone detection thresholds and supra-threshold auditory difficulties , requiriResearchers have attempted to explain the association between hearing impairment and mobility decline in terms of competition for limited shared cognitive resources . In everSince older adults often exhibit hearing impairments that severely affect their lives, investigating the interaction between age-related hearing impairment and decline in other domains  at the behavioral and neurophysiological levels could elucidate the underlying mechanisms. In addition, this research could lead to therapeutically promising insights by providing a better understanding of the risk of falls leading toward improved fall prevention programs.Daily dual-task situations entail different levels of cognitive complexity and therefore will require different cognitive abilities. According to Previous research on cognitive-motor interference (CMI) while dual-task walking showed that spatio-temporal gait parameters like walking speed, step length, and arm swing symmetry are affected by the secondary task . MoreoveThe following experiment will use walking tasks with different complexities and priorities, and record behavioral  as well as neurophysiological data.Mobile brain/body imaging MoBI; , 2014 coEvidence indicates several anatomical and functional brain alterations in hearing-impaired older adults. These changes occur not only in regions involved in auditory processing but also in regions involved in attention and emotional processing cf. . For theTwo studies by Campbell and Sharma examined auditory  and visuRegarding the current literature, existing studies with hearing impaired older adults only addressed one of the described aspects but not the comparison of the two most relevant domains for daily activities (vision and hearing) for this target group. Moreover, the neural correlates of existing studies with hearing impaired participants were only examined in a sitting condition. It remains unclear if these findings can be transferred to daily situations that reflect dual-tasking aspects during real life activities. Therefore, the multicomponent MoBI-approach will help to overcome the research gap and gain deeper insights into the neural underpinnings of the interaction of motor and cognitive tasks in different dual-task conditions . We will further systematically control for the impact of age and potential performance decrements of older adults with hearing impairments.The present study is designed to investigate the following three foci using a MoBI approach:Focus 1: General characteristics of dual-task walking of all participants.•How does cognitive task performance differ when using visual or auditory stimuli in single- and dual-task conditions?•How are dual-task costs represented in gait parameters?•How are neuronal correlates of auditory and visual information processing impacted by dual-task interference during walking?Focus 2: Age-related differences in dual-task walking.•Can we replicate the age-related increase in dual-task costs?•How are the age-related differences in performance reflected in the respective brain activity of younger and older adults?•How do younger and older adults differ in their gait parameters and gait-phase related stimuli processing?Focus 3: Differences of hearing-impaired and healthy older participants in dual-task walking.•How do auditory vs. visual information processing and movement control vary with regards to the effect of hearing impairment represented in both cognitive task stimuli modalities and dual-task vs. single-task performance?•How are dual-task costs reflected in biomechanical and neuropsychological measures of hearing-impaired participants?The overall hypothesis is that there are differences in dual-task costs and their corresponding neuronal correlates between the three groups with the highest disadvantages for the group of older adults with impaired hearing. We hypothesize that the performance differences are linked to the different cognitive-motor processes; i.e., information or stimulus input, resource allocation, and movement execution. Further, we hypothesize that the increasing task complexity , as well as the stimulus modality , will further diminish the walking performance and increase neuronal activity.This protocol paper was drafted according to the SPIRIT statement .age (younger vs. older adults) and hearing impairment (mild hearing-impaired vs. not hearing impaired). The design will be incomplete as the sample contains older adults with hearing impairments and healthy controls matched by age and gender as well as a younger age group. No data of young hearing-impaired adults will be recorded.This protocol will reflect a multifactorial mixed-measure design with the two two-level between-subject factors, task condition  and cognitive task modality . Stimuli of the cognitive task will vary according to the presentation side (left vs. right), modality-specific properties , and presentation-response compatibility . Analyses of dual-task costs and underlying neuronal correlates can focus either on gait parameters or cognitive task performance.The within-subject factors will be the The chosen colors and tone pitch levels are the conclusion of extensive piloting. In case further testing reveals that other properties are more appropriate for the experimental paradigm, we keep the option open to change the modality-specific properties.DRKS.de with registration number DRKS00024453 on April 14th, 2021.The study will be conducted in agreement with the principles of the Declaration of Helsinki and the guidelines of Good Clinical Practice. Written informed consent will be obtained from all participants before enrolment in the study. The local ethics committee of the TU Berlin, Germany, has approved the study protocol {BPN_WOL_1_210129}. The trial was registered at To assure eligibility and recruitment of participants, community-dwelling older adults will be recruited from a database of the TU Berlin  as well as public advertisement and collaborating audiologists in the surrounding areas of Berlin and Hamburg.Based on sample size calculation , a group of 96 community-dwelling older adults (50–70 years) and 48 younger adults (20–30 years) will be recruited. The older experimental group will be divided into the following 2 equally sized subgroups: (1) hearing impaired, (2) not hearing impaired. The participants’ allocation to the group will be done after prior assessment using a test battery in a first session. Data analyses will be done on anonymized data.All recorded data will be pseudonymized using a participants’ number. Only the individual participant code recreated by the participant will allow identifying the participants number of the respective data set in case data deletion is requested within thirty days after end of the data recording. No questionnaire or digital data file will include names or other personal information that would allow identification of data-participant-relations. Video recordings will be stored only after pixelating the face . Raw data of video will be already deleted permanently on the day of the recording as soon as the pixelating is done.The group assignment will be based on the severity of hearing impairment using 4-frequency  pure-tone average (PTA 0.5–4 kHz) and defining PTA 0.5–4 kHz ≤ 25 dB HL as normal and PTA 2–4 kHz = 26–40 dB HL as mild in the better hearing ear. Participants will be asked to do the hearing acuity testing with and without their hearing aid to record if their hearing ability was corrected to normal which has effects on the sensory stimulation of the brain.Inclusion criteria for the healthy young participants will be (1) no diagnosis of hearing impairment (PTA 0.5–4 kHz ≤ 25 dB HL), (2) age range between 20 and 30 years, (3) no color blindness.Inclusion criteria for the non-hearing-impaired older participants will be: (1) no diagnosis of hearing impairment (PTA 0.5–4 kHz ≤ 25 dB HL), (2) score > 7 for the Short Physical Performance Battery (SPPB), (3) living independently in the community, (4) maximally moderate risk of falls , (5) age range between 50 and 70 years, (6) no color blindness.Inclusion criteria for the hearing-impaired older participants will be: (1) diagnosis of mild hearing impairment (PTA 2–4 kHz = 26–41 dB HL), (2) score > 7 for the SPPB, (3) living independently in the community, (4) maximally moderate risk of falls , (5) age range between 50 and 70 years, (6) no color blindness. The severity of hearing impairment will be based on the pure tone audiometry results .Exclusion criteria will be (1) severe hearing impairment (PTA 0.5–4 kHz ≥ 41 dB), (2) any acute or chronic diseases, especially of the peripheral and central nervous system, (3) recurrent falls, (4) impaired vision that is not corrected with e.g., glasses, (5) SPPB score ≤ 7, (6) indication for impaired cognition (MoCA), (7) risk of falls > 13% .The assessment will focus on behavioral, gait-related as well as neurophysiological markers to gain a deeper understanding of the CMI during dual-task walking. Standardized questionnaires and assessments, as described in the section “Secondary Outcomes,” will be used to collect general health information and used to control for covarying factors.The primary outcome of the present study will be the dual-task cost occurring in over-ground walking with a cognitive secondary task. Gait parameters will be recorded for single and dual task walking, EEG measures will be conducted throughout the entire experiment .Participants will receive an auditory or visual discrimination task which fits all criteria for the analyses of gait parameters and event-related as well as continuous brain activity. Task performance will be analyzed using response accuracy and response time.p < 0.001; Gait parameters like walking speed, step length, double support time, etc., will be captured by the OptoGait system . The OptoGait utilizes photoelectric bridges between LEDs and photodiodes to record ground contacts. Therefore, two parallel positioned rows of bars frame the area of measurement. The temporal resolution of the OptoGait is 1 kHz, with a spatial resolution of 1.041 cm. The OptoGait has already been cross-validated against a three-dimensional motion capture system . Both measures will be analyzed for regular and natural patterns using the amplitude and variability of the respective measure.EEG activity will be recorded using 64 active electrodes on an elastic cap  with electrode positions of the 10% system  and one Event-related measures of interest will be event-related potentials  as well as event-related spectral perturbations  and beta (18–30 Hz) rhythms during walking). Further analyzed ERPs will be response-related slow cortical potentials , and eye-movement as well as gait-phase related analysis. EEG data will be analyzed in the time and frequency domain. In addition, functional connectivity measures will be investigated.Secondary outcome measures will be recorded in order to ensure the eligibility criteria and to control for the influence of various covarying factors.Demographic data such as age, body height and body mass, sex, and socio-educational status will be collected, as well as data on the current state of health on the respective assessment day. As a possible contributing factor to the impact of the response side , participants will be asked for their handedness in ten everyday life situations.The Short Falls-Efficacy-Scale-International (SFES-I) is a 7-item questionnaire addressing fear of falling during easy and complex physical activities as well as social activities . A validThe QuickScreen Clinical Falls Risk Assessment is a multifactorial assessment tool adapted to clinical settings. Measurement properties have already been confirmed in cohorts of community-dwelling older adults. The QuickScreen shows low measurement error, good reliability, and high sensitivity for physical status changes . The insThe Montreal Cognitive Assessment is a one-page 30-items test developed for screening Mild Cognitive Impairment. It involves items to assess a range of cognitive domains, including executive functions, visuospatial abilities, language, attention, working memory, abstraction, and orientation to time and place. The internal consistency of the MoCA is good The cross-sectional study will consist of 2 days of measurement for each participant. After recruitment and signing informed consent, participants’ characteristics will be gathered via a standardized assessment (Prescreening) on day one lasting approximately 1.5 h. Questionnaires will be utilized to capture demographic characteristics, health assessment, fear of falls, fall risk, and cognitive capacity. The physical function will be rated by leg strength, gait- and balance testing. Pure tone audiometry and familiarization with the measurement setup of day two will complete the first day of measurement. The utilized instruments are listed in chronicle order of application below:a)Demographic and general questionnaire regarding participants’ current stateb)Handedness Questionnairec)Short Falls Efficacy-Scale-International (SFES-I)d)QuickScreen Clinical Falls Assessment Toole)Montreal Cognitive Assessment (MoCA)f)Short Physical Performance Battery (SPPB)g)Pure Tone Audiometryh)Familiarization with the experimental setupAt the end of day one, participants fulfilling the requirements for inclusion in the study will be invited to return on another day for the second set of measurements. The measurements on day two will mainly comprise EEG measurements while sitting and walking under single- and dual-task conditions. The order of measurement conditions will be pseudo-randomized on day two, always starting with a walking condition and then constantly switching between walking and sitting conditions. Dependent on the task instructions, one of the combinations will represent motor-response ipsilateral  or contra-lateral  to the presentation side . Followia)General questionnaire regarding participants’ current stateb)Baseline EEG and Gait Performance without response devicec)Single-Task-Walking with a response deviced)Cognitive tasks while sitting (Single-Task-Conditions)e)Cognitive tasks while walking Measurement day 2 will take approximately 2.5–3.5 h per participant and will string together conditions of sitting and walking. Breaks will be at least 2 min between the conditions and may be extended as required. At the end of the measurement of day 2, the participants will be asked about their dual-task strategy.To collect EEG baseline data and to familiarize participants with the setting, participants will first sit quietly for 3 min and then walk at their preferred walking speed within a 10-m gangway of the OptoGait  system without the response device (3 min). Following the baseline measurements, a 2 min break will take place.Single-task walking will take place as one of five conditions in pseudo-randomized order. Participants will walk constantly 520 m (400 m within the OptoGait), but with the response devices in their hands. Participants will be able to choose their preferred walking speed and turn around by walking around a cone placed at least 1 m from the ends of the OptoGait gangway. From the single-task walking, we will also extract the distance walked within the first 6 min as a slightly modified measure of the 6-min walk test .Participants will be asked to perform cognitive tasks (stimulus-discrimination). During these tasks, participants will be wearing the EEG-system, a custom-made spectacle frame with two LEDs attached to present light stimuli in the peripheral visual field. In addition, participants will wear headphones for presenting auditory stimuli. While sitting in the middle of the OptoGait and performing the task, participants will be asked to look in a walking direction. 200 stimuli  will be presented with a varying inter-stimulus interval (400–800 ms) and a duration of 100 ms. Participants will be asked to react within a time window of 900 ms to the stimuli by pressing a button on the Vive controller in the respective hand. Thus, the maximal trial duration will vary between 1.4–1.8 s. The participant’s response will initiate the next trial and in case no response is given within the required time window, the next trial will start after 900 ms.Visual task: Visual light stimuli, magenta (red and blue LED) and/or cyan (green and blue LED) flashes, will be presented counterbalanced and pseudo-randomized on the left or right side of the spectacle frame. Participants will have to which color (magenta or cyan) was presented (color discrimination task) with a right/left hand button press.Auditory task: Auditory stimuli (high and low tone of 1000 and 500 Hz) will be presented for the duration of 100 ms either binaurally or to the left or right side with a volume of 50–60 dB  and 200 presented stimuli.Both, single-task (ST) and dual-task (DT) will be investigated in separate conditions in the experiment. For this purpose, over ground walking will serve as the primary task, while secondary tasks comprise visual or auditory stimulus discrimination. The within-subject comparison between conditions will enable the investigation of dual-task costs vs. task-specific demands. Furthermore, a between-subject comparison will allow for comparing the performance of hearing-impaired older persons with healthy young and older adults. All groups will be treated identically to allow for a comparison of results of dual-task performance across groups.All data gathered by questionnaires will be digitalized for further processing. Functional testing will be controlled via Unity3D , which also assigns basic demographic data to the measurement data of each participant. All functional measurements will be streamed and synchronized using the LabStreamingLayer . Synchronized data streams will comprise gait analyses , EEG recording , kinematics , and secondary task performance .1 This pipeline comprises filtering, data cleaning (channel and line noise), independent component analysis computation and equivalent dipole modeling for activity sources. Gait data will be analyzed separately as well as events will be extracted which in turn will be used in joint analyses like gait-phase-related brain activity changes. Following processing of the event-related potentials or spectral measures will be done with respective processing pipelines like the unfold-toolbox , EEGLAB . After i-toolbox . Source-M) and standard deviation (SD). Normal distribution and homoscedasticity will be checked by the Shapiro-Wilk-Test and the Levene-Test, respectively. Dual-task costs will be analyzed using univariate analyses of variances (ANOVA) including the between-subject factors age (younger vs. older) and in case of older hearing ability (hearing impaired vs. non-hearing impaired) and the within-subject factors task complexity  and stimulus modality .Descriptive data will be presented as mean . Statistical analyses will be done by using SPSS  or R  or R .∗power sample size calculation  = 0.8; number of groups = 3) revealed a total of N = 36 for each group. Due to an expected drop-out rate of about 20 percent, we will integrate at least 44 participants for each group. We aim to recruit 48 participants per group for the Prescreening.A gThis study aims to gain more insights into CMI while walking of older adults with hearing impairments by using a MoBI-approach. The analysis will be conducted to investigate whether older adults with and without hearing impairments as well as younger adults differ in their cognitive-motor performance while DT walking. Moreover, underlying processes of the interaction between motor and cognitive tasks will be identified at a behavioral and neurophysiological level comparing people with hearing impairments with healthy younger and older adults and while walking with an auditory or a visual secondary task. The overall hypothesis is that there are performance differences and corresponding neuronal correlates between the subgroups with the highest disadvantages for the group of hearing-impaired older adults. We hypothesize that the performance differences are linked to the different cognitive-motor processes; i.e., stimulus input, resource allocation, and movement execution. Moreover, for the different DT conditions  we assume performance decrements within the auditory condition, especially for older, hearing-impaired adults.As multitask performance mimics everyday life , an undeStarting with the general characteristics of dual-task walking for all participants this study will compare the influence of visual or auditory secondary stimuli while walking. One might expect that with respect to age comparison the behavioral data might be different and that older adults show more changes in the observed gait parameters . Because the walking performance between younger and older adults already differs at ST walking , we expeRegarding the EEG, it is expected that during DT walking as compared to the single cognitive task, the early evoked P1 covaries in amplitude and latency with walking speed independent of age . In addiIn addition, older participants with hearing impairments are expected to show reduced amplitudes in auditory evoked potentials compared to older participants with normal hearing and younger controls. Previous studies suggest that visual-evoked P1, N1, and P2 amplitudes might be significantly increased in hearing-impaired participants accompanied by increased activation of temporal areas underlying auditory processing. This suggests visual cross-modal reorganization  as well as task-specific effects underlying changes in dual-task performance while over ground walking. We will use the newly acquired knowledge to tailor intervention programs on physical activity and falls prevention to the special needs of the target group of older adults with hearing impairments. Systematic assessment of individual dual-task performance compared to their healthy cohort, and gained insights into the neural-correlates of motor-control in different conditions will guide training interventions with the overall goal to reduce the number of falls within this target population.The study was approved by the Ethics Committee of the Department of Psychology and Ergonomics of the Technical University Berlin (registration number BPN_WOL_1_210129). Written informed consent will be obtained from all participants or their legal guardians before enrolment in the study according to the Declaration of Helsinki. Participation in the study is voluntary and there will be no inappropriate financial incentives. The consent form explicitly points to the voluntary character of participation as well as the option to terminate the experiment at any given time without consequences and without giving reasons. All participant information and data will be stored securely and identified by a coded ID number only to maintain participants’ confidentiality.BW conceived of the study. AW with help of OV, MŠ, and BW drafted the manuscript. AW, OV, MŠ, MP, MF, KG, JP, UM, and BW initiated the study design and AW and OV helped with implementation. BW, UM, and KG were grant holders. All authors contributed to refinement of the study protocol and approved the final manuscript.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.


Left bundle branch area pacing (LBBAP) is a novel form of conduction system pacing which can reverse left bundle branch block and deliver cardiac resynchronization therapy (CRT). The WiSE-CRT system delivers leadless endocardial pacing with symptomatic and left ventricular (LV) remodelling improvements following intervention. We report the technical feasibility of delivering leadless LBBAP using the WiSE-CRT system.In Case 1, a 57-year-old male with ischaemic cardiomyopathy and complete heart block underwent implantation of the WiSE-CRT system, using a retrograde transaortic approach, after failed conventional CRT. Temporary left bundle stimulation from the LV septum achieved superior electrical resynchronization and equivalent haemodynamic response compared to endocardial pacing at the lateral LV wall. In Case 2, an 82-year-old gentleman with tachyarrhythmia-induced cardiomyopathy underwent WiSE-CRT implantation via a trans-septal inter-atrial approach, with the endocardial electrode successfully deployed in the LV septum.Here we report the first case of deployment of the WiSE-CRT endocardial electrode in the LV septum and demonstrate the technical feasibility of leadless LBBAP. Entirely leadless CRT is an attractive option for patients with venous access issues or recurrent lead complications and has previously been successful using the WiSE-CRT system and a leadless pacemaker in the right ventricle. Further studies are required to assess long-term efficacy and safety of leadless LBBAP. Learning pointsLeft bundle branch area pacing (LBBAP) from the left ventricular (LV) aspect of the septum achieves excellent electrical resynchronization and haemodynamic response.Deployment of the WiSE-CRT endocardial electrode in the LV septum is feasible.This demonstrates the technical feasibility of leadless LBBAP using the WiSE-CRT system.,Figure  1. After pre-procedural acoustic screening to identify an appropriate intercostal space, patients undergo implantation of the transmitter over the intercostal muscle and implantation of the generator placed in the adjacent mid-axillary line. The endocardial electrode is implanted either on the same sitting or as a separate procedure in a two-stage technique. Implantation can be performed via a retrograde aortic approach using femoral arterial access or via an inter-atrial trans-septal approach using femoral venous access. The system requires the presence of a co-implant capable of delivering continuous right ventricular (RV) pacing. After identification of the RV pacing signal, the transmitter delivers a focused beam of ultrasound energy to the endocardial electrode, which converts this into electrical energy to capture to the LV myocardium and achieve biventricular pacing. We describe two cases of patients undergoing leadless LV endocardial pacing following failed conventional CRT. In the first case, temporary stimulation of the LV septum achieved optimal electrical and haemodynamic indices. In the second case, the endocardial electrode was successfully deployed in the LV septum. These cases demonstrate the feasibility of conduction system pacing by leadless stimulation of the left bundle branch.Left bundle branch area pacing (LBBAP) has been proposed as an alternative to His bundle pacing (HBP), and has been shown to reverse left bundle branch block (LBBB) and deliver cardiac resynchronization therapy (CRT) in observational studies.A 57-year-old male with ischaemic cardiomyopathy, prior anterior myocardial infarction, and a dual-chamber pacemaker for complete heart block underwent upgrade to a CRT-defibrillator. He had New York Heart Association (NYHA) Class III symptoms and severe LV systolic impairment (ejection fraction 32%) despite optimal medical therapy. Physical examination findings were in keeping with chronic heart failure. The upgrade procedure was difficult due to small calibre coronary sinus (CS) tributaries. The LV lead was placed in a lateral branch of the CS, however, during routine follow-up the lead threshold increased with eventual loss of capture. Further transvenous attempts were unlikely to be successful given the difficulty of the original procedure and so the patient underwent leadless endocardial pacing using the WiSE-CRT system.max) was performed with a pressure wire in the LV cavity using a previously described protocol.max measurements were recorded using CoroFlow  and AHR was expressed as percentage improvement from baseline dual-chamber RV pacing to biventricular pacing at different LV endocardial sites. Left bundle branch area pacing was achieved by pacing the LV aspect of the interventricular septum  at the site of a left bundle potential . The greatest AHR was seen when pacing the left bundle (34% increase from baseline) and was equivalent to endocardial stimulation at the mid-lateral wall (34%) as shown in Table 1. However, LBBAP showed greater electrical resynchronization (QRS duration 106 ms) compared to pacing at the mid-lateral LV wall (QRS 132 ms) and baseline RV pacing (172 ms) as shown in Figure  3. The endocardial electrode was deployed in the mid-lateral wall of the LV as the current WiSE-CRT system is not designed to target the septum when a retrograde aortic approach is used .The WiSE-CRT system was implanted using a previously described technique with a retrograde transaortic approach.Figure  4A). Four years later the patient was re-admitted with syncope associated with RV lead dysfunction and a high LV lead threshold with intermittent loss of capture. The left subclavian vein was occluded, and so a new RV lead was implanted via the right subclavian vein. It was not possible to transfer the previously tunnelled LV lead to the right side, and so the existing LV lead was extracted. Re-implantation of a new LV lead failed due to thrombosis of the posterolateral branch of the CS. Without biventricular pacing, the patient deteriorated with worsening LV systolic function (ejection fraction 30%) and heart failure symptoms (NYHA Class III) despite optimal medical therapy. Physical examination findings were in keeping with chronic heart failure. The patient subsequently underwent implantation of the WiSE-CRT system, which was performed via a trans-septal inter-atrial approach using the FlexCath Advance Steerable Sheath . Sensing and pacing threshold measurements in the LV lateral wall were not acceptable and so the endocardial electrode was implanted in the LV septum  with significantly improved electrical resynchronization on electrocardiogram . A stable LV capture threshold (1.5 V at 0.5 ms) and high biventricular pacing percentage (98%) were reported on the pre-discharge device check. At 6-month follow-up, device function was satisfactory and the patient reported significant symptomatic improvement (NYHA Class II).An 82-year-old gentleman with tachyarrhythmia-induced cardiomyopathy required upgrade to a CRT-pacemaker prior to undergoing an atrioventricular node ablation for poorly controlled atrial fibrillation. He had an existing dual-chamber pacemaker which was implanted 4 years previously for sinus node disease, with leads placed via a persistent left-sided superior vena cava (SVC). LV lead placement in the CS was difficult due to the left-sided SVC, and was ultimately implanted via right subclavian access and tunnelled across to the left-sided generator  and endocardial CRT deliver two non-physiological wavefronts which merge to resynchronize the myocardium. Conduction system pacing can recruit the intrinsic His–Purkinje system and reverse LBBB. His bundle pacing is feasible in delivering CRT in heart failure patients, with electrical resynchronization and AHR superior to conventional CRT.In Case 1, temporary LBBAP was associated with excellent electrical resynchronization (QRS duration 106 ms) and haemodynamic indices (AHR 34%). However, the endocardial electrode was ultimately deployed in the LV lateral wall as the current WiSE-CRT delivery system is not designed to target the septum when a retrograde transaortic approach is used, and rotation of the delivery catheter to reach the septum is technically challenging. In Case 2, a trans-septal inter-atrial approach to the LV was used, which allowed successful deployment of the endocardial electrode in the septum. This is the first reported case of LBBAP delivered via the WiSE-CRT system and, to the best of our knowledge, this is the first reported case of permanent LBBAP from the LV aspect of the interventricular septum. Left ventricular septal mapping was not performed to identify the specific location of a left bundle branch potential in Case 2, and therefore selective stimulation of the left bundle branch cannot be guaranteed, however, the marked reduction in QRS duration (from 207 ms during RV pacing to 142 ms during biventricular pacing) suggests that at least non-selective stimulation of the left bundle branch was achieved. Comparison of the QRS morphology during LBBAP via the WiSE-CRT system with that of previously reported lead-based LBBAPEntirely leadless CRT systems are an attractive option in patients with vascular access issues, such as haemodialysis patients, and in those with recurrent lead complications. While the majority of WiSE-CRT systems are implanted in patients with standard right-sided pacing systems, there have been reports of entirely leadless systems using the WiSE-CRT system in conjunction with a leadless pacemaker in the RV.In conclusion, in the first case, electrical resynchronization appeared superior during temporary LBBAP, compared to endocardial pacing in the lateral LV wall, with similar haemodynamic responses. In the second case, the endocardial electrode was successfully deployed in the LV septum and is the first reported case of LBBAP via the WiSE-CRT system. Together, these cases demonstrate the feasibility of leadless LBBAP. Further studies are required to assess long-term safety and performance.Mark Elliott is a cardiology trainee in the North East Thames deanery and a PhD research fellow working in the school of Biomedical Engineering and Imaging Sciences at King’s College London. His research interests include cardiac resynchronization therapy, endocardial left ventricular pacing, conduction system pacing and electrocardiographic imaging.European Heart Journal - Case Reports online.ytab379_Supplementary_DataClick here for additional data file.


Animal studies and preclinical studies in cancer patients suggest that the induction of immunogenic cell death (ICD) by neoadjuvant chemotherapy with doxorubicin and cyclophosphamide (NAC-AC) recovers the functional performance of the immune system. This could favor immunotherapy schemes such as the administration of antigen-free autologous dendritic cells (DCs) in combination with NAC-AC to profit as cryptic vaccine immunogenicity of treated tumors.To explore the safety and immunogenicity of autologous antigen-free DCs administered to breast cancer patients (BCPs) in combination with NAC-AC.in vitro. This study was registered at clinicaltrials.gov (NCT03450044).A phase I/II cohort clinical trial was performed with 20 BCPs treated with NAC-AC [nine who received DCs and 11 who did not (control group)]. The occurrence of adverse effects and the functional performance of lymphocytes from BCPs before and after four cycles of NAC-AC receiving DCs or not were assessed using flow cytometry and compared with that from healthy donors (HDs). Flow cytometry analysis using manual and automated algorithms led us to examine functional performance and frequency of different lymphocyte compartments in response to a stimulus in vitro stimulation, deficient phosphorylation of Zap70 and AKT proteins observed before chemotherapy in most patients’ CD4 T cells significantly recovered after NAC-AC only in patients who received DCs.No grade II or higher adverse effects were observed associated with the transfer of DCs to patients during NAC-AC. Interestingly, in response to the The transfer of autologous DCs in combination with NAC-AC in BCPs is a safe procedure. That, in BCPs, the administration of DCs in combination with NAC-AC favors the recovery of the functional capacity of T cells suggests that this combination may potentiate the adjuvant effect of ICD induced by NAC-AC on T cells and, hence, potentiate the immunogenicity of tumors as cryptic vaccines. The development of immunotherapy for patients with breast cancer has been limited by the low immunogenicity of tumor antigens; however, recent studies combining chemotherapy with anti-checkpoint antibodies such as programmed cell death protein 1 (PD-1) and cytotoxic T lymphocyte-associated protein 4 (CTLA-4)  and morein vivo to rescue the unresponsiveness of T cells seen in cancer patients prior to treatment. If this turns out to be the case, tumor antigens and danger signals elicited by tumors treated with NAC-AC could enhance the immunogenicity of the tumors; hence, administration of DC to patients in NAC-AC might promote cross-presentation to activated T cells of these antigens, making the patient’s tumor antigens—whose identification is laborious and its production under Good Manufacturing Practice (GMP) conditions very costly—dispensable for the developing DC-based therapeutic cancer vaccines.The results recently published by others and preclinical studies performed by our group have shown that the functional deficiency of T cells, dendritic cells (DCs), natural killer (NK) cells, and other immune cells observed in breast cancer patients (BCPs) with invasive ductal carcinoma before treatment is efficiently recovered after NAC-AC  –12. Howein vivo favors the induction of ICD and the release of danger signals and tumor antigens from tumor cells led us to hypothesize that the administration of autologous DCs to BCPs receiving NAC-AC will selectively rescue the functional performance of T cells in these patients. To prove this, autologous monocytes were administered in combination with the NAC-AC scheme to a group of BCPs with invasive ductal carcinoma.Monocyte-derived DCs pulsed with tumor antigens have been used as natural adjuvants and for the presentation of tumor antigens to T cells in multiple clinical studies, showing a broad spectrum of clinical responses . The posIn the present phase I/II clinical study, we evaluated the safety and immunogenicity of two types of monocyte-derived DC administered in combination with NAC-AC to patients with invasive ductal breast cancer. The results presented here confirm the safety of the use of these cells in patients with breast cancer under NAC-AC. Using a manual and unbiased analysis system to characterize lymphocyte subpopulations by flow cytometry and the evaluation of the T-cell receptor (TCR) repertoire in a vaccinated patient suggest that the combined use of DCs with NAC-AC increases the functionality of T lymphocytes to levels comparable to cells obtained from healthy donors (HDs).www.clinicaltrials.gov (NCT03450044). All patients signed an informed consent, and inclusion criteria were evaluated by the clinical committee. Patients were randomized to one of two groups: (i) patients who received only NAC [non-vaccinated (NV) group] or (ii) patients who received NAC in addition to autologous monocyte-derived DCs [vaccinated (VAC) group]  and ethics committee of the Universidad del Rosario–Méderi Clinic. This study was registered at ®) configured to enrich monocytes and peripheral blood stem cell (PBSC) set . The whole leukapheresis was washed several times to remove ACD-A anticoagulant, and PBMCs were enriched using density gradient centrifugation with Ficoll-Paque and freshly used for monocyte enrichment (see details below). The clinical characteristics of the patients involved in this study are summarized in Samples from HDs and BCPs of the NV group (NAC only) were collected and processed as previously described . BrieflyAll cell processes were done in a Good Laboratory Practice (GLP)-compliant laboratory at Fundación Salud de los Andes. Monocytes were enriched by plastic adherence of freshly isolated PBMCs for 2 h at 37°C; non-adherent cells were cryopreserved as described before for further use. Adherent cells were differentiated to immature DCs (iDCs) culturing in serum-free medium  by adding granulocyte–macrophage colony-stimulating factor (GM-CSF) and interleukin (IL)-4  for 36 h and matured using two different cocktails  of pro-inflammatory cytokines as previously described –16. The 7 cells per dose for a total of six doses. Between each session of A/C chemotherapy (scheduled every 21 days), we apply two doses of cells, one per week. The cells were injected intradermally near the tumor lesson in the affected breast. During each dose, patients were monitored in the hospital for adverse effects for 3–4 h; after that, a daily check was done to evaluate the appearance of adverse effects  for 48 h in a ratio 2:1 (cells:beads) in a high-density system . After i5 events in singlets region determined by FSC-A vs. FSC-H and SSC-H vs. SSC-W gates. Data files were exported in FCS version 3.0. Manual analysis was done with FlowJo v10 (BD). For automated analysis, live/single cells lymphocytes (determined by SSC-A vs. FSC-A) were exported to a new FCS file. Automated analysis was done following the strategy described in ex vivo and after in vitro stimulation.Data were acquired using FACS Aria II (BD) with a minimum of 107 PBMCs) simultaneously with cryopreserved cells from tumor (2 × 106 viable cells) and lymph node (107 viable cells) using DNeasy® Blood and tissue DNA extraction kit  following the manufacturer’s protocol. TCR-Vβ CDR3 regions were then sequenced by ImmunoSEQ technology .From one vaccinated patient we obtained a sample from remaining tumor tissue and a draining lymph node after NAC plus DCs, during surgery. Those samples were processed immediately for single-cell suspension and cryopreserved as previously described. DNA was extracted from PBMCs before (PRE) and after NAC plus DC (VAC) treatment  between control and stimulated T cells]. For the evaluation of protein phosphorylation, MFI values of p-ZAP70, p-AKT, and p-mTOR were normalized by fold increase between stimulated and control samples. Non-parametric tests were used to determine statistical differences between groups. Non-parametric Mann–Whitney test between populations was used. Analyses were done with Prism v9 software (GraphPad). For CITRUS analyses, data were processed in R software (v3.6.3) with CITRUS package (v0.08)  . The Mor2 saturation, ECG, and arterial pressure soon after the inoculation of the cells  compartments in BCPs before and after three doses of NAC-AC. We found that before treatment, T cells and DCs exhibited marked unresponsiveness to the r burden . Herein,in vitro stimulation  and the internalization of the TCR/CD3 complex (determined by the relative reduction in CD3 MFI) in cells obtained from the four groups of samples before and after To determine if CD3 molecules were internalized or degraded, we quantified the MFI of internalized CD3 by intracellular staining. We sought to assess the proportion of CD3 at the cell membrane (in vitro stimulation at similar levels of cells obtained from HDs and at a higher proportion compared to samples before chemotherapy (PRE)  similar to the response of HD T cells  or in combination with DCs (VAC) internalized the majority of TCR/CD3 complexes in cell surface after in vitro TCR stimulation. We found that before treatment in both CD4 and CD8 T cells (TCM and TEF cells), the proportion of p-ZAP70 among the four groups did not change significantly upon in vitro stimulation  and FlowSOM  the enrichment of populations 1 and 2 . That this distribution was observed neither in cells of patients who received only NAC-AC without DC (NV group) nor in the cells of the HD group is intriguing.For the inhibitory panel, the expression profile and the hierarchical relation of the eight cell clusters revealed by the FlowSOM analysis represented in the heat map shown in in vitro with a significant increase in HDs of population 2 (in vitro).The analyses with FlowSOM of cells stained with the panel designed to assess TCR signaling  observed in patients after NAC-AC when compared to HD was lost when the cells were stimulated in vitro. Finally, when the TCR activation panel was used (in vitro (but not ex vivo) exhibited the increased expansion of population 2 .We then sought differences in populations’ percentage between the four groups of individuals studied. Using the inhibitory panel .To assess if the immune response observed in the periphery of vaccinated patients could have a relationship with tumor-infiltrating lymphocytes (TILs), we determine the frequency and sequence of TCR-CDR3 region from PBMCs before and after vaccination  and compare them with the sequence of TCR-CDR3 detected in TILs from the remaining tumor and draining lymph node obtained during surgery from one vaccinated patient after NAC-AC in combination with DC transfer (VAC) using ImmunoSEQ service (Adaptive Biotechnologies)  lymphoid leukemia. However, in pathologies such as breast cancer and many other solid tumors, advances in immunotherapy are incipient. One immunotherapy scheme evaluated in BCPs has been the use of DCs in different combinations of antigens and routes , 23. TheAs this is the first clinical study in Colombia with DCs derived from monocytes, we evaluated the safety and immunogenicity of these cells in patients newly diagnosed with infiltrating ductal breast cancer who were treated with NAC for a minimum of three cycles. DCs were derived from autologous monocytes with two previously defined maturation cocktails , 30, 31.in vitro stimulation obtained from patients after vaccination with DCs express CD69 in cells that internalized the TCR/CD3 complex  and CD8+ T cells in TCM in patients after the treatment with NAC-AC; this is a known effect of doxorubicin therapy where the production of reactive oxygen species (ROS) activates the AMP-activated protein kinase (AMPK) pathway, and this activation leads to the inhibition of mTORC1 , which could favor the antitumor immune response.In conclusion, this clinical study confirms the safety of monocyte-derived autologous DC transfer in 2 days in combination with primary chemotherapy with doxorubicin and cyclophosphamide. DCs would take advantage of the induction of immunogenic cell death generated by this chemotherapy scheme to generate a greater response of T lymphocytes, where we observed that in the patients who received the combined therapy, the ability of the T cells to respond to an unintended stimulus caparral@unal.edu.co.The datasets presented in this article are not readily available because they are not genomic or sequence data. Requests to access the datasets should be directed to The studies involving human participants were reviewed and approved by Comité de Ética e Investigaciones de la Universidad del Rosario, Hospital Universitario Mayor de Méderi. The patients/participants provided their written informed consent to participate in this study.DB-E and CP-L: wrote the paper. DB-E and MO: executed the experiments. DB-E, MO, PO-M, and CP-L: analyzed the data. DB-E, CC, RS, and CP-L: patient monitoring and clinical assessment. All authors contributed to the article and approved the submitted version.This work has been supported by a joint grant between Fundación Salud de los Andes and the Universidad Nacional de Colombia, DIB, Vicedecanatura de Investigación Universidad Nacional Medical School (HERMES: 42207 and 41790) and MinCiencias/COLCIENCIAS (grant 110150227509 CT. 671-2013 and grant 6952080763382 CT. 840-2018).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.


From conception, the impact of molecular dynamics (MD) simulations has grown dramatically , even thDing et al. presented case studies on two IDPs by an iterative screening-after-sampling strategy. In their study accelerated molecular dynamics was used to enhance the sampling of highly diverse conformational ensembles of IDPs, with Small-angle X-ray scattering (SAXS) to guide the sampling iteratively and obtain ensembles in good agreement with experimental data. Such integrative modeling might be more broadly useful for modeling IDPs ensembles. In general, the conformational dynamics of IDPs are strongly affected by the binding to other molecular partners or by aggregation. There are three excellent studies in this Research Topic, focusing on the conformational dynamics and aggregation properties of two Alzheimer’s disease-related IDPs: the Aβ42 peptide and the tau protein  , elucidating the molecular mechanism of amyloid inhibition by HSA. Their results suggest that Aβ42 binds to multiple sites on HSA, which shifts the conformational propensity of the peptide towards a more disordered state altering its aggregation propensity altogether. The reward behind the quest to mechanistically characterize fibrillar nucleation in proteopathies is enormous as it would suggest effective strategies for therapeutic approaches to neurodegeneration. Ma et al. employed coarse-grained simulations to energetically define the fibril growth of the Aβ-peptide: discovering the binding site of new filaments to the protofibril and a downhill mechanism of filament addition. Together with the identification of an emerging mechanical property of the Aβ-peptide protofibril, their research adds valuable insights to our understanding of the nucleation of Aβ-peptide fibrils for the development of strategies to pharmaceutically tackle fibril growth. McCarty and co-workers performed non-equilibrium steered MD simulations to investigate the structural changes of the tau paired-helical filament (PHF) and straight filament (SF) under mechanical force. In particular, the authors identified weak spots of interchain interactions additionally providing the dissociation pathway of a single tau peptide from the protofibril, through metadynamics simulations , which show a more shallow and rugged energy landscape when compared to folded proteins . Ding et protein . In the g (REST)  has beenulations . In addiMahmood et al. introduced a simple cutoff scheme to improve the definition of native contacts in the structure-based protein model of MARTINI  models for biomolecules . MahmoodS) model , Stevensdynamics . Howevervia clustering and dimensionality reduction analyses. The humanly understandable thermodynamic and kinetic information can then be reconstructed based on Markov State Models (MSM)  . In the Do et al. employed all-atom MD simulations with the aid of an enhanced sampling method called Gaussian-accelerated molecular dynamics (GaMD)   to deterWang and Li developed and tested force field parameters for some noncanonical amino acids (NAAs). NAAs have been widely applied in protein engineering, virus vaccine development, and medical therapeutics due to their strong site specificity, without the need to introduce significant perturbations to a protein structure. Based on quantum mechanics (QM) calculations and experimental data as a benchmark, the authors determined force field parameters for phenylalanine and tyrosine derivatives showing that the newly identified parameters well describe protein-ligand interactions with NAAs as substrates. Finally, to aid structural modeling useful for MD simulations, Xian et al. developed a structure manipulation (StructureMan) tool that proved to be comprehensive and efficient when studying interactions in large biomolecular systems.As an essential element in MD simulations, the adopted force field is key to affect the precision of the simulation results. Overall, we believe that this Research Topic provides a well-rounded picture of the latest state-of-the-art developments useful to overcome historical limitations in modeling and sampling of large biomolecular systems and slow processes using classical molecular dynamics simulations.


To evaluate the performance of three measurement strategies to test compliance with occupational exposure limits of similarly exposed groups (SEGs): the old and new versions of EN689, and the BOHS-NVvA guidance on measuring compliance.n = 1383) measured within the member companies of IMA-Europe were used to compare compliance decisions between the three measurement strategies. A total of 210 SEGs of which 158 with repeated measurements were analysed. An R studio OHcomplianceStrategies package was created for the purpose.Respirable dust exposures concentrations  with lower percentages of compliance with the new EN689 standard (32–44% and 71%). The percentage of non-compliant SEGs was relatively similar between the old and new EN689 for the preliminary tests (1–12% versus 6–11%). However, the new EN689 declared almost twofold more SEGs non-compliant when applying the statistical test (29% versus 17%). The BOHS-NVvA individual test showed results in between the 26% non-compliant SEGs.This study showed differences in compliance decisions between the old and new EN689, with the new EN689 being considerably more stringent and resulting in more non-compliant SEGs. Performance of the recently updated European method to assess compliance with occupational exposure limits for exposures to airborne substances in the workplace (EN689) was tested for 1383 full-shift respirable dust measurements collected among 867 workers employed in 210 similar exposure groups (SEGs). It showed that based on the same exposure data the new EN-689 was considerably more stringent and resulted in more non-compliant SEGs than the 1995 version of EN689. The BOHS-NVvA individual test taking into account within- and between-worker variability in exposure concentrations showed non-compliance percentages in between the two versions of EN-689.The European standard EN689 was developed in 1995  and updaAnnals of Work Exposures and Health online).Compliance strategies  (OHcomplianceStrategies package (https://github.com/tonyderrico/OHcomplianceStrategies) was built and used to apply the strategies for testing compliance detailed in both versions of EN689 and BOHS/NVvA. We assumed an OEL for respirable dust of 1 mg m−3.R studio (version 1.3.959) The numbers and percentages of compliance, uncertain compliance, and non-compliance decisions for the European and BOHS-NVvA strategies are presented for all SEGs  and for The measurement results were similar for all 210 SEGs compared with the subgroup of 158 SEGs with repeated measurements.The EN689:1995 reported the highest percentage of groups in compliance with the OEL, which ranged from 52 to 49% in the preliminary tests and 83% in the statistical test of EN689:1995. The revised EN689 showed lower percentages of compliance . The largest difference of 20% was, as expected, seen for the first step in the preliminary test for a SEG based on only 1 (EN689:1995) compared to a SEG with 3 observations (EN689:2018). Increasing the number of observations in the preliminary phase resulted in lower percentages of uncertain compliance decisions in both standards .The statistical test of non-compliance (exceedance) resulted in almost twice as many non-compliant SEGs when using EN689:2018 compared with EN689:1995 (29% versus 17%).n = 26 (16%)] were removed led to a comparable percentage of non-compliant SEGs (26%).Following the BOHS/NVvA guidance, we had to determine individual compliance  for 67 (42%) of the SEGs with repeated measurements). Individual compliance within a SEG showed non-compliance to be in between the two EN689 versions at 27% of the SEGs. A sensitivity analysis in which groups with only one worker with repeats [95,70 value to base a compliance decision upon. Similar percentages but slightly lower percentages of non-compliance were reported with the individual compliance strategy propagated by the BOHS-NVvA guidance.Differences in compliance decisions between the old and new European standard, and BOHS/NVvA individual compliance test were investigated. Respirable dust measurements collected within SEGs from the IMA-Europe Dust Monitoring Programme were used as a basis for comparison of the results of the compliance testing. The old EN689 demonstrated to be less stringent in both the preliminary test and the statistical test when compared with the new standard. The new EN689 will encourage occupational hygienists to collect more measurements within a SEG (at least three) and will therefore improve the precision and accuracy of the risk assessment. Interestingly, in the old EN689, the number of compliant SEGs decreased with increasing number of samples in the preliminary test, suggesting doubtful decisions based on one sample only. Like for the preliminary test, the statistical test turned out to be more restrictive in the new EN689 with an almost twofold higher amount of non-compliant SEGs compared with the old EN689 clearly due to the introduction of UTLIndividual compliance testing does require repeated measurements within a SEG and explicitly takes into account temporal and individual variability in (average) exposure within a SEG (This study showed clear differences in compliance decisions between the old and new EN689. The largest differences were seen for the number of compliant SEGs in the preliminary tests and for non-compliance in the statistical test. Both clearly showed that the revised EN689 is considerably more stringent than the original EN689. It is clear that the limited number of measurements proposed in the original EN689 could easily result in more doubtful decisions during the preliminary tests. Incorporating the individual compliance test, that takes into account between-worker differences in exposure, into a next version of EN689 will result in even further improvement.wxab111_suppl_Supplementary_Table_S1Click here for additional data file.


Pulmonary drug delivery has recognized benefits for both local and systemic treatments. Dry powder inhalers (DPIs) are convenient, portable and environmentally friendly devices, becoming an optimal choice for patients. The tailoring of novel formulations for DPIs, namely in the form of porous particles, is stimulating in the pharmaceutical research area to improve delivery efficiency. Suitable powder technological approaches are being sought to design such formulations. Namely, aerogel powders are nanostructured porous particles with particularly attractive properties  for these purposes. In this review, the most recent development on powder technologies used for the processing of particulate porous carriers are described via updated examples and critically discussed. A special focus will be devoted to the most recent advances and uses of aerogel technology to obtain porous particles with advanced performance in pulmonary delivery. Aerogel powders are advantageous porous particles in dry powder inhalers for the pulmonary drug delivery in local and systemic treatments. The comPatients’ needs for inhaler products to favor medication adherence are summarized in the 6E’s principle: “Effective, Efficient, Engaging, Error-tolerant, Easy-to-teach, Easy-to-switch to” . MoreoveDPIs are inhaler devices gaining special interest and market share for pulmonary delivery as they are portable, environmentally-friendly and convenient to achieve a high degree of patient compliance . MoreoveLung deposition is a determinant factor to reach the desired therapeutic outcomes in pulmonary drug delivery . Mathemaa)  in the alveolar region  . The micr region . The tair region .The relationship between the aerodynamic size and the particle size, morphology, shape and density of inhaled particles can be expressed by the simplified Stokes law :b is the bulk density, and χ is the dynamic shape factor, defined as the deviation from the sphericity related to the shape, surface roughness and surface area of inhaled particles.where ρAccording to Eq. 1, particles with acceptable aerodynamic diameters and high geometric diameters could be achieved by reducing the bulk density or by enhancing the dynamic shape factor . The dyna = 1–5 μm) could create strong intermolecular forces causing the aggregation and reducing the flowability of the inhaled powder  and “freezing induced”  . SelecteSpray drying is a well-established technique in the pharmaceutical industry . BrieflyTM formulations and large porous particles (LPP) used in commercial drug products -in-water emulsions as liquid feed containing also calcium chloride and distearoylphosphatidylcholine (DSPC), a primary component of endogenous pulmonary surfactant (TM types can be used to incorporate APIs into the porous particles depending on the nature of the drug and the desired solid state (PulmoSphereμm range . PulmoSprfactant . The disid state :(1)TM: the continuous phase of the emulsion is responsible to dissolve API and then this emulsion is spray dried producing porous formulations containing amorphous drugs. Commercial product TOBI® PodhalerTM (tobramycin) is produced using solution-based PulmoSphereTM (Solution-based PulmoSphereSphereTM .(2)TM: API is added into the emulsion feed in form of fine particles. The obtained suspension is spray-dried producing the final product with the amorphous or crystalline drug covered by a porous surface (Suspension-based PulmoSphere surface .(3)TM: the liquid feed contains fluorinated medium to suspend micronized API and prepare particles as small porous carriers. Agglomeration of API and porous PulmoSphereTM carriers occurs when liquid feed is evaporated via spray drying (Carrier-based PulmoSpherey drying .TM (levodopa) LPP-powder received EMA and FDA commercialization authorizations functioning as quick response doubled with increasing rapidly the concentration of levodopa in plasma for the treatment of Parkinson (Large porous particles (LPP) are characterized by geometric sizes in the 5–30 μm range . Comparearkinson .2 (scCO2) is the most common fluid in SCF technology and an approved solvent by the FDA, due to its harmless and non-combustible nature. Moreover, it has a recycled source and is economic. The low viscosity, high diffusivity and null surface tension of scCO2 allow its easy penetration to porous matrices under mild conditions  are exploited in particle technology through anti-solvent strategies. Namely, the so-called precipitation of compressed CO2 antisolvent (PCA) and supercritical fluid anti-solvent process (SAS) techniques offer a great advantage for inhaled particles with desired size  are used in green powder technologies receiving attention for the formulation of DPIs as cost-effective, non-toxic approach able to modify the solid-state form of the dry powder . SCF tecnditions . The affred size .2. Then, ammonium bicarbonate porogen was removed by vacuum drying. High insulin encapsulation efficiency (97%) and the desired aerodynamic deposition (4.46 ± 0.06 μm) were reported in the obtained porous particles (in vivo hypoglycemic performance to that produced after subcutaneous injection.Insulin-loaded poly-L-lactide porous microspheres were prepared using PCA technique and ammonium bicarbonate as porogen . Brieflyarticles . Low infSpray freeze drying (SFD) is an advanced technology for the production of LPP in pulmonary drug delivery with high production yields and being especially suitable for thermally sensitive materials . Three sThe porous structure of the particles obtained by SFD not only can satisfy aerodynamic deposition demands, but also can improve the apparent solubility of the formulations . VoriconAerogels are ultra-light porous materials with a potential scarcely explored for biomedical applications so far . AerogelAerogels were firstly prepared in 1931 by Samuel Kistler who replaced liquid inside gels without causing the collapse of the structure . HoweverLoading of drugs into aerogels can be mainly achieved by four approaches that can determine the mechanisms of drug release . Drugs cRegarding the drug release from the aerogel carriers, it mainly depends on the hydration properties of both drugs and carriers (erosion and swelling), the intermolecular forces between drugs and carriers  and the mass transfer . Hydrati2 solutions into the pores of aerogels usually takes place in a non-crystalline form as reflected by XRD analysis of drug-loaded aerogels, which greatly enhances the dissolution rate and bioavailability of these ingredients , high porosity (97.7%) and nanometric pore sizes  combined with image analysis . FIB-SEMa = 2.4 μm)  and higher fine particle fraction (FPF) than some commercial formulations. The aerogels also sustained the release of salbutamol sulfate for 10 h. Finally, recent (unpublished) works confirmed that these salbutamol-loaded aerogels processed by inkjet printing resulted in formulations which are cytocompatible with human lung epithelial cell lines. Thus, alginate aerogels produced by thermal inkjet printing followed by supercritical drying proved to be suitable and safe carriers for pulmonary drug delivery.Alginate aerogel particles had suitable aerodynamic sizes (d 2.4 μm) . The in Aerogels are advanced materials with high potential for novel inhaled formulations . The comFrom a therapeutic impact perspective, the primary goal of innovative inhaled compounds using aerogels carriers is to tackle the current needs in local treatment of respiratory diseases. The large surface area of the aerogels allows enhancing the dissolution rate of poorly water-soluble drugs, which can be especially valuable for novel inhaled chemotherapy. Additionally, aerogels have a high porosity and vast surface area that also make them well-qualified candidates for inhaled systemic delivery or vaccination. Namely, inhaled vaccination is known as “one-off administration,” which requires high performance of aerodynamic deposition in the target site . ResearcFrom a technological point of view, bioaerogels present high porosity and can deliver drugs to the bronchi minimizing systemic exposure, besides the possibility of reducing the total drug dose with less frequency of inhaled administration in a controlled-release system. Since patients with respiratory diseases normally find difficulty to supply sufficient flow rate in using DPIs, aerogel-based novel inhaled formulations can have a better performance as they depend less on the respiratory flow rate of patients. The validation of mathematical models or the development of new ones to predict aerogel particle deposition in the lungs might be advantageous for the aerogel design. Moreover, a higher knowledge on the drug-aerogel interaction at the molecular level would also favor the prediction of drug loading capacities and drug release behavior in respiratory fluid medium. The chemical, physical and biopharmaceutical stability of aerogels under controlled storage conditions also needs to be evaluated as this will influence the feasibility of the formulation of the drug product as well as the packaging and shelf conditions required. The safety of aerogels regarding the cytocompatibility with lung cells and the absence of inflammatory responses should be evaluated for each specific drug-aerogel combination. Current aerogel formulations tested for pulmonary delivery correspond to bench-scale production. The evaluation of the possibility of the aerogel production at a large  scale and under GMP guideline practices is still required.2 with SCF technology also contributes in tailoring green inhalers that could contribute to reduce the greenhouse effect. In other words, “green inhalers” containing bioaerogels could make a joint effort creating a “zero-carbon” healthcare system fit for the 21st century.Finally, from an environmental point of view, bioaerogels also open the possibility to reduce the burden of sociosanitary costs by using available and renewable materials. The valorisation of COAll authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Adaptive MR-guided radiotherapy (MRgRT) is a new treatment paradigm and its role as a non-invasive treatment option for renal cell carcinoma is evolving. The early clinical experience to date shows that real-time plan adaptation based on the daily MRI anatomy can lead to improved target coverage and normal tissue sparing. Continued technological innovations will further mitigate the challenges of organ motion and enable more advanced treatment adaptation, and potentially lead to enhanced oncologic outcomes and preservation of renal function. Future applications look promising to make a positive clinical impact and further the personalization of radiotherapy in the management of renal cell carcinoma. Renal cell carcinoma (RCC) is the seventh most common malignancy in the world, where an estimated 400 000 people are diagnosed per year . North ASurgical resection remains the gold standard of care in patients with localized RCC. Oftentimes surgery is not possible in an elderly population with other competing medical comorbidities, such as chronic kidney disease (CKD), and carries significant risks of morbidity and/or mortality . As a reA closer look at the existing pooled analyses suggests there may be further gains to be made. Limitations of these analyses include the absence of pre- and post-treatment comorbidity assessment, retrospective data collection with possible under-reporting of toxicity, and short follow-up. Single fraction SBRT was associated with better progression-free and cancer-specific survival and distant control compared to multi-fraction SBRT, however, patients experienced more nausea. Patients who received a single fraction had better baseline renal function, but demonstrated a trend toward a greater decline compared to patients receiving multiple fractions . A furthRCC is traditionally perceived to be radioresistant to conventionally fractionated radiation; however, studies using hypofractionated doses of radiotherapy (RT) demonstrated exponential cell kill , 15. HisMR-guided radiotherapy (MRgRT) is a new treatment paradigm that provides high-definition soft-tissue contrast which permits direct visualization of tumors and adjacent radiosensitive organs-at-risk (OAR). MRgRT offers real-time, online monitoring of tumor motion through the different phases of the respiratory cycle and the opportunity for daily adaptation – optimization of tumor targeting and OAR sparing, and dose delivery based on the anatomy from the daily acquired MRI. This may potentially lead to PTV margin reduction and improving the therapeutic ratio. The advantages of online adaptive MRgRT and in which clinical case scenarios maximum benefit will be achieved is yet to be determined.The MRIdian 0.35T Co-60 MR-linac  workflow entails patients undergoing both a high-resolution volumetric MR scan and a planning computed tomography (CT) scan with a breath-hold. The CT scan is used for dose calculation purposes and to verify tumor size and shape. The GTV and OARs are delineated on the planning MR image. A PTV is generated by adding a 3 to 5mm margin to the GTV. Daily MRIs are fused with the planning MRI for online adaptation and reoptimization. The system utilizes cine imaging at 4 frames per second in a sagittal plane for real-time anatomic tracking, deformable registration and respiratory-gated, visual patient feedback beam control. The tracking algorithm deforms the anatomical contour on every cine frame and compares it to the gating boundary contour, typically the PTV. Radiation delivery is stopped if the target moves outside the gating boundary, and resumes when it returns to treatment portal –27. EarlRecently Timmeren et al.  retrospeMembers of the Elekta MR-Linac consortium contribute to the Momentum study (NCT04075305)  which isHall et al.  recentlyIt is a natural evolution to apply MRgRT for kidney tumors alongside other abdominal/pelvic targets that share the same adjacent radiosensitive OARs . The high-definition soft-tissue contrast of MRgRT permits better visualization of kidney substructures — such as the renal hilum (vasculature and collecting system) and parenchyma — that are hard to differentiate with conventional cone beam CT-guided radiotherapy, which may lead to increased tissue sparing and preservation of renal function.Rudra et al.  publishe2 (SD ±19.0), and the mean decline in eGFR post-MRgRT was 6.0 mL/min/1.73 m2. While the follow-up interval is short, oncologic outcomes and preservation of renal function in this cohort of mainly large tumors are favorable and consistent with a recent analysis of RCC SBRT , and then re-optimized using the target and OAR optimization objectives of the baseline plan (re-optimized plan). The priority of plan re-optimization was to minimize high dose to OARs, even at the expense of decreased PTV coverage. The re-optimized plan was used for treatment delivery. MRgRT was delivered with respiratory gating where the gated structure was either the kidney itself, or the primary tumor if visible. Gating was augmented by visual and/or auditory feedback where patients were able to visualize the gated structure and the gating boundary, generally corresponding to the PTV (3mm). Treatment times for these patients ranged from 30–45 minutes for real time contour propagation, plan re-optimization and treatment delivery. The University of Texas MD Anderson Cancer Center is building experience in the treatment of primary kidney tumors and metastatic lesions within the kidney parenchyma on a 1.5T MR-linac. In collaboration with the urology department, non-operable RCC patients are currently being enrolled into the MRI-MARK trial evaluating the feasibility and effectiveness of MRI-based SBRT at a dose of 42 Gy in 3 fractions to the gross tumor volume (NCT04580836). An ITV method for motion management is employed and daily adaptation is done with the acquisition of pretreatment free-breathing T2 MRIs, followed by an adapt-to-position (ATP) or adapt-to-shape (ATS) workflow. Monitoring is achieved using real-time cine MRI with 3 orthogonal planes through the PTV during beam-on. Therapies maximizing nephron-sparing is a priority for RCC patients in whom the prevalence of CKD is high . More efAl-Ward et al.  evaluatePrins et al.  evaluate+ proliferating T cells and other key immune-modulating cytokines  and enable future comparative studies to thermal ablative procedures. The next step in the evolution of MRgRT for RCC will be the ability to treat: multiple targets in the ipsilateral and/or contralateral kidney; oligometastatic  or oligoytokines , 52. Theytokines . MRgRT wytokines . Acquiriytokines , 55, 56.ytokines , MRgRT oThe role of MRgRT in the treatment of RCC continues to evolve. MRgRT can potentially facilitate dose escalation and smaller treatment margins by overcoming the challenge of complex kidney motion, and reduce treatment-related toxicities by carefully evaluating and sparing critical OARs in real time. In the primary setting, this technology will help advance the use of SBRT for small and large renal tumors with potentially less renal toxicity, and improve the therapeutic ratio which will facilitate future comparative effectiveness studies versus other ablative modalities. In the metastatic setting, the benefits of MRgRT for oligometastatic or oligoprogressive tumors, and in combination with immunotherapy, may even be more pronounced where online tumor monitoring and daily adaptation to optimize dose delivery and OAR sparing may further mitigate toxicity. Such an approach would allow for potentially more effective combined modality therapy and brings us closer to realizing the promise of high-precision and personalized medicine in the field of radiation oncology.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.Ethical approval was not provided for this study on human participants because this perspective highlights previously published and ongoing studies that have received local ethics approval. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.All authors contributed to the article and approved the submitted version.AB reports personal fees from ViewRay Inc., outside the submitted work. AS has received honoraria from Bristol Myers Squibb, AstraZeneca, and Eisai, and trial funding in kind from Bristol Myers Squibb. BK, CT, LK and WC are members of the Elekta MR-Linac Consortium, and Elekta financially supports projects in the member institutes. BK and WC have received travel support from Elekta.


P < 0.01) was built in an independent sample to create a naturalistic model representing the HC-ROP hyperplane. This model was out-of-sample cross-validated in the ROP patients from the CCT trial to assess associations between rsFC pattern change, cognitive gains and SP during CCT. Patients with intact SP threshold at baseline showed improved attention despite psychosis status on the SVM hyperplane at follow-up (p < 0.05). Contrarily, the attentional gains occurred in the ROP patients who showed impaired SP at baseline only if rsfMRI diagnosis status shifted to the healthy-like side of the SVM continuum. Our results reveal the utility of MVPA for elucidating treatment response neuromarkers based on rsFC-SP change and pave the road to more personalized interventions.Two decades of studies suggest that computerized cognitive training (CCT) has an effect on cognitive improvement and the restoration of brain activity. Nevertheless, individual response to CCT remains heterogenous, and the predictive potential of neuroimaging in gauging response to CCT remains unknown. We employed multivariate pattern analysis (MVPA) on whole-brain resting-state functional connectivity (rsFC) to (neuro)monitor clinical outcome defined as psychosis-likeness change after 10-hours of CCT in recent onset psychosis (ROP) patients. Additionally, we investigated if sensory processing (SP) change during CCT is associated with individual psychosis-likeness change and cognitive gains after CCT. 26 ROP patients were divided into maintainers and improvers based on their SP change during CCT. A support vector machine (SVM) classifier separating 56 healthy controls (HC) from 35 ROP patients using rsFC (balanced accuracy of 65.5%,  Neuroplasticity-based computerized cognitive training (CCT) has frequently been used as a supplementary treatment in psychotic illness , 2. CCT Importantly, the variability in neuroplastic response induced by intermediate neurocognitive and brain phenotypes may moderate the neuroplastic response induced by respective training paradigms . To mitiFinally, the high degree of variability in cognitive gains may be explained by individual differences in engagement level of the underlying neural system target and learning progress in CCT , 37. TheThe aim was to investigate individual response to 10 h of CCT by measuring changes in psychosis-likeness based on rsFC patterns in relation to sensory processing. First, we developed an original multivariate model, able to distinguish HC from ROP patients using rsFC in a naturalistic sample. Second, this model was applied to the CCT intervention sample, to assess and monitor clinical outcome in response to CCT. Hereby, we measured the change of psychosis-likeness after 10 h of CCT at the single-subject level employing machine learning on rsFC pattern before and after CCT. In the third step, we investigated how psychosis-likeness change was related to sensory processing. In the final step, we investigated the effects of sensory processing change (SPC), psychosis-likeness change (ROP-HC continuum) and their association on cognitive gains, in response to the intervention. We expected to observe cognitive gains in lower-order cognitive functions due to the drill-and-practice approach used and short duration of the intervention.Two samples were included from the Early Detection and Intervention Center at the Department of Psychiatry and Psychotherapy of the Ludwig-Maximilians-University (LMU) in Munich, Germany: 1) the original PRONIA study diagnostic sample of 35 ROP patients and 56 HC recruited from the LMU Munich site of the naturalistic, European multi-center PRONIA study   and improvers (N = 12) based on a median split of their learning scores  and again at follow-up (FU) post-intervention. Clinical diagnosis was assessed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) . In ordeA cross-domain neuropsychological test battery comprising 9 tests were administered to patients in the intervention sample at T0 and FU in a fixed order . Tests were z-score transformed based on the study sample to closely reflect cognitive domains based on the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) recommended procedures  Table S.http://www.brainwavelet.org/)  = −0.35), whereas maintainers showed rather stable decision score values from T0 to FU , with no significant differences in the number of patients whose rsFC shifted in the healthy-like direction  as opposed to the psychosis-like direction  and decision score change  alone on the attentional change was not significant. We observed a moderate effect size of improvement in attention despite psychosis-likeness change in the psychosis-like direction on the SVM hyperplane only in patients who showed intact SPC at baseline and maintained peak performance throughout the CCT . Contrarily, attentional gains showed a large effect size in the ROP patients who showed impaired SPC at baseline only if the rsFC shifted to the healthy-like side of the SVM hyperplane .Comparing maintainers and improvers further, we found a significant interaction between the group and the change in decision scores on the attentional gain , EU-FP7 project PRONIA  under the Grant Agreement No° 602152 (PI: NK) and NARSAD Young Investigator Award of the Brain & Behavior Research Foundation No° 28474 (PI: LK-I).BB is Senior Scientist at Posit Science, a company that produces cognitive training and assessment software. The training programs described in this study were provided for research purposes free of charge by Posit Science. All other authors report no conflict of interest. RU reports grants from Medical Research Council, grants from the National Institute for Health Research, and personal fees from Sunovion, outside the submitted work. NK, JK, and RS received honoraria for talks presented at education meetings organized by Otsuka/Lundbeck. All other authors report no biomedical financial interests or potential conflicts of interest. Open Access funding enabled and organized by Projekt DEAL.Supplementary Information