Amyotrophic lateral sclerosis is a progressive and devastating neurodegenerative disease. Despite decades of clinical trials, effective disease-modifying drugs remain scarce. To understand the challenges of trial design and delivery, we performed a systematic review of Phase II, Phase II/III and Phase III amyotrophic lateral sclerosis clinical drug trials on trial registries and PubMed between 2008 and 2019. We identified 125 trials, investigating 76 drugs and recruiting more than 15 000 people with amyotrophic lateral sclerosis. About 90% of trials used traditional fixed designs. The limitations in understanding of disease biology, outcome measures, resources and barriers to trial participation in a rapidly progressive, disabling and heterogenous disease hindered timely and definitive evaluation of drugs in two-arm trials. Innovative trial designs, especially adaptive platform trials may offer significant efficiency gains to this end. We propose a flexible and scalable multi-arm, multi-stage trial platform where opportunities to participate in a clinical trial can become the default for people with amyotrophic lateral sclerosis. Wong et al. reviewed historical approaches to clinical trials in amyotrophic lateral sclerosis. Lack of sensitive outcome measures, limitations in resources and barriers to trial participation were challenges for timely and definitive evaluation of drugs in two-arm trials. They concluded that future trials should be more flexible, scalable and efficient.  Amyotrophic lateral sclerosis is a rapidly progressive disease with a median survival of 2–3 years.Limitations of pre-clinical models and incomplete knowledge of the underlying biology of amyotrophic lateral sclerosis are some of the factors hindering translational success.Here, we evaluate previous trial designs and consider specific methodological challenges. These include the rapid pace of decline and accumulating disability in amyotrophic lateral sclerosis, the clinically heterogeneous nature of amyotrophic lateral sclerosis and a range of trial design and conduct issues. We review emerging innovative trial designs and propose a flexible multi-arm, multi-stage trial platform model that can incorporate new candidate drugs as they are identified.We conducted a systematic search of trial registries including clinicaltrials.gov,We performed a narrative synthesis on all included trials to summarize trials according to phase, study status, study duration, number of participants, investigational medicinal products (IMPs), eligibility criteria and primary outcome measures. For studies with entries on multiple registries, data from ClinicalTrials.gov were used as the primary data source. For studies registered on registries with results published in journals, publications were used as primary source of data. To review sample size considerations including recruitment and retention, we summarized trials for completed trials with efficacy-based primary outcome measures according to number of study arms, number of participants recruited, number of participants recruited per arm, withdrawal rates and reasons for withdrawal.Data for this review are available in the ,A total of 1152 records were identified [see Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram in About 73% of trials specified amyotrophic lateral sclerosis disease duration within their inclusion criteria. Median permitted maximum disease duration was 36 months [interquartile range (IQR) 24–36 months]. Amyotrophic lateral sclerosis participants at King’s stage 4  were excluded from 119 trials. Total of 53 trials stipulated use of riluzole as part of their inclusion or exclusion criteria.,A total of 76 IMPs were evaluated in these 125 trials , of whicMasitinib in combination with riluzole reduced progression of ALSFRS-R in ‘normal progressors’ in a Phase II/III studyP = 0.023] in participants originally randomized to AMX0035 compared to participants originally randomized to placebo.More recently, Food and Drug Administration (FDA) and EMA have granted orphan drug designation for AMX0035 following a positive Phase II trialpost hoc-analysis of a long-term Phase II/III randomized controlled study, ultra-high-dose methylcobalamin treated pwALS prolonged time to death or ventilation support and reduced decrease in ALSFRS-R score compared to placebo for pwALS diagnosed and entered into trial within 12 months of symptom duration.In a Nuedexta (dextromethorphan/quinidine) was approved for treatment of pseudobulbar affect in amyotrophic lateral sclerosis in 2011 by the FDA and 2013 by EMA. Following reports from pwALS noting an improvement of their bulbar symptoms on Nuedexta, a Phase II randomized, blinded, crossover study of 60 participants was performed. Nuedexta was associated with significantly improvement in the Centre for Neurologic Study Bulbar Function Scale (CNS-BFS), a self-reported measure of swallowing, salivation and speech, compared to placebo over a treatment period of 28–30 days.About 90% of the included trials used traditional fixed designs where each trial evaluated one active IMP (including dose-ranging studies testing one active IMP at multiple doses) and were designed, conducted then analysed in a consecutive manner, with no flexibility to adopt changes, which may become desirable over the course of the trial. A total of 12 trials used ‘novel’ or ‘alternative’ trial designs . In the Next, we reviewed sample size considerations including recruitment and retention. To do this, we analysed studies with efficacy-based primary outcome measures . Results,Total 24 of the 49 studies used ALSFRS-R, while 10 trials used survival, and 2 used compound scores combining survival and ALSFRS-R as primary outcome measures.ALSFRS-R scores were reported as mean rate of decline or slope of decline, or as an absolute or percentage change from baseline score, measured over durations ranging between 8 and 90 weeks. Trials using ALSFRS-R were planned to detect a range of treatment effects, including a reduction in the rate of decline of anything from 10% to 50%, or a 3-point difference in ALSFRS-R scores over 24–40 weeks.Survival results were reported in several ways including number of deaths, proportion alive at a specified timepoint, Kaplan–Meier curves, time-to-event including death or proxies for survival such as tracheostomy or the initiation of permanent assisted ventilation. Follow-up periods for survival ranged from 12 to 18 months.Biomarkers were specified as outcome measures in 42 (34%) of trials: 27 trials included biofluid biomarkers, 3 measured imaging biomarkers and 13 measured neurophysiological biomarkers.To determine the approximate proportion of pwALS participating in clinical trials, we evaluated reported recruitment data for trials identified in our systematic search and compared this to amyotrophic lateral sclerosis epidemiology data . We iden,,Our analysis of trials between 2008 and 2019 found 76 IMPs evaluated in 125 trials, predominantly with two-arm trial designs with a range of sample sizes and a variety of outcome measures. We estimate that fewer than 5% of newly diagnosed pwALS entered a clinical trial. Limitations of this review include incomplete reporting of completed trials, which may reflect reporting bias. A total of 73 trials were recorded as completed, but for 12, the results were not available in a manner consistent with EU or FDA regulations. Of these 12, 2 did not provide completion dates, 2 were completed within the preceding 12 months and 8 were completed more than 12 months prior, noting that FDA and EU regulations mandate reporting of results within 12 months of completion. Three of these trials published results in either journals or on trial registries between April 2019 at the time of writing,Here, we discuss challenges in designing, delivering and conducting trials in amyotrophic lateral sclerosis, and review the possible causes of low proportion of pwALS entering CTIMPs.,While our understanding of amyotrophic lateral sclerosis disease biology, especially in genetics and molecular biology, has improved over recent years, there remains significant gaps in our knowledge of mechanistic targets and networks in amyotrophic lateral sclerosis.Heterogeneity of clinical presentation, site of onset and rate of progression often result in diagnostic delay, with an average time from symptom onset to diagnosis of 12–15 months.In addition to practical and logistical considerations, phenotypic heterogeneity in amyotrophic lateral sclerosis adds complexity to participant selection. This includes variation in survival, which is well recognized in amyotrophic lateral sclerosis.To create a more homogenous cohort, increase trial protocol adherence and exclude long survivors, investigators often use restricted eligibility criteria as demonstrated in our review as well as a review of amyotrophic lateral sclerosis clinical trials between 2000 and 2017 by van Eijk et al.An alternative approach is to adopt broad inclusion criteria recruiting all subtypes of amyotrophic lateral sclerosis including long survivors, supported by protocol innovations to allow participation of pwALS with more advanced disease. Examples include liquid IMP preparations and home/telephone/video assessments.,The recent development of personalized risk prediction models,The tension between practical considerations of feasibility of recruitment, compliance and retention, versus adequate power for evaluation of meaningful outcome measures is apparent throughout the amyotrophic lateral sclerosis trial literature. Indeed, what constitutes a clinically meaningful change on these endpoints is difficult to define. The range of primary outcome measures and primary endpoints reflects the absence of widely available, robust and sensitive biomarkers. There is, however, an encouraging trend towards the use and development of biomarkers in more recent trials. Out of 29 trials including biomarkers as outcome measures with trial start dates available in registries, 21 (72%) were conducted within the past 5 years. Meanwhile, there remains a dependency on clinical ordinal scales, in particular the ALSFRS-R. ALSFRS-R was the most common primary outcome measure used (41% of Phase II studies and 35% of Phase III studies). Survival was the second most common primary outcome measure used in Phase III studies (30%).,Although ALSFRS-R is widely used and validated, a Rasch analysis identified that ALSFRS-R total score lacks unidimensionality, meaning investigators cannot be confident that the same total ALSFRS-R score in two pwALS reflects comparable clinical conditions.These sample sizes demonstrate a major challenge in amyotrophic lateral sclerosis trials. More than half of the studies in our review with efficacy-based primary outcome measures recruited fewer than 100 participants, notwithstanding allowances for missing data, dropouts and death. Thus, with hindsight, these studies were highly unlikely to answer—in a statistically robust manner—whether the proposed intervention was clinically effective or warranted further evaluation in a Phase III trial. The inability to determine drug efficacy or futility in a single, definitive and timely trial, may lead to re-evaluation of the same IMP in subsequent trials. This is inefficient in time, cost and patient resource.,,Another important challenge in amyotrophic lateral sclerosis trials is the variation in regulatory requirements and complex administrative processes across different countries and jurisdictions. These often hinder and delay multinational clinical trials as demonstrated in other diseases and may detract pharmaceutical companies from running trials in some countries.,,While efforts to harmonize national regulations are underway, considering the small proportion of pwALS entering interventional clinical trials and the increasing emergence of candidate medicines, there is an opportunity to improve trial design in ALS. This requires innovation in how drugs are selected and how trials are undertaken. The emerging trends in drug selection encompass four broad approaches; machine learning assisted systematic evaluation of the pre-clinical and clinical literature,,,,Innovative trial designs pioneered in cancer medicinea priori evidence to favour one over the other.,Another class of trial design that offers promise for amyotrophic lateral sclerosis is the platform trial. These are trials, which evaluate multiple treatments simultaneously using a single master protocol, typically against a shared control or standard-of-care arm. Platform trials are especially effective where there are several promising medicines without any The time and cost efficiencies gained by stopping ineffective arms early, while being able to introduce new arms in what is in effect a continuous trial platform without initiating further independent RCTs, are significant. It is estimated that a multi-arm study evaluating two active arms within the same trial against control halves the cost of separate traditional two-arm RCTs to evaluate two drugs.Notwithstanding the benefits of MAMS platform, they present significant operational and statistical challenges. One operational challenge is the need for substantial and sustained funding to enable the creation of an integrated and long-term administrative, project and statistical trial infrastructure.UNC13A homozygous patients. MND-SMART is initially testing two IMPs (trazodone and memantine) against a single placebo arm with a seamless adaptive Phase II/Phase III multi-arm, multi-stage design, incorporating measures to maximize accessibility to pwALS including using broad inclusion criteria, liquid IMP and video/telephone assessments.Accordingly, the development of platform trials in amyotrophic lateral sclerosis is gathering momentum with three declared initiatives: USA-based HEALEY amyotrophic lateral sclerosis Platform TrialPhenotypic heterogeneity, disease-related disability and the lack of sensitive and reliable outcome measures are some of the challenges in designing and conducting amyotrophic lateral sclerosis clinical trials. With improved understanding of amyotrophic lateral sclerosis disease biology and increasing number of promising candidate medicines being identified for evaluation, innovative trial designs can be instrumental in making trials more efficient, flexible, scalable and accessible. Together these advances will bring closer a new default where every pwALS has the opportunity to participate in a clinical trial.Brain Communications online.fcab242_Supplementary_DataClick here for additional data file.


Respiratory syncytial virus (RSV) is an important cause of infant morbidity and mortality and a potential target for maternal immunization strategies. However, data on the role of RSV in young infant deaths in developing countries are limited.We conducted a community-based mortality surveillance from August 2018–March 2020 for infants ≤6 months in Karachi, Pakistan. We tested (reverse transcription–polymerase chain reaction) nasopharyngeal swabs from deceased infants for presence of RSV. We performed verbal autopsies and calculated odds of RSV-associated mortality with 95% CIs and used multivariable logistic regression to evaluate associations.We collected 490 nasopharyngeal specimens from 1280 eligible infant deaths. There were 377/490 (76.9%) live births and 14/377  were RSV positive. Most deaths occurred in neonates , males , and respiratory illnesses . Postneonatal age , respiratory symptoms , and high RSV season  were associated with RSV mortality. In multivariable logistic regression analysis, respiratory symptoms , RSV seasonality , and age  were significant predictors of RSV-associated mortality.RSV has a significant mortality burden in early infancy in Karachi, Pakistan. Age, RSV seasonality, and respiratory symptoms were significant predictors of RSV-associated mortality. Our findings have implications for clinical management of young infants with cold-like symptoms, policy development, and research regarding maternal immunization against RSV during pregnancy, in resource-constrained, low-income, and vaccine-hesitant populations. Respiratory syncytial virus is a potential target for maternal immunization with significant disease burden in young infants. Limited knowledge regarding RSV infant mortality in developing countries exists. We assessed the burden and determinants of RSV infant mortality in Karachi, Pakistan. Respiratory syncytial virus (RSV) is a respiratory pathogen with an initial global burden of disease estimates indicating a moderate to high burden in developing countries, specifically among young infants . This viPakistan has one of the highest infant mortality rates globally due to multiple causes, but little is known about the RSV burden in infant mortality . The priThis was an observational community-based mortality surveillance study conducted in 4 peri-urban low-income settlements  in Karachi, Pakistan. The overall population of the catchment area is approximately 249 128, with a cohort of approximately 7525 new births per year [Data were collected from August 2018 to March 2020. The primary outcome measure was prevalence of laboratory-confirmed (reverse transcription–polymerase chain reaction [RT-PCR]) RSV infection in nasopharyngeal specimens from recently deceased infants younger than 6 months. The study enrollment inclusion criteria comprised stillborn or recently deceased infants under 6 months of age in the catchment areas. Parents or other caregivers gave informed verbal consent for a nasopharyngeal swab collection from their deceased infant at the household preferably before ritual cleansing and shrouding, and before burial.Prior to the onset of the surveillance phase, we conducted a formative phase where we explored the acceptance of study procedures within the communities and assessed the benefits to families of deceased infants for participating in the study. We obtained approval and religious rulings from religious scholars that collecting specimens via nasopharyngeal swabs after death and before burial is religiously acceptable in the context of the Islamic, Christian, and Hindu faiths. Infant death alerts were conveyed to the team from key community stakeholders, such as religious leaders, traditional birthing attendants, and graveyard personnel.Upon receiving a death alert from a key community partner or community member, the RSV study team mobilized from the primary health center at the field site to the identified household of the deceased infant. Due to the religious beliefs of predominantly Muslim communities, burial of the deceased occurs as soon as possible. Hence, there was a short time window for enrollment before the ritual bathing, shrouding, and burial of the infant. A 24 × 7 surveillance system was established to mobilize the study team to approach a household within 25 minutes of receiving a death alert.As Muslim burials generally occur within 24 hours of death and the staff received most alerts within 1 hour of the infant’s death, we had no concerns about the viability of specimens for collection. The nurse performing the nasopharyngeal specimen collection donned a surgical mask and clean gloves to minimize exposure. Laboratory staff were trained in specimen testing methods for RSV. After obtaining verbal consent from the deceased infant’s parents/caregivers and completing the Case Record Form see , trainedNasopharyngeal specimens were stored at 70°C or lower prior to nucleic acid extraction until sufficient samples were available for batch testing. Nucleic acid was extracted from frozen aliquots using QIAamp Viral RNA Mini Kit (Qiagen).The extracted nucleic acids (from a Roche MagNApure compact automated system) were used for 1-step real-time PCR for RSV detection, using a Qiagen 1-step RT-PCR kit. Real-time RT-PCR assays were performed with primers and probes for RSV, using the CDC protocol . All assA psychologist trained the field team in grief support and communication skills to conduct home visits for bereaved parents at the time of and up to 2 months after the infant’s death. The World Health Organization (WHO) verbal and social autopsy tool was administered during grief-support home visits within a week of enrollment. A cause of death report containing verbal and social autopsy findings and laboratory-confirmed PCR results for RSV was shared with enrolled parents alongside continuous community engagement activities.To determine the cause of death, the following was considered: (1) nasopharyngeal swab test results, (2) medical records of symptoms (when available), and (3) verbal and social autopsy. Symptoms obtained through verbal autopsy as well as medical records, when available, were considered to determine the likely cause of death. Cases were deceased infants who had respiratory symptoms as per acute lower respiratory infection (ALRI) criteria . Controls were deceased infants who did not have any of the defined respiratory symptoms.To determine RSV burden, we calculated crude RSV mortality proportions and the odds of having laboratory-confirmed RSV among cases and controls of deceased infants captured through our surveillance system. Our symptom-based case definitions for respiratory disease cases was a deceased live-birth infant who had at least 1 of these respiratory symptoms that occurred within 2 weeks immediately preceding death, with no asymptomatic period between symptom onset and death: (1) cough, (2) difficulty breathing, (3) chest wall indrawing, (4) wheezing, (5) rhonchus, or (6) crackles when breathing and any one of the very severe symptoms  , 12. VerTo determine predictors of RSV mortality, we compared the distribution of covariates such as hospital deaths versus community deaths and gender, age, or seasonality among infants with and without laboratory-confirmed RSV (controls) using chi-square tests and odds ratios (ORs). Since we did not have access to the medical records of most of the deceased infants to determine the details of length of hospital stay for the entire sample, we defined hospital deaths as deaths that occurred inside a tertiary care hospital, regardless of duration of time in the hospital. Community deaths were defined as infants who died either on the way to the hospital, in the traditional birth attendant’s home, at the clinic, at home, or in a community-based health center. Age was categorized as 0–3 months and 4–6 months, as well as neonatal (0–28 days old) and post-neonatal (29 days and older) for analysis. Stillborn infants were not included in the analyses as we would not expect to see any RSV in them (never exposed to RSV). RSV seasonality in Pakistan was defined based on a prospective surveillance study conducted at the Aga Khan University Hospital in Karachi, Pakistan . RSV is Approval from the Ethical Review Committee/Institutional Review Boards (IRBs) of Yale University and Aga Khan University was obtained. Study protocol, all data-collection instruments, and consent forms  were also approved by both institutions’ IRBs.Of 1280 eligible infant deaths that occurred between August 2018 and March 2020 in the catchment areas, 490 nasopharyngeal specimens were obtained; 113 of 490 (23.1%) were stillborn and 14 of 377  live-birth infant specimens tested positive for RSV. The proportion of deceased infants with laboratory-confirmed RSV was 14 of 377 (3.7%) . There wTo compare the distribution of covariates among deceased infants with laboratory-confirmed RSV status vs no RSV, we calculated odds ratio see . While tIn multivariable logistic regression, we found that age (>28 days) , having respiratory symptoms , and RSV seasonality  were significant predictors of testing RSV positive .This is the first community-based study examining RSV mortality in young, vulnerable infants in Pakistan. This is a seminal community-based, real-time surveillance study documenting a moderate to high burden of RSV mortality in young infants. We found the burden of infant mortality attributed to RSV in Karachi, Pakistan, to be similar to the systematic review findings by Nair et al  of 2.1% Symptom-based case definition of respiratory disease and community surveillance allowed us to collect data on infants who had never been to a hospital and therefore never identified as a case, as well as infants who may have had misclassified hospital outcomes or comorbid conditions that overshadowed the RSV diagnosis . Community engagement and support from religious and community leaders and community religious buy-in through supporting religious rulings allowed us to conduct 24/7 surveillance and obtain consent for specimen collection in a timely, sensitive manner. In such low-income communities, home/community-acquired RSV infection may never be tested or treated in a hospital. Therefore, hospital-based data for RSV infection and mortality may not be entirely representative of the true prevalence. In this study, 4 of the 14 RSV-positive cases did not seek care in a hospital for their fatal illness.Limitations include the unavailability of access to medical records for some of the hospitalized deceased infants. Approaching households and obtaining consent in high-refusal areas was a data-collection challenge that was overcome with community-based study advocacy strategies. We collected data over multiple high seasons (2018–2020); however, comparisons could not be made between the 3 years since the first high season (2018) was a pilot phase with few enrollments and the third high season (2020) was interrupted by the coronavirus disease 2019 (COVID-19) pandemic. The 2019 high season captured the majority of total enrollments (deaths and cases), indicating that overall mortality increases during the RSV high season.Ongoing surveillance of the community-based RSV infant mortality study includes minimally invasive tissue sampling of lung and thorax specimens to further improve classification of upper respiratory tract infections, including RSV. As neonates and young infants have been found to be particularly vulnerable, this study has substantive implications for policy development and research regarding maternal immunization against RSV, specifically in resource-constrained, low-income, and vaccine-hesitant populations.Clinical Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.Supplementary materials are available at ciab488_suppl_Supplementary_MaterialClick here for additional data file.


ACS Appl. Mater.Interfaces2021, 13, 12603–12609, Pranavet al. report that incorporating a thin C60 interlayerat the MoO3 anode results in reduced surface recombinationof electrons, which is ascribed to a decreased electron accumulationnear the anode on account of an increased built-in voltage. Here,we offer an alternative explanation: the introduction of a C60 interlayer renders the MoO3 contact Ohmic. The reducedanode barrier simultaneously increases the built-in voltage, minimizesnonradiative voltage losses upon the extraction of majority carriers(holes), and suppresses minority-carrier (electron) surface recombination,the latter being the result of hole accumulation and associated bandbending near the Ohmic hole contact. We therefore argue that Ohmiccontact formation suppresses both majority- and minority-carrier surfacerecombination losses, whereas the built-in voltage per se does notplay a major role in this respect.Understanding interface-relatedphenomena is important for improvingthe performance of thin-film solar cells. In  Mater. Interfaces2021, 13, 12603–12609, Pranav et al.7 demonstrate that the incorporation of a tunneling C60 interlayer at the anode of organic solar cells can increase theirefficiency by reducing surface recombination losses. The authors ascribethe reduced surface recombination to an increased built-in voltage,which reduces the accumulation of minority carriers (electrons) nearthe anode. As such, minority carriers would not be lost at the anodeinterface, thereby decreasing voltage losses due to nonradiative surfacerecombination. Here, we would like to provide an alternative explanationfor the reduction in surface recombination, being due to the formationof an Ohmic hole contact, which is accompanied by diffused hole accumulationand corresponding band bending near the anode interface. Furthermore,the Ohmic contact minimizes nonradiative voltage losses upon extractionof majority carriers.In 3, and organic semiconductors.8 Although such metal oxides form an energetic barrier for holes upondirect contact with an organic semiconductor because of electrostaticinteractions, the interlayer acts as a spacer layer, decoupling theelectrode from the organic semiconductor. The key requirement forthe formation of an Ohmic hole contact is that the interlayer hasa higher ionization energy than the organic semiconductor, which resultsin realignment of the Fermi level of the metal oxide and the highestoccupied molecular orbital (HOMO) of the organic semiconductor. AsC60 has a high ionization energy of 6.4 eV, this is anideal candidate to be used as an interlayer to form Ohmic contactswith organic semiconductors with high ionization energies, even surpassing6 eV.8Recently, we demonstrated that the insertionof a thin interlayerof several nanometers universally results in the formation of an Ohmichole contact between high-work-function transition metal oxides, likeMoO8 which provides electrostatic decoupling on the one hand and allowscharge tunneling on the other. The concept has been verified for alarge range of interlayers and organic semiconductors, showing itsuniversality. As an example, Ohmic contact formation has been demonstratedfor C60 interlayers and triarylamine-based hole-transportmaterials, such as also used here by Pranav et al.7In agreement with what the authors have found, the optimum thicknessfor such an interlayer is 3–5 nm,60 interlayer provides a straightforward explanationfor the increasedbuilt-in voltage, simply lowering the energy barrier (∼0.4eV8) at the anode that is present whenonly MoO3 is being used. We note that an increased built-involtage by insertion of a C60 interlayer has been verifiedexperimentally for an ultraviolet-emitting organic light-emittingdiode (OLED), where the reduction of the injection barrier at theanode increased the electroluminescence efficiency by several ordersof magnitude.8 The main effect of an increasedbuilt-in voltage in a solar cell is that it allows for a higher appliedvoltage to partly compensate the built-in field, and thus higher open-circuitvoltages are obtained.6 When expressed in terms of nonradiativevoltage losses, energy barriers at the electrodes first and foremostresult in voltage losses upon the extraction of majority carriers,6 which was not discussed by Pranav et al.7 Therefore, one could argue that the formationof Ohmic contacts reduces losses due to majority-carrier surface recombination.The formation of an Ohmic hole contact by insertinga C8 The accumulation of holes near the anode causesband bending. The high density of holes near the electrode preventselectrons from reaching the contact, as the sharp band bending imposesan electric field in the other direction. Therefore, nonradiativesurface recombination is effectively suppressed. Instead, electronsrather recombine radiatively with the high density of free holes nearthe electrode  of the TAPC electron-blockinglayer, which would be the rate-limiting factor with regard to surfacerecombination of electrons.We further note that in the MIS-CELIV  measurement byPranav et al.,12 By using a 3 nm C60 interlayer, an Ohmic hole contact was formed between MoO3 and the efficient emitter CzDBA. Especially in OLEDs, anynonradiative surface recombination would be detrimental for the efficiencyof the device. Despite the high electron affinity and low energy gapof C60, which conventionally would be expected to be asink for both electrons and excitons, the external quantum efficiencyof the OLED reached almost 20%,12 whichamounts to an internal efficiency close to 100% when accounting forlight-outcoupling losses.13 This demonstratesthat the formed Ohmic hole contact prevents electrons from reachingthe anode and subsequent nonradiative surface recombination, evenin high forward bias. Insertion of a conventional electron-blockinglayer with a low electron affinity, as typically used in OLEDs, didnot improve the efficiency,12 proving thatsurface recombination at the anode is indeed completely suppressed,simply by the use of an Ohmic hole contact. As OLEDs typically operateabove the built-in voltage where electrons drift toward the anodeunder the applied electric field, an increased built-in voltage cannotexplain the absence of surface recombination in this OLED.Further experimental evidence forthe charge selectivity inducedby Ohmic contacts formed with the universal interlayer strategy isprovided by our recent work on single-layer organic light-emittingdiodes (OLEDs).Althoughwe agree that an increased built-in voltage reduces theelectron density near the anode in a solar cell near short-circuitconditions, we would respectfully argue that band bending due to holeaccumulation near the formed Ohmic contact would be the main contributorto the suppression of surface recombination of minority carriers.Near the maximum power point of a solar cell, the built-in voltageper se is of minor importance for minority-carrier surface recombination,as it is almost compensated by the applied voltage, whereas the formationof an Ohmic contact eliminates surface recombination even in highforward bias and promotes radiative bimolecular recombination instead.Additionally, the Ohmic contact minimizes energy—and thus voltage—lossesupon the extraction of majority carriers.Such Ohmic contactscan be universally achieved with an interlayerwith a higher ionization energy than the used donor material. As theformation of Ohmic contacts invariably results in charge accumulationand band bending near the electrodes, surface recombination is effectivelysuppressed by using Ohmic contacts in organic devices.


Ocrelizumab is often used as an alternative therapy in natalizumab-treated MS patients at risk for progressive multifocal leukoencephalopathy (PML). Our objective was to assess efficacy and safety of JC-virus positive patients switching (either directly or indirectly) from natalizumab to ocrelizumab. Forty-two patients were included from an observational cohort (median follow-up 21 months). No evidence of disease activity was found in 83% of direct switchers and 50% of indirect switchers. Two direct switchers were diagnosed with carry-over PML. Our data support a direct switch for adequate disease suppression, although carry-over PML illustrates the dilemma when choosing between a direct or indirect switch. The objectives of this observational cohort study are to report on the efficacy and safety of switching JC-virus (JCV) positive MS patients from natalizumab to ocrelizumab, and to share the switch protocol of the MS Center Amsterdam.Ocrelizumab is considered an appropriate alternative therapy for relapsing remitting MS (RRMS) patients with an increased risk of natalizumab-associated progressive multifocal leukoencephalopathy (PML). Challenging aspects of switching patients from natalizumab to ocrelizumab include the choice between a direct switch or bridging with other disease-modifying therapies (DMTs) without a long-lasting pharmacodynamic effect, which can be halted more easily in case of carry-over PML. The local switch protocol as implemented in the MS Center Amsterdam is presented in We selected all patients who switched to ocrelizumab (either directly or indirectly) because of PML risk from our prospective natalizumab cohort. No evidence of disease activity (NEDA) status, defined as no relapses, no evidence of radiological disease activity and no EDSS progression  was assessed 6-monthly during ocrelizumab treatment. We corrected for spill-over disease activity by excluding events that occurred during or within 3 months after the switch. Our brain MRI protocol followed international guidelines.Clinical evaluation during the switch was performed directly by or under supervision of the treating neurologist and included registration of relapses , steroid treatment, adverse events and expanded disability status scale (EDSS) assessed by certified personnel.JCV indices were determined 6-monthly  during natalizumab and ocrelizumab treatment. These were compared to IgG levels in light of PML risk, measured at ocrelizumab screening and before every infusion. We analyzed serum neurofilament-light (sNfL) in concurrently biobanked samples using the Simoa NF-light® Advantage Kit. In SPSS for Windows version 26, we used Mann-Whitney U tests to compare between groups and Friedman’s test to compare JCV indices, IgG and sNfL levels over time. Risk factors for not achieving NEDA status after 1 year of OCR treatment  were explored within groups by logistic regression analysis.This study was approved by the local ethics board (number 2016.554) and complied with the declaration of Helsinki. All patients gave written informed consent. Respective natalizumab treatment durations were 6 and 10 years with JCV indices of 2.76 and 0.38 prior to switch. NEDA was found in 50% of indirect switchers after 1 year of ocrelizumab treatment.Forty-two JCV positive patients were included: 27 direct switchers and 15 indirect switchers . Follow-JCV indices in the total cohort decreased significantly during ocrelizumab treatment, while no significant changes occurred in IgG levels . Indirec Although carry-over PML is rare, switching to DMT with long-lasting immunosuppressive effects poses a possible risk for JC-virus positive natalizumab-treated patients. The sNfL levels at ocrelizumab FU1 complied with the higher prevalence of disease activity on baseline MRI in indirect switchers, whereas the stable levels over time in both groups indicates effective disease suppression over the course of ocrelizumab treatment in accordance to previous studies.In this study, ocrelizumab treatment showed to be an effective alternative therapy for patients at risk of natalizumab associated PML. The rate of patients who established or maintained NEDA in our cohort is relatively lower in indirect switchers compared to direct switchers. As both groups were similar with regard to other risk factors for not achieving NEDA, this could mainly be due to the less effective treatment with other DMTs prior to ocrelizumab initiation. Despite our stringent surveillance protocol, 2 cases of carry-over PML occurred in the direct switch group. Switching to ocrelizumab did not cause PML in these cases, but we are unsure of the effect of B-cell depletion on the course of PML, which was mild in both patients.79So far, other clinical studies on the efficacy and safety of switching patients from natalizumab to ocrelizumab are scarce, apart from one ongoing clinical trial with expected completion in June 2022 . Three previous studies have comparable cohort sizes with a shorter follow-up and do not describe indirect switchers or biomarkers. yet others reported no significant changes during ocrelizumab treatment. While awaiting future data, a low JCV index in MS patients treated with ocrelizumab should not necessarily be interpreted as JCV sero-negativity or a low PML risk category.Interestingly, JCV indices decreased during ocrelizumab treatment in this study. Since JCV carrier status is unlikely affected by switching to ocrelizumab, the decrease could reflect depletion of antibody producing cells induced by anti-CD20 therapy, although total IgG levels remained stable. A similar finding was previously reported in rituximab and fingolimod treatment,Limitations of our study include the small and differing sample sizes of the two groups and the fact that treatment decisions were based on individual preferences, although these reflect real-life practice.In conclusion, our cohort supports the use of ocrelizumab after natalizumab to maintain suppression of disease activity. However, carry-over PML can still occur. This risk needs to be weighed against the risk of recurrence of disease activity when considering switching or bridging with other less effective DMTs.


Methods: PubMed, CINHAL, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL) and Nursing and Allied health were searched for randomised controlled trials from inception to September 2020. Eligible studies included the comparison between IET and CET, reporting measures of exercise capacity, cardiorespiratory fitness and symptoms in individuals with CRDs. Results: Thirteen randomised control trials (530 patients with CRDs) with fair to good quality on the PEDro scale were included. Eleven studies involved n = 446 patients with COPD, one involved n = 24 patients with cystic fibrosis (CF) and one n = 60 lung transplantation (LT) candidates. IET resulted in greater improvements in peak work rate (WRpeak)  and lower exercise-induced dyspnoea  compared to CET; however, these improvements did not exceed the minimal important difference for these outcomes. No significant differences in peak values for oxygen uptake (VO2peak), heart rate (HRpeak), minute ventilation (VEpeak), lactate threshold (LAT) and leg discomfort were found between the interventions. Conclusions: IET is superior to CET in improving exercise capacity and exercise-induced dyspnoea sensations in patients with CRDs; however, the extent of the clinical benefit is not considered clinically meaningful.Current evidence suggests that interval exercise training (IET) and continuous exercise training (CET) produce comparable benefits in exercise capacity, cardiorespiratory fitness and symptoms in patients with chronic obstructive pulmonary disease (COPD). However, the effects of these modalities have only been reviewed in patients with COPD. This meta-analysis compares the effectiveness of IET versus CET on exercise capacity, cardiorespiratory fitness and exertional symptoms in patients with chronic respiratory diseases (CRDs).  Regardless of the type of CRD, this inability is commonly caused by impairment of several physiological systems and associated with the intensification of breathlessness and peripheral muscle discomfort.In patients with chronic respiratory diseases (CRDs), exercise intolerance, the inability to undertake exercise at the work rate expected for a healthy age‐matched individual, is common. However, patients with profound ventilatory limitation are unable to sustain moderately intense exercise for sufficiently long periods to induce significant physiological adaptations when continuous exercise modalities are implemented. This is primarily due to intense breathlessness compromising exercise tolerance. In these patients, high intensity interval exercise training (IET), consisting of repeated bouts of maximal/high intensity exercise, alternated with short intervals of rest or low intensity exercise, constitutes a suitable alternative to continuous exercise training (CET).Exercise training aims to improve cardiorespiratory fitness and condition the muscles of ambulation, to increase exercise tolerance and reduce breathlessness and leg discomfort. To obtain improvements in exercise tolerance, an increased volume of moderately intense continuous exercise is recommended. A subsequent Cochrane review examining the optimal intensity of exercise training in COPD patients concluded that high intensity IET was equally effective to moderate CET in improving exercise capacity, symptoms and HRQoL. Similarly, a recent narrative review concluded that IET produces similar changes in cardiorespiratory fitness and exercise capacity as CET in COPD patients, while noting a paucity of studies exploring the effects of IET in other types of CRDs.A meta-analysis comparing the effect of IET and CET on cardiorespiratory, functional capacity and health-related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD), concluded that IET was as effective as CET in improving these outcomes.This study extends previous findings by assessing the effectiveness of IET compared to CET across a range of CRDs  and lung transplant (LT) candidates). Outcome variables investigated include physiological responses (1) at peak exercise , (2) during submaximal levels of incremental exercise (anaerobic threshold) and (3) peak sensations of dyspnoea and leg discomfort. We aimed to investigate whether IET is superior to CET in improving exercise capacity and physiological responses in patients with CRDs. and the Cochrane Handbook for Systematic Reviews of Interventions and is registered with the International Prospective Register of Systematic Reviews (CRD42021173562).This systematic review and meta-analysis was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines6 Search strategies used MeSH terms combined with keywords related to the target population (‘lung diseases’), intervention , comparator  and outcomes . Searches were limited to English language articles published in peer-reviewed journals. Additionally, reference lists of included studies and related reviews were hand searched to identify any eligible studies. The completed PubMed search strategy is presented in Table S1 (online supplement). Two authors (CA and EH) independently screened titles, abstracts and full texts of retrieved articles, with any disagreements resolved through discussion with a third author (MA).A comprehensive search was conducted in clinically relevant databases: PubMed, CINHAL, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL) and Nursing and Allied Health. Databases were searched from inception to September 2020. Search strategies were developed and piloted in consultation with a librarian, with reference to previous reviews.Participants: Adults aged > 18 years old, diagnosed with one of the following CRDs: COPD, CF, bronchiectasis, asthma, pulmonary arterial hypertension, interstitial lung disease and lung transplantation candidates.Intervention: Studies comparing the effectiveness of IET versus CET incorporated into pulmonary rehabilitation. IET consisted of repeated brief bouts of high intensity exercise, alternated with either passive or low-moderate intensity recovery periods on treadmill or cycle ergometer. CET consisted of constant-load exercise on treadmill or cycle ergometer sustained at moderate intensities.Outcome Measures: Peak work rate (WRpeak), peak oxygen uptake (VO2peak), peak minute ventilation (VEpeak), peak heart rate (HRpeak), oxygen uptake at the lactate threshold (LAT), modified Borg’s scale (CR-10) for dyspnoea and leg discomfort assessed through incremental cardiopulmonary exercise testing. Accordingly, we focused on the effect of IET versus CET on physiological variables recorded during cardiopulmonary exercise testing, to justify potential differences in WRpeak, in conjunction with differences in the magnitude of physiological adaptations.Study Design: Randomised control trials (RCTs)Study eligibility was pre-determined according to the following inclusion criteria:Study characteristics and outcome data were extracted relating to article information , participant characteristics  and study design and setting, intervention parameters and outcome measures  .Table 1.6 were used. Any missing data were imputed from other reviews.6 To determine the magnitude and clinical benefit for each outcome, we compared the treatment effect and 95% confidence interval (CI) with the minimal important difference (MID).Outcome data related to mean difference (pre-training to post-training) and standard deviation were extracted. If pre-training values were lacking, baseline values obtained from the symptom limited incremental exercise protocol The difference in pre- to post-training change between IET and CET was calculated (IET minus CET) for each study. Treatment effects between studies were anticipated to vary; hence, meta-analysis was undertaken using the random-effects model. The random-effects model involves the extent of heterogeneity between study variations. Pooled effect sizes were expressed as mean difference (MD) between training groups with 95% CIs, with a threshold of p < 0.05 considered significant.A meta-analysis comparing the different training types included in the studies was conducted using review manager.Q statistic and I2 statistic. If significant heterogeneity was noted (I2 >40%), subgroup analysis was performed to investigate the heterogeneous results. Subgroup analysis involved splitting studies as follows: Participants’ characteristics: BMI < 30 kg/m2 and BMI > 30 kg/m2 since tailoring exercise prescription to patients’ needs and capabilities could importantly influence physiological responses.For outcomes where improvement was indicated by an increased outcome value, a positive MD represented a beneficial effect of IET over CET and a negative MD favoured CET. Conversely, where improvement in outcome measures was indicated by a decreased score following training , a negative MD favoured IET and a positive MD favoured CET. Forest plots were produced for each outcome to compare results across studies. Heterogeneity was assessed using the  A triangular 95% confidence region based on a fixed-effect meta-analysis was included in the plot. The funnel plot should be symmetrical in the absence of publication bias.Assessment of publication bias using a funnel plot analysis was feasible when at least 10 studies showed outcome data.Sensitivity analysis was used to examine whether the overall findings from the primary meta-analysis were robust to potentially influential decisions. Sensitivity analysis was conducted if there was evidence of poor to fair quality according to the PEDro scale score, indicating high or unclear risk of bias to treatment effects. with discrepancies resolved by consensus. The PEDro scale assesses 11 items relating to allocation, baseline similarity, blinding, follow-up rates and analysis. Ten of the 11 items are scored as yes (1) or no (0), with summative scores indicative of excellent (9–10), good (6–8), fair (4–5) or poor (≤3) methodological quality. Trials were not excluded based on quality.Quality appraisal was independently assessed by two authors (CA and EH), using the Physiotherapy Evidence Database (PEDro) scale making a total of 13 studies included in this review.Searches generated 3119 studies ; hand se25 were conducted in patients with COPD, one in patients with CF patients and one in LT candidates  and elderly patients with mean age 65 ± 6 years for the IET and 62 ± 6 years for the CET group. Patients had been diagnosed with moderate to severe COPD  on the cycle ergometer.25 Three studies26 applied longer intervals ranging from 2 to 4 min at 70–80% WRpeak alternating with 1–3 min at 40–70% WRpeak active recovery periods. Two studies24 implemented high intensity 1-min intervals at 90% WRpeak alternating with 2-min active recovery periods of low intensity at <75% WRpeak. In one study, participants performed shorter intervals of 20 s at 100% WRpeak alternating with 40-s at 20% WRpeak.Fourlitation . The pre24 reported equivalent total training work rate between IET and CET. Two studies17 reported that IET and CET protocols were matched in terms of equivalent energy expenditure. Four studies25 presented a tendency towards a lower total work in the IET group.Total volume of work: Seven of the 13 studies reported blinded study assessors. Intention-to-treat analysis was reported in four studies.24Overall, study quality was fair to good, with a mean PEDro score of six out of a possible 10 (range 5 to 8) . Lower mpeak; VO2peak; HRpeak; VEpeak and LAT.Five indicators were used to assess the cardiorespiratory fitness of participants following completion of the IET and CET programmes: WR25 out of 13 studies using incremental cycle ergometry. Pooled results in the primary meta-analysis revealed a significant effect on WRpeak favouring IET compared to CET . No important heterogeneity was detected   , and as 2peak (L/min) was assessed in nine studies.26 No significant effect was shown in the primary meta-analysis , indicating no difference in VO2peak between training groups. No important heterogeneity was detected among studies  , and as a result, subgroup analysis was not performed for this outcome. Funnel plot was not feasible as less than ten studies were included in the meta-analysis. Sensitivity analysis did not affect the direction or significance of the treatment effect, suggesting no difference between training modalities.VO26 assessed HRpeak, presenting no significant differences between IET and CET  . However, considerable heterogeneity was identified among studies . Significant subgroup differences were identified, suggesting that BMI had an influence on the treatment effect between subsets of studies. Publication bias was not assessed as less than ten studies were included in the meta-analysis of this outcome. Sensitivity analysis did not affect the direction or significance of the outcome.Seven studiespeak (L/min) was comparable among seven studies,26 with no significant difference between IET and CET  . Significant heterogeneity was evident in the overall treatment effect . Significant subgroup differences and heterogeneity were found in the subgroup analysis, suggesting that BMI had an influence on the treatment effect of this outcome. Publication bias was not assessed as less than ten studies were included in the meta-analysis of this outcome. Sensitivity analysis did not affect the direction or significance of the outcome, showing no difference between IET compared to CET; however, participants with BMI >30 kg/m2 had a greater benefit from IET compared to CET.VE26 assessed VO2 at the LAT, demonstrating no significant difference between groups  . Meta-analytic results of IET compared to CET reported non-important heterogeneity, suggesting consistency between studies , and as a result subgroup analysis were not performed. Publication bias was not assessed as less than ten studies were included in the meta-analysis of this outcome. Sensitivity analysis did not affect the direction or significance of the outcome, showing no difference between IET compared to CET.Four out of 13 studies25 assessed by the modified Borg CR 0-10 scale. Pooled results in the primary meta-analysis revealed a significant effect on peak dyspnoea favouring IET compared to CET  . Significant subgroup differences and heterogeneity were detected, suggesting no difference between IET compared to CET in participants with normal BMI; however, participants with BMI >30 kg/m2 had a greater benefit from IET compared to CET. Publication bias was not assessed as less than ten studies were included in the meta-analysis of this outcome. Sensitivity analysis influenced the direction and significance of the outcome showing no differences between the two training modalities.Peak dyspnoea was reported in seven studies, = 0.02) . However25 assessed by the modified Borg CR 0-10 scale and in one study assessed by the Borg RPE scale (6–20). Pooled results in the primary meta-analysis revealed no significant difference between groups on peak leg discomfort  . Significant heterogeneity was indicated in the overall treatment effect for this outcome . No subgroup differences or heterogeneity were found in the subgroup analysis and presence of publication bias was demonstrated by the asymmetric funnel plot. Sensitivity analysis did not affect the direction of the outcome, showing no differences between the two training modalities.Peak leg discomfort was reported in five studies25 comparing CET and IET modalities, revealed that the total training volume was highly comparable between the two modalities .Calculation of total training volume applied in earlier studies26 to previous reviews,6 providing an updated evidence synthesis. Our meta-analysis differs from the review by Sawyer et al. as it pooled data from RCTs only, therefore providing a review of the highest quality evidence on the effects of the two training modalities on exercise capacity, cardiorespiratory fitness and exertional symptoms.This meta-analysis assessed the efficacy of IET versus CET on exercise capacity, cardiorespiratory fitness and exertional symptoms in patients with COPD, CF and LT candidates. To our knowledge, this is the first meta-analysis to investigate the impact of IET compared to CET on physiological responses not only in COPD but also in other CRDs. Furthermore, our review includes five additional RCTspeak and dyspnoea, these did not exceed the MID of 4 W for WRpeak and 1 unit for dyspnoea points, respectively. These results including several new studies are in contrast to previous meta-analyses6 which reported no significant differences between IET and CET for these variables in patients with COPD. Lack of differences were previously attributed to highly comparable total training volume between the two training modalities .6 However, while total training volume (frequency × duration × length of training programme) may have been matched between IET and CET, improvements in exercise capacity in COPD depend on exercise intensity.30 Accordingly, despite normalising for total training volume between modalities, higher intensity during IET may have resulted in greater improvements in exercise capacity compared to CET.The primary findings indicate that IET is superior to CET in improving peak exercise capacity while inducing lower dyspnoea sensations at the limit of peak exercise tolerance. Despite the significantly better overall improvements for the IET on WRpeak suggest that IET may yield greater improvements in exercise capacity, compared to CET in patients with CRDs. This may be attributed to greater structural alterations induced by high intensity exercise within the locomotor muscles, thereby enhancing the oxidative potential of these muscles. Earlier work by Morris et al. suggested that the higher intensity during IET may result in greater improvements in exercise capacity compared to CET. In support of this notion, a recent study in people with CF demonstrated that IET compared to Cet allowed greater improvements in exercise intensity throughout the training programme, leading to greater improvements in quadriceps muscle strength compared to CET.Findings for WR Quantifiable changes in muscle hypertrophy and fibre-type distribution are noted after high intensity IET, increasing the amount of type-I fibres. Furthermore, Vogiatzis et al. supported that IET was more effective than CET in enhancing the expression of anabolic growth hormones [insulin-like growth factor-1 (IGF-1) and myogenic differentiation factor-D (MGF)] that stimulate muscle fibre hypertrophy and protein synthesis. In 2010, Vogiatzis et al. reported enhanced muscle hypertrophy after high intensity IET when mRNA expression of both IGF-I and the MGF, an isoform of IGF-I, were significantly higher in both cachectic and non-cachectic COPD patients post-training. In healthy untrained individuals, high intensity IET promoted the upregulation of muscle growth and mitochondrial pathways. A previous study on healthy untrained individuals found that 2 weeks of high intensity IET induced increased protein expression and mitochondrial enzyme activity, leading to enhanced oxidative capacity of the skeletal muscles. Improved tissue oxidative activity of the skeletal muscles during exercise facilitates higher gains in exercise tolerance and is associated with reduced ventilatory drive to breathe. The latter may justify the reduced dyspnoea sensations following IET in our meta-analysis.It has been proposed that exercise training can partially reverse the shift towards glycolytic fibres in COPD patients.25 indicated that IET was associated with lower dyspnoea sensations than CET at the limit of tolerance. This is an important finding when considering that IET elicited greater improvements in WRpeak. A likely explanation for this finding may be that in two of the studies16 inpatients with COPD showed less ventilatory requirement at an identical submaximal work rate after IET. These adaptations at submaximal levels were associated with clinically meaningful increases in inspiratory capacity (IC), thereby suggesting the mitigation of exercise-induced dynamic hyperinflation and subsequent dyspnoea sensations. Inspiratory capacity has been found to be a major contributor to endurance capacity, reflecting the operating limits for tidal volume expansion and CO2 retention during incremental exercise. This finding confirms the established relationship between dyspnoea intensity and the degree of dynamic hyperinflation, where lower dyspnoea during IET might trigger smaller increases in end-expiratory lung volume as compared with CET.Four studies which indicated higher IC values at exercise isotime in COPD patients. Less exercise-induced dynamic hyperinflation was supported by greater tidal volume, inspiratory time and, in turn, lower breathing frequency compared to continuous exercise. Minute ventilation was similar between the two exercise modalities; however, patients could sustain the same level of minute ventilation for prolonged periods of time during interval compared to continuous exercise. In agreement with this study, evidence by Vogiatzis et al. demonstrated that comparable levels of minute ventilation between the two exercise modalities were sustained for a threefold amount of time during interval exercise, to the point of exercise limitation. Moreover, Sabapathy et al. reported significantly lower dynamic hyperinflation during interval exercise in COPD patients, supporting the proposed superiority of this modality in COPD.Improvements in the degree of dynamic hyperinflation with interval exercise could be explained by one studypeak and dyspnoea sensations between IET and CET needs to be treated with caution as it may not fully reflect the real effect between the two training modalities. Sensitivity analyses removed four studies25 from the primary meta-analysis for WRpeak and three studies25 for dyspnoea that exhibited fair quality in the PEDro scale, due to limitations in study designs. The excluded studies failed to report whether allocation sequence was properly concealed, and if any blinding of subjects, therapists or assessors was conducted. Therefore, elimination of the potential risk of bias and the production of spurious summary measures that overestimate the treatment effects should be achieved. Pooled results of sensitivity analyses for both outcomes revealed no significant differences between IET and CET, alternating the direction and the significance (p = 0.93) of the overall effect estimates from the primary meta-analyses.The interpretation of the improvements in WR2 as indicated in the methods section (when I >40%). Hence, subgroup analysis for dyspnoea demonstrated significant differences (p = 0.02) between the two subsets of studies, suggesting that IET was superior to CET for obese participants with COPD; however, no differences were demonstrated between the training modalities for the subset of studies with participants with a BMI < 30 kg/m2.Subgroup analysis was only feasible for dyspnoea, where significant heterogeneity was presented suggesting variation across studies. It is likely that the variability in the intervention effects is a result of clinical diversity among subjects across the different studies. Indeed, this hypothesis is further supported by the fact that there was no identification of tailoring exercise protocols on patients’ specific characteristics or comorbidities. Precise exercise tailoring to patients’ needs and capabilities greatly affects the physiological responses as different exercise prescriptions contribute to different physiological responses. Consequently, to explore heterogeneity, we conducted subgroup analysis on participants with BMI <30 kg/m Our results demonstrated that higher BMI (>30 kg/m2) could influence the impact of the training modality, suggesting that IET could be more beneficial than CET for obese participants with COPD, alleviating dyspnoea sensations to a greater extent and increasing exercise capacity during cycling. It is well documented that high intensity aerobic exercise training is highly beneficial for the components of metabolic syndrome in obese individuals. This fact together with the obesity ‘paradox’, where individuals with COPD and obesity develop less dynamic hyperinflation during cycling than normal weight, suggests that IET may be an effective training modality to improve exercise capacity and dyspnoea during cycling in these patients. Hence, for a successful pulmonary rehabilitation delivery, it is necessary to sufficiently address comorbidities such as obesity, by tailoring carefully exercise recommendations to patients’ needs and capabilities.The presence of obesity constitutes an important comorbid factor associated with increased dyspnoea, elevated work of breathing and decreased exercise capacity than normal individuals, independently of the presence of airflow limitation. and Zainuldin et al. who reported no differences between the two training modalities. Sensitivity analysis revealed no change in the direction of the overall effect from the primary meta-analysis for VO2peak, HRpeak, VEpeak, LAT and leg discomfort. When investigating heterogeneity for several of the outcomes , there were significant subgroup differences (p = 0.00001 for HRpeak and p = 0.01 for VEpeak) demonstrating that higher BMI (>30 kg/m2) could influence the impact of the training modality, thereby suggesting that IET could be more beneficial than CET in terms of minute ventilation for obese participants with COPD.When observing cardiovascular and metabolic responses, our results are consistent with Beauchamp et al. supports that the exclusion of non-English articles affects only 5% of the estimates of effect. Funnel plots were not feasible due to insufficient number of studies for most of the physiological responses, apart from WRpeak. Locating and including unpublished studies and unpublished outcomes of published studies would be a recommendation for an updated version of this meta-analysis to provide a better estimate of effectiveness. Additionally, the authors acknowledge that the registration of this study in PROSPERO (prospective register of systematic reviews) was conducted after the formal screening of search results against eligibility criteria. Since we appreciate the importance of trial registration, we believe that this would be a crucial mechanism for eliminating the impact of publication bias in future meta-analysis. Furthermore, since different interval protocols may give different results as previously noted by Morris et al. more studies should address these training parameters and their impact on physiological adaptations. Future studies should investigate the optimal total training volume for producing the most beneficial training adaptations specifically tailored to patients’ needs. Finally, our meta-analysis was focused on data obtained from cardiopulmonary exercise testing on the cycle ergometer but not on field-based walking tests.Limitations involved the small sample sizes of included studies and the predominance of COPD patients. There is a lack of RCTs investigating the impact of IET compared to CET on exercise capacity, symptoms and HRQoL on respiratory conditions other than COPD. Given that IET is associated with reduced symptoms and exercise-induced arterial oxygen desaturation, future larger scale and high-quality studies investigating the effectiveness of this modality in comparison to CET in patients with other types of respiratory disease than COPD are warranted. Furthermore, some of the trials had fair methodological quality when assessed by the PEDro scale. Since the overall study quality was fair to good, caution is needed when interpreting the results. Many of the included RCTs were unable to blind patients or therapists to the treatment group, leaving the results exposed to bias. Another limitation was the decision to include only English language articles; however, this was necessary as access to a translator was not available. EvidenceThis meta-analysis indicates that IET is superior to CET in patients with CRDs, in improving peak exercise capacity and lessening breathlessness at the limit of tolerance during exercise. Physiological adaptations after IET would be beneficial for the performance of daily activities with lower breathlessness for longer periods of time. Thus, interval exercise may be a preferable training option in respiratory patients unable to sustain continuous exercise due to profound breathlessness and exercise-induced arterial hypoxaemia.Click here for additional data file.Supplemental Material, sj-pdf-1-crd-10.1177_14799731211041506 for Effect of interval compared to continuous exercise training on physiological responses in patients with chronic respiratory diseases: A systematic review and meta-analysis by Charikleia Alexiou, Lesley Ward, Emily Hume, Matthew Armstrong, Mick Wilkinson and Ioannis Vogiatzis in Chronic Respiratory Disease


Defective DNA mismatch repair (dMMR) is associated with many cancer types including colon, gastric, endometrial, ovarian, hepatobiliary tract, urinary tract, brain and skin cancers. Lynch syndrome – a hereditary cause of dMMR – confers increased lifetime risk of malignancy in different organs and tissues. These Lynch syndrome pathogenic alleles are widely present in humans at a 1:320 population frequency of a single allele and associated with an up to 80% risk of developing microsatellite unstable cancer . Advanced MSI-H tumors can be effectively treated with checkpoint inhibitors (CPI), however, that has led to response rates of only 30-60% despite their high tumor mutational burden and favorable immune gene signatures in the tumor microenvironment (TME). We and others have characterized a subset of MSI-H associated highly recurrent frameshift mutations that yield shared immunogenic neoantigens. These frameshifts might serve as targets for off-the-shelf cancer vaccine designs. In this review we discuss the current state of research around MSI-H cancer vaccine development, its application to MSI-H and Lynch syndrome cancer patients and the utility of MSI-H as a biomarker for CPI therapy. We also summarize the tumor intrinsic mechanisms underlying the high occurrence rates of certain frameshifts in MSI-H. Finally, we provide an overview of pivotal clinical trials investigating MSI-H as a biomarker for CPI therapy and MSI-H vaccines. Overall, this review aims to inform the development of novel research paradigms and therapeutics. Cancer is a genetic disorder in which somatic mutations in specific genes confer a selective growth advantage for tumors. Such mutations can be inherited through the germline, which results in a hereditary predisposition to an early-onset cancer, or can occur sporadically in non-germline carriers. One example is the hereditary nonpolyposis colorectal cancer syndrome known as Lynch syndrome. Defining the genetic causes for Lynch syndrome has uncovered a connection between the cellular machinery that regulates DNA repair, cancer formation and informed clinical approaches to manage the disease.In the United States, an individual’s lifetime risk for developing cancer is estimated to be as high as 40%  is characterized by germline inactivation of one allele of genes involved in the mismatch repair system, namely nce 1985 –5, splicme cases . Lynch-ame cases –18.PMS2 allele) or epigenetic silencing of gene expression  and subsequent acquisition of driver mutations in genes such as APC, KRAS, PI3K, PTEN, BRAF and/or p53  to bind to the DNA and bring DNA exonuclease with PCNA to the mutation site -based regiments turned out to be ineffective in dMMR cases due to the lack of enzymes recognizing DNA damage inflicted by the drug , 49. MorH tumors , 51. PhacGAS-STING as “non-self” inducing Type I interferon and inflammatory NFkB responses  and comparatively strong immune cell infiltration of dMMR tumors sparked interest in applying checkpoint inhibitor (CPI) and other immunotherapy approaches , 52–54. esponses , 75. In mor site . Both “fAPC, TP53 or BRAF genes are clonal, positively selected by the developing tumor and overrepresented within dMMR patient samples. Similarly, certain frameshift mutations are found to be under positive selection despite encoding immunogenic neoantigens  – a gene required for MHC-I antigen presentation and processing; up to 70% frequency of mutations in TGFBR2 – cytokine receptor, rendering tumors non-responsive to TGF-β mediated suppression; up to 80% cumulative frequency of mutations in other genes related to innate and adaptive immune signaling pathways, namely IFN-γ response  and inflammasome activation . Other genomic mechanisms include loss of heterozygosity in HLA-I loci which drives tumor escape from CD8+ T cell cytotoxicity , adjuvant, routes of administration and etc. – have been extensively reviewed elsewhere , but hertoxicity . Additiotoxicity , 96. Nonic cells , 97, 98.ejection , 100. A R tumors . These aUnderstanding the trajectories of dMMR tumor genome evolution at the single cell level with and without applied immune pressure will help to describe the landscape of acquired and intrinsic tumor resistance. Knowledge of these mechanisms might inform additional interventions important to include in the shared vaccine formulations such as MHC-II epitopes and/or NK cell engagers or myeloid cell modulation . CPI cliin vitro and in dMMR cancer/Lynch syndrome patients? Which frameshift combination confers the best protective and cytotoxic potential in different cellular models of dMMR cancer progression? Extensive immunological studies will be very informative to address these points. Finally, characterizing and quantifying tumor intrinsic and acquired mechanisms of resistance from either clinical CPI trials or tumor model studies will be important to find alternative ways of improving therapeutic responses in patients’ populations. Overall, immunotherapeutic development to treat or protect against dMMR tumorigenesis experiences a new spiral of fruitful and exciting research.In conclusion, we highlight several questions which remain important to address regarding treatment and prevention of MSI tumor in the near future. How many novel MS indels appear per each genome replication in dMMR lesions and/or dMMR Lynch syndrome crypts? What is the probability of acquiring a frameshift expressed at the protein level? Can sequence-based motifs predict the earliest frameshift to appear during dMMR development? Computational modelling leveraging whole genome MSI-H samples will be informative to answer these questions. Which frameshifts generate the most frequent immune responses VR wrote the manuscript. VR, CC, BG, AL, RS, and NB revised the manuscript. All authors contributed to the article and approved the submitted version.Support is provided by seed fund from Tisch Cancer Institute at Mount Sinai Hospital.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


We confirm that DOs in the LFP are of neural origin and consistently evoked within certain patients. We then characterize the frequency and dynamics of DOs, observing significant variability in DO behavior across patients. Under the hypothesis that LFP-DOs reflect network engagement, we characterize the white matter tracts associated with LFP-DO observations and report a preliminary observation of DO-like activity measured in a single patient's electroencephalography (dEEG). These results support further study of DOs as an objective signal for mechanistic study and connectomics guided DBS.Deep brain stimulation (DBS) of subcallosal cingulate white matter (SCCwm) alleviates symptoms of depression, but its mechanistic effects on brain dynamics remain unclear. In this study we used novel intracranial recordings (LFP) in  Deep brain stimulation (DBS) of subcallosal cingulate white matter (SCCwm) has long term, sustained antidepressant effect in patients with treatment resistant depression (TRD)  recordings during active therapy enable opportunistic study in novel patient cohorts  in a set of six treatment resistant depression (TRD) patients during initial testing of subcallosal cingulate white matter (SCCwm) DBS parameters, before initiation of chronic therapy. Here, we confirmed that DOs are of neural origin and characterized their properties before attempting a preliminary explanation of their mechanistic origins.In this report, we present a serendipitous observation of ClinicalTrials.gov NCT00367003, IDE G060028). Patients were recruited based on strict inclusion and exclusion criteria [described in Riva-Posse et al.  was simulated using StimVision in high resolution CT space for both ONTarget and OffTarget electrodes at various stimulation amplitudes 2 to 7 V and 2 to 7 A , with 1 min washout periods between configurations. Each target required a separate 30 min recording and LFP download session.Multi-modal electrophysiology is collected with DBS both ON and OFF, with ON being delivered at a specific ptimized . Each taChronic antidepressant DBS is done with bilateral SCCwm-DBS, so only the bilateral stimulation conditions are analyzed in this report. All DBS was monopolar stimulation at therapeutic 130 Hz frequency, and supratherapeutic 6 mA amplitude with 90 μs pulsewidth, delivered to the predetermined target bilaterally. Patients were seated in a neutral position facing a blank monitor and asked to close their eyes. Before every recording session there was an EEG impedance measurement and appropriate saline application on EEG electrodes to ensure all scalp impedances were below 1 kΩ.n = 3/6, dense-array EEG (dEEG) were collected. Intracranial LFP from bilateral SCC was recorded using the Activa PC+S™ device (Medtronic PLC)  representations were calculated by a Welch estimator with 1024 bins, 0% overlap, 1024 NFFT, and Blackman-Harris windowing to minimize artifact-related spectral leakage. The TF representation was visualized as a spectrogram with 50% overlap for temporal smoothing. Spectrograms were used to identify distinct time periods, or regimes, of the DO for focused analysis of time windows with similar dynamics. Analysis in the frequency domain is done by averaging across the relevant time windows in the spectrogram to yield power spectral densities (PSD). PSDs measured during active DBS are baseline corrected by subtracting the average logPSD of the final 30 s of the previous baseline period.The SINDy algorithm .DOs were observed in four of six patients under bilateral DBS using the PC+S™ , though regimes  within the same patient (Patient 4) . In bothSimilarly, LFP-DOs were observed in recordings taken months apart . Here, ULFP-DOs were observed in 4/6 patients at different stimulation conditions , mostly Power spectral density (PSD) changes from pre-stimulation baseline is analyzed . PSD charegimes within a DO. A summary of properties for these DOs is provided in In all observed DOs, distinct phases of smoothly changing dynamics were observed over the stimulation timecourse, separated by abrupt changes in fundamental frequency and its harmonics . These aTo better capture dynamic and non-linear properties of LFP-DOs, we apply the SINDy algorithms to analzse coefficients reflecting canonical types of dynamics.SINDy models trained along a sliding window across the stimulation interval yield cross-coefficient maps  These max0= left-SCC and xi= right-SCC, and a non-linear dynamics model was learned for each regime . Filtered 256-channel dEEG is analyzed in the low-frequency 0 to 10 Hz range for , with maDynamics in LFP have been measured before in epilepsy  stimulation . The DOsThe DO itself exhibited stereotyped signal structure, both in the filtered time domain signal and the time-frequency domain spectrogram views . In the To better capture the dynamics and non-linearities likely underlying the DOs, we propose the use of SINDy as a complement to traditional analyses. SINDy is a neural-network based algorithm that fits canonical dynamics to multiple timeseries, yielding a sparse set of coefficients for each basis function of a library of non-linear basis functions  and Cross-coefficients, coefficients for Left-LFP dynamics involving Right-LFP and n LFP-DO , particuThese results suggest DOs arise from DBS modulation of Left-SCC to Right-SCC dynamics, leaving Right-SCC to Left-SCC dynamics intact to effect downstream changes. The sliding-window SINDy exhibits sustained patterns of coefficients, further development of SINDy in DO analysis can be used to automate regime definitions from full coefficient sets . The manThe region around the SCC is associated with various white matter tracts  during subcallosal cingulate cortex (SCC) deep brain stimulation (DBS) and perform a preliminary characterization suggesting a network-level mechanism for DO generation. These DOs were observed robustly in local field potentials (LFPs) measured at bilateral SCC, were associated with white matter tract engagement, and exhibited distinct changes in dynamics that appear preserved across large-scale networks. Our preliminary characterization of these DOs can inform broader efforts to identify specific electrophysiologic markers of tractography engagement. Further study of DOs across distributed networks is needed to gain deeper insights into the neural generators of DOs, to build mechanistic models that can inform therapeutic optimization, and to rigorously test DO generation with steerable leads , Hope for Depression Research Foundation and European Union's Horizon 2020 Framework Programme for Research and Innovation under the Specific Grant Agreement No. 945539 (Human Brain Project SGA3). Implanted devices used in the work were donated by Medtronic, Inc. .HM report consulting and intellectual licensing fees from Abbott Labs. RG serves as a consultant to and receives research support from Medtronic, and serves as a consultant to Abbott Labs. The terms of these arrangements have been reviewed and approved by Emory University in accordance with its conflict of interest policies. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Mycobacterium tuberculosis complex, diagnosed post-mortem. SARS-CoV-2 infection contributed to worsened clinical conditions and surgical site infection. A high degree of suspicion to avoid unnecessary treatments and progression to severe disease with dismal prognosis is necessary in these types of infections.Infection of surgical wounds with acid-fast bacilli, including tubercle bacilli, is rare, and is poorly described in the literature. We present the case of a 74-year-old male who developed a sternal wound infection after cardiac surgery due to  Staphylococcus aureus [Mycobacterium tuberculosis complex after heart surgery are rare, and less than 20 cases have been reported in the literature [Mycobacterium tuberculosis complex diagnosed in a patient in a tertiary care hospital in North-West Italy.Sternal surgical wound infections after heart surgery have a cumulative incidence ranging between 0.2% and 3% overall , and are® 1500 Intelligent Lab—Siemens) serum levels were 67 mg/L, and white blood cell levels were 5000/mm3. Wound cultures were performed and produced a negative result for bacterial and fungal growth. A chest computed tomography (CT) scan was performed and showed focal bone lysis in the cranial third of the sternal body, together with pre-sternal tissue oedema. No pulmonary lesions were present. Surgical debridement was planned. In the operating room, three fistulae communicating with three subcutaneous abscesses were removed, together with the sternal scar “en bloc”. The wound was reconstructed with a pectoralis major mucocutaneous flap. Intraoperative specimen cultures tested positive for Candida parapsilosis, and therapy with voriconazole at 6 mg/kg loading doses, then 4 mg/kg twice daily, was started. Due to liver toxicity, voriconazole was interrupted 15 days after; however, the wound displayed progressive spontaneous resolution and the patient was discharged. About one month later, the patient was hospitalized for SARS-CoV-2 infection. The CT scan showed bilateral ground-glass opacities and dilated segmental and subsegmental vessels. The patient had a mild COVID-19 clinical presentation  with no respiratory failure  and for which no oxygen supplementation and no antiviral, immunomodulatory, or corticosteroid therapy was eventually necessary in line with current guidelines for mild infections [Mycobacterium tuberculosis complex.A 74-year-old South American male was admitted to the cardiac surgery division of a tertiary care hospital in North-West Italy in August 2020 for the onset of purulent discharge and sternal wound dehiscence 14 months after open heart surgery performed for mitral valve replacement following culture-negative mitral valve endocarditis and coronary artery bypass. Soon after the index operation, he presented superficial sternal wound dehiscence that was treated with doxycycline 100 mg twice a day with complete resolution. At that time, three consecutive wound swab cultures (APTACA Spa—Acqui Terme (AL)—Italy) were performed and produced a negative result for bacterial and fungal growth . The patient’s medical history included chronic sclerosing glomerulonephritis diagnosed by kidney biopsy in 2014 with kidney failure, for which he was on renal replacement therapy through peritoneal dialysis since 2017, hyperlipidaemia, hypertension, and a definitive pacemaker for atrio-ventricular block. On admission, he presented a 2 cm dehiscence on the inferior third of the median sternotomy scar without purulent exudate. C-reactive protein (CRP, assessed with Dimension Vista Mycobacterium tuberculosis complex. This entity is rare among tuberculosis cases, where sternal infections represent only 1% of tubercular bone and joint infections, which in turn constitute 15% of all tuberculosis cases [We presented a rare case of post-surgical sternal osteomyelitis following a surgical wound infection caused by Candida spp. by tissue cultures was misleading as it represented a reasonable etiological agent of chronic sternal wound infection [In our case, the long and recrudescing course of the sternal wound dehiscence was pivotal to raising the suspicion on the mycobacterial origin of the infection, although the previous identification of nfection , and it nfection . AnotherMycobacterium tuberculosis complex and the associated diseases is still unclear. The add-on effect of SARS-CoV-2 infection on the immune alterations caused by tuberculosis may result in increased immunosuppression and immunological anergy, as described by Musso and colleagues [Initial data on the relationship between tuberculosis and COVID-19 are currently emerging and show that global deaths due to tuberculosis rose worldwide in 2020 due to a decrease in diagnosis and access to care in the context of the interruption of essential health services due to the pandemic . From thlleagues . A studylleagues  in 2020 lleagues  suggestsWe described a case of tubercular sternal wound infection with sternal osteomyelitis after heart surgery in a patient who also suffered from COVID-19 concomitantly. Tubercular sternal infections following cardiac surgery are rare and require a high degree of suspicion to avoid unnecessary treatments and progression to severe disease with dismal prognosis. The relationship between COVID-19 and tuberculosis is a vast and interesting topic for which large cohort studies are warranted.