Cardiac resynchronization therapy (CRT) is a major device therapy used to treat patients suffering from heart failure (HF) and electrical asynchrony. It can improve HF symptoms, reduce HF hospitalization time, and improve long-term survival in HF with and without implantable cardioverter (ICD) therapy. However, the benefit of defibrillator therapy in CRT-eligible patients with nonischemic cardiomyopathy (NICM) remains unknown. As a result, we conducted a systematic review and meta-analysis to compare clinical outcomes in patients with NICM and HF who were treated with implantable CRT defibrillators (CRT-D) vs. a CRT pacemaker (CRT-P) alone.We searched the electronic databases PubMed, Embase, and Cochrane for all studies comparing CRT-D vs. CRT-P treatment in patients with NICM. The time frame was from 1990 to September 2022. All-cause mortality and cardiovascular mortality were the primary clinical outcomes of interest to us. To pool adjusted hazard ratios (HRs) and 95% confidence intervals (CIs), a random-effects model with inverse variance was used.A pooled meta-analysis included two randomized controlled trials (RCTs), each with 1,200 CRT-eligible patients with NICM (592 with CRT-D and 608 with CRT-P) and nine cohort studies representing 27,568 CRT-eligible patients with NICM . The adjusted HR for all-cause mortality for CRT-D vs. CRT-P was 0.90 . In a subgroup analysis of two RCTs and nine cohort studies, the adjusted HR for all-cause mortality was 0.72  and HR 0.92  for CRT-D vs. CRT-P, respectively.With the addition of defibrillation leads, we found a significantly lower risk of all-cause mortality in patients with NICM, but this association was not found in subgroup analyses of RCTs and observational studies. Heart failure (HF) is a leading cause of morbidity and mortality worldwide and one of the most common cardiovascular diseases in the United States. According to one survey, 6.2 million Americans suffer from HF, and $30.7 billion is spent on HF treatment each year . Over thIn the management of HF, cardiac resynchronization therapy (CRT) represents a significant advancement. By resynchronizing intraventricular conduction/contraction and encouraging favorable reverse remodeling, CRT increases the quality of life and survival in patients with ventricular asynchrony and reduced left ventricular ejection fraction. Its efficacy has been proven in numerous randomized controlled trials (RCTs) –5. PatieThere is limited availability of recent, randomized data that directly evaluate the efficacy of ICD in CRT patients, i.e., a CRT-D vs. CRT-P comparison. The DANISH trial, which was completed in 2016, revealed that ICDs may not be beneficial for patients with NICM . PreviouThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed in our research .We searched the PubMed, EMBASE, and Cochrane databases from 1990 to September 2022 to identify studies evaluating CRT with primary prevention in patients with NICM. We designed the search strategy ahead of time based on the differences in the database. The following two subject terms will be combined with the Boolean operator “and” in our search strategy: (1) cardiomyopathies OR cardiomyopathy. (2) cardiac resynchronization therapy OR cardiac resynchronization therapy OR CRT. We did not restrict the literature search by language. The list of references from the included studies was screened to find additional pertinent studies, preventing literature omission.The following were the inclusion requirements for this study: (1) patients who were selected with NICM diagnoses; (2) CRT-D vs. CRT-P; and (3) outcomes: all-cause mortality, cardiac cause of mortality, hospitalization. Any associated procedural and postprocedural risks were also of interest. (4) Effect estimates: adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). Reviews, case series, case reports, letters, editorials, guidelines, and conference abstracts were all excluded because they did not contain effect estimates. The study with the largest sample size or the longest duration was chosen as the final inclusion study if patients from different studies came from the same data source.FW-Liu and X-Gao) performed all study screens. The first author’s name, the publication journal, the date of publication, the type of study, the database source, the sample size, the primary outcome endpoint, any secondary outcomes, and the model corrected for confounders were all taken from the included studies. Any disagreements that arose during the process were left to a third investigator (J-Luo) who made the final decision on inclusion in the meta-analysis. The authors of any studies with insufficient data to be included in the meta-analysis were contacted twice to obtain the information they needed. The study would not be taken into account for the quantitative analysis of the species if there was no response or insufficient data, or it would only be taken into account for the qualitative analysis.Two investigators  tool was used to appraise study quality. The NOS tool had three major sections: cohort selection (0–4 points), cohort comparability (0–2 points), and outcome assessment (0–3 points). We regarded an NOS score of ≥6 points as moderate-to-high quality and an NOS score of <6 points as low quality . The random effects model was used to calculate adjusted HRs for clinical outcomes with 95% CIs. The Cochrane statistic IUsing a predefined search strategy, we extracted 5,352 studies from the database .Finally, we included 11 studies, 2 of which were RCTs , 15 and We assessed the included randomized controlled trials using the Cochrane Risk of Bias Instrument criteria. The risk of bias with Kber et al. and Doran et al. was thought to be low overall (2 = 0%). In the study of all-cause mortality, the funnel plot revealed no significant asymmetry  investigated the risk of infection and discovered no difference between CRT-D and CRT-P patients .Two cohort studies , 23 and Doran et al.  found thIn the total combined analysis of this systematic review and meta-analysis, we found a slight reduction in the risk of all-cause mortality with CRT-D vs. CRT-P in patients with NICM, This finding suggests that in patients with NICM, CRT-D would be more beneficial to CRT-P. But no such difference was found in the subgroup analysis of the RCTs and cohort studies.post hoc analyses of RCTs (It is worth noting that we found only two  of RCTs , 15. The of RCTs  found no of RCTs . Differe of RCTs . Third, The pooled analysis of RCTs was not designed to determine whether adding defibrillation to CRT-eligible patients with NICM would benefit them. As a result, we included nine cohort studies with a total of 27,568 NICM patients, and after controlling for confounding factors such as baseline variables in NICM patients eligible for CRT indications, there was no statistically significant difference in all-cause mortality between CRT-D and CRT-P. In contrast to Patel et al’s systematic review and meta-analysis , in whicIt is still debated whether additional defibrillator leads should be implanted in patients with NICM and heart failure who are candidates for CRT. There is no denying that the ability of implanted defibrillators to terminate life-threatening malignant ventricular arrhythmias is a critical benefit. However, REVERSE trial data revealed that patients implanted with a CRT-D device cost approximately $200,000 more than those implanted with a CRT-P device and had a battery life of only 3.6 years . AccordiAs a primary recommendation, the 2017 AHA/ACC/HRS Guidelines for the Treatment of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death suggest that NICM patients with an LVEF ≤35% after three months of drug therapy have a defibrillator implanted . As a reThe current study has some limitations that should be mentioned. First, there were very few RCT studies included, and the risk of death in NICM patients receiving CRT-D vs. CRT-P was only a subgroup analysis among RCT studies. Second, there were fewer prospective cohort studies included. Despite the fact that all of the observational studies we included controlled for baseline covariates, the effect of residual confounding factors such as age or other comorbidities may influence whether defibrillators improve the risk of survival in NICM. Because of the inherent limitations of observational studies, the level of evidence that can be provided is low. Third, due to limited data, we were unable to perform a pooled analysis of secondary outcomes. Although different secondary outcomes were considered and could be inferred in the search strategy designed, such as the risk of hospitalization, infection, and cardiovascular death, we were unable to perform a pooled analysis of secondary outcomes.With the addition of defibrillation leads, we found a significantly lower risk of all-cause mortality in patients with NICM, but this association was not found in subgroup analyses of RCTs and observational studies. More randomized trials are required to help inform decisions about the best device for this patient group.


Alzheimer’s disease (AD) is to blame for about 60% of dementia cases worldwide. The blood–brain barrier (BBB) prevents many medications for AD from having clinical therapeutic effects that can be used to treat the affected area. Many researchers have turned their attention to cell membrane biomimetic nanoparticles (NPs) to solve this situation. Among them, NPs can extend the half-life of drugs in the body as the “core” of the wrapped drug, and the cell membrane acts as the “shell” of the wrapped NPs to functionalize the NPs, which can further improve the delivery efficiency of nano-drug delivery systems. Researchers are learning that cell membrane biomimetic NPs can circumvent the BBB’s restriction, prevent harm to the body’s immune system, extend the period that NPs spend in circulation, and have good biocompatibility and cytotoxicity, which increases efficacy of drug release. This review summarized the detailed production process and features of core NPs and further introduced the extraction methods of cell membrane and fusion methods of cell membrane biomimetic NPs. In addition, the targeting peptides for modifying biomimetic NPs to target the BBB to demonstrate the broad prospects of cell membrane biomimetic NPs drug delivery systems were summarized. The most prevalent type of dementia in the world is Alzheimer’s disease (AD), which is a progressive and irreversible neurodegenerative disease . The posTo solve this problem, many researchers have designed a class of cell membrane biomimetic nanoparticles (NPs) that can cross the BBB to the affected area in the brain. Cell membrane biomimetic NPs typically consist of a thin cytoplasmic membrane and encapsulated therapeutic NPs, resulting in a “core–shell” structure in which drug-encapsulated NPs  are the “core”  and the The “core” of drug-carrying cell membrane biomimetic NPs is prepared from nanomaterials and drugs, which can prolong the drug’s half-life and increase biocompatibility in nerve tissues to enhance the therapeutic effect . To furtIn the following review, we focused on the influence of BBB and application of cell membrane biomimetic NPs in treatment of AD. In addition, NPs synthesis methods, cell membrane extraction methods, and cell membrane biomimetic NPs fusion methods were reviewed in this paper. Finally, targeting peptides commonly used to enhance BBB targeting of biomimetic NPs were summarized, aiming to achieve drug delivery to AD lesion areas.N-methyl-d-aspartate (NMDA) receptor antagonists [Less successful treatment drugs have been developed to treat AD , and mosagonists . ChEIs, agonists . In addiagonists  and aducagonists . Aducanuagonists . Howeveragonists .Drug efficiency is enormously limited due to the existence of BBB . BBB is The BBB’s BCECs are surrounded by AS, whose feet processes form connections to neurons. Pericytes are sporadically scattered along the brain capillaries and work with the basement membrane to stabilize the BBB. Microglia are sorts of immune cells exiting the central nervous system. Tight junctions are created by a complex network of parallel, linked transmembrane, and cytoplasmic proteins and are found in the apical/luminal area of BMECs. Only particles smaller than 1 nm are permitted to cross the passage of tight junctions. Thus, the BBB provides a protective mechanism for maintaining brain homeostasis and protecting the central nervous system from harmful hematogenous, endogenous, and exogenous substances. Although drugs or endogenous components cross the BBB into the brain via transcellular pathways   local sustained release, a highly invasive procedure in which a drug is injected directly into the brain through the meninges. However, it is clinically prone to bleeding and central nervous system infection and should be used in very severe cases or only when a patient is hospitalized. (B) Intranasal administration: the brain receives medication directly by bypassing the BBB via the olfactory and trigeminal pathways. However, there are problems, such as insufficient absorption of drugs from the nasal mucosa, small nasal volume, large variability, and poor stability . (C) SysIn addition to medicines already in use mentioned in Tau phosphorylation, neurotransmitter dysfunction, neuroinflammation, oxidative stress, and neurotrophic factors in the brain to restore degenerative nerves and thus achieve the therapeutic effect of AD. NPs carry fluorescent molecules for early diagnosis of brain diseases. In conclusion, application of NPs in treatment of AD across the BBB has shown great potential.There are several routes in which nanocarriers carry therapeutic drugs across the BBB into the brain to treat degenerative neurological disease: (A) open the tight connections between BCECs or cause local toxic effects that make the BBB more permeable, allowing NPs to enter the brain; (B) through endocytosis through BCECs, NPs enter the BCECs cytoplasm and then are expelled into the brain by the BCECs lumen; (C) through transcellular action through BCECs into the brain. NPs’ biocompatibility and biodegradability allow them to protect pharmaceuticals, increase their bioavailability, and enable active targeting through surface functionalization, making it easier to distribute drugs to specific places. NPs may be able to transport therapeutic medications directly to the brain due to these advantageous effects without endangering the BBB’s neuroprotective qualities . TherefoIn the systemic delivery system, cell membrane biomimetic NPs have shown great advantages for brain drug delivery, with the features of high drug loading, good biocompatibility, long circulation time, instinctual targeting ability, and low immunogenicity. Cell membrane biomimetic NPs simultaneously combine the advantages of unique natural cell membranes and an artificial core and can disguise as autologous cells, providing a new idea for brain drug delivery.With the introduction of the concept of nanotechnology, nanotechnology has become a field to ensure safety of human life, involving many aspects, such as medicine and bioscience, agriculture, the food industry, electronics, transportation, communication, energy, etc. . NPs conBecause of their flexible architecture (10–1000 nm), low toxicity, biocompatibility, and regulated drug release, polymeric NPs—both synthetic and natural—have been extensively exploited in an astounding variety of drug delivery systems . Theraped,l-lactide-co-glycolide) (PLGA), polyethylene glycol, polylactic acid, poly(caprolactone), poly(glutamic acid), N-(2-hydroxypropyl)-methacrylate copolymers, poly(n-butylcyanoacrylate), 4-(Hydroxymethyl) phenylboronic acid pinacol ester (PBAP), and poly(amino acids), etc. PLGA is a synthetic polymer that has received FDA approval and has excellent biocompatibility and biodegradability features. It has been utilized extensively in medicinal applications, including treatment of AD [The most common biodegradable and biocompatible polymers used to create polymeric NPs include poly (RBC-NP-Cur). In aneuronal-like cells (HT22) and primary brain capillary endothelial cell Transwell co-culture test, RBC-NP-Cur was confirmed to show significantly better permeability than Cur. In addition, after injection of RBC-NP-Cur in AD model mice, more accumulation of Cur, reduced cognitive decline, suppressed nerve cell death, and decreased ur group . Tang etur group . These r1-42 aggregation in AD mice [Polymer nanomicelles (PM) carrying a wide range of proteins, such as mRNAs or antibodies, can specifically and efficiently penetrate the BBB by injection to reach the brain parenchyma to release active agents’ fragments. In addition to preventing early degradation of mRNA, use of mRNA-loaded PM altered intracellular mRNA transport, increased mRNA detection and expression in neurons in vivo, and reduced amyloid load in mouse models of acute amyloidosis . It was  AD mice . Accordi AD mice .Liposomes , solid lSong et al. encapsulated rapamycin in liposomes and coated with platelet membrane by extrusion (P-Lipo). After intravenous injection of P-Lipo, the extracted brain tissue was observed under a fluorescence microscope and it was found that accumulation of P-Lipo in atherosclerotic lesions increased by 5.91 times compared with control liposomes, indicating that P-Lipo-specific targets to atherosclerotic plaques . Han et 3O4) [Inorganic NPs are usually based on metals and non-carbon sources. The shape and size of inorganic NPs, including gold (Au) , silica 3O4)  NPs, can3O4) . Additio3O4) . However3O4) .1–42, KLVFF and LPFFD. KLVFF matches the short hydrophobic core Aβ segment and LPFFD binds the hydrophobic area in Aβ’s center, respectively, for Aβ-amyloid-plaque-targeted treatment of AD. Both functionalized NPs attach specifically to the amyloid plaque made up of Aβ protein in vitro hippocampus of AD model mice, as shown by immunohistochemical labeling with Pittsburgh compound on brain slices of transgenic mice with AD [Plissonneau et al. prepared sub-5 nm gadolinium-based NPs (AGuIX) co-modified by two small peptides derived from the sequence of Aβ with AD . Gao et  with AD .Single emulsion (W/O) of polymeric NPs for hydrophobic drugs can be synthesized by emulsification–solvent evaporation method. First, the nano carries and interested ingredients are dissolved in organic solvents as organic phase. The organic phase is dropped into water phase containing sodium cholate, poloxamer, etc. Then, the mixtures are stirred and phaco-emulsified to produce a stable nano-emulsion. The organic solvent is evaporated off to generate NPs  Figure .Generally, hydrophilic drugs (such as proteins) can be prepared as polymeric NPs and lipid-based NPs by this double emulsion (W/O/W) method . The hydNanoprecipitation method can be used to prepare hydrophobic polymers into NPs. Materials and drugs are dissolved and dispersed in organic solvents. The resulting organic solvent is added into an aqueous solution with surfactants magnetically stirred. Due to the difference in the solubility of hydrophobic polymers in the two solvents, the polymers that exist in stretched form in organic solvents will aggregate and form NPs once they enter the aqueous phase. By using lower pressure evaporation or nitrogen blowing, the solvent and water from the particle dispersions are eliminated. NPs are precipitated from the suspo-emulsion by centrifugation in a differential centrifuge  Figure .No toxic organic solvent is used in salting out emulsification–diffusion method. Natural polymer materials, such as albumin and gelatin, are used as carrier materials to prepare polymeric NPs. Dissolve nanocarriers and hydrophobic drugs in water with surfactant, and then add salt precipitating agent or change the pH value to precipitate the polymer while stirring. An emulsifier is added to emulsify the precipitate and an appropriate amount of curing agent is used to stabilize the NPs. Dialysis membrane or gel column chromatography can be used to purify the products  Figure .Supercritical fluid is a substance in a supercritical state that can improve solubility of poorly soluble drugs . PolymerSpray drying method has been shown to be an effective way for improving long-term stability of NPs and is suitable for industrial largescale preparation of NPs. With removal of water, NPs material turned from fluid state to powdered material. The atomizer atomizes a certain concentration of fluid, falls into a certain flow of dry gas for vaporization/drying, and finally separates NPs from the dry gas . This meIn closed reactors (such as autoclave) with high temperatures and pressures, the solvothermal approach typically functioned and is suitable for preparation of inorganic NPs . The rawWhen using the sol–gel process, the inorganic material is uniformly dissolved in the precursor solvent before being transferred to a container. Heat the container, store under vacuum for a period of time and cause its gelation, and then cool to room temperature. The product is washed with ethanol and subsequently dried under vacuum to obtain inorganic NPs with core–shell structure. By adjusting the reaction time and material ratio as well as the proportion of the reaction product, the sol–gel method can control the thickness of the shell, which in turn affects the overall particle size  Figure .The weighed precursor and inorganic material are added into an organic solvent. The mixture is stirred to dissolve during heating and then kept at a specific temperature in the reactor. The samples are allowed to cool down at room temperature. Products are collected by filtration, washed several times, and dried overnight . ThermalAs the “shell” of the cell membrane biomimetic NPs, the cell membrane plays the role of modifying the NPs. Membrane proteins embedded in semipermeable phospholipid bilayers, such as integrins, peripherins, and lipid-anchored proteins, make up around one-third of all the proteins in an organism . NPs, wrDistinct types of cells in the human body perform several physiological tasks, such as lengthy blood circulation, migration to particular body areas, and traversing physical barriers. To deliver medications with retained cellular structure and function, it is crucial to choose particular cell types.Erythrocytes, also known as red blood cells, lack organelles and nuclei and are biconcave blood cells, with a diameter of between 7 and 8 μm and a central thickness of about 1 μm. Erythrocytes are the most prevalent cell in blood, making up a quarter of the total number of cells in the body, and can be easily isolated from the blood . In addiGao et al. coated Cur-loaded human serum albumin NPs with RBCm and then modified the RBCm surface with triphenylphosphine (TPP) molecules and AV-1451 (T807) (T807/TPP-RBC-Cur-NPs). In the in vitro co-culture model of BMECs, AS, and HT22 cells, significant fluorescence intensity was observed in the T807/TPP-RBC-NPs group, proving that RBCm-coated biomimetic NPs could effectively traverse the BBB and fully enhance the Cur cell uptake. Hematoxylin and eosin staining was used to check the survival of neurons in the hippocampus of AD model mice after injection of T807/TPP-RBC-Cur-NPs into the tail vein. The neuronal survival rate in the hippocampus of AD model mice treated with T807/TPP-RBC-Cur-NPs was greatly increased .Platelets are disc-shaped anucleate cellular fragments from bone marrow stem cell line megakaryocytes . Platele2-modified platelet membranes coated with neuroprotectant (ZL006e) and recombinant-tissue-plasminogen-activator-loaded polymeric NPs of glucan derivatives (TP-NP-rtPA/ZL006e). It was found that the cell penetration rate of TP-NP-rtPA/ZL006e in BCECs cells was significantly higher than that of free ZL006e. The concentration of TP-NP-rtPA/ZL006e in the brain was 14.6% after injection of coumarin-6-labeled TP-NP-rtPA/ZL006e into a mouse model, which was higher than that in liver tissue at 2 h administration. TP-NP-rtPA/ZL006e was found to penetrate the BBB and accumulate in injured neural tissue [Xu et al. synthesized YGRKKRRQRRR-NHl tissue .Leukocytes, commonly termed as white blood cells, are between 7 and 20 μm in diameter, larger than erythrocytes due to their nucleus. Leukocytes play an important function in protecting bodies from infection and injury and are widely distributed in blood arteries, lymphatics, and other organs. The CD11b protein on the surface of leukocyte membranes can target activated BCECs and evade uptake by the mononuclear phagocytosis system via CD45 protein . Based oMesoporous Prussian blue nanozyme, which has a cell membrane coating of NCM (MPBzyme@NCM), was created by Feng et al. After co-culture with MPBzyme@NCM and Transwell system (bEnd.3 and mouse microglia cells), it was found that MPBzyme@NCM could not only cross BBB but also had strong reactive oxygen species scavenging ability. Fluorescence imaging of mice injected with fluorescein isothiocyanate labeled MPBzyme@NCM showed that NCM coating promoted continuous accumulation of MPBzyme@NCM in brain tissue compared with NCM or non-coating .Macrophages are immune cells that recognize, engulf, and digest cellular debris and other foreign substances that lack biomarkers of their own . RecentlLong et al. prepared Baicalin liposomes (BA-LP) modified with MA (MA-BA-LP). Intensity and duration of fluorescence in brains of mice injected with MA-DiR-LP in tail veins were substantially higher than those in the DiR-LP group. The findings demonstrated that MA-BA-LP had a greater brain targeting impact than BA-LP .Cancer-cells-modified NPs can be easily bound to homologous tumor cells because of the homologous adhesion molecules on cell membranes, such as lectins, integrins, cadherins, selectors, and proteins . Cancer-Multi-membrane-modified NPs showed better performance compared with single-membrane-modified NPs . MembranIn a particular design found in the study, Niu et al. attached doxorubicin-loaded heparin NPs to the surface of native grapefruit extracellular vesicles, creating biomimetic grapefruit for drug delivery NPs; compared with traditional cell membrane encapsulation, the therapeutic effect of modified NPs can reach 4 times the drug loading. Biomimetic grapefruit NPs can bypass BBB and enter glioma tissue through receptor-mediated cell penetration and membrane fusion, which greatly promotes cellular internalization and anti-proliferation capabilities and extends the cycle time .Natural, intact, and functional cell membranes are separated from source cells by destroying or lysing cells to empty their intracellular components. Cell membranes can be separated from blood or tissues by ultrasound, freeze–thaw, extrusion, hypotonicity, and Dounce homogenizers . Cell destruction occurs after at least two cycles of freezing and thawing . This isCell membranes with large cross-sectional area are extruded through a die to obtain cell vesicles with smaller cross-section. After pretreatment of membranes with large cross-sectional areas, the cell membrane is mechanically pushed through a mold with a specified cross-section to obtain cell membrane vesicles of a certain desired shape and size . The celWhen the hypotonic lysate is added to the culture dish containing the cells, the water molecules in the hypotonic lysate will diffuse into the cells and increase the volume of the cytoplasm, resulting in rupture of the cells to acquire the cell membrane . AlternaHomogenization is a process of micronizing and homogenizing dispersion in a suspension (or emulsion) system. The Dounce homogenizer  is a cylAfter the cell membrane is extracted, the extracted cell membrane vesicles need to be fused with NPs to form cell membrane biomimetic NPs. Several methods have been proposed to fuse cell membranes with NPs, including co-extrusion , ultrasound (endocytosis by ultrasonic energy), extrusion/microfluidic electroporation , etc. .In the co-extrusion method, the cell membrane suspension and the NPs suspension are mixed in certain proportion. The mixed suspension is co-extruded multiple times through a porous filter membrane of the specified size of the extruder . After eThe mixture of cell membranes and core NPs is incubated under the effect of ultrasound to obtain cell membrane biomimetic NPs . The eneMicrofluidic electroporation technology is a new technology developed in recent years that simultaneously solves the problems of destruction of NPs via ultrasonic/extrusion and time-consuming and labor-intensive nature of the co-extrusion method . When thIn addition to the three methods summarized in Nowadays, application of membrane biomimetic NPs is becoming more and more common, and the multifunctional demand for membrane biomimetic NPs is also increasing. On this basis, peptides with additional functions can be used, which provide the particles with various additional functions beyond the natural functions of the cell membrane, greatly increasing application of NPs. The usual method includes (A) lipid insertion: ligand–joint–lipid junctions are first synthesized and then the lipid chains are inserted into the membrane depending on the fluidity of the bilayer lipid membrane ; (B) memOn this basis, bi-functional ligands can also be used to modify the cell membrane surface .Nanomaterials have been developed to treat AD based on promotion of drug delivery across the BBB to achieve accumulation at desired sites. NPs carry therapeutic drugs by encapsulation or surface modification, which has the advantage of effectively delivering drugs to the target area and enhancing the therapeutic effect. Cell membrane biomimetic NPs, which fuse NPs with the membrane of the extracted cell, have the main biological traits and additional physiological functions of the source cell. Cell membrane biomimetic NPs are shielded from the body’s immune system, which prevents immune cells from being absorbed. Surface-modified targeting peptides on cell membrane biomimetic NPs can improve the targeting capabilities and precision to a damaged location.At present, biomimetic nanomedicine, represented by cell membrane biomimetic NPs used to treat AD, is still in its infancy and has many problems that need to be improved upon. First, maintaining stability of cell membrane biomimetic NPs is one of the issues that must be resolved for application, which requires certain stability of drugs for long-term effective preservation. Delivery efficiency of cell membrane biomimetic NPs is greatly influenced by their size, shape, elasticity, and other physical and chemical properties. Additionally, therapeutic and diagnostic nanomedicine products are currently administered via parenteral injection, typically intravenously. Oral administration is an ideal administration, with high patient compliance. Due to low absorption of solid NPs and biochemical barriers in the gastrointestinal tract, oral delivery of NPs has not proven feasible. Therefore, effective implementation of cell membrane biomimetic NPs administered orally will represent significant advancement in the field of nanomedicine.


Despite the rapid growth of cardio-oncology as a subspecialty, cancer patients are still underserved from a cardiovascular perspective. A new care model is needed to integrate comprehensive cardio-oncology care with community-based facilities to improve care access, quality, and equity. Here, we present a cardio-oncology service line model for large, multi-hospital health systems to address this need.An academic cardio-oncology program was first established using a multidisciplinary approach. Five infrastructure elements for a service line model were created, including strategic accountability, standardized care, dedicated resources, patient experience/education, and branding/identity. We then utilized these elements across our healthcare system to establish a quality-controlled and centrally governed cardio-oncology service line structure. Protocols were created to standardize care and ensure consistency and quality, including referral workflow, imaging, cardiotoxicity surveillance, and clinical management. An IRB-approved cardio-oncology registry was established for outcome tracking.The standardized cardio-oncology services were expanded to eight hospitals and ten outpatient care centers, including rural outreach offices, resulting in increased patient access and improved clinical quality measures. The service area expanded 17-fold, and an estimated rural population of 204,133 gained access to care. Cardio-oncology office visits increased by approximately 600% three years after implementation of the service line model.A cardio-oncology service line with standardized care is a feasible and effective care model to improve cardio-oncology care quality, patient access, and health equity in large, multi-hospital health systems. It can be used in conjunction with academic cardio-oncology programs to improve the overall cardio-oncology healthcare efficacy in the US. Cardiovascular disease (CVD) and cancer are the top two causes of mortality in the US and worldwide , 2 despiThe academic cardio-oncology program was initially established in partnership with a cancer center, with the core principles of multidisciplinary collaboration, a focus on whole-person care, and an objective of optimizing overall patient outcomes Fig. . The comTo develop the cardio-oncology service line, we defined and implemented five key elements of infrastructure, including strategic vision and accountability, standardized system of care, dedicated staff and resources, patient experience and education, and branding and identity Fig. . These eOur strategic vision was established to address the unmet demand and urgent need for comprehensive cardio-oncology care both within and beyond our healthcare system. Strategic accountability was enforced through goal-directed efforts from both health system and cardio-oncology leadership. Bimonthly service line meetings were held system-wide, led by the cardio-oncology director and attended by health system and physician group leadership, to address needs and challenges. To support data collection and reporting, a dashboard based on an IRB-backed cardio-oncology registry was implemented Fig. .During the three-year service line development, dedicated staff and resources were gradually established. This included multiple cardio-oncology physicians, such as cardio-oncologist/imaging specialists, a vascular oncologist with a focus on vascular and coronary intervention, and an advanced heart failure/infiltrative heart disease specialist. Additionally, two cardio-oncology nurse practitioners, one cardio-oncology pharmacist, and an administrative nursing coordinator were brought on board. It's worth noting that the service line was established during the pandemic, which posed unique challenges in recruiting and hiring staff.To provide comprehensive cardio-oncology care, a dedicated clinical and administrative space was created with cardio-oncology signage prominently displayed. This helped patients feel more at ease and supported as they navigated the challenges of their cancer and cardiovascular conditions. The service line was also equipped with designated echocardiogram technologists who were experienced in 3D and strain echocardiography, and who received periodic training across the health system based on a newly created cardio-oncology echocardiogram protocol Fig. .The foundational element of developing a service line model was the establishment and implementation of a standardized system of care across our multi-hospital organization. Over a three-year period, we developed five essential protocols for care standardization Fig. A. We sucThe standardized system of care includes a fourth component, which consists of a therapy-specific cardiotoxicity risk and surveillance guide Tables  and 3, bClose collaborations have been established with internal and external referral providers, including oncology practices, cancer centers, primary care providers, and survivor clinic providers, to ensure that consistent care is provided in accordance with the standardized protocols. To monitor the outcomes, an IRB-approved cardio-oncology registry has been established. All protocols and guidelines have been made readily available to staff and providers across the healthcare system through a designated intranet link. These protocols and guidelines are updated periodically based on the latest evidence during the cardio-oncology service line meetings.In building the cardio-oncology service line Fig.  as a newWe have developed and distributed a patient educational manual and hold periodic patient educational forums for active cancer patients and cancer survivors. The final element of the service line model is branding and identity Fig. , which iAfter implementing the new cardio-oncology service line, the standardized cardio-oncology services expanded significantly, from being available at one medical center to eight hospitals across the hospital system, which included two rural hospitals Fig. . AdditioFurthermore, the establishment of the service line allowed cardio-oncology care to become newly accessible to an estimated rural population of 204,133 Fig. . The quaThe cardio-oncology service line, which incorporates key infrastructure elements centered on a standardized system of care, is a feasible and effective care model for improving cardio-oncology care quality, patient access, and health equity in large, multi-hospital health systems. It can be used in conjunction with academic cardio-oncology programs to improve the overall efficacy of cardio-oncology healthcare for this patient population. Furthermore, due to the highly specialized nature of this area and the relatively limited patient population, the expanded patient population resulting from this care model can establish a strong foundation for patient care, supporting academic research and education Fig. . This, i


Electromechanically-assisted gait training has been introduced in stroke rehabilitation as a means to enable gait training with a large number of reproducible and symmetrical task repetitions, i.e. steps. However, few studies have evaluated its impact on gait pattern functions. This study includes persons with no independent ambulation function at the start of a 4-week neurorehabilitation period in the sub-acute phase after stroke. The primary aim of the study was to evaluate whether the addition of electromechanically-assisted gait training to conventional training resulted in better gait pattern function than conventional training alone. The secondary aim was to identify correlations between overall gait quality and standardized clinical assessments.n = 7) to undergo conventional training only (CONV group) and the other group (n = 10) to undergo conventional training with additional electromechanically-assisted gait training (HAL group). All patients were assessed with 3D gait analysis and clinical assessments after the 4-week intervention period. Overall gait quality as per the Gait Profile Score (GPS), as well as kinematic, and kinetic and other spatiotemporal metrics were collected and compared between intervention groups. Correlations between biomechanical and clinical outcomes were evaluated.Seventeen patients with no independent ambulation function who participated in a Prospective Randomized Open Blinded End-point study in the sub-acute phase after stroke were randomized into two groups; one group (p = 0.887). Overall gait quality was correlated with independence in walking, walking speed, movement function and balance. We found no added benefit in gait pattern function from the electromechanically-assisted gait training compared to the conventional training alone.Both the CONV and HAL groups exhibited similar gait patterns with no significant differences between groups in any kinematic, kinetic parameters or other spatiotemporal metrics. The GPS for the paretic limb had a median (IQR) of 12.9° (7.8°) and 13.4° (4.3°) for the CONV and HAL groups, respectively  on April 2015.The study was retrospectively registered at  Normal gait depends on sensory-motor neural networks at spinal and supraspinal levels , 2 and iCurrent evidence accentuates the importance of intensive, repetitive, and task-specific training of movement functions to drive neuroplasticity  and suppElectromechanically-assisted gait training has been introduced in rehabilitation to facilitate higher dosage (i.e. more steps) per training session, more reproducible and symmetrical gait than through manual support from a therapist, and potentially earlier start of intensive gait training after stroke despite even severe impairment . A recenSeveral types of robotic exoskeletons are currently in clinical use or under development. Most of these support gait training by use of automatic motions, such as the Lokomat  . HoweverThe Hybrid Assistive Limb HAL,  is an inThus, the primary aim of the study was to evaluate whether the addition of electromechanically-assisted gait training to conventional training resulted in better gait pattern function than conventional training alone. A secondary aim was to evaluate whether correlations between overall gait quality and standardized clinical assessments exist, in order to better identify which clinical presentation variables may be related to, or serve as a proxy for, a greater potential for gait pattern function improvement in this patient group.ClinicalTrials.gov (Identifier: NCT02410915) and has been described in detail in previous publication , referred to as “the main study”. The main study protocol can be found at lication . Among pAll patients participated in conventional team-based training provided by a multidisciplinary team, following current evidence and best practice for inpatient rehabilitation after stroke . Directly after inclusion, block-randomization was performed by a nurse who was otherwise not involved in the study into (1) conventional training or (2) HAL-training in addition to conventional training.The conventional training included physiotherapy training that could be comprised of training of movement functions in both the upper and lower extremity, balance, and gait. The gait training could include stepping, weight shifting, over ground walking as well as the use of treadmill with or without body-weight support.Individualized HAL-training was planned for 4 days/week for 4 weeks (i.e. 16 sessions) with the single-leg version of HAL, in voluntary mode, on a treadmill with body-weight support. To obtain a symmetrical gait pattern as close to normal gait as possible, the therapist continuously optimized HAL-settings based on observational gait analysis during each session.n = 7) and HAL-training in addition to the conventional training group . It was not possible to perform GA at the start of the intervention due to the patients' severe walking limitations at inclusion.Patients in the main study were recruited from a sub-acute inpatient rehabilitation unit  admitting patients aged 18–67 years, during February 2014 and May 2017. Inclusion criteria were:< 8 weeks since onset of ischemic or hemorrhagic stroke (verified by computerized tomography and/or magnetic resonance imaging), Functional Ambulation Categories (FAC) score of 0–1 and thus need for continuous manual support to walk due to lower extremity paresis, ability to maintain a sitting posture for >5 min, sufficient postural control to allow an upright position in standing with aids and/or manual support, ability to understand training instructions, ability to understand written and oral study information to express informed consent, and a body size compatible with the HAL-suit. Exclusion criteria included cerebellar stroke, primary subarachnoid bleeding, lower limb contracture that restricted gait movements, cardiovascular or other somatic condition incompatible with intensive gait training, and severe, contagious infections. The main study included 36 patients, of whom 32 completed the intervention. After inclusion of the 11th patient, gait analysis (GA) was added as an outcome evalution method, at which point consecutive sampling for the current study began. Of the 22 patients recruited after GA was included, 17 patients were able to walk barefoot over a 10-meter walkway with or without a walking aids after the 4-week intervention period, and were thus included in the current study . They coAt inclusion in the current study, patients exhibited moderate-to-severe stroke; 57% (4/7) in the CONV group and 60% (6/10) in the HAL group had FAC 0 , all others FAC 1 . There were no significant differences in patient characteristics between the CONV and the HAL groups . The GA The GA was performed after the intervention period with a motion capture system  and two force plates . Twenty-seven reflective markers were placed over anatomical landmarks on the pelvis, legs, trunk and head according to a conventional model (Vicon Plug-in-Gait) . PatientThe blinded standardized clinical assessments analyzed in the current study were conducted before and after the intervention period, and included the FAC, which evaluates independence in walking on a six-grade ordinal scale ranging from non-functional walking (FAC 0) to independent walking on non-level surfaces (FAC 5) , the 2 MThe primary outcome in this study was overall gait quality assessed as the Gait Profile Score (GPS) for the paretic and non-paretic leg separately . SecondaKinematic data were calculated from three gait cycles per side for each patient (only two cycles per side were available for two patients). The gait cycles used were considered sufficient and representative after visual inspection of video and curve correspondence, in accordance with the standard practices of GA. Kinetics in the paretic limb were successfully collected in 13 patients with a mean of two cycles per patient. Kinetics in the non-paretic limb were only successfully collected in four patients  and are Quantitative parameters of kinematics and kinetics, as well as GPS, were obtained for each gait cycle, and average parameters for each side (paretic and non-paretic) were computed. Other spatiotemporal metrics describing speed, step frequency and distance were non-dimensionalized according to Hof . KineticThe GPS quantifies the magnitude of gait kinematics deviation in degrees in the lower body (GPS-LB) or whole body  wherein larger GPS indicate greater deviation from a normative dataset. More specifically, the GPS-LB is the average Euclidean difference in degrees from the normative dataset of the pelvis and hip angles in all three planes, the sagittal knee and ankle angles and the transverse foot progression angle. The GPS-WB further includes the trunk angle deviation in all three planes. The GPS can be divided into Gait Variable Scores (GVSs) to show each gait variable's deviation throughout the gait cycle . The Movp < 0.05 or, in case of multiple testing, p < 0.01.Descriptive statistics and tests for normality were performed using Shapiro-Wilk's test, skewness, boxplots and QQ-plots. Calculations were performed in SPSS (IBM SPSS Statistics 22) with 2-tailed significant levels of t-test for time to inclusion and normally-distributed kinematics, kinetics and other spatiotemporal variables; and with the Fisher exact test for gender, diagnosis, and paretic side. Differences within groups (paretic vs. non-paretic side) for GPS and GVSs, and FAC, BBS, FMA-LE, 2MWT (baseline vs. post-intervention) were tested with Wilcoxon signed-rank tests.Group differences were tested with Mann-Whitney U-test for age, stroke severity, GPS, GVSs, and non-normally distributed kinematics, kinetics, and other spatiotemporal variables as well as for data on training intensity and distances and on FAC, BBS, FMA-LE, 2MWT change scores; with independent sample S). Correlations were interpreted as little or no relationship for RS ≤ 0.25, fair for RS between 0.25 and 0.50, moderate to good for RS between 0.50 and 0.75, and very good to excellent relationship for RS ≥ 0.75  and overall gait quality, defined as GPS-LB on the paretic side (GPS-LBP), were computed for the whole (merged) group by Spearman's rank correlation  body weight. During HAL training, patients walked a median (Interquartile range IQR) distance of 519  meters per session, with 219  and 760  meters during the first and last session, respectively.p = 0.022], and a significant difference in the median number of conventional gait training sessions performed in the two groups, wherein more sessions were performed in the CONV group . There was a significant difference between groups in the median distance walked during these conventional gait training sessions, wherein a greater distance was walked in the CONV group .Data on the conventional gait training were retrieved from the patients' medical records. Estimated distance walked during the conventional gait training sessions were recorded in 82%  of the records (missing fully for one patient in the CONV group). There was a significant difference in the total number of gait training sessions  performed in each group, wherein more sessions were performed in the HAL group [median (IQR): HAL group 22.5 , CONV group 12.5 , p = 0.887).There were no significant differences in GPS or any GVSs between the CONV group and the HAL group for either the paretic or the non-paretic leg . The medAll patients demonstrated impaired gait kinematics and step spatiotemporal asymmetry, with no significant differences between groups after the intervention period . Gait paThe proportional contributions of each joint to total positive work were similar in both groups (no significant difference) and much lower than in controls .Between the baseline and post-intervention assessments, FAC, 2MWT and BBS improved significantly in both groups, and FMA-LE Motor improved in the HAL group. However, there were no significant differences in change scores (difference from baseline to post-intervention) in any of these clinical outcomes between CONV and HAL groups . After in = 17). We found a moderate-to-good and significant correlation between overall gait quality (GPS-LBP) and independence in walking (FAC) , walking speed/endurance (2MWT) , balance (BBS)  and movement function (FMA-LE Motor) .Due to the small study sample and homogeneity in results between the two groups, the correlations between clinical assessment and overall gait quality were computed for one merged group . These deviations are similar to findings from Devetak et al. , who repDuring HAL-training, knee flexion was assisted during swing to obtain foot clearance with minimal compensatory movements. However, knee flexion in swing on the paretic side was similar in both groups and less than that in the non-paretic side and in the non-disabled subjects (Controls). This corroborates earlier observations suggesting that recovering pre-stroke joint kinematics might not be required for improved independence in walking and that a stiff-knee pattern might even be useful to accommodate walking . One couOur results suggest furthermore that the repetitive, reproducible and symmetrical gait pattern strived for during HAL-training was not transferred to symmetrical over-ground walking after the intervention period. Whether gait patterns are different in treadmill-walking compared to over ground walking in patients in the acute post-stroke phase has not yet been ascertained, to the best of our knowledge. However, in non-disabled individuals and in chronic stroke patients, treadmill-walking is reported to be less variable , 44, whiThe lower overall positive joint work in the HAL group compared to the CONV group can be attributed to their somewhat slower walking speed . The vasIn most exoskeletons for walking, including HAL, the ankle joint does not articulate, restricting ankle motion and likely not encouraging voluntary ankle muscle activation. However, in normal gait, ankle motion is the largest contributor to forward propulsion . Recent In contrast to Baker et al. , who fouThe overall gait quality (GPS-LBP) was moderate-to-good and significantly correlated with independence in walking (FAC). The cognitive involvement associated with walking performance after stroke , partialWe found a moderate correlation between overall gait quality (GPS-LBP) and movement function (FMA-LE Motor) in the present study. Previous studies in chronic stroke , 54, havImpaired sensory function is known to contribute negatively to the probability of achieving independent gait  and to cIt is study limitation that no patients were able to walk independently at inclusion and could not have adequately undergone a GA, thus making it impossible to compare changes in gait variables between intervention groups. It was also difficult to collect gait kinetics in the non-paretic limb in many patients, as walking aids frequently contacted the force plate. This consequently restricted between-leg comparisons of joint kinetics. It is worth noting that hemiparetic gait also has a large impact on kinematic and kinetics in the non-paretic side. Further, the non-disabled subjects were similar in age to the study sample but walked more quickly, which affected the GPS. Sample size calculation was based on the main study, as it was linked to prognoses of required study group sizes. Due to small sample size and high variability, the statistical power for this study is low, and the risk for type-2 errors is not negligible.In the sub-acute phase after stroke, there appears to be a dose-response relationship  where inLastly, participants in the current study were younger and more severely disabled that the overall stroke population, which should be taken into consideration when generalizing our findings. However, this group of patients warrants attention for these same reasons and thus might also face long-term disability. This study does not provide any firm conclusions, but it provides important information and a rationale for larger studies.We found that the addition of HAL-training to evidence-based conventional training did not improve the outcome in terms of gait deviation, spatiotemporal asymmetry, or positive joint work in this small, relatively young and severely impaired stroke population. The overall gait quality was correlated with independence in walking, walking speed, balance and movement function, but not with sensory function. Though of limited scope, this study suggests that retraining of a normal gait pattern might not be attainable by conventional gait training according to today's standards nor by electromechanically-assisted gait training in patients with severe limitations in walking. This raises new questions regarding how post-stroke rehabilitation programs, with or without electromechanically-assisted gait training, for patients with moderate to severe gait impairments should be designed in order to further improve both walking ability and recovery of gait pattern functions. Findings from this study may be useful in planning of future larger studies exploring whether electromechanically-assisted gait training can improve gait function, and if so, in whom.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by Swedish Ethical Review Authority. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.AW, SP, JB, and EG-F participated in the study design and drafted and provided important intellectual content to the manuscript. AW coordinated the data collection. AW and EG-F performed gait analyses and including data processing. AW performed the statistical analysis in cooperation with SP. All authors have approved the final manuscript.


Measures of medication adherence and persistence are important for researchers and policymakers to assess quality of care. Lack of adherence has been associated with adverse outcomes and higher costs of care. Long-acting medication formulations, including injectable forms, have been proposed as interventions to increase adherence and in turn improve health outcomes and costs. Standard measures of adherence/persistence were developed for orally administered medications. Methods for assessing adherence/persistence of long-acting injectable dose forms are understudied.To compare the consistency between standard measures of adherence/persistence versus proposed variations that consider the data quality and injectable administration method for a long-acting injectable second-generation antipsychotic (SGA) using an orally administered SGA as the reference.Standard adherence/persistence measures were designed for oral tablet formulations, in particular accounting for accumulation of pills caused by early refills. To address this limitation and the accuracy of the days supply field for long-acting injectable SGAs in pharmacy claims, 2 alternatives are proposed. The first approach calculates days supply using the labeled dosing schedule for the given injectable. The second approach builds on the first and sets days supply to the minimum of the time between injections and the time frame according to the labeled dosing schedule. Administrative health care claims data from the Missouri Medicaid system were analyzed to compare adherence/persistence measures between formulations. Common adherence/persistence measures, including medication possession ratio (MPR) and proportion of days covered (PDC), were evaluated in this study. The analysis cohorts comprised 195 adult patients with schizophrenia who initiated a long-acting injectable SGA (LA-SGA) and 369 patients initiating an oral SGA (O-SGA) from August 1, 2009, through April 30, 2010. Chi-squared tests, the Kruskal-Wallis test, and Kaplan-Meier curves were used to compare adherence/persistence measures between cohorts.Days supply was most frequently recorded as 30 days for O-SGA and 28 days for LA-SGA. Time between claim fills was most commonly 28 days for both cohorts. Using the LA-SGA pharmacy claims data, MPR was 0.91 and did not vary significantly from MPR of O-SGA . When applying the labeled dosing schedule to compute days supply, the LA-SGA MPR rose to 0.97 and varied significantly from MPR of O-SGA . Additionally controlling for the inability for excess medication accumulation, MPR for LA-SGA dropped to 0.86, which varied significantly from MPR of O-SGA . PDC varied from 0.55 to 0.61 for LA-SGA but was consistently significantly different from the 0.37 PDC value of O-SGA (P  less than  0.05 for each comparison).Standard medication adherence/persistence measures yielded different conclusions when comparing a LA-SGA and an O-SGA, depending on the measure and underlying assumption for days supply. Adherence/persistence measures that address pharmacological differences in terms of formulation and duration of therapeutic drug levels between medications may be necessary and are particularly important as more injectable antipsychotic medications are approved in the United States. Therefore, payers and investigators should consider sensitivity analysis using different adherence/persistence definitions when making product comparisons to ensure confidence in conclusions.


A decreased uptake on DaT-SPECT was associated with motor impairment, and MIBG scintigraphy defects were associated with hyposmia. The simultaneous evaluation of DaT-SPECT and MIBG scintigraphy may capture a wide range of individuals with prodromal LBD.Individuals with prodromal symptoms of Lewy body disease (LBD), such as rapid eye movement sleep behavior disorder (RBD), often showed imaging defects similar to patients with Parkinson’s disease and dementia with Lewy bodies. We examined dopamine transporter (DaT) single-photon-emission computed tomography (SPECT) and metaiodobenzylguanidine (MIBG) scintigraphy in 69 high-risk subjects with ≥2 prodromal symptoms  and 32 low-risk subjects without prodromal symptoms, whom were identified through a questionnaire survey of health checkup examinees. The high-risk subjects had significantly worse scores on Stroop test, line orientation test, and the Odor Stick Identification Test for Japanese than the low-risk subjects. The prevalence of abnormalities on DaT-SPECT was higher in the high-risk group than in the low-risk group (24.6% vs. 6.3%,  Among these prodromal symptoms, RBD has a strong association with the risk of LBD. Several studies have reported the validity of questionnaires for detecting probable RBD, although the accuracy of them is less than polysomnography5.Lewy body disease (LBD) is a neurodegenerative disorder associated with the intra-neuronal accumulation of alpha-synuclein and includes Parkinson’s disease (PD) and dementia with Lewy bodies (DLB). PD and DLB share common prodromal symptoms, such as autonomic dysfunction, hyposmia, and rapid eye movement sleep behavior disorder (RBD), of which constipation and RBD emerge earlier than other prodromes (as early as 15 years before the onset of motor function issues)6. Various studies have thus been initiated to identify individuals at risk for LBD. Most studies have recruited elderly subjects with prodromal features, gene mutations, or a relevant family history, focusing on olfaction and RBD as prodromes. In these studies, longitudinal follow-up of the motor and cognitive functions, non-motor symptoms (e.g. hyposmia and RBD), blood and spinal fluid biomarkers, transcranial ultrasound, and dopamine transporter (DaT) single-photon-emission computed tomography (SPECT) were used to track the incidence of PD or DLB10.Early identification of individuals at risk for LBD is important, as motor and cognitive defects in LBD are progressive after diagnosis, and more than 50% of dopaminergic neurons within the substantia nigra are degenerated by the time of the clinical diagnosis of PD13. The uptake of MIBG is associated with the olfactory function in patients with PD14. Previous studies have shown that a decreased cardiac uptake of MIBG frequently appears in patients with idiopathic RBD, suggesting that this modality is a useful diagnostic tool for prodromal-stage LBD15. However, few studies have conducted myocardial MIBG scintigraphy together with DaT-SPECT in subjects at risk of developing LBD, particularly those without RBD but with other prodromal symptoms.DaT-SPECT and myocardial metaiodobenzylguanidine (MIBG) scintigraphy are imaging diagnostic tools for LBD. DaT-SPECT detects degeneration of dopaminergic neurons within the substantia nigra with LBD even before the onset of motor symptoms, but defects in DaT-SPECT are not specific to LBD. In contrast, myocardial MIBG scintigraphy, which visualizes cardiac sympathetic denervation, is a sensitive, specific imaging marker for LBD, even at an early stage16. Here we analyzed neurological and imaging indices, including DaT-SPECT and MIBG scintigraphy, in the high-risk individuals with multiple prodromal symptoms as well as in low-risk individuals without prodromal symptoms, to clarify the manifest LBD-related changes at possible prodromal subjects and to verify the plausibility of our screening methods using questionnaires.In our previous study using questionnaires on prodromal symptoms, we found that 5.7% of health checkup examinees with age ≥50 years old had ≥2 prodromal symptoms , and defined them as high-riskAmong the high-risk and low-risk subjects who received an invitation to the present study, 70 and 34, respectively, provided their written informed consent. After exclusion of one high-risk subject who was diagnosed with PD, one low-risk subject with brain atrophy on MRI, and one low-risk subject with subjective hyposmia according to the SAOQ, the baseline cohort included 69 high-risk and 32 healthy subjects Fig. . There wThe high-risk subjects had significantly worse scores of the Movement Disorder Society-Sponsored Revision of the Unified Parkinson’s Disease Rating Scale MDS-UPDRS, Stroop test, line orientation test, and OSIT-J scores than the low-risk group Table . The higTo investigate the relationship between the neurological function and imaging features in high-risk subjects, we classified them into the following subgroups: subjects with abnormalities in both DaT and MIBG, those with abnormalities only in DaT, those with abnormalities only in MIBG, and those with normal DaT and MIBG findings.The high-risk subjects with both DaT and MIBG abnormalities were older with significantly worse MDS-UPDRS part 3, Stroop test, trail making test, line orientation test, and OSIT-J scores than the high-risk subjects without imaging abnormalities Table . The higWe next investigated the manifest LBD-related features of high-risk individuals with normal imaging findings. The high-risk subjects without DaT or MIBG abnormalities had significantly higher MDS-UPDRS scores and worse Stroop test and line orientation test scores than the low-risk group  of health checkup examinees had mild changes in motor and cognitive scales with a higher prevalence of imaging abnormalities on DaT-SPECT than normal subjects without prodromal symptoms. In addition, those high-risk subjects also had worse scores on other questionnaires about depression and daytime sleepiness, indicating that they had multiple non-motor symptoms similar to patients with LBD. The high rate of LBD-related neurological and imaging defects in the high-risk subjects confirms the utility of a questionnaire on prodromal symptoms as a method of screening individuals at high risk of developing LBD.17. In the present study, the presence of DaT-SPECT abnormalities and absence of MIBG abnormalities seemed to correspond to brain-first PD, wherein patients develop dopaminergic degeneration prior to myocardial sympathetic denervation. In contrast, a decreased uptake of MIBG without DaT abnormalities was likely indicative of body-first PD, wherein the disease is initiated by non-motor features, such as myocardial sympathetic denervation, olfactory dysfunction, or RBD18. In addition, the high-risk group with both DaT and MIBG defects were characterized by an old age and motor, cognitive, and olfactory impairment, suggesting that LBD-related pathological changes developed more extensively in such subjects and possibly closer to the onset of LBD than in other groups. Taken together, our results appear to support the different patterns of pathological development during a prodromal phase of LBD.Regarding the relationship between functional and imaging features, we found that DaT-SPECT abnormalities were associated with motor impairment, while MIBG scintigraphy abnormalities were associated with olfactory impairment. These findings were in line with the two major pathological development patterns of PD (brain-first and body-first) proposed based on chronological changes in imaging biomarkersIn the present study, the high-risk subjects with normal DaT and MIBG findings still had more minor motor and cognitive impairment and milder reductions in DaT-SPECT SBR values, albeit still within the normal range, than low-risk subjects. This result suggests that the presence of prodromal symptoms without overt imaging defects may be associated with early pathological changes of LBD. Given that these high-risk subjects’ ages were about three years younger than the groups with defects in either DaT-SPECT or MIBG scintigraphy, a longitudinal study is needed to determine if imaging abnormalities of DaT or MIBG appear within the next few years in high-risk subjects with normal imaging. We are currently performing a prospective longitudinal study, the results of which are expected to provide insight into the progression of LBD at a very early stage.19 but were not identical to our previous finding that male  subjects at risk of LBD had decreased hematocrit values16. The discrepancy between the previous and present studies may stem from the size and age of the population examined, but further studies will be necessary to clarify the systemic changes in the prodromal stage of LBD.In our study, both the high-risk and low-risk subjects were identified through a questionnaire survey linked to a health checkup. This enabled us to investigate the changes in anthropometric and blood markers in the high-risk subjects of our cohort. Our results demonstrated that female high-risk subjects had decreased hematocrit with normal hemoglobin values compared with female subjects without prodromal symptoms, a pattern indicating a mild iron defect. Although not significant, similar findings were shown for the male high-risk subjects in the present study. These results were in line with literature indicating iron deficiency anemia as associated with a risk of PD onset20, it is necessary to confirm the findings of REM sleep without atonia on polysomnography to make a definitive diagnosis of RBD. Third, only the baseline, but not followed-up, findings were available in the present study. It is thus important to determine the natural history of neurological and imaging indices as well as the incidence of LBD conversion in these high-risk individuals through further longitudinal analyses and pathological confirmation.The present study was associated with several limitations. First, this study had a small sample size of high-risk and low-risk subjects, and the data were limited to Asians. We thus cannot exclude the possible selection bias. In particular, there were fewer participants in the low-risk group, partly because participation in the present study was voluntary and the low-risk subjects were less motivated to participate. We therefore plan to increase the number of institutes in our cohort study to expand the sample size. Second, in the present study, RBD was assessed only with the RBDSQ questionnaire and not with polysomnography. Although a previous study showed that RBD can be diagnosed with an RBDSQ cut-off value of 5, as was used in our study, with a sensitivity of 88.5% and specificity of 96.9% in Japanese subjectsIn summary, our study demonstrates that high-risk subjects for LBD identified in a questionnaire survey on prodromal symptoms had low SBR of DaT-SPECT. A decreased uptake in DaT-SPECT was associated with motor impairment, and a reduced MIBG uptake was associated with olfactory dysfunction. A longitudinal evaluation of both the high-risk and low-risk groups is warranted to determine the natural history of prodromal LBD.This study was conducted in accordance with the 1964 Declaration of Helsinki and its later amendments, the Ethics Guidelines for Human Genome/Gene Analysis Research, and the Ethical Guidelines for Medical and Health Research Involving Human Subjects endorsed by the Japanese government. The study protocol was approved by the Ethics Review Committee of Nagoya University Graduate School of Medicine (No. 2017-0521). All participants provided their written informed consent before participation in the study.16. Since March 2017, we have been conducting a survey of prodromal symptoms in healthy individuals who visited Kumiai Kosei Hospital or Daido Clinic, Japan, for their annual health checkup. In Japan, regular medical checkups, which are obligatory for employees, are performed annually according to the Industrial Safety and Health Law. We used health checkup cohorts in Kumiai Kosei Hospital and Daido Clinic to screen for prodromal symptoms in the Japanese community-based population by using the following questionnaires: the Japanese version of the Scale for Outcomes in Parkinson’s disease for Autonomic Symptoms (SCOPA-AUT); the Self-administered Odor Question (SAOQ); the RBD screening scale (RBDSQ); the Beck Depression Inventory-Second Edition (BDI-II); the Epworth Sleepiness Scale (ESS); and the Physical Activity Scale for the Elderly (PASE). Based on the results of our previous study16, we classified subjects who were ≥50 years old and had ≥2 abnormal scores in the SCOPA-AUT, SAOQ, and RBDSQ into the high-risk group. The cut-off value for identifying the high-risk group was 10 for SCOPA-AUT, 90.0% for SAOQ, and 5 for RBDSQ16. Subjects who were ≥50 years old and had no abnormalities in any of the questionnaires were classified into the low-risk group.The Nagoya-Takayama preclinical/prodromal Lewy body disease study (NaT-PROBE study) is a prospective, longitudinal, multi-center, community-based cohort study coordinated by Nagoya University School of MedicineBetween April 2018 and March 2021, we sent invitations to undergo neurological and imaging examinations for LBD to 341 high-risk and 169 low-risk individuals who were identified in the NaT-PROBE study. On the high-risk and low-risk subjects who gave written consent for the present study, we performed a detailed examination of the motor, cognitive, and physiological functions, non-motor symptoms, and DaT-SPECT and cardiac MIBG scintigraphy. All the examinations for both low- and high-risk groups were performed for solely research purposes with the funds supporting this study.We excluded participants who had PD or DLB at the baseline assessment. In addition, participants with a history of psychiatric or neurological disorders other than depression and those with brain MRI abnormalities were also excluded from this study. Serum, plasma, and urine samples were collected from all participants for future research use.The Movement Disorder Society-sponsored revision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) was scored by neurologists who were certified as MDS-UPDRS evaluators  for assessing motor and non-motor symptoms related to PD. The Japanese version of the Montreal Cognitive Assessment (MoCA-J) was administered to assess the general cognitive function, the Stroop test and trail making test were conducted to assess the frontal lobe function, and the line orientation test and pareidolia test were conducted to assess the visuospatial cognitive function.21. The CVRR was measured as previously described22. In brief, participants maintained a supine position with normal breathing for more than 5 min. The resting-CVRR was calculated as a percentage of the standard deviation of the last 100 R-R intervals divided by their mean. To assess the deep breath-CVRR, participants took 12 deep breaths over a 2-min period, and the deep breath-CVRR was calculated using the first 100 successive electrocardiogram R-R intervals.We conducted the Odor Stick Identification Test for Japanese (OSIT-J) to assess objective olfactory dysfunction. The OSIT-J is a stick-type olfaction test, consisting of 12 odorants typically familiar to Japanese subjects, and is a simple test that takes approximately 10 min to complete23 in the same way as in a recent Japanese study24 on DaT-SPECT. The specific binding ratio (SBR) values were obtained for both the right and left striatum regions. The Southampton method is widely used in Japan and uses a large volume of interest (VOI), including the entire striatum, to correct the partial-volume effect (PVE)25. The SPECT count density computed by this method was defined as CSouthampton. We used the software program DaTView , which adopted the Southampton method to compute the CSouthampton for the left and right striatum and BG regions. We defined the most affected striatum side as the ‘lower side’ and the opposite side as the ‘higher side’ with SBR values. We used the average of the right and left sides as the SBR ‘average’. The asymmetry index of SBR was calculated using the following equation: asymmetry index [%] = (SBRpredominantly affected – SBRless affected) × 2/(SBRpredominantly affected + SBRless affected) × 10026. The decrease in SBR was evaluated in reference to the values of Japanese volunteers27.We conducted DaT-SPECT imaging with [123I]FP-CIT to detect presynaptic dopamine neuronal dysfunction. All patients were scanned at Nagoya University Hospital or Kumiai Kosei Hospital. DaT-SPECT data were acquired using a Symbia T , equipped with a low-medium energy general-purpose (LMEGP) collimator at Nagoya University Hospital, and an Infinia , equipped with a low-energy high-resolution (LEHR) collimator at Kumiai Kosei Hospital. Ninety projections over 360° orbit with 2 detectors were acquired on a 128 × 128 matrix , giving a pixel size of 3.3 mm and acquisition time of 28 min. The main energy window was 159 keV±10%, and 2 subwindows were set at 8% at both ends of the main window. Images were reconstructed using a three-dimensional ordered subset expectation maximization method (3D-OSEM)  and Gaussian filter full width at half maximum (FWHM) 6 mm with attenuation correction (AC) by computed tomography (CT) and scatter correction (SC) using the triple energy window method123I]MIBG scintigraphy (123I-MIBG) was performed to assess postganglionic cardiac autonomic denervation. MIBG (111 mBq) was injected intravenously into the participants. Early images were obtained 15 min after the injection, and delayed images were obtained after 4 h. The myocardial MIBG uptake was measured using the heart-to-mediastinum ratio (H/M ratio) according to methods described previously22. None of our patients had taken drugs known to affect the MIBG uptake . Normal values for myocardial MIBG scintigraphy are ≥2.2 for the early H/M ratio, ≥2.2 for the delayed H/M ratio, and ≤34% for the washout rate28.Cardiac [We used the PASE to evaluate the amount of physical activity, the Japanese version of the SCOPA-AUT to evaluate autonomic dysfunction, the SAOQ to evaluate olfactory dysfunction, the RBDSQ to evaluate RBD, the BDI-II to evaluate depressive symptoms, the ESS to evaluate excessive daytime sleepiness, the Parkinson’s Disease Questionnaire-39 (PDQ-39) to evaluate the PD-specific health-related quality of life, and the Questionnaire for Impulsive-Compulsive Disorders in Parkinson’s Disease (QUIP) to evaluate impulse control disorder.35.All scales used in this study were validated for self-administration in a Japanese populationt-test or the Mann–Whitney U-test when appropriate. Fisher’s exact test was used to compare categorical variables between groups, and Bonferroni correction was used to calculate adjusted p-values for multiple comparisons. For the comparisons among the high-risk subjects with and without abnormal DaT-SPECT and/or MIBG, a parametric one-way analysis of variance (ANOVA) followed by Dunnett tests or non-parametric Kruskal–Wallis tests followed by Steel tests were performed. For the comparison of the high-risk subjects with and without DaT-SPECT and MIBG abnormalities, the analysis was performed after adjusting for age with an analysis of covariance (ANCOVA). Pearson’s correlation coefficient was used to determine the relationships between each clinical score and the DaT-SPECT SBR or delayed MIBG H/M ratio.All data represent the mean±standard deviation unless otherwise stated. The demographic and clinical scores of the high-risk and low-risk groups were compared using Student’s P-values of <0.05 were considered to indicate statistical significance. Correlation coefficients (r) were interpreted as follows: >0.8, very strong; 0.5–0.8, moderately strong; and 0.3–0.5, weak. All statistical analyses were conducted using EZR 36, which is a graphical user interface for R .Further information on research design is available in the Supplemental materialReporting Summary Flattened